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A case for Physical Exam after blunt trauma

Gross, Ronald Ronald.Gross at baystatehealth.org
Thu Dec 27 12:25:37 GMT 2012


Agreed - but I don't think that would explain the hypotension.....

Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
Sent: Wednesday, December 26, 2012 6:01 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: A case for Physical Exam after blunt trauma 

Well, certainly the pulmonary vascular bed has been suddenly re-expanded if the intrusion of the abdominal contents caused the left chest to not move. 

Rob






Robert Smith, MD, MPH
Secretary War Dogs Making It Home
Chair, Div Pre-hospital Care and Prevention (ret)
Department of Trauma John H.Stroger Jr. Hospital of Cook County
http://wardogsmakingithome.org/
Tiny service dog heals Hampshire Marine - DailyHerald.com 

http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-dogs-making-it-home/




On Dec 26, 2012, at 5:30 PM, "Duchesne, Juan C" <jduchesn at tulane.edu> wrote:

> Really appreciate everyones input!
> After it was evident we had an esophageal intubation with bradycardia and
> hypoxemia (never less than 90%) in combination with seat belt sign and no
> movement of the left chest, my first concerned was diaphragmatic rupture.
> For this we  did the following:
> Quickly decompress the over distended bowel suspected to be incarcerated
> in the left chest with an OG tube, ET intubation to 22 with great color
> change, Heart rate increased to 90's and o2 sats now 100%. No chest tube
> placed, CXR demonstrated small bowel, stomach into the L chest. Patient
> taken to OR for exploration, injuries:
> 
> 1. diaphragmatic rupture at GE hiatus with small bowel, colon, stomach
> herniation==>hernia reduced and immediately systolic drooped to 60 from
> 120.
> 2. Zone III pelvic hemorrhage controlled with extraperitoneal
> packing.Foley palpated inside bladder. No intra-peritoneal disruption.
> 
> No other injuries, Hct 38
> 
> Why hypotension?
> 
> J
> 
> Juan C Duchesne MD FACS FCCP FCCM
> Associate Professor of Surgery
> Tulane SICU Medical Director
> Louisiana State Chair for Committee of Trauma
> 
> 1430 Tulane Ave., SL-22
> New Orleans, LA 70112
> T. 504.988.5111
> F. 504.988.3683
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> On 12/26/12 2:31 PM, "Ian Seppelt" <seppelt at med.usyd.edu.au> wrote:
> 
>> The ETT is oesophageal and always was, in a preoxygenated patient.
>> Classic (and unfortunately common) error of kidding yourself that it is
>> in the trachea because you want it to be.
>> 
>> If ED want to put in a left chest tube the patient will probably die
>> before it is done. If not, they will put the tube into the distended
>> stomach caused by their oesophageal ventilation, and make the situation a
>> whole lot worse. 
>> 
>> Come right back to basics, pull tubes out, get an airway (LMA may well be
>> life saving here), decompress the stomach with an orogastric tube, and
>> start again from the top......
>> 
>> Ian
>> 
>> Sent from my iPhone
>> 
>> On 27/12/2012, at 1:26, "Duchesne, Juan C" <jduchesn at tulane.edu> wrote:
>> 
>>> Because of his low GCS patient was intubated with some
>>> difficulty......there was no good CO2 color change but his o2sats
>>> remained
>>> 100%.... not for long.....suddenly his o2 sats started dropping and
>>> after
>>> couple of good ambu-bag ventilation his heart rate drop down to 30,
>>> right
>>> chest expanding, left chest not moving. ET tube mark at 22 from mouth.
>>> 
>>> What went wrong? ED wants to put a chest tube on left
>>> 
>>> /
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