Monday, January 17, 2005
Tales From the Trauma Service V...
Or how hypothermia destroys the best laid plans. A young man in a MVC, initially hypertensive but after the intubation has a hypotensive episode. Responds well to the fluid challenge. Initial FAST images:
Fluid in Morrison's pouch.
None seen in the LUQ, but the spleen has an unusual appearance to it. As long as the fluid keeps going his pressure does OK. A chest tube is placed for a left pneumothorax without difficulty. Two units of packed cells transfused. BP still very labile. He is too cold for the oral thermometer to register a temp. His pH on an initial ABG is 7.10. I repeat the FAST:
As you can see, time for the operating room. Inside there is about 1500cc of blood. The LUQ is packed off and the remainder of the abdomen explored. Liver, stomach, large and small bowel are all OK. The packs are removed from the spleen and:
The following images may be offensive!!!!
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You have been warned!!!!
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This patient's spleen was so pulped up that it was pretty much already dissected out:
You can see the rather pale appearing small bowel to the left. Here it is ex vivo:
He received 6 units PRBC's in the ED and OR. The spleen was out in 45 minutes but I spent another 15 pouring warm saline in his peritoneal cavity in an attempt to raise his temperature. It was raised about a degree. We took him up to the ICU and since I had no information about his brain or his aorta (he had both a first rib and scapular fracture) he was bundled up and taken to CT. The crucial cut of his chest CT:
Half of his lungs were contused. Oxygenation became increasingly difficult, and increases in PEEP were not well tolerated. His coagulopathy was profound with a PT higher than his platelet count. It would have been difficult to resuscitate him out of this, but not impossible. His family then inexplicably made him a DNR. This pretty much deflated the balloon. The residents and nurses seem to move at about three-quarter speed. He expired about five hours postop.
Or how hypothermia destroys the best laid plans. A young man in a MVC, initially hypertensive but after the intubation has a hypotensive episode. Responds well to the fluid challenge. Initial FAST images:
Fluid in Morrison's pouch.
None seen in the LUQ, but the spleen has an unusual appearance to it. As long as the fluid keeps going his pressure does OK. A chest tube is placed for a left pneumothorax without difficulty. Two units of packed cells transfused. BP still very labile. He is too cold for the oral thermometer to register a temp. His pH on an initial ABG is 7.10. I repeat the FAST:
As you can see, time for the operating room. Inside there is about 1500cc of blood. The LUQ is packed off and the remainder of the abdomen explored. Liver, stomach, large and small bowel are all OK. The packs are removed from the spleen and:
The following images may be offensive!!!!
[
]
[
]
[
]
[
]
[
]
[
]
[
]
[
]
[
]
[
]
[
]
You have been warned!!!!
[
]
[
]
[
]
This patient's spleen was so pulped up that it was pretty much already dissected out:
You can see the rather pale appearing small bowel to the left. Here it is ex vivo:
He received 6 units PRBC's in the ED and OR. The spleen was out in 45 minutes but I spent another 15 pouring warm saline in his peritoneal cavity in an attempt to raise his temperature. It was raised about a degree. We took him up to the ICU and since I had no information about his brain or his aorta (he had both a first rib and scapular fracture) he was bundled up and taken to CT. The crucial cut of his chest CT:
Half of his lungs were contused. Oxygenation became increasingly difficult, and increases in PEEP were not well tolerated. His coagulopathy was profound with a PT higher than his platelet count. It would have been difficult to resuscitate him out of this, but not impossible. His family then inexplicably made him a DNR. This pretty much deflated the balloon. The residents and nurses seem to move at about three-quarter speed. He expired about five hours postop.
Labels: Tales from the Trauma Service
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