trauma-list Digest, Vol 42, Issue 6

[Ronald Gross]

Adnan,

If the fellow continues to require transfusion over the course of (as I
count it) almost 5 days, then you cannot chalk this up to
"equilibration', but rather you need to think about continued blood loss
from the spleen........or is it something else?  If it is the spleen
then you need to squirt and embolize.  In the absense of this, then you
need to look at the spleen, and at everything else in there, find the
bleeder and stop the bleeding.  I guess I am saying that you need to (1)
send the guy to the place that can image him, or (2) operate on him.

Keep us posted on what happens.

Good luck,
Ron

>>> "Adnan Alseidi" <aaatrek at hotmail.com> 12/7/2006 8:22 PM >>>




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:
>
> 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 
>________________________________________________________________________
>Check out the new AOL. Most comprehensive set of free safety and
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>End of trauma-list Digest, Vol 42, Issue 6
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