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  #1  
Old 08-06-2012
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ER Abdomen Gunshot Management?

A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot wound to the abdomen. His pulse is 120/min, and blood pressure is 70/40 mm Hg. Breath sounds are normal on the right and decreased on the left. Abdominal examination shows an entrance wound in the left upper quadrant at the midclavicular line below the left costal margin. There is an exit wound laterally in the left axillary line at the 4th rib. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in in management?

  • upright xray of chest
  • CT scan of chest
  • intubation and mechanical ventilation
  • peritoneal lavage
  • left tube thoracostomy
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  #2  
Old 08-06-2012
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left tube thoracostomy

He has a left diaphragmatic injury with left lung injury with hemothorax. Eventually he is going to need a laparotomy ( for possible stomach and splenic injury)as well as a thoracotomy to repair the lung/diaphragm.
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Old 08-06-2012
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Quote:
Originally Posted by novobiocin View Post
left tube thoracostomy

he has a left diaphragmatic injury with left lung injury with hemothorax. Eventually he is going to need a laparotomy ( for possible stomach and splenic injury)as well as a thoracotomy to repair the lung/diaphragm.
why not peritoneal lavage and then laprotomy... ?
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Quote:
Originally Posted by tyagee View Post
why not peritoneal lavage and then laprotomy ... ?
Why do you want to do a peritoneal lavage in an obvious penetrating abdominal injury. Pt is taken straight for laparotomy after ABCs.
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  #5  
Old 08-06-2012
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So why not Intubation? Obv his diaphragm wont work since he got popped + theres going to be a ton of blood collecting between lungs/diaphragm.
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  #6  
Old 08-06-2012
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mechanical intubation and ventilation. No matter what, the first step is securing the airway ,part of ABC. next step would be to obtain a chest xray.then acc to xray findings go for peritoneal lavage or thoracostomy
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Old 08-06-2012
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should be intubation ......
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  #8  
Old 08-07-2012
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Quote:
Originally Posted by tyagee View Post
A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot wound to the abdomen. His pulse is 120/min, and blood pressure is 70/40 mm Hg. Breath sounds are normal on the right and decreased on the left. Abdominal examination shows an entrance wound in the left upper quadrant at the midclavicular line below the left costal margin. There is an exit wound laterally in the left axillary line at the 4th rib. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in in management?
He does not need mechanical ventilation at this stage. There is nothing in the vignette to suggest that he has respiratory decompensation.
All the info in this vignette show that he is tachycardic with a low BP suggesting hypovolemia due to hemorrhage and the most likely site is bleeding into left pleural cavity.
So, all he needs first is a tube thoracostomy to drain that blood allowing lung expansion. Mechanical ventilation will not help as the lung cannot expand as long as he has hemothorax. His other lung is working fine and he will be better once the blood in his left pleural cavity is drained.
Mechanical ventilation will be the next step after tube thoracostomy if he develops respiratory decompensation.

Normal breath sounds mean that his Airway is intact so he does not need intubation.

Also, tube thoracostomy is a part of ABC (Breathing) here.

And they have already started him on IV resuscitation taking care of the Circulation part of ABC.

Last edited by Novobiocin; 08-07-2012 at 06:05 AM.
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  #9  
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Quote:
Originally Posted by Novobiocin View Post
He does not need mechanical ventilation at this stage. There is nothing in the vignette to suggest that he has respiratory decompensation.
All the info in this vignette show that he is tachycardic with a low BP suggesting hypovolemia due to hemorrhage and the most likely site is bleeding into left pleural cavity.
So, all he needs first is a tube thoracostomy to drain that blood allowing lung expansion. Mechanical ventilation will not help as the lung cannot expand as long as he has hemothorax. His other lung is working fine and he will be better once the blood in his left pleural cavity is drained.
Mechanical ventilation will be the next step after tube thoracostomy if he develops respiratory decompensation.

Normal breath sounds mean that his Airway is intact so he does not need intubation.

Also, tube thoracostomy is a part of ABC (Breathing) here.

And they have already started him on IV resuscitation taking care of the Circulation part of ABC.
U cannot perform thoracostomy without confirming it on xray .And before xray u need to intubate him as to secure his airway .its just what is think may be i m wrong ,lets see when the OP post the answer
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Quote:
Originally Posted by step_enhancer View Post
U cannot perform thoracostomy without confirming it on xray .
Wow........what's the source of that information.

Quote:
Originally Posted by step_enhancer View Post
And before xray u need to intubate him as to secure his airway .its just what is think may be i m wrong ,lets see when the OP post the answer
So what in the vignette makes you think that he needs to be intubated?

Quote:
Normal breath sounds mean that his Airway is intact so he does not need intubation.
You remind me of the saying "You can lead a horse to water, but you can't make it drink "
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@novobiocin Breath sounds are normal on the right and decreased on the left they r not absent
may be u've never been to a ward

bedside chest xray hardly takes any time and u will get a clear picture on how to proceed .may be patient just needs a chest tube ,dont u think thoracostomy is overdoing .

u dont have to a as**ole about it ,u r a doctor ,these r healthy discussions ,next time u want prove something prove it with your knowledge rather than your laughters and humiliations .
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  #12  
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with respect to both of u,

ans is chest tube thoracostomy.


as of personal note, i lost my questions i posted recently on this forum

mods plz help :sorry::sorry::sorry:

Last edited by tyagee; 08-07-2012 at 08:01 AM.
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  #13  
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Quote:
Originally Posted by step_enhancer View Post
@novobiocin Breath sounds are normal on the right and decreased on the left they r not absent
So what does that proves? Normal breath sounds mean his airway is intact.
Besides Intubation is not even a choice in this question. The choice is intubation and mechanical ventilation.
So, please explain, what is the indication of mechanical ventilation in this patient.
Quote:
Originally Posted by step_enhancer View Post
may be u've never been to a ward
That shows your ignorance. Making opinions about people you don't know anything about.
That reminds me of another saying--"Never argue with an idiot. They will only bring you down to their level and beat you with experience."

Quote:
Originally Posted by step_enhancer View Post
bedside chest xray hardly takes any time and u will get a clear picture on how to proceed .may be patient just needs a chest tube ,dont u think thoracostomy is overdoing .
Stop making an ass of yourself. Thoracostomy is chest tube insertion.

Remind me of another saying "When you find yourself in a hole, stop digging"

Quote:
Originally Posted by step_enhancer View Post
u dont have to a as**ole about it ,u r a doctor ,these r healthy discussions ,next time u want prove something prove it with your knowledge rather than your laughters and humiliations .
I am proving everything with my knowledge with detailed explanations.
What about you?


Last edited by Novobiocin; 08-07-2012 at 08:09 AM.
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  #14  
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i apologize i mixed between terms ,thoracostomy and thoracotomy
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Originally Posted by Novobiocin View Post
Stop making an ass of yourself. Thoracostomy is chest tube insertion.

Its not making ass of myself ,these thing happen .u r just being immature.And i should not argue with as*holes .idiots i can manage.

Last edited by step_enhancer; 08-07-2012 at 08:13 AM.
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  #16  
Old 08-07-2012
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Quote:
Originally Posted by tyagee View Post
with respect to both of u,

ans is chest tube thoracostomy.


as of personal note, i lost my questions i posted recently on this forum

mods plz help :sorry::sorry::sorry:
your question got lost coz u pasted the picture of the question,so they deleted it .it happened to my question too .may be due to copyright. they want us to type the whole question .
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  #17  
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Default left tube thoracostomy

left tube thoracostomy
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  #18  
Old 02-25-2015
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This is a USMLE Tutorial question and their answer key says left tube thoracostomy.
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