I would probably not have CT scanned the chest in a stable patient if 
the mechanism, clinical examination and chest radiograph were 
normal. However I think that we do now have a lower threshold for 
scanning the chest as spiral scanning means that the only 
disadvantage is the radiation.

Matt - I am surprised that your radiologists are using a non-spiral 
scanner to evalute potential aortic injury. I think that it is well know 
that without a spiral scanner significant injuries will be missed (there 
is a medico-legal risk here which it might be worth discussing within 
your hospital). Arch aortogram (or TOE) is probably a much better 
investigation.

Steve - Once on-table for the laparotomy an arch aortogram would 
be rather difficult, a much better investigation would be a trans 
oesphageal echo. TOE is very good for picking up aortic injury (and 
would combine well with a repeat CXR for reevaluating the thoracic 
cavity).

Opening the chest in aortic injury without any idea of where the 
initmal laceration is situated creates a significant problem. Opening 
the chest is easy, but then you are confronted by a large 
mediasteinal haematoma which bleeds torrentially as soon as it is 
opened. Unless you know exactly where to go to control the 
bleeding you are probably on a hiding to nothing. So I would 
suggest that 'blind' thoracotomy is probably not indicated except as 
a last ditch effort (even then I think that it could be argued that it is 
not a worthwhile intervention).

Tim.



> In message <000d01c04e80$1ec548c0$edcf883e@LocalHost>, Simon McCormick
> <[log in to unmask]> writes >I've been wondering
> something since seeing a trauma patient recently and >wonder what
> other people think.  Obviously I can't go in to specific details >but
> the patient involved had head trauma requiring CT scan and enough abdo
> >symptom/signs pre intubation to require a CT of his abdomen (although
> the >radiologist wouldn't take my word for it...needed the surgical
> reg to >agree!!).  The scan confirmed significant intraabdominal
> injury and >mild/moderate brain injury.  Later when he became unstable
> and went to >theatre there was a question over thoracic dissection and
> he went on to have >a thoracotomy as no urgent imaging was available. 
> This revealed no thoracic >bleed and the patient is now recovering. >
> >My questions are: > >1)  Given he had head trauma and abdo trauma
> would 'routine' CT of the chest >be appropriate (there were no chest
> injuries obvious and the initial CXR was >normal although he had
> aspirated some blood) > >2)  If the initial CT showed significant
> damage to the head and abdo should >thoracic injury have been assumed
> and a CT of that area been performed then. > >3)  Given the speed of
> new CT scanners is routine zonal scanning an >appropriate way forward
> purely on mechanism of injury/examination (ie head >and abdo trauma so
> do a chest CT as well) or after investigation (ie >pneumothorax and
> fractured femur on x-rays so scan the abdomen) > >Common sense tells
> us that if you damage more than one of the head, thorax, >abdomen or
> pelvic/femur areas then the area or areas in between are at high
> >risk.  If you have a stable, fully conscious patient then you may be
> happy >to watch and wait but if they have a decreased level of
> consciousness and/or >are less than completely stable then should we
> be investigating them more >aggressively? > >Simon McCormick > >SpR
> North Trent
> 
> Now, it is all very well doing total body scanning. What you do then
> is produce a vast amount of information. This then has to be
> interpreted. Do more than a couple of these in an evening and all of a
> sudden you have a huge workload. The margin for error is rather small.
> 
> The radiation dose is not insignificant.
> 
> In your case, the patient had a negative thoracotomy. This is, of
> course, painful and alters respiratory mechanics. Postop morbidity is
> considerable. Perhaps a CT chest would have helped. Could an on-table
> arch aortogram have been done? Are they technically difficult? (After
> all, on table cholangiograms can be done by a surgeon in an emergency
> and routinely)
> 
> In order to resolve this issue, do we have any Radiologists who might
> wish to pass an opinion? -- Stephen Hughes SpR Cloud Cuckoo Land



Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%