[ccm-l] FW: GSW to liver

[Sam Picone]

Isn't there the very real possibility with this injury of forcing air into
the biliary tree or (more importantly) into the system venous system with
the positive pressure required from the scope. What pressure do you scope
these people with...can you see evrything. have you ever had an air
embolis...or am I just being paranoid?

Sam Picone MD FACS
Wisconsin USA

On Dec 30, 2007 1:32 PM, Ben Reynolds <aneurysm_42 at yahoo.com> wrote:

> 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
> >
> >
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> >
> >
>
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