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Splenic injury case

William Bromberg brombwi1 at memorialhealth.com
Sun Dec 28 02:51:09 GMT 2014


OK. But this is actually different than the old dictum which was fluid + NO solid organ injury should go to OR. Which was why I was confused. 

William J. Bromberg, MD, FACS
Sent from my iPhone

> On Dec 27, 2014, at 17:44, Duchesne, Juan C <jduchesn at tulane.edu> wrote:
> 
> William- read carefully what I stated. Multiple variables : spleen, fluid in abdomen, questionable bowel or mesenteric injury due to presence of seat belt. That's my point. To answer your question : NOT in isolated seat belts signs
> J
> 
> Juan Duchesne
> Trauma Medical Director
> GME Medical Director
> North Oaks Health System
> Hammond LA
> Associate Professor of Surgery
> Tulane New Orleans LA
> LSUHSC New Orleans LA
> 
> 
> 
> On Dec 27, 2014, at 15:45, William Bromberg <brombwi1 at memorialhealth.com<mailto:brombwi1 at memorialhealth.com>> wrote:
> 
> So you recommend DPL, laparoscopic exploration or laparotomy in every patient with a seat belt sign?
> 
> William J. Bromberg, MD, FACS
> Sent from my iPhone
> 
> On Dec 27, 2014, at 16:34, Duchesne, Juan C <jduchesn at tulane.edu<mailto:jduchesn at tulane.edu>> wrote:
> 
> Seat belt syndrome is a real issue here, this combine with a splenic
> injury and shock in blunt trauma needs further attention. If you are a
> minimalist the least I will recommend is a DPL. If you are an aggressive
> minimalist then I will recommend a diagnostic laparoscopic exam.......and
> if you just want to do what is the right answer on the ABS boards you
> extend that DPL incision a little bit more upward until you reach the
> xiphoid and a little bit more downward to reach the pubis ;)
> 
> Key points: Define observation?
> 1.FAST as documented by Nicole in Archives 2002 doest have any role in
> seatbelt syndrome. Title: Abdominal Seatbelt Marks in the ERA of FAST.
> 2. F/U CT scans are inconclusive at best
> 3. Serial PE- this needs to be done by the same examiner and although it
> sounds great.....good luck in finding that person. When to finish this
> serial PE? Once SIRS is identified? Small Bowel devascularization with
> gangrene and perforation might not occur until late (day 5 to day 8)
> 4. Serial labs: WBC might increase due to 1. bowel injury 2.spleen infarct
> 3.sepsis 4. Other missed injuries
> 
> 
> I personally don't like to observe polytrauma patients with too many
> variables in the air
> 
> My 2 cents
> 
> J
> 
> 
> 
> On 12/27/14 2:44 PM, "Karim Brohi" <karimbrohi at gmail.com<mailto:karimbrohi at gmail.com>> wrote:
> 
> Miklosh hi
> 
> Assuming this patient has no on-going fluid requirements then she would be
> suitable for observation.  There's no active bleed on CT so embolisation
> would be proximal splenic artery to reduce overall flow.   I think the
> jury
> is still out on whether proximal coil embolisation reduces the subsequent
> splenectomy rate for these injuries although I think the evidence is
> tending to support it.
> 
> Given this patient has previous surgery and has lost her short gastrics I
> would avoid embolisation and just manage her conservatively( - and do a
> splenectomy if she fails observation).
> 
> Karim
> 
> On Sat, Dec 27, 2014 at 8:31 AM, Miklosh Bala <mikloshbala at gmail.com<mailto:mikloshbala at gmail.com>>
> wrote:
> 
> 22 yo female following car crush, on arrival HR 120, BP 90/60,
> seatbelt sign and posterior hip dislocation. Following resuscitation
> (crystalloids) and hip reduction, CT showed splenic rupture (Grade 4)
> -no active contrast extravasation.
> BP 100' HP 100. No other injury.
> The patient 2 years following Sleeve Gastrectomy.
> Do you thing angio is safe for this specific case? Short gastric
> arteries are divided - is that come to consideration?
> 
> --
> Miklosh Bala, MD
> Head of Trauma and Acute Care Surgery Unit
> Hadassah - Hebrew University Medical Center
> Tel: (972) 26778800; Fax: (972) 26449412
> Email: mikloshbala at gmail.com<mailto:mikloshbala at gmail.com>
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