80yo lady doesnt have too much of a margin of error.
this is a very good point and one which should not be ignored
I agree completely. This is a situation where I trained where we would utilize an ABG and a base deficit, and not go to the scanner if the base deficit was over 6 in an elderly patient. .
i agree with abg, BD was -5
I think the answer to this question depends quite a bit on the hospital resources available. At my institution, with the trauma scanner in close proximity to the trauma bay and trauma OR, this patient would probably go to the scanner IF she was responsive to fluid (with the trauma senior and probably trauma attending as an escort). Obviously if she isn't responsive to fluid, or having worsening hemodynamic instability, I would proceed instead to the OR.
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agree, our CT scanner is 50 feet away
1) We did not use FAST routinely, unless the trauma attending was in the bay doing it
3) We were aggressive with DPL. Depending on attending, any blood pressure less than 90 in ER mandated DPL rather than scanner. Very old school, and very institution and attending dependent.
I think FAST is very important and an easy test to do, i have only done one DPL in residency, it is a lost technique IMO, or atleast at my institution, FAST has replaced it
Well, one reason to do the FAST frequently is so the junior residents become quick and accurate with the ultrasound, and so they see a few positive findings. It's definitely a more benign teaching method than mandatory ER Thoracotomies on all coding patients 🙂:Cough::cough:: LA County).
The FAST is also very useful for detecting pleural slide (or lack thereof) and can indicate the need for a chest tube.
I'm not sure how positive findings on DPL are any different than FAST, and I'm unsure then in your algorithm when DPL would ever be indicated. There's definitely no way you'll convince me it's quicker.
The only advantage would be the finding of enteric contents, and my question to you would be: how many times have you had that in a patient without other indications for laparotomy? Enteric contents in the pelvis (where you're aiming your catheter) after a blunt injury? If there's no enteric contents, does that mean we're off the hook and the patient can have a steak dinner? If you only find blood, are you taking that patient to the OR?
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agree
Anyway ... so here is what happened ...
Went to CT scan
while in scanner, pt dropped BP again, got blood
was not in scanner for more than 15 min
immediatly saw massive gross hemoperitoneum and active bleeding in lesser sac (OH MY!)
straight to OR
Found:
massive hemoperitoneum (2L blood loss)
completely transected pancreas
grade 2 spleen
duodenal hematoma x2, one was a perforation
right colonic mesenteric hematoma with right colon devasc
great case, pt still alive at this point
However, M&M was fun trying to explain why I was in CT when I should have been in the OR, and in retrospect ... I thinkl I should have been in the OR, not CT
as stated above, i wanted to r/o grade 2/3 liver or spleen causeing blood in belly that would likely not need an operation and I had a potential source of blood loss from the femur
but it was decided that a neg lap or even a lap/spleen would have been more acceptable than a dead patient in the CT scanner
thoughts?
