Trauma case

[Ronald Gross]

Patrick,

First off, why the IVC filter if the clot was allegedly "in the inferior IVC just below its junction with the atrium"?  What the heck is an IVC filter below the clot gonna do except make one more payment towards the IR doc's Lexus.  Second, why draw all of these cardiac enzymes?  EVEN IF, and that is a big IF, the kid had a BCI - formerly known as myocardial confusion aka contusion ;-)  - I think we could all agree that there is no need whatsoever to draw anything, or for that matter do an echo in the absence of any arrythmias and/or hemodynamic instability.  Third, is that "clot" just a flow artifact on the cavagram?  I seem to remember a similar case where this exact scenario was reported and the "clot" was not a clot, but a flow artifact that can occasionally be seen, and that amazingly disappears on the next cavagram!  And last but not least, how tight were your sphincters when you started a kid with a grade IV spleen on full anticoagulation?  If i were in this kid's bed, I would refuse the anticoaglation in any way shape or form.

I think you were right the first time - sounds like a bazillion dollar VOMIT to me.  But that is just the cynical me speaking, having just had 2 patients transferred to me from another hospital in the state; these poor elderly patients were scanned up the wazoo (for which you know they will bill a whole lot) and then sent them on their merry way BY HELICOPTER to us for a bunch of extremity fractures and a couple of rib fractures and a VERY bogus "possible aortic dissection", ALL of which could and should have been handled by the general and ortho surgeons on call at the referring facility.  But then again, it is Thanksgiving, "I (meaning the guys on call there) don't want to come in and see the patients and that is why we have Level I Trauma Centers, right?"

OK< I'll shut up not.  I am truly sounding like the grinch!!!

Happy Thanksgiving to all,
Ron

>>> "Offner, Patrick" <PatrickOffner at Centura.Org> 11/22/2007 9:31 PM >>>
I have a case I would like some opinion on. The patient is a 19 yo who
fell while snowboarding and hit his head and left torso. He had about 15
seconds of unconsciousness. His main complaint was left posterior chest
wall pain. Evaluation at an outlying facility revealed a left 1st rib
fracture, left pulmonary contusion, occult left pneumothorax and a grade
IV splenic laceration without extravasation of pseudoaneurysm. He was
hemodynamically stable with a normal hematocrit. For some reason,
troponin was drawn and revealed mild elevation. He was transferred to us
for further management. We put him in our ICU for observation and
nonoperative management of his splenic injury. We felt that he likely
had a myocardial contusion as well. Subsequent EKG show 2mm ST segment
elevation in the anterior leads. Somehow, the pulmonary/critical care
service became involved (haven't figured out how yet)--but order serial
troponins, serial EKG's and an ECHO. I saw this the next day and made
fun of them to the nurses--asking how they got involved anyway.
Unfortunately, the echo shows normal cardiac function--BUT an apparent
thrombus in the inferior IVC just below its junction with the atrium.
Well this starts the ball rolling---CTA, MRA, cavagram, IVC filter
placement and full anticoagulation. The IVC gram showed a clear thrombus
adherent to the IVC just above the confluence of the hepatic
veins--measuring about 1.5 x 2 cm.  All of this was accomplished over a
24 hour period when I was off. When I got back, I was worried that this
was VOMIT. I would not have even gotten the echo to begin with. But the
IVC gram seemed pretty clear cut when reviewed with the interventional
radiologist.  Fortunately, the kid has done well. NO splenic
complications despite anticoagulation--although I used a conservative
PTT target of 50-60. Repeat duplex ultrasound shows persistent thrombus
that is smaller--now about 1 cm. My plan is to continue his
anticoagulation for the present and repeat the duplex in 3 or 4 days. If
the thrombus has completely resolved, I want to stop his anticoagulation
altogether. Would anyone continue it for 3-6 months empirically? Would
anyone just stop it now? 


Patrick J. Offner MD MPH
Chief, Surgical Critical Care
St Anthony Central Hospital


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