jean robert
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During a campaign appearance, a political candidate is shot point blank in the right chest with a .22 caliber revolver. The entrance wound is well above the nipple line, just under the third rib, at the level of the anterior axillary line. His motorcade brings him to the emergency department, but he makes it a point to walk in, holding his right chest with a bloody hand and waving for the news media. A chest x-ray shows a hemothorax on the right, and the bullet is seen to be embedded in the right paraspinous muscles. A chest tube is placed in the right pleural cavity, and 650 mL blood is recovered. Over the ensuing 4 hours, he continues to drain between 250 and 350 mL blood per hour. Which of the following is the most appropriate next step in management?
A. Continued observation and appropriate blood replacement
B. A second chest tube in a better position to drain the blood
C. Thoracotomy and ligation of bleeding vessels
D. Thoracotomy, ligation of bleeding vessels, and removal of the bullet
E. Thoracotomy and pneumonectomy
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Le découragement, c’est du temps perdu.Ce qui est fait n’est plus à faire. Vouloir ce que l’on veut ; le vouloir constamment est le secret des forts.Great works are performed not by strength but PERSEVERANCE.
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| maoudoody
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c
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| drduck
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....C.......heavy bleeding so ligate vessel, but bullet is safe in the muscle...dont remove.
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| jean robert
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The correct answer is C.
Although most penetrating wounds of the chest that produce hemothorax require no surgery, there are cases in which systemic vessels (almost invariably intercostals), rather than the injured lung (which has low pressure circulation) are the source of bleeding. In those cases, surgical hemostasis is required. They are identified by the magnitude of the blood loss. Typical criteria suggest the need for thoracotomy if the initial blood recovery exceeds 1000 mL, or if subsequent drainage adds up to 600 mL or more, over the ensuing 6 hours.
Continued observation (choice A) would be inappropriate given the rate of 250-350 mL of blood loss per hour.
The problem is not lack of drainage; thus, another tube (choice B) would not resolve the problem.
Although choice D is almost identical to choice C, it adds a medically unnecessary step: the bullet does not have to be removed. Additional operative time and operative dissection are not justified if the bullet is not pressing on some vital structure. If it happens to be lying there, just waiting to be plucked, we would of course take it.
Pneumonectomy (choice E) targets the wrong organ. Bleeding from the lung is usually self-limiting. Bleeding that requires surgery is usually from systemic vessels, most commonly the intercostals.
___________________
Le découragement, c’est du temps perdu.Ce qui est fait n’est plus à faire. Vouloir ce que l’on veut ; le vouloir constamment est le secret des forts.Great works are performed not by strength but PERSEVERANCE.
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| drduck
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nice Q,
can anyone answer this...is a magnum and revolver the same.
I hear a lot about the .45 magnum. And i was really impressed....it is a revolver but I dont know why it is really powerful?
One of the most powerful weapons in Resident Evil 4 game...powerful than a shotgun!!!!! I never understood why.
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