disagree with UW answer to a question- input?

[poloace]

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the scenario is a mid 40's woman rescued from a car accident site. on arrival to ED, T=95.6, PR=150, RR=24, BP=70/0 and JVP:0. she is shivering and perspiring profusely. abdominal exam reveals mid distention but not tenderness. on further exam she has a scalp laceration but no other signs of external bleeding. her CXR, xray pelvis and xray extremities are normal. airway is secured and she is given rapid IV isotonc fluid and remains hypotensive. what would the next step be in management?

diagnostic peritnoeal lavage
CT abdomen
exploratory laparotomy
MRI abdomen
CT head


the answer it givs is that they would do a DPL. it says that the XRAYS rule out pretty much everything but an abdominal bleed.... so, if you know the patient is going to have an abdominal bleed because you have negative films - wouldn't you just go straight to a laparotomy??? patient is hypotensive and fluids aren't F*ing helping... though a DPL is relatively quick - 1- people stopped doing them in the 70's, and 2- you KNOW where the patient is bleeding, right? or, am i a ****?

input?

love,
p

 

[MeganRose]

the scenario is a mid 40's woman rescued from a car accident site. on arrival to ED, T=95.6, PR=150, RR=24, BP=70/0 and JVP:0. she is shivering and perspiring profusely. abdominal exam reveals mid distention but not tenderness. on further exam she has a scalp laceration but no other signs of external bleeding. her CXR, xray pelvis and xray extremities are normal. airway is secured and she is given rapid IV isotonc fluid and remains hypotensive. what would the next step be in management?

diagnostic peritnoeal lavage
CT abdomen
exploratory laparotomy
MRI abdomen
CT head


the answer it givs is that they would do a DPL. it says that the XRAYS rule out pretty much everything but an abdominal bleed.... so, if you know the patient is going to have an abdominal bleed because you have negative films - wouldn't you just go straight to a laparotomy??? patient is hypotensive and fluids aren't F*ing helping... though a DPL is relatively quick - 1- people stopped doing them in the 70's, and 2- you KNOW where the patient is bleeding, right? or, am i a ****?

input?

love,
p

Yeah, I put ex-lap too. If I remember correctly, the percentage of ppl that got this one right was~20% meaning we're probably correct, not the UW answer.
M

 

[poloace]

i was going to put the percentage down-

it was 41%. meaning, F*ing 41 people out of a 100 are smarter than me, dammit.... at least its not one of those where 97% get it right and i'm like the one person holding it back from a 100%

p

 

[footcramp]

negative DPL will rule out intraperitoneal bleed. however the patient can be bleeding retroperitoneally. DPL is a quick way to figure out one vs the other. If it's positive then proceed to ex lap. If negative then... not sure but do something about the retroperitoneal bleed i guess. i dunno, that's my reasoning.

 

[ucbdancn00]

the scenario is a mid 40's woman rescued from a car accident site. on arrival to ED, T=95.6, PR=150, RR=24, BP=70/0 and JVP:0. she is shivering and perspiring profusely. abdominal exam reveals mid distention but not tenderness. on further exam she has a scalp laceration but no other signs of external bleeding. her CXR, xray pelvis and xray extremities are normal. airway is secured and she is given rapid IV isotonc fluid and remains hypotensive. what would the next step be in management?

diagnostic peritnoeal lavage
CT abdomen
exploratory laparotomy
MRI abdomen
CT head


the answer it givs is that they would do a DPL. it says that the XRAYS rule out pretty much everything but an abdominal bleed.... so, if you know the patient is going to have an abdominal bleed because you have negative films - wouldn't you just go straight to a laparotomy??? patient is hypotensive and fluids aren't F*ing helping... though a DPL is relatively quick - 1- people stopped doing them in the 70's, and 2- you KNOW where the patient is bleeding, right? or, am i a ****?

input?

love,
p

I think one thing to remember is that you need to know where the bleeding is before you go in and start looking at the abdomen surgically. As stated, the patient could be bleeding retroperitoneally and an ex-lap will take even longer than expected w/o knowing where the bleeding is taking place.

rule of thumb is:

1) Penetrating injury--> ex-lap
2) Blunt trauma and not stable even after initial resuscitation--> DPL
3) Blunt trauma and stable after initial resuscitation--> CT scan

hope this helps

ucb

 

[razorback831]

Agree with UCB but would add this...if abdominal signs + instability, you can go straight to OR. The case the OP gave had no Abd Si, so unclear where bleed is (although most likely Abd) so you have to do DPL or FAST U/S.

 

[scully]

Since we are on the topic of disagreeing with UW-

Workup of thyroid nodule-

first step is FNA NOT measure TSH, isn't it?

 

[poloace]

scully...
wow- haven't seen you on here for a while (guess i haven't been on in years anyway)- i thought TSH was first thing you did. but, i could be wrong. i tend to be. hey, btw- who is that in your avatar? i've wondered that for years now. probably some famous actress from the 50's.. its not marilyn, is it?

p

 

[Doc Ivy]

Since we are on the topic of disagreeing with UW-

Workup of thyroid nodule-

first step is FNA NOT measure TSH, isn't it?

I could be wrong, but I think the key is symptoms vs no symptoms. If a pt comes in with si/sxs of hyperthyroidism and a nodule you would send TSH to determine if it is a functional "hot" mass or not-- if so, it's likely a benign toxic adenoma causing the sxs, if not you start thinking badness ("cold" non-functioning nodule makes cancer more likely)-- you'd still get an FNA though, so I think the question is kind of poorly constructed.