Bullet through mediastinum - Forum

Scalpel

Bullet through mediastinum - Ärzteforum

Post#1 »

Patient 22 years , male , was admitted yesterey because thorax gun shot with entry site wound in right subclavicular area and the bullet get lodge posteriously in left sbscapular area .He was stable .Rx of thorax = bilateral pneumothorax both grade I-II ,neither mediastinal widening or emphysema .normal neck auscultation .
Treated with bilateral thorax seal drainage ,we permormed esophageal, endoscopy and esophagogram both neither perforation or blood or spillage.

The questions are :
-You explore mediastinum as a rule because the bullet have gone through it by itself just in case of unsuspected injury .
-you first perform A.C.T. with contrast
-you prefer echodopler
-you prefer angiography
-you prefer all or some of the forementionated studies before to take decision for to operate or not.
-whats is the reliability and the benefit-cost relations of the called methods in the case that I have presented .


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Surgeon

Re: Bullet through mediastinum - Ärzteforum

Post#2 »

I prefer an angiogram. CT scans will have some false positive and false negatives. The angio is the gold standard. Do not accept less.

Noro

Re: Bullet through mediastinum - Ärzteforum

Post#3 »

I would obtain an angiogram of the aortic arch and great vessels; the patient sounds at risk of having a traumatic pseudoaneurysm from the described trajectory of the bullet. In addition, if an air leak was present at tube thoracostomy, I'd have a low threshold for performing fiberoptic bronchoscopy.

John Dissector

Re: Bullet through mediastinum - Ärzteforum

Post#4 »

It is very possible that this patient has no mediastinal injury. I would study him with an angiogram to r/o vascular injury. If negative, it is safe to watch him. Angiogram will be much more sensitive that CT or Echo.

bonjorno

Re: Bullet through mediastinum - Ärzteforum

Post#5 »

I would do an aortogram and not operate if normal. CT is too non specific.

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Alalo

Re: Bullet through mediastinum - Ärzteforum

Post#6 »

Obviously, TRANSMEDIASTINAL INJURIES are associated with a high incidence of vascular and visceral injuries.

What to do in a stable patient is controversial at depends on the local unit policy and philosphy. In a stable case such as presented I would go for cardiac ultrasonogrpahy, and fibrooptic esophagoscopy. In the presence of normal vascular physical examination and absence of mediastinal widening on CXR I was trained to avoid angiography. CT is not fantastic but normal tissue plans adjacent to major vascular structure will exclude significant vascular injury. Certainly, angiography in this situation is not a mistake.

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