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VOMIT - Victim of Modern Imaging Technology

Blueflightmedic trauma at emergencyunit.com
Thu Aug 25 20:46:36 BST 2011


I don't give crystalloids if volume resuscitation is required. If I look on
the floor, the patient appears to have lost blood. When I meet a patient who
bleeds crystalloid I'll administer some.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Kmattox
Sent: 25 August 2011 15:57
To: Trauma-List [TRAUMA.ORG]
Cc: Trauma-List [TRAUMA.ORG]
Subject: Re: VOMIT - Victim of Modern Imaging Technology

And what about the ER, OR, and ICU crystalloids?    

I am not certain that the patients death can be blamed on an indicated
Arteriogram.   The stick for an aortogram should be in the femoral not iliac
artery after all.   

k

Sent from my iPhone

On 2011-08-25, at 11:19 AM, Sanjay Gupta <sanjaygupta99_91 at yahoo.com> wrote:

> Well, so it was decided to a CT of this patient's head - an extradural
hematoma was found which was drained.  In the OR, the neurosurgeon wanted to
maintain his MAP above 60/65 mm Hg, but the trauma surgeon said that there
is a traumatic rupture of aorta and so they could not let the patient have a
systolic above 90.  I do not know what happened between them finally, but
they were not friends any longer after the OR conversation.  Anyhow, the
patient was taken to the radiology / IR suite after that and an angiogram
was performed - all great vessels were normal.  The patient was transferred
to the ICU - 
> 
> and just let me complete the whole thing.  I feel like an examiner in the
American Board of Surgery, screwing a smart alec of a candidate. 
> 
> Still no CT - no need as VOMIT may happen.
> 
> In the ICU, the patient had a drop in his blood pressure after about 2
hours along with a severe tachycardia.   He was taken to the OR because of
the free fluid in his abdomen on the fast exam - a small amount of
hemoperitoneum was found and there was a non-bleeding liver laceration.  But
there was a large hematoma around the iliac artery and on exploring this it
was found that the angiogram access site was bleeding copiously into the
retroperitoneum.  The artery was repaired.  The patient lost an estimated
2.5 litres of blood (to do a test which was completely useless in the end).
He became severely hypotensive in the OR.  However, survived and was taken
back to the ICU.  However, after the hypotensive episode, the patient never
really regained consciousness and stayed at a GCS of 4 for the next 2 weeks.
Family decided to withdraw care and the trauma surgeon was nice enough to
send them flowers. 
> 
> 
> So, following this great protocol being touted on the trauma list (that
is, no CT scans, no IV lines, no IV fluids) a young patient with an
extradural hematoma - with no other significant injuries essentially became
brain dead.  
> 
> 
> A CT scan is a non-invasive test - at most this guy's kidneys would have
been knocked out.  We would have ruled out any significant aortic injury,
would have figured out that abdomen is not a concern in this patient, and
would have avoided a major arterial bleed. Also, would have been able to
maintain an adequate perfusion pressure to this patient's brain at all times
and would probably have diagnosed the epidural hematoma before his
conciousness level deteriorated.  
> 
> Comments - are appreciated. 
> 
> I know this list is not peer- reviewed, but let us try to at least make it
reasonable.  
> 
>  
> Sanjay Gupta
> 
> From: Kmattox <kmattox at aol.com>
> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Cc: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Sent: Wednesday, August 24, 2011 11:02 PM
> Subject: Re: VOMIT - Victim of Modern Imaging Technology
> 
> Finish the CT of the head.  Cut his head appropriately.  Reassess abdomen.

> 
> k
> 
> Sent from my iPhone
> 
> On 2011-08-24, at 10:07 PM, Sanjay Gupta <sanjaygupta99_91 at yahoo.com>
wrote:
> 
>> Well, this patient had come into a level 1 trauma center.  When he was
being transferred to the radiology suite, within 3 minutes of reaching the
trauma center (especially as no line had been deemed necessary), his
consciousness level deteriorated to a GCS of 5 and his right pupil was
noticed to be larger.  What to do next?
>>   
>> Sanjay Gupta
>> 
>> 
>> ________________________________
>> From: Kmattox <kmattox at aol.com>
>> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
>> Cc: "trauma-list at trauma.org" <trauma-list at trauma.org>
>> Sent: Wednesday, August 24, 2011 5:24 PM
>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>> 
>> I would put pt on afterlife reduction, cut his abdomen, starting venous
access in the OR for 1:1:1 blood, plasma, platelets.    If no aortogram
capability by radiology, I would make the best thoracic injury I could with
the screening tests available to me.    
>> 
>> k
>> 
>> Sent from my iPhone
>> 
>> On 2011-08-24, at 6:01 PM, Krin135 at aol.com wrote:
>> 
>>> Dr. Mattox:
>>> 
>>> What if you were working at a smaller (level III) center without rapid  
>>> angio capability, and was not able to transfer the patient in a
reasonable  
>>> period of time?
>>> 
>>> Would you still want more radiographs, or would you proceed to the test
of  
>>> Bard-Parker?
>>> 
>>> ck
>>> 
>>> 
>>> In a message dated 08/24/11 14:58:36 Central Daylight Time,
kmattox at aol.com 
>>> writes:
>>> 
>>> 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.
>>>> 
>>>> 
>>>> Sanjay  Gupta
>>>> 
>>>> 
>>>> From: Charles Brault  <c_brault at yahoo.com>
>>>> To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org>
>>>> Sent: Wednesday, August 24, 2011 3:21  AM
>>>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>>>> 
>>>> Dogmatisimes !
>>>> 
>>>> Is surprisingly ALWAYS coming  from other people 
>>>> 
>>>> Never quietly understood  that
>>>> 
>>>> Charles
>>>> 
>>>> From: Sanjay Gupta  <sanjaygupta99_91 at yahoo.com>
>>>> To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org>
>>>> Sent: Tuesday, August 23, 2011 8:12  PM
>>>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>>>> 
>>>> What I can figure out after all these discussions is - 
>>>> 
>>>> Trauma patient arrives, do not put in a line and certainly do not  give

>>> crystalloids.  I am not sure about giving blood and if we do give  blood
- do 
>>> we draw a specimen to cross-match or not.  Maybe a chest x-ray  will
help.  
>>> If something is clinically obvious fix it.  If the  patient is
hypotensive 
>>> - do some surgery based on clinical exam and chest  x-ray.  And if the 
>>> patient is hypotensive - again do not put in a line -  open the abdomen
first, do 
>>> something and then see if a line will help.  
>>>> 
>>>> 
>>>> If not in shock - I am not clear what  to do - Whether send the patient

>>> home or admit and observe his pulse, blood  pressure and GCS?  or there
is 
>>> something else that needs to be  done.  
>>>> 
>>>> 
>>>> Never do a CT scan because  80% are useless - I thought the purpose of
CT 
>>> scan is to figure out the 20% in  which it would be useful.  If we all
knew 
>>> the 80% in whom the CT will not  be useful and also the 20% in which it 
>>> would be useful, I guess the scan will  not be done in anyone - I
thought a CT 
>>> scan is a diagnostic test - not to  prove your clinical diagnosis. 
>>>> 
>>>> Oh yes - you pick up  VOMIT with CT scan.  Great acronym, makes you
sound 
>>> very smart. 
>>>> 
>>>> Sanjay Gupta
>>>> 
>>>> From: caesar ursic  <cmursic at gmail.com>
>>>> To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org>
>>>> Sent: Tuesday, August 23, 2011 1:58  PM
>>>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>>>> 
>>>> *The, Dr. Mattox, you must be placing great faith in the sensitivity
of 
>>> the
>>>> supine AP portable chest x-ray to rule-out a thoracic aortic or  great 
>>> vessel
>>>> traumatic pseudoaneurysm.*
>>>> 
>>>> 
>>>> C.  Ursic, MD
>>>> Honolulu
>>>> 
>>>> 
>>>> 
>>>> On Mon, Aug 22,  2011 at 9:30 AM, <KMATTOX at aol.com> wrote:
>>>> 
>>>>> I know of  almost NO indications for an ACUTE CT OF THE CHEST
following
>>>>> chest  trauma, especially blunt chest trauma.        Mediastinal  
>>> traverse
>>>>> following GSW,  maybe, depending on the finding of  the  initial plain

>>> chest
>>>>> X-ray.
>>>>> 
>>>>> 
>>>>> k
>>>>> 
>>>>> 
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