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Sun Sep 13 17:17:12 BST 2009

OK, so why go to CT then, with a pt. who's bp is in the 40s?

Rob Smith

On Sep 13, 2009, at 12:02 PM, KMATTOX at aol.com wrote:

> I am sorry that I am late for this discussion.    As many of  you  
> know so
> very well, I do not believe that the CT of the chest in acute  
> trauma  gives
> much information to change decision making, except in mediastinal   
> traverse.
>  In the case presented I would have proceeded a bit  differently.
>
> 1.   There is no need to do any of the attempts to elevate the BP   
> in the
> EC.   Either go to CT quickly on the way to the OR, or just to  the  
> OR.   I
> would have obtained a CT after the initial chest X-ray,  but NOT to  
> evaluate
> the great vessels
>
> 2.   I do not rely on CTA for evaluation of vessel injury   
> ANYWHERE.  I
> have been burned too many times in both  directions.   Injury not  
> shown by CTA.
>  CTA reports an  injury which was not present.   AND believe me this  
> is
> happening all  over the country, and world.
>
> 3.    My first incision would have been the left  anteriolateral for
> control of any bleeding and removal of the clot which was not   
> evacuated by the
> chest tube.
>
> 4.    As described, the surgeon discovered a T-2 esophageal  injury  
> via the
> left thoracotomy.  Pretty good, as that area of the  esophagus is  
> covered
> by the aorta and aortic arch.   So, in this  case the CT provided no
> information which would not have been provided at  the time of the  
> thoracotomy
>
> 5.    I would have closed the left chest after hemorrhage  control,  
> and
> performed a 4th interspace RIGHT posterolateral thoracotomy,   
> divided the
> azygous vein and repaired the esophagus, having obtained an   
> intercostal muscle
> flap on the way in to wrap the esophageal  repair.    It is almost  
> impossible
> to fix an esophageal  injury through an anterior incision,  
> especially a T-2
> injury via a  left anterolateral incision.
>
> 6.    I would then make a decision to make an abdominal  incision  
> via a
> midline laparotomy depending on what I had seen on the EC  abdominal  
> x-ray, and
> the two chest incisions.     It appears  that the CT might have also  
> have
> mislead the team.
>
> I am increasingly becoming disenchanted with CT for  most penetrating
> trauma.
>
> k
>
>
>
>
>
>
> In a message dated 9/13/2009 10:02:43 A.M. Central Daylight Time,
> nmcswai at tulane.edu writes:
>
> We did a  large study almost 20 years ago that showed NO INCREASE in
> infection when  cell saver was used as compared to similar volume of
> banked  blood
>
> Norman
>
> Norman McSwain MD
> Professor - Tulane Univ.  SOM
> Trauma Director - Charity Hospital
> 504 988 5111
>
> -----Original  Message-----
> From:  trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On  Behalf Of Dr Timothy
> Hardcastle
> Sent: Sunday, September 13, 2009 3:16  AM
> To: ?" Trauma-List [TRAUMA.ORG] "
> Subject: Re: TRANSMEDIASTINAL  GSW
>
> Why?
> There is good evidence that the amount of contamination is  small  
> and is
> washed clean by the cellsaver, therefore safe to use this  blood -  
> study
> from Johannesburg by Bowley and Boffard clearly showed  that!
>
> Dell wrote:
>> We did have cellsaver ready and available,  but did not use because  
>> of
> the
>> esophageal injury
>
> Tim
> Dr T  C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS  (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Lecturer University  of KwaZulu-Natal Dept Surgery
> Deputy Director - IALCH Trauma  Service
> Durban - South Africa
>
> Dr T C Hardcastle
> M.B., Ch.B.  (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma  Surgeon /
> Honorary Lecturer University of KwaZulu-Natal Dept  Surgery
> Deputy Director - IALCH Trauma Service
> Durban - South  Africa
>
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