To catheterise or not to catheterise...
Ronald Gross
Rgross at harthosp.org
Fri Mar 23 15:09:44 GMT 2007
Ross,
You are right, the senior is wrong, and should probably re-take ATLS or re-read Mattox's text.
See, that was simple. Now just send the posts from this site to the receiving hospital and you are all set.................just kidding ;-)
Take care,
Ron
>>> <RWolfer at aol.com> 3/22/2007 5:22 PM >>>
In a message dated 3/22/2007 4:59:09 PM Eastern Daylight Time,
wildmedic at gmail.com writes:
Rebecca et al,
I am in complete agreement - as you read from my original post, the patient
is awaiting transfer. In my setting, this is likely to take anywhere
between 30 and 300 minutes to arrive. (That's another discussion, Dr K,
before you start yelling "Sentinel Event!")
To elucidate my concern: I arrived for duty this morning to find the
patient in the condition described above. He had been catheterised
transurethrally. I assessed him to have blunt abdo injuries, recognised the
need for a tincture of cold steel, and encertained that the patient was
booked for transfer. he had recieved 1000 mls of Ringer's lactate IVI. I
decided this was insufficient, given his condition and lack of urine
output, amd taking into account the principles of permissive hypotention
restarted the infusion. At this point a senior arrived and lambasted the
doctor on call overnight fotr placing the catheter, citing risk of infection
in a patient with possible bladder rupture. I disagreed and was told to
remove the catheter, because "We don't want the receiving hospital to think
we don't know what we're doing." I intimated that this course of action
would result in precisely that outcome, but was reprimanded.
I'm still convinced that the catheter was indicated, the correct procedure
was followed and the senior mistaken in his treatment, but the other doctor
involved (who had been on duty when the patient arrived) has taken this
senior's appoach to heart.
Am I off the mark here?
Ross.
On 22/03/07, RWolfer at aol.com <RWolfer at aol.com> wrote:
>
>
>
> In a message dated 3/22/2007 12:16:33 PM Eastern Daylight Time,
> Rgross at harthosp.org writes:
>
> Tim,
> I couldn't agree with you more!
> Ron
>
> >>> "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
> 3/22/2007 11:29
> AM >>>
> Ross
>
> Should have gone to Trauma Centre directly - or did he walk to you?
> Surely
> Metro-EMS or other should have been on scene? Provincial protocol directs
> these direct to GSH or TBH????
>
> If there is no frank blood and the pelvis appears stable there is NO
> reason
> to not catheterise prior to transfer if time permits: you can then at
> least
> monitor output.
>
> If the catheter goes in easily and no urine comes out - either: a bladder
> rupture or the catheter is not in right or the patient is more shocked
> than you
> thought and needs to be transferred more urgently. Again - this patient
> should not be at a CHC!
>
> 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 Dr Ross Hofmeyr
> Sent: Thursday, March 22, 2007 2:43 PM
> To: TRAUMA-L
> Subject: To catheterise or not to catheterise...
> 32 male pedestrian run over by minibus taxi. GCS 15, Resp NAD,
> hypovolaemic
> but perfusing well, closed tib/fib fracture. HR 110, BP 100/60, Sp02 99%
> on
> air. Chest & pelvis NAD but severe abdominal
> bruising. Abdomen distended,
> tense, becoming peritonitic. Rectal NAD. Patient is, of course, booked
> for
> urgent transfer to trauma center.
>
> 1) Do you catheterise this patient?
> 2) Suprapubic or transurethral?
> 3) If the patient is already catheterised and no urine is forthcoming
> (doc
> reports no difficulty in procedure), do you remove it?
> 4) Is this presentation suggestive of bladder rupture?
>
> I have my opinions, which were overridden by a senior colleague. I, of
> course, am right, (*grin*) but need ammo.
>
> Your thoughts?
>
> R.
> _____________________
> Dr Ross Hofmeyr
> MBChB (Stell) ATLS ACLS
> wildmedic at gmail.com
> ross at wildmedix.com
> www.wildmedix.com
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>
> remeber he is still relatively young. Yound healthy pts do not drop
> there
> pressure until the very end. some do not even get much of
> a tachycardia. I
> bet he is drier than you think. I destended abd with possible peritneal
> signs
> tell me there is something going on in the belly and he may need a knife.
> get
> him where needs to be ASAP and dont keep him out "running tests anddoing
> procedures" unless you are doing definitive care; Ihave seen to many
> people die
> because the transferring hostpial wanted to run one more test or do one
> procedure. Do life saving things only and get them out, ie chest tube,
> tie off
> bleeders that are visable, give fluid blood
> RW
>
> Rebecca Wolfer, MD, FCCP,FACS
> Assoc. Prof
> Dept. of Surgery, Marshall University, JCESOM
> Director, Thoracic Surgery
> Director, Surgical Critical Care, Cabell Huntington Hospital
> Director, Trauma Cabell Huntington Hospital
>
>
>
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--
_____________________
Ross Hofmeyr
MBChB (Stell) ATLS ACLS
wildmedic at gmail.com
ross at wildmedix.com
www.wildmedix.com
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leave the foley in. It is the best way to assess resussitation. I recently
saw a 14 year old MVA with NORMAL VS except pulse 110. NO URINE OUTPUT. Some
tenderness to belly, free fluid in abdomen. We took her to OR based upon
volume of fluid. As we cut the labs came back, Hgb was 3........ She had
completely destroyed her R hepatic lobe, got oversewn, packed and embolized. She
got over 50 units blood products, went back 3 times for pack changes. got no
blood after the first 48 hours. was left with open abd for over a week and
eventually closed primarly. If we had not of acted when we did she would not
have made it. Young and or healthy people often do not have significant
changes in VS until they arrest. this girl never dropped BP until we induced
anesthesia. She got severalliters of fluid and 2 units of blood prior to surgery.
We gave alot because of the min UO. She survived without sequelea, other
then going thru withdraw post op from her " extracurricular activities" You
were right to want to leave it in.
RW
Rebecca Wolfer, MD, FCCP,FACS
Assoc. Prof
Dept. of Surgery, Marshall University, JCESOM
Director, Thoracic Surgery
Director, Surgical Critical Care, Cabell Huntington Hospital
Director, Trauma Cabell Huntington Hospital
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