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VOMIT and ER workup of a MAJOR trauma patient

KMATTOX at aol.com KMATTOX at aol.com
Thu Aug 25 14:27:22 BST 2011


Dr. Ursic:      
 
As described, the patient is clearly a surgical patient that has a head  
injury, a possible hemomediastium, and a possible "something" in the abdomen ( 
 positive FAST for fluid), but apparently BP and pulse stable. 
 
 
As presented, this patient has an apparent abnormal screen on his chest  
X-ray, so the next test is a diagnostic, not another SCREENING test to 
evaluate  the mediastinum.    That test is an aortogram, as one needs to  evaluate 
the innominate artery, the ascending aorta, the aortic arch and the  distal 
thoracic aorta.    A C.T does NOT evaluate these locations  as virtually the 
entire radiographic, trauma, and vascular literature for the  past decade 
have focused only on the proximal descending thoracic  aorta.   SO your 
recommendation for a CT of the chest is unfounded,  although often done because 
radiologists do not often like to get up at night to  do aortograms.      
 
Second, you said NOTHING about use of afterload reduction  agents.   The 
very second that you suspect a thoracic vascular injury,  one should start 
afterload reduction to decrease the shear factor on the aortic  wall.    
 
Third:   There is NO indication to start two large bore  IVs.   NONE in the 
case as presented.   To start one small  bore IV I have no argument, but if 
one starts a large bore IV, then lots of  crystalloid ALWAYS goes in.   One 
could give a LONG LIST of reasons  why ANY CRYSTALLOID of the clinicians 
choice has an unfavorable impact on the  patient, creation of clotting 
problems, turning on inflammatory mediators (bad  humors), etc. etc. etc.      The 
examiners on the ABS  mostly now know these lists and would be looking for 
crystalloid prevention in  the patient as presented.     
 
Fourth:   As presented, this patient would require a CT of the  head and 
neck soon after arrival in the ER, say within the first 10  minutes.     As 
presented the priority in this patient is to  do something to his head injury, 
directed by the head CT.   
 
Fifth:    There is NO reason as presented for a FAST of the  heart and 
pericardium, and I have heard many more lectures and papers than I  wish to 
count anymore on the misleading information from a FAST of the  abdomen.    Many 
trauma centers have abandoned the abdominal  FAST.    I see PROBLEMS every 
week from over reading and mis  reading of ultrasounds in the ER by 
emergency physicians, in patients that had  no reasons for an ultrasound in the 
first place.   I would hate to  teach students and residents a dependency and 
use of a test which has almost no  impact on treatment and decision making, 
and then most often a NEGATIVE  impact.   
 
Sixth:   I still do not have a good impression of the PHYSICAL  EXAMINATION 
of the abdomen or pelvis at any time in this patient.    Are there any 
physical findings suggestive of an injury in either of these  locations.    If 
there is and you have intubated the patient, I  could make a case for a CT of 
the abdomen prior to the crainiotomy or admission  to the Neurosurgery  
ICU.    
 
My greatest concerns with your suggested treatment of the patient was the  
reliance on abdominal FAST, the starting of two large bore IVs, and the 
Chest  CT.      It is long overdue time for us to put these  tests and 
treatments into their proper perspective.   I would suspect  that both you and the 
examiners on the American Board of Surgery would have some  element of 
agreement.      
 
The time this patient should remain in the ER should be very very short and 
 it is essential that you do not over treat him.   Many members of the  ABS 
are concerned that we are training a group of young surgeons who are  
infatuated with technology, and have forgotten judgment, physical examination  
and perspective.     
 
k


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