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Mon Sep 14 13:01:58 BST 2009

WOULD have gone to the OR, bypassing the institution of the MTP in the ED to the "tunnel of death".  That's a lot of heme in the chest, and clearly thoracotomy is necessary

Ronald I. Gross, MD, FACS
Chief of Trauma & Emergency Surgery Services
Baystate Medical Center
Assistant Professor of Surgery
Tufts University School of Medicine
759 Chestnut Street
Springfield, MA  01199
413-794-4022  phone
413-794-0142  fax
ronald.gross at baystatehealth.org

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of moore677 at aol.com
Sent: Saturday, September 12, 2009 2:43 PM
To: trauma-list at trauma.org
Subject: TRANSMEDIASTINAL GSW

Two patients arrived with GSW's, first with GSW L shoulder to L chest (didn't require chest tube though) and second with GSW L shoulder, through L chest, mediastinum, lodging in R chest.? Hypotensive, placed 2 left chest tubes (first failed to evacuate HTX) and one left chest tube, MTP protocol initiated.? Prepping chest for ED thoracotomy as pressure initially in 40's, but responded to blood products.? Managed to resusc to get CT scan which showed persistent large L HTX despite 2 chest tubes, ? esophag injury, ? L SCL artery injury.? CT's initially out about 1000, with second tube 200, and by finishing?CAT scan?about 1800-2000.? ? intra-abd injury on CT.

Would any of you went straight to OR without CT knowing this could provide invaluable information regarding trajectory (great vessel injury, etc.)?

?

In OR, started with L anterolateral thoracotomy to explore L chest for massive HTX.? Multiple injuries to LUL and LLL but didn't require anything, obvious injury to esophagus at T2/T3 level.? Bronch clean, EGD shows possibly 2 full thickness injuries.? 

Would any of you extend the?L thoracotomy to a clamshell or do a?R posterolateral thoracotomy?? 

We examined L diaphragm and didn't identify any breaches/injury and EGD didn't reveal any gastric injury so did not pursue exlap (CT with ? fragments below diaphragm, possibly anterior to stomach).? Patient very stable with resuscitation (used 1:1:1), no FVIIA.

Dell..............

Forrest "Dell" Moore, MD, FACS

Director, Trauma/Surgical Critical Care

St. Joseph's Hospital and Medical Center

Phoenix, AZ

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TRANSMEDIASTINAL GSW