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Fri Aug 13 07:16:08 BST 2010

Sounds like the issues were of an orthopaedic and critical care nature, therefore I don't see why the decision would have had to come from the general surgical colleagues.

On 13 Aug 2010, at 05:21, Gad Shaked wrote:

> Crit care team wanted legs stabilised as quickly as possible ? external 
> fixators/traction splints then ICU but ortho team insisted that femurs must be 
> fixed.
> As he was warm and not acidotic the Anaes team went with ortho view and BOTH 
> femurs were nailed
> 
> In my opinion a major point in this case is the fact that the decisions were taken by other professionals rather than by the general surgeon trauma team leader. 
> Gadi
> 
> ----- Original Message -----
> From: MARK FORREST 
> Date: Thursday, August 12, 2010 14:16
> Subject: DCO or not?
> To: Trauma & Critical Care mailing list 
> 
>> Dear All
>> A case to consider and answer our debate at a recent trauma audit:
>> 
>> 39 yr old male, motorcycle RTC, knocked off bike and then hit by 
>> a second 
>> vehicle:
>> 
>> GCS 3 on scene but improves to 11/15 in ambulance
>> Airway secure
>> Obvious chest injuries with apparent left sided flail but 
>> oxygenating well on 
>> FiO2 1.0 with sats of 97%
>> CVS - periph pulses present, BP 130/70, HR 130bpm
>> X-rays: chest multiple rib fractures on both sides from rib 3 
>> downwards, 
>> pneumotx on L and drain inserted.
>> Pelvis: NAD
>> FAST-NAD
>> CT: head -NAD, Neck - NAD, Chest - rib fractures and small left 
>> pneumotx with 
>> drain in situ, Abdo - possible small retroperitoneal haem, small 
>> liver 
>> lacerations, Pelvis - NAD
>> Femurs- bilat comminuted shaft fractures.
>> One femur was compound and had a small skin wound
>> 
>> He dropped his pressure moderately (sys 80mmHg) twice during 
>> resus and scan and 
>> was given fluid boluses with good response (crystalloid then 
>> blood/FFP) but his 
>> lowest.
>> 
>> Crit care team wanted legs stabilised as quickly as possible ? 
>> external 
>> fixators/traction splints then ICU but ortho team insisted that 
>> femurs must be 
>> fixed.
>> 
>> As he was warm and not acidotic the Anaes team went with ortho 
>> view and BOTH 
>> femurs were nailed which took nearly 6 hours!! Inevitably he 
>> deteriorated and 
>> required significant volumes of fluid/ blood/FFP etc and 
>> subsequently a moderate 
>> dose of inotrope before ICU.
>> 
>> The question: I think that we all agree that the surgery took 
>> far too long 
>> BUT......in the resus room what do you all think......DCO or 
>> definitive fix?
>> 
>> Was immediate nailing the best call in this guy and was he 
>> stable enough to not 
>> warrant damage control?
>> 
>> Who would nail one leg and then re-consider the situation?
>> 
>> Many trauma cases obviously suggest DCS but certainly in our 
>> hospitals, there is 
>> often considerable debate on who benefits and who doesn't.
>> 
>> Regards
>> Mark F
>> UK
>> --
>> trauma-list : TRAUMA.ORG
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>> 
> 
> Gadi Shaked, MD
> Department of Surgery
> Trauma Unit
> Soroka University Medical Center
> Beer Sheva
> Israel‎
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/

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DCO or not?