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Wed Aug 24 21:49:39 BST 2011

Amazing coincidence.

We had a case like that some time back. Well that's no surprise - they are not rare - but what IS a coincidence is that it was used as an example in a lecture on imaging decisions...

It wasn't EXACTLY the same:
- We had no CXR indication, according to our methods, so it was not done (but the mediastinum would have been "wide")
- FAST was not indicated either, but one of our trainees did it for practise and it was positive for fluid (true positive)
- GCS was AROUND 9 - I cannot recall exactly - but he was NOT cooperative for a decent examination...
- Few limb injuries as well...

The patient was obese, in his 40s (if I recall correctly) and had driven his small van through an intrsection at precisely the same time as a MUCH BIGGER truck did the same... Frontal collision for him...

We did panCT, which is what we do...
1. Aortic dissection with a wee leak did show up very nicely, as did some strange enlarged lymph nodes...
2. He had a "new baby liver", right next to his older one ;-)
3. His pelvis was fractured quite significantly (no clue for that clinically other than mechanism - I recall the point being made that he was moving legs a lot)

But he went straight to theatre for number 4, which was the extradural + subdural haemorrhage beginning to cone...

Nice case.

I was not directly involved.

The Aorta waited its turn and I THINK the initial management for the bits of liver was conservative (but this might have changed later - can't recall).

I can't recall whether the pelvis got any metal-work...

> CC: trauma-list at trauma.org
> From: kmattox at aol.com
> Subject: Re: VOMIT - Victim of Modern Imaging Technology
> Date: Wed, 24 Aug 2011 16:58:31 -0300
> To: trauma-list at trauma.org
> 
> Thoracic aortogram. If there had been a screening positive chest CT for a mediastinal hematoma I would always also do a diagnostic thoracic aortogram. The physical exam would determine further tests on the abdomen vs straight to lap. Increasingly I am using FAST only to evaluate for hemopericardium, not for any confusing belly interpretations. Sorry to not be dogmatic enough, nut one states a point to make a point. 
> 
> k
> 
> Sent from my iPhone
> 
> On 2011-08-24, at 4:21 PM, Sanjay Gupta <sanjaygupta99_91 at yahoo.com> wrote:
> 
> > Dogmatism is a way of looking at facts - or rather a way of refusing to look at facts.
> > 
> > For instance: 
> > 
> > How do you manage a trauma patient who is hemodynamically stable, with a GCS of 9 and who has a widened mediastinum on a chest X-ray? Lets throw in a positive FAST exam with fluid in the abdomen. 
> > 
> > 
> > Remember - no IV fluids, no IV lines, no CT scans.
> 
> > This is a "real world" example - not an uncommon scenario.

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