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Sun Sep 13 18:41:25 BST 2009

Patient's pressure was 100-110 by time of CT.? As I have said numerous times, he would have went straight to the OR if I was unable to resuscitate him.? I considered him a responder and felt I had 10-15 minutes to evaluate his chest and abdomen by CT.........abd CT was an over-read by me and with no evidence of diaphragm injury on either side I was confident I did not miss an injury......

This has been great practice for M & M!!.........Dell

-----Original Message-----
From: Robert Smith <rfsmithmd at comcast.net>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sun, Sep 13, 2009 9:17 am
Subject: Re: GSW Mediastinal Travverse

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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