trauma-list Digest, Vol 42, Issue 6

Fri Dec 8 05:10:26 GMT 2006

Adnan

The treatment of bleeding is to stop the bleeding - if you are unable to keep the Hgb up despite a double set of transfusions then the next step is either embolise via angio or surgically remove/repair the spleen. Without the CT scan and in a patient with a large habitus Ultrasound is inaccurate. You cannot say there is no ooze from a mesenteric tear, or even that there is no liver injury bleeding slowly (they don't necessarily leak bile!). You need either better imaging/embolization or the open abdominal review (i.e. laparotomy).

Regards
Tim
Dr T C Hardcastle 
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA) 
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU) 
ATLS  instructor and DSTC Cape Town Course Director 
Intern program Coordinator: Surgery 
M.Med (Emergency Medicine) Executive Committee member 
Clinical Head (Director): Diana Princess of Wales Trauma Unit 
Division of Surgery (General) Room 4064 
Department of Surgical Sciences 
Tygerberg Hospital / University of Stellenbosch 
PO Box 19063 
Tygerberg 7505 
Western Cape 
South Africa 
e-mail: tch at sun.ac.za 
Cell: +27824681615 
Office: +27219389281 or 4911 pager 0302 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of Adnan Alseidi
Sent: Friday, December 08, 2006 3:22 AM
To: trauma-list at trauma.org
Subject: RE: trauma-list Digest, Vol 42, Issue 6

I apologize if I am submitting this to the wrong email, Long time reader, first time submitter. 

My case: 

22y/o w/m who fell from a roof of a shed while perparing x-mas decorations (~8ft). No Loc, no amensia, witnessed, and fell on his left chest/flank.  He did not present to the ED except 3 days later with complains of abdominal pain, nausea and vomiting.  At that point pt was found to have Left post rib fx, h&h of 8/25, and a positive FAST.

Unfortinoutly the pt could not be scanned due to his wieght (340lbs).  He was however very stable and clinically had a picture of a contained (delayed presentation) splenic ruptur (Left rib fxs, kerr sign, tender LUQ, positive FAST)(VS HR 110, BP 160/80).  NO evidence of any sepsis, infection, or acidosis and no gross pertoneal signs (just diffuse tenderness to deep palp).

At this point (although very unliky since 3days out and very stable) I elected to do a DPL to r/o a hollow viscuss injury (esp due to the pts body habbitus and limited exam).  DPL was grossly positive for blood (but we knew that), a liter was infused and sent to lab and showed RBC 1.66million, 3000wbc, no bile, no veg matter, neg gram stain.  At this point I was comforatable to say that he does not have a hollow viscus injury and thus just admitted him and observed him. 

Today (Post trauma day 5) he looks great, tol po (yesterday, with postive flatus), no fevers, no acidosis, great u/o (~100cc/hr) but he continues to have his hgb drifting down. 

He hgb went from 8(admission) to 5.6 (after resus). He reciceved two units and went up to 7.6 only to drift down to 6.4 (over 24hrs).  With 6.4 he was orthostatic, thus I gave him 2 more units adn he went up to 8.2.  12hrs later he is 7 (this am).  

I hate to operate on him only based on one number (since everything else tells me he has stopped bleeding).  But what makes this case different is that I do not have a CT scan to confirm that it is infact the spleen? but does it matter what is causing the intrabdominal slow bleed in someone who is very stable with no signs of any hollow viscuss injury (for got to say, his LFTS, amylase, lipase, U/A, Pelvic xray all nl). ?  Getting a scan (CT) or angio whould meed transporting him via ambulance about 30 min ride, he is stable enough for this, but not sure that transposrting him to a foregin hospital (he would have to go to a japanese hospital, whom we traditonally trust) is the correct idea at this time?   or should I just take him to the OR?  

Any ideas are wellcomed.  Thank you 

Adnan Alseidi, MD  

We are what we repeatedly do. Excellence, then, is not an act, but a habit. 
Aristotle 

  _____  

From: trauma-list-request at trauma.org
Reply-To: trauma-list at trauma.org
To: trauma-list at trauma.org
Subject: trauma-list Digest, Vol 42, Issue 6
Date: Thu, 7 Dec 2006 12:00:32 +0000 (GMT)
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>Today's Topics:
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> 1. HOSPS PREPARE FOR CHEM, NUKE ATTACKS (bcarney1123 at aol.com)
>
>
>----------------------------------------------------------------------
>
>Message: 1
>Date: Wed, 06 Dec 2006 09:53:02 -0500
>From: bcarney1123 at aol.com
>Subject: HOSPS PREPARE FOR CHEM, NUKE ATTACKS
>To: trauma-list at trauma.org
>Message-ID: <8C8E75D5D194D4E-B1C-2E90 at MBLK-M19.sysops.aol.com>
>Content-Type: text/plain; charset="us-ascii"
>
> From the NY Post
>HOSPS PREPARE FOR CHEM, NUKE ATTACKS
>By CARL CAMPANILE
>
>December 4, 2006 --
>
>The city plans to designate 30 Big Apple hospitals as special emergency burn units to treat victims in a chemical or nuclear attack, The Post has learned.
>
>Each hospital will get burn-care equipment and supplies, and staff training.
>
>"Being prepared is the best defense against an emergency," said Carol Berg, medical director of the city Health Department's Bioterrorism Hospital Preparedness program. "We want to make sure we have enough capacity for patients."
>
>The city has 71 beds to treat serious burn victims at four burn centers: New York Presbyterian and Harlem hospitals in Manhattan; Jacobi in The Bronx and Staten Island University.
>While that's enough in normal times, the centers would be overwhelmed in the event of a catastrophe.
>Post-9/11, the city has to be ready for a "very large emergency" or even a "mass casualty emergency" involving 400 or more burn patients, Berg said.
>
>"An effective citywide response to this type of event requires coordinated mobilization of hospital, city, state and federal resources," the written proposal to hospitals said.
>
>Hospitals interested in being designated will apply to the city and contracts will be awarded by the city Fund for Public Health.
>
>Under the plan, a triage team under the New York Cornell Burn Center would monitor reports from all the designated emergency burn-unit hospitals to determine the number of victims treated and how many beds are available.
>
>City health and hospital officials would also work with medical facilities throughout the metropolitan region to help admit more patients during a burn catastrophe.
>
>Hospital executives said they're already working closely with city health and emergency officials on disaster planning - including training and use of radiation detectors, setting up decontamination units, holding evacuation drills for pandemic flu and sharing information about bioterror agents such as anthrax.
>
>"We have invested mightily in emergency preparedness. We don't know what's going to be thrown our way," said Kenneth Raske, head of the Greater New York Hospital Association.
>
>"But we're as well prepared as any city in the country."
>
>The city has spent about $1 billion on anti-terror initiatives since 9/11 - much of it coming from the federal government.
>
>In health care, tens of millions of dollars have already been spent to buy radiation detectors and other equipment for all the city's hospitals, and to cover planning and training costs.
>
>"We've come a long way in a short period of time," Berg said of the city's medical-disaster planning since the Sept. 11, 2001, attacks.
>
>Meanwhile, the city also plans on providing clinical training to more than 200 doctors and nurses on treating patients affected by "chemical, biological, radiological nuclear or explosive agents."
>
>carl.campanile at nypost.com
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