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VOMIT and ER workup of a MAJOR trauma patient

jjsurgmd at aol.com jjsurgmd at aol.com
Thu Aug 25 20:46:24 BST 2011



Sent from my iPhone

On Aug 25, 2011, at 9:27 AM, KMATTOX at aol.com wrote:

> 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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