trauma-list Digest, Vol 52, Issue 31
Hardcastle, Tim, Dr <tch at sun.ac.za>
tch at sun.ac.za
Thu Nov 8 11:42:20 GMT 2007
Naveed & Khumar
The best access to both SCA and the (L) chest is actually the median sternotomy. The trapdoor incision has so much morbidity accociated with it that it is considered obsolete.
I seldom if even divide the clavicle as this too leads to severe morbidity. The left chest can be easily inspected through the sternotomy. Only a posterior intercostal bleeder may be more difficult to access, the lung can be tractotomised through the sternal access.
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 Ahmed, Naveed
Sent: Wednesday, November 07, 2007 6:28 PM
To: Trauma & Critical Care mailing list
Subject: RE: trauma-list Digest, Vol 52, Issue 31
Dear Dr Huseynova,
A left thoracotomy initially with proximal control of subclavian vessels, than left clavicle incision/excision to access proximal and distal ends of injured vessels for possible repair/ ligation. If proximal part of the damaged vessel is hard to access, we than proceed to partial sternotomy to complete the trap door, Is how we usually handle this. I will love to have some input from the group.
Naveed Ahmed MD FACS
Pictures attached after consent of the patient.(Injury at the junction of L subclavian vein and L IJ, brachiochephalic/left IJ and subclavian veins ligated.)
-----Original Message-----
From: khumar huseynova [mailto:khumarhuse at yahoo.ca]
Sent: Saturday, November 03, 2007 6:03 PM
To: trauma-list at trauma.org
Subject: Re: trauma-list Digest, Vol 52, Issue 31
Pt with GSW to the L chest with 1 hole in the L supraclavicular area and another in the 8-9th ICS. Hemodynamically unstable. What incision would you use to access both the subclavians and the L chest? We;ve debated between trapdoor and clamshell. What's yoru experience?
Thanks
Khumar Huseynova
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Today's Topics:
1. RE: [ccm-l] RE: Pelvic fracture (Stephen Luk) 2. Sending Power Point Presentations (Charlene M Morris) 3. RE: Pelvic fracture (Olav R?ise) 4. Pelvic fracture - operative findings (Saboor Khan) 5. RE: Pelvic fracture - operative findings (Lorick Fox, MPAS, PA-C) 6. RE: Pelvic fracture - operative findings (Olav R?ise) 7. RE: Pelvic fracture (Hardcastle, Tim, Dr ) 8. RE: Pelvic fracture - operative findings (Hardcastle, Tim, Dr ) 9. RE: Pelvic fracture - operative findings (Sanjay Gupta MD)
----------------------------------------------------------------------
Message: 1
Date: Sun, 28 Oct 2007 08:48:41 -0400
From: "Stephen Luk"
Subject: RE: [ccm-l] RE: Pelvic fracture
To: , "Dr Brahma Balakrishnan"
, "'Trauma & Critical Care mailing list'"
Cc: ccm-l at ccm-l.org
Message-ID: <47244CE5.F618.0087.0 at harthosp.org>
Content-Type: text/plain; charset=UTF-8
try this link - browse through the selections, the pelvic packing lecture is on the bottom of the left hand column
http://www.panamtrauma.org/Lectures/Lectures.htm
Stephen S. Luk, MD, FACS, FCCP
Assistant Professor of Surgery
Associate Director of Trauma
Medical Director, ATOM Course
Hartford Hospital
EMS/Trauma Program
80 Seymour Street
Hartford, CT 06102-5037
(860) 545-3766
sluk at harthosp.org
>>> Dr Brahma Balakrishnan 10/27/2007 1:23 PM >>>
Dear Stephen,
Nothing happens when I click on the link.
Regards Dr B
Dr. Brahma Balakrishnan
Clinical Director
Wijaya International Medical Center
Malaysia
-----Original Message-----
From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Stephen Luk
Sent: Saturday, October 27, 2007 11:19 PM
To: Olav Røise; 'Trauma & Critical Care mailing list'
Cc: ccm-l at ccm-l.org
Subject: [ccm-l] RE: Pelvic fracture
A presentation by Dr. Moore from the Panamerican Trauma Society meeting on Pelvic Packing.
http://www.panamtrauma.org/Lectures/Pelvic%20Retroperitoneal%20Packing%20Rel
ated%20to%20Hemorrhage%20by%20Fractures/player.html
Stephen S. Luk, MD, FACS, FCCP
Assistant Professor of Surgery
Associate Director of Trauma
Medical Director, ATOM Course
Hartford Hospital
EMS/Trauma Program
80 Seymour Street
Hartford, CT 06102-5037
(860) 545-3766
sluk at harthosp.org
>>> Olav Røise 10/27/2007 10:26 AM >>>
I agree with Ken Mattox. I introduced extrapelvic packing in Oslo in
1994
and it has been part of our pelvic bleeding protocol ever since.
So as the patient is haemodynamically unstable this would be the option in this case. First the fracture should be stabilized with the binder or sheet around the trochanter region and kept in place during the surgical procedure of damage control.
For the urethral injury I would not have put the catheter in before the urethra was cleared by an urethra-graphy. It is known that catheter can put a partial rupture into a total disruption. I would not focus on the urethra before the pelvic bleed is under controll.
With regard to the possible rectal injury we are doing a rectal/sigmoidoscopy to exclude injury. We have seen false negative contrast exam. of the rectum. This has of low priority and should not be done before control of the bleed. Eventually a sigmoidotomy shoul be done - keeping in mind the later reconstruction of the pelvis - and talk to the pelvic surgeon to avoid incision conflict for later reconstruction of the pelvis
With kind regards,
Olav
Olav Røise
Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal University Hospital, Oslo
Cellular phone;+4790895062
E-mail;olro at uus.no or; olav.roise at medisin.uio.no
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: 27. oktober 2007 15:44
To: trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: Re: Pelvic fracture
In a message dated 10/27/2007 5:39:42 A.M. Central Daylight Time, hpb.surgery at gmail.com writes:
1. Pelvic fracture + suspected ongoing retro peritoneal venous bleed,
what
surgical strategy would you employ?
2. If a rectal tear is suspected, without any perioneal trauma, how would you de-function, loop colostomy? Or end colostomy and mucous fistula?
Would you
try and establish the site of perforation - on-table flexible sigmoidoscopy etc.?
I agree with Bjorn regarding the excessive fluid administration.
The patient appears to be hemodynamically stable. If unstable, then one of several tactics to impede ongoing blood loss is indicated. I have never been totally satisfied with arterial embolization for control of venous bleeding. I also have not been satisfied with external fixation to reduce blood loss. The orthopedic community is mixed in its suppor t of external
fixation. The new extra peritoneal packing as reported from Europe and from a couple of centers in the United States bears watching. I might have
considered such a procedure in this patient. It is a temporizing ("damage
control")
tactic.
With the case as you describe, I would consider going to OR for an examination under anesthesia, looking mainly at the rectum. For this one does not need to do a flexible sigmoidoscopy, as it is only the rectum which is of concern. This can be done with a straight short scope. Even a full thickness injury might be missed, but your CT description is suggestive of a rectal injury. I would strongly consider a LOOP colostomy, but to be sure that the distal stoma is totally defunctionalized, unless the patient is obese and the mesentery is foreshortened and to do a loop would create vascular compromise to the exteriorized segment. If the patient's pelvis was operatively repaired, and he did not become febrile, I would study the distal rectum via the loop colostomy and if NO LEAK, I would consider closing this colostomy at the first hospitalization.
k
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------------------------------
Message: 2
Date: Sun, 28 Oct 2007 08:57:06 -0400
From: "Charlene M Morris"
Subject: Sending Power Point Presentations
To: "Trauma &, Critical Care mailing list"
Message-ID:
Content-Type: text/plain; charset=ISO-8859-1
for sending ppp, use www.yousendit.com. It is still free for the basic and
TERRIFIC for alrge files.
Charlene Morris
On 10/28/07, Charles Brault wrote:
>
> I find that
> Goop powerpoint presentation
> Are normaly bad reference document
>
> The poerpoint when well used is but a frame
> That does not hold much without IT's presenter
>
> ... or take on an all other form (god or bad)
>
>
> Charles
>
> ----- Original Message ----
> From: "Bjorn, Pret"
> To: "Trauma & Critical Care mailing list"
> Sent: Friday, October 26, 2007 9:14:06 PM
> Subject: RE: Pedi Pointers and Pertinent Propaganda
>
> Just to show I tried: my slides apparently got confiscated at the border
> (at least, I never saw this on the other end). Still available
> off-List, I think; but again: low expectations are advised.
>
> Pret
>
> -----Original Message-----
> From: Bjorn, Pret
> Sent: Wednesday, October 24, 2007 12:44 PM
> To: 'Trauma & Critical Care mailing list'
> Cc: 'Andrew J Bowman'
> Subject: RE: Pedi Pointers and Pertinent Propaganda
>
>
> Sorry Andrew and everybody. Bangor can be a busy place, and I really
> intended to annotate these (there's of course a lot of scripting that
> wouldn't be intuitive from the slides); but that's not gonna happen any
> time soon.
>
> Please forgive the colloquiality, and be patient with the format:
> PowerPoints don't tend to travel well over the internet. The fonts and
> bullets and layouts will probably not translate cleanly.
>
> And above all, know that these were very short presentations for a local
> audience, not by any means definitive or comprehensive. But if there's
> a slide or two that you can use, have at it.
>
> Pret Bjorn, RN
> Bangor, ME USA
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Andrew J Bowman
> Sent: Sunday, October 14, 2007 5:20 PM
> To: Trauma & Critical Care mailing list
> Subject: Re: Pedi Pointers and Pertinent Propaganda
>
>
> Pret,
>
> How did your presentation go?
>
> Andrew Bowman
>
> ----- Original Message -----
> From: "Bjorn, Pret"
>
>
>
> I'm speaking to a group of nurse anesthetists this weekend who want to
> know cool stuff about pediatric trauma. I've got a couple of canned
> lectures on my hard drive, but they (and surely I) could use some
> freshening up.
>
> Pret Bjorn, RN
> Bangor, ME USA
>
> --
> trauma-list : TRAUMA.ORG
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>
------------------------------
Message: 3
Date: Sun, 28 Oct 2007 15:12:45 +0100
From: Olav R?ise
Subject: RE: Pelvic fracture
To: "'Trauma & Critical Care mailing list'"
Message-ID: <002201c8196c$9c998bd0$63faf081 at uio.no>
Content-Type: text/plain; charset="iso-8859-1"
Technically this is a very simple method. We have described it in a recent
issue of Journal of Trauma(1).The Denver group presented their results in
the same issue.
We are doing the procedure in the ER. We have embolization as the main
method for controlling bleeding for pelvic bleeding. However, our angio
suite is located far from ER and for patients in shock embolization is no
option as such patients will die during transfer - even though we have
intervention services on call 24hrs/365. So packing is for patients that
otherwise would exanguinate.
Pelvic packing is done with the sheet or pelvic binder placed around the
trochanter regions and the extremities internally rotated. A short midline
incision from the symphysis to 4- 5 cm below the umbilicus is made. The
haemotoma makes the surgical dissection easy as the bleed is
extraperitoneal. The bladder is held cranially and then you just go
laterally along the pelvic brim under the external illac vessels and the
psoas muscle. The pelvic bleeding is controlled by a minimum of 3-4 large
swabs on each side in the interspace between the bony pelvic ring and the
peritoneum, starting from caudal and posterior at the ileosacral joint and
advancing anteriorily to the symphysis. The swabs are directed toward
branches of the internal iliac artery and the pelvic venous plexus situated
in the retroperitoneal space. Usually access to the site of bleeding is
simple as haematoma has already dissected the retroperitoneal space. To
obtain maximum compression the contra-lateral side is packed in the same
manner. In unstable pelvic fractures (vertical shear and major open book
injuries - C and B1) the muscles and ligaments of the pelvic floor may be
torn. This increases the volume of the true pelvis and more swabs may be
needed. After completing pelvic packing the linea alba is closed with
continuous sutures in order to achieve additional tamponading effect. No
wound drains are left.
The swabs are left for 48 hours. Usually definitive internal fixation can be
performed at the time of swab removal. However, if the patients starts to
rebleed at the time of swab removal the EPP is repeated and swabs left for
another 48 hours.
This procedure is done by the resident on call. We have established a
systematic training for the trauma team leaders at the lab of pathology. The
residents are not allowed to serve as a team leader without knowing the
procedure.
The procedure is very simple and can easily be learned by any surgeon. You
will be able to do this in just few minutes.
Reference;
1. Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvic
packing: a salvage procedure to control massive traumatic pelvic hemorrhage.
J Trauma. 2007 Apr;62(4):843-52.
Olav
Olav Røise
Chairman, MD, Ph.D
Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal University
Hospital
Cellular phone;+4790895062
E-mail;olro at uus.no or; olav.roise at medisin.uio.no
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Robert F. Smith
Sent: 28. oktober 2007 12:37
To: 'Trauma & Critical Care mailing list'
Subject: RE: Pelvic fracture
Doesn't work for me either even if I cut and paste.
How does one technically do this? Do you worry about violating expanding
hematoma?
Rob Smith
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Richard Wigle MD FACS
Sent: Saturday, October 27, 2007 10:19 PM
To: Trauma &, Critical Care mailing list
Subject: RE: Pelvic fracture
Having had the opportunity to hear Dr Moore speak on this
topic I would very much like to have access to this
presentation. This link- and the previous link- are,
however not working for me despite my trying all the usual
tricks to milk reticent data from web sites. Any other
suggestions?
R Wigle
--- Stephen Luk wrote:
> A presentation by Dr. Moore from the Panamerican Trauma
> Society meeting
> on Pelvic Packing.
>
>
http://www.panamtrauma.org/Lectures/Pelvic%20Retroperitoneal%20Packing%20Rel
ated%20to%20Hemorrhage%20by%20Fractures/player.html
>
>
>
>
> Stephen S. Luk, MD, FACS, FCCP
> Assistant Professor of Surgery
> Associate Director of Trauma
> Medical Director, ATOM Course
> Hartford Hospital
> EMS/Trauma Program
> 80 Seymour Street
> Hartford, CT 06102-5037
> (860) 545-3766
> sluk at harthosp.org
>
>
> >>> Olav Røise 10/27/2007
> 10:26 AM >>>
> I agree with Ken Mattox. I introduced extrapelvic packing
> in Oslo in
> 1994
> and it has been part of our pelvic bleeding protocol ever
> since.
>
> So as the patient is haemodynamically unstable this would
> be the option
> in
> this case. First the fracture should be stabilized with
> the binder or
> sheet
> around the trochanter region and kept in place during the
> surgical
> procedure
> of damage control.
>
> For the urethral injury I would not have put the catheter
> in before
> the
> urethra was cleared by an urethra-graphy. It is known
> that catheter
> can put
> a partial rupture into a total disruption. I would not
> focus on the
> urethra
> before the pelvic bleed is under controll.
>
> With regard to the possible rectal injury we are doing a
> rectal/sigmoidoscopy to exclude injury. We have seen
> false negative
> contrast
> exam. of the rectum. This has of low priority and should
> not be done
> before
> control of the bleed. Eventually a sigmoidotomy shoul be
> done - keeping
> in
> mind the later reconstruction of the pelvis - and talk to
> the pelvic
> surgeon
> to avoid incision conflict for later reconstruction of
> the pelvis
>
>
>
> With kind regards,
>
> Olav
>
> Olav Røise
>
> Division of Neuroscience and Muscoloskeletal Medicine,
> Ullevaal
> University
> Hospital, Oslo
>
> Cellular phone;+4790895062
> E-mail;olro at uus.no or; olav.roise at medisin.uio.no
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of KMATTOX at aol.com
> Sent: 27. oktober 2007 15:44
> To: trauma-list at trauma.org
> Cc: ccm-l at ccm-l.org
> Subject: Re: Pelvic fracture
>
>
> In a message dated 10/27/2007 5:39:42 A.M. Central
> Daylight Time,
> hpb.surgery at gmail.com writes:
>
> 1. Pelvic fracture + suspected ongoing retro peritoneal
> venous bleed,
> what
> surgical strategy would you employ?
> 2. If a rectal tear is suspected, without any perioneal
> trauma, how
> would
> you
> de-function, loop colostomy? Or end colostomy and mucous
> fistula?
> Would you
> try and establish the site of perforation - on-table
> flexible
> sigmoidoscopy
> etc.?
>
>
>
> I agree with Bjorn regarding the excessive fluid
> administration.
>
> The patient appears to be hemodynamically stable. If
> unstable, then
> one
> of several tactics to impede ongoing blood loss is
> indicated. I
> have
> never
> been totally satisfied with arterial embolization for
> control of
> venous
> bleeding. I also have not been satisfied with
> external fixation to
> reduce blood
> loss. The orthopedic community is mixed in its support
> of external
>
> fixation. The new extra peritoneal packing as reported
> from Europe
> and
> from a
> couple of centers in the United States bears watching.
> I might have
>
> considered such a procedure in this patient. It is a
> temporizing
> ("damage
> control")
> tactic.
>
> With the case as you describe, I would consider going to
> OR for an
> examination under anesthesia, looking mainly at the
> rectum. For
> this one
> does not
> need to do a flexible sigmoidoscopy, as it is only the
> rectum which is
> of
> concern. This can be done with a straight short
> scope. Even a
> full
> thickness injury might be missed, but your CT
> description is
> suggestive of
> a rectal
> injury. I would strongly consider a LOOP colostomy,
> but to be
> sure
> that
> the distal stoma is totally defunctionalized, unless the
> patient is
> obese
> and the mesentery is foreshortened and to do a loop would
> create
> vascular
> compromise to the exteriorized
> segment. If the patient's pelvis
> was
> operatively repaired, and he did not become febrile, I
> would study
> the
> distal rectum
> via the loop colostomy and if NO LEAK, I would consider
> closing this
> colostomy
> at the first hospitalization.
>
> k
>
>
>
> ************************************** See what's new at
> http://www.aol.com
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
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>
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------------------------------
Message: 4
Date: Sun, 28 Oct 2007 15:52:02 +0000
From: "Saboor Khan"
Subject: Pelvic fracture - operative findings
To: "Trauma &, Critical Care mailing list"
Message-ID:
<5a6885120710280852w4690731dnad7821b2d3947b39 at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1
Thanks to those who replied: Just to mention a few points:
1. I agree, with such an injury a urethrogram should have been performed.
2. Cannot comment on whether the crystalloid resuscitation was excessive.
3. The CT scan did not show a blush, however my (experienced) orthopaedic
=== message truncated ===
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