penetrating posterior torax injury

[Hardcastle, Tim, Dr <tch at sun.ac.za>]

Richard
 
The treatment of bleeding is stop the bleeding! This patient is likely to exanguinate over the next 40 mins, even with permissive hypotension. He needs the tinture of surgical steel.
 
If your surgeon CAN do a thoracotomy he should - stop the obvious bleeding (oversew / staple off intercostals or lung, or clamp lung hilum), treat any tamponade and THEN transport to the Trauma Center for definitive care; this is DAMAGE CONTROL for the chest.
 
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 Richard van der Kleyn
Sent: Wednesday, November 01, 2006 12:00 PM
To: trauma-list at trauma.org
Subject: penetrating posterior torax injury


Dear list,
would like your coments on a recent case as i am planning to review the case for lessons learned:
 
39 year old female, penetrating injury from a knife right posterior torax level 6/7 rib. Found on the streat, brought in to our small hospital by the ambulance (personal not qualified for bringing in infusions- unfortunatly the medicalized ambulance was occupied with an MI), pacient entered our ED following signs: A- clear B/ sat 80%, dimished breath sounds right hand side C/ pulse 130 RR 80/30 (class 3 shock). D glasgow 9 (hipoperfusion). 
RxTorax: hematotorax right hand side, pneumotorax right hand side with shift of of the mediastinum tio the left.
Pacient was intubated while the surgeon placed a chest tube right hand side which produced 1,500-2000 ml blood and air.
Libral fluid infusion first o negative then type specific without respons (4 concentrats and 2 L saline)- tensions remain same.
 
At this moment ther is a medicalized ambulance waiting to bring the pacient to the nearest trauma center (35-40 minutes). Ours is a small hospital, 1 surgeon who happened to be new but with some experiance in toractomy, last toracotomy performed about 8 years ago
 
question: toractomy or transport to traumacenter   (easy answer for people who deal with these cases everyday)

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