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Great Case Yesterday
20 year old GSW to right back (.38 cal) with bullet palpable just above his xyphoid process. Okay, the trajectory says it hit something in his abdomen and he needs an operation. Hit IVC with 2 holes (in and out) just below renal veins, hit duodenum on its edge and came out pancreatic head, through and through liver and stopped just above xyphoid. Alot of blood in abdomen as expected.
My issues: keep patients mean arterial pressure in the 55-60mmHg range, DO NOT over resuscitate with IVF...give blood.
Now for my editorial: it is my firm belief that had this guy received the typical 4-8 liters of IVF, he' have bled to death. His BP higher would make him bleed faster, the IVF would dilute his coagulation factors and with no clot, he hemorrhages to death. The medics that brought him in with a BP of 70-80 gave a total of 200mL IVF in the 25 minutes it took from scene to trauma bay.
Good news, finished the case at 5pm yesterday, he's leaving the ICU today to the stepdown area. Never got below 35.9 degrees, never got a pH below 7.34, and no coagulopathy in the OR.
This ties into the last thread's discussion and I believe is such an important point to make for all of the medics/docs/PAs, etc.....more may not be beneficial and may be harmful (resus fluids)....until the bleeding is controlled
ss
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'Revel in action, translate perceptions into instant judgements, and these into actions that are irrevocable, monumentous and dreadful - all this with lightning speed, in conditions of great stress and in an environment of high tension:what is expected of "us" is the impossible, yet we deliver just that.
(adapted from: Sherwin B. Nuland, MD, surgeon and author: The Wisdom of the Body, 1997 )
Education is the anti-ignorance we all need to better treat our patients. ss, 2008.
The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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