[ccm-l] FW: GSW to liver

[Ben Reynolds]

On the whole, I think Errington's approach was the safest. 

The impetus for nonoperative management of penetrating (specifically civilian FIREARM) abdominal trauma comes primarily out of LA and Baltimore (overwhelmingly the former).  Their results, I think are mixed and do NOT provide a strong enough foundation to defend a reproducible and sustainable "standard of care" in all institutions.  Way too many questions are left unanswered and no papers from other centers have come out duplicating their results (THAT I KNOW OF).  Probably because few other places see as much penetrating trauma as they do in order to accomplish nonoperative management successfully.

A laparotomy is a DIAGNOSTIC test with as near to a 100% sensitivity and specificity as one can get and is THERAPEUTIC if you make a diagnosis that requires intervention.  In general one shouldn't fall into believing that a penetrating wound to the right upper quadrant would ONLY involve liver.  CT cannot accurately diagnose a penetrating injury to the bile ducts, the gallbladder or the colon (among other structures).  

I think that it's important to keep in mind that the morbidity of a diagnostic (nontherapeutic) laparotomy can PALE in comparison to the mortality associated with missed injury (hollow viscus, biliary, vascular).    

Ben Reynolds, PA-C
Pittsburgh, PA

----- Original Message ----
From: Errington Thompson <errington at erringtonthompson.com>
To: "Louis Brusco Jr., M.D." <lb86 at columbia.edu>
Cc: Critical Care List <ccm-l at ccm-l.org>
Sent: Sunday, December 30, 2007 11:26:27 AM
Subject: RE: [ccm-l] FW: GSW to liver

There is a growing body of literature that says that CT'ing these patients
are safe.  I believe that a good CT scan is only as good as the radiologists
reading the scan.  I fear missing bowel injuries in patients I know will
have fluid on their CT scans. 

Of course, I could laparoscope the patient.  That is something that I
considered at the time.  The patient probably could have benefitted from
being scoped.  I'm still on the fence on this one. 

Serial exams - Eddie Cornwell and the guys at LA County looked at this.   You
need a specialized unit to this protocol.  Breaking the protocol has
significant consequences to the patient - prolonged ICU/hospital
stay/infectious complications.  Great study. 

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Author - Letter to America
Asheville, NC

-----Original Message-----
From: Louis Brusco Jr., M.D. [mailto:lb86 at columbia.edu] 
Sent: Sunday, December 30, 2007 10:54 AM
To: errington at erringtonthompson.com
Cc: 'Critical Care List'
Subject: Re: [ccm-l] FW: GSW to liver

E

Isn't this one where the literature is little help?  If you look at the 
literature - the patient should go to OR or get a DPL - but sometimes 
they look SO SO good - and you go in and find nothing that you had to do 
anything about - with modern, good SICU care - why not admit them and 
wait it out?  The down side - he bleeds out and you get him to the OR 
too late - if that happens one out of 1000 - is that too much of a risk 
for you?  I am sure Ken M will have an opinion here that I am 
interesting in hearing.  When I get these patients in the ICU - and I 
hear the absolutes (take GSW to Abd to OR - take Zone X neck stab wound 
to OR) I wonder if modern imaging and ICU care has yet changed that...

Lou

-- 
Louis Brusco Jr., M.D., F.C.C.M.
Associate Medical Director
St. Luke's-Roosevelt Hospital Center
NYC

Co-Director, Surgical Intensive Care Unit
Director, Critical Care Anesthesiology
Medical Director, Post-Anesthesia Care Unit




Errington Thompson wrote:
> I have a couple of questions on a recent case.  30 yo male was too drunk
to
> have a gun but had one nonetheless.  He shot himself in the right upper
> quadrant.  He was stable, awake and talking in the ER.  Entrance wound
> easily seen just under the ribs and just lateral to the mid-clavicular
line.
> The bullet was palpable just under the skin at about the 12th rib.   No
SOB.
>
>
> 1) CT or not CT scan.  IF you do scan the patient and see a thru and thru
> wound the liver, can you just watch him?
>
> I take the patient to the OR.  He indeed has a thru and thru GSW to the
> liver.  The wounds are not really bleeding.  There is no bile oozing from
> either wound.
>
> 2) Drain or no drain?
>
> The patient develops an ileus and bile peritonitis.  He is percutaneously
> drained.  On day 5 with his drain output still over 300 cc per day the
> character of the drainage changes to a dark green.  CT scan revealed an
> abscess posterior to the liver.  Percutaneous drainage was performed.
> Enterococcus in the fluid.  Antibiotics were started.  Antiobiotics
stopped
> after 7 days. 
>
> Thoughts?
>
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Surgical Critical Care
> Mission Hospital
> Asheville, NC
> Author - A Letter to America
> www.whereistheoutrage.net
>
>  
> Everyone deserves to make an informed decision
>                                - Errington Thompson, MD
>
>
> _______________________________________________
> ccm-l mailing list
> ccm-l at ccm-l.org
> http://ccm-l.org/mailman/listinfo/ccm-l
>
>  

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