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Mon Sep 14 02:42:45 BST 2009

Allow me to move further thru the case i tried to describe yesterday. CT might well have avoided a nontherapeutic laparotomy and sigmoidoscopy and led to an earlier diagnosis of his injuries.

23 year old male sustained
multiple gunshot wounds two months after release after nine years in
prison. Yes, been incarcerated since age 14. 

There were through and through wounds of the right arm, the right
forearm and the right wrist.pulses are intact.? The arm bullet looks
like it entered the right chest in the posterior axillary line. Chest
tube drained 200 ml of hemothorax. There was also an entry in the right
upper quadrant of the abdomen and one in the left flank at the
posterior axillary line. Briefly hypotensive on admission but , he responded? rapidly
to a small amount of fluid and remained normotensive.

Taken for exploratory laparotomy which was nontherapeutic. no inuries identified.

A bullet subsequently found in the soft tissues of the abdomen,
indicating a tangential abdominal wall injury. There was nonexpanding
hematoma of the right thigh. 

postop chest and abdomen/ppelvis? showed a bullet thought to be in the pleura and a? left buttock bullet fractured the right femur

A CT was finally done after laparotomy. It showed a bullet that was possibly in the right atrium. No hemothorax. Abdominal CT showed nothing. The tract of the buttock bullet was outside the true pelvis and fractured the femur.

Based upon the CT and the trajectories, arteriograms of the right arm and the right thigh were performed and they showed brachial artery, radial and ulnar artery injuries, non occlusive or bleeding. We are now observing them.

An inferior vena cavogram and right atriogram showed the bullet in the right atrium. Multiple negative echocardiograms had been normal. The bullet was removed from the right atrium with a 27 mm balloon catheter used like an embolectomy catheter. The bullet was then dragged down into the pelvis where it promptly fell into the right internal iliac vein . By deploying a stent in the common/external iliac vein, the bullet was "caged" in the internal iliac vein where it will remain.

Cardiothoracic surgeon elected to observe the cardiac injury. Nonoperative management of cardiac, brachial, radial and ulnar arteries? combined with unnecessary laparotomy!??? What will come next? Patient is now almost 2 weeks post injury and in fairly good shape. Only surgery so far was an non-therapeutic laparotomy

Other than sharing an unusual case, i want to illustrate that CT was invaluable in managing this patient. It detected a intracardiac bullet that was not thought likely be multiple chest xrays and a couple of echos.

For better or worse, CT will become the physical examination of the future. The use of the stethescope is an atrophying art. This did not happen by accident. Too many patients had unnecessary operations, wrong body cavity priorites and missed injuries based upon physical examination.

I believe our goal needs to be to figure out how to use CT better.  The newer scanners will reduce radiation explosure making that debate less pertinent. 

Dr. Moore has an interesting paradigm for his scanner, although it does seem cost ineffective if those scanners are only used for trauma patients. 
We have moved our scanner so close to the trauma bay that it is often used more than I would have allowed just a few years ago.

sal

-----Original Message-----

From: KMATTOX at aol.com

To: trauma-list at trauma.org

Sent: Sun, Sep 13, 2009 8:33 pm

Subject: Re: GSW Mediastinal Travverse

Sal:   You and I find some cases of CT helpful.   We  use CT in conjunction 

with all of the findings, including history, physical  examination, regular 

x-rays, and arteriograms when indicated.  I dont think  you and really 

recognize just how prevalent ordering CT and CTA in stead of  doing an 

examination really is.    AND then a very junior person  reads the CT and most 

persons do not ever go look at themselves, but merely  react to the reading.    

k

In a message dated 9/13/2009 4:41:56 P.M. Central Daylight Time,  

sjasmd at aol.com writes:

CT  have been helpful in missing the VOMITs that occured in the case I 

added to  this discussion

Would like some  comments

sal

-----Original  Message-----

From: KMATTOX at aol.com

To: trauma-list at trauma.org

Sent:  Sun, Sep 13, 2009 2:02 pm

Subject: Re: GSW Mediastinal  Travverse

I am increasingly  convinced that CT for trauma has more VOMITS than  

benefits.   

k

In a message dated 9/13/2009 12:42:21 P.M.  Central Daylight Time,  

moore677 at aol.com writes:

abd CT   was an over-read by me 

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