Quote:
Originally Posted by RichL025
Beautiful pic, thanks DD.
Please tell me you have residents working with you!
Qs-
did you get CXR in the trauma bay or just empiric chest tube enroute to OR?
What did you close diaphragm with?
Let's change the scenario a little - same wound, except with a fair amount of EBL and a hypotensive patient. Maybe it's bleeding right now copiously. Chest or abdomen first?
Thanks,
RL
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Great questions and yes we do have residents . . .
First, yes, I did get a chest x-ray in the trauma bay. A good rule of thumb is that no trauma patient should ever leave the trauma bay without a chest x-ray. It is critical that if you can only get one x-ray that it is the chest x-ray. In this patient you would be looking for a pneumo- or hemothorax or both potentially. His chest x-ray showed a moderate pneumothorax. So, I placed the chest tube at the time of intubation in the OR as he was hemodynamically stable.
Now, if he was hemodynamically unstable in the trauma bay, I would have placed it there. As it turned out, we only had about 50 to 60 cc's of blood come out of the chest tube in the OR. His pneumothorax resolved, I want to say in three or four days and then we pulled it out.
Second question: I used to use an O Ethibond or Number 1 Vicryl but now I use a number 1 PDS in an interrupted or a figure of eight suture.
Third question: If I have placed the chest tube in the ED, I look for how much is coming out of the chest tube into the pleuravac. If it is greater than 20cc/kg or greater than 1.5 liters immediately, I would go where the trouble is. So, it would be the chest, first. Now, if the chest tube is putting out minimal blood and he is hypotensive, then straight to the abdomen because the spleen is right there and may have been transected or the aorta that may have a hole lacerated in it. This is especially true with abdominal distension or peritonitis. If fluids stabilize him (he is a IV fluid responder and we buy some time, you might consider a CT of the abdomen with IV contrast).
If it is the wound pouring out blood and you do not know which cavity it is, I would stop, place the chest tube and examine the abdomen. Again, if the chest tube is pouring out blood, then go to the chest and if the chest tube made no difference and there is no blood coming out or very little, then go to the abdomen. If you have an ultrasound in the ED, do a FAST (Focused Assesment Sonography for Trauma) examination. You can see the abdomen, pelvis, retroperitoneum, pericardium, and chest as well.
Really good questions!
Dutch