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
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