virgola82
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A 23 yo previously healthy caucasian male presents to the ER after sustainig a single gunshot wound to the left chest. The entrance wound is 3 cm inferior to the nipple and the exit wound is just below the scapula. A chest tube is placed that drains 400 mL of blood and continues to drain 50-75 mL/h during the initial resuscitation. Initial BP of 70/0 mmHg responds to 2 L crystalloid and is now 100/70 mmHg. Abdominal examination is unremarkable. Chest x-ray reveals a re-expanded lung and no free air under the diaphgram. The next step in the management of this patient should be:
A. Admission and observation
B. Peritoneal lavage
C. Exploratory thoracotomy
D. Exploratory celiotomy
E. Local wound exploration
Edited by virgola82 on 05/31/07 - 05:59 AM
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| kingsofke
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B. Peritoneal Lavage
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| virgola82
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It's funny that you always give the same answer I gave when did these qs....
I realized after reading the explanation that I knew this but got it wrong anyway... As Pestana says in his lectures, every gunshot wound to the abdomen gets an exploratory lap performed and every gunshot wound below the nipple is very likely to involve the abdomen.
so the right answer is D
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| sherry39
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what is exploratory celiotomy
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| lq2006
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D. Exploratory celiotomy
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| hir
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D
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| dr19
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celiotomy=laparatomy
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| mygf99
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For answering in exams yes... D...go for an exploratory laparotomy.. quite the practice for a very long time...but trends are changing... earlier dictum was to explore every patient with penetrating injuries but now the trend with good intensive care facilities and better imging techniques with high sensitivity and specificty is changing, the answer probably would be a lil different.. firstly the patient is stable... the ICD output doesnot satisfy the criteria for undertaking a thoracotomy... admit the patient.. send serial hematocrits.. get a CT thorax and abdomen with oral and iv contrast.. be prepared for a surgery but not if it is not indicated... if ct abdomen has no fluid.. no visceral injuries one can wait and observe..vitally stable without inotropic support, hematocrit stable with out blood transfusions...minimal ongoing losses..no clinical detoriation...OBSERVE...equivocal cases go for a diagnostic laparoscopy.... if indicated operate
Edited by mygf99 on 05/30/08 - 12:20 PM. Reason: spelling mistakes
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| mygf99
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Gun shot injuries are associated with a phenomenon called the blast effect...injuries may appear subtle on first look like a simple extraluminal hematoma and the surgeon might decide to leave it untouched but in 24-48 hrs it will develop into a perforation.... even more a reason to keep a stable patient under observation and operate only if indicated.. in sugery nowadays the word"exploratory laparotomy" is phasing out...its either always diagnosed before hand or is replaced by diagnostic laparoscopy
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