Exam. On call that evening
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- Mervyn Ray
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1 On call that evening 27 y/o M, law student, GSW R. chest x 2 Breathing comfortably, phonating BP 118/p, 83, 22, GCS=15 A&A&O one GSW, R. axilla one GSW, R. lateral chest, ~ 3 rd intersp. One bullet palpable, sub-q, posterior midline at ~ T1 Exam No neurologic deficits No active bleeding No hematoma,, no bruit, no sub-q Q air No expectoration of blood or blood in mouth Patient had altered phonation w/ slightly hoarse, higher-pitched voice. No stridor. No dysphagia,, but c/o slight numbness in posterior oropharynx. What to do next? CT neck What next?
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3 CT neck: wet read bullet lodged adjacent to IJ v. & near carotid a. minimal hematoma,, no active bleeding substantial metal artifact:? Possible compression of IJ v. versus occulsion?? Possible filling defect (intimal( flap) in carotid a.? Normal carotid flow Pulmonary contusion tract RUL w/ blood What to do next?
4 Neck exploration: bullet found as shown & removed complete vascular dissection both IJ v. and carotid a. without hematoma,, laceration, dissection, or other evidence of injury No evidence of esophageal injury No evidence of tracheal injury What next (if anything)? intra-operative carotid doppler: : mild distal bruit Now what? carotid U/S about 8 hrs. later Now what? On re-operation IJ v. => no change carotid a. => subtle anteriolateral enlargement w/ focal discoloration of vessel wall. No thrill, good pulse. Now what? Heparin given, oblique arteriotomy => disrupted intima + media w/ small intimal flaps & developing pseudoaneurysm ~ 1 cm length Not amenable to simple repair of intima
5 Options? Segmental resection w/ primary repair? Graft interposition? (best material to use?) Partial resection w/ patch? (best material to use?) Is a carotid shunt needed? Now what? Damaged arterial wall resected Primary repair possible, but under tension Saphenous vein patch repair performed No shunt used (neosynephrine( for MAP) ENT => laryngoscopy unremarkable, fine-cut repeat CT unremarkable Uneventful recovery w/ slow improvement in phonation What follow-up? Case Presentation 17 year old girl struck by car Presents to ER hemodynamically stable, awake and alert with RR = 22 with CXR similar to the one on the right Pneumomediastinum is present medcyclopaedia/volume
6 22 yo male arrived in ER after multiple GSW to left flank, no exit wounds. GCS 15, BP 130/P, HR 84. Chest X-ray normal, Abd X-ray showed two bullet fragments adjacent to L-3 and one central bullet right mid abdomen. Normal urinalysis, no peripheral motor/sensory deficit, FAST exam positive for intra-abdominal blood, NG positive for blood. To OR: Laparotomy findings: ~500 ml fresh intra-abdominal blood, left retroperitoneal hematoma, large hematoma base of small bowel mesentery, multiple small bowel enterotomies, thru-and-thru transverse colon injury, blowout of fourth duodenum, moderate enteric spillage from duodenum and colon. Damage Control: Enterotomies rapidly controlled with suture ligation. Left medial visceral rotation revealed tangential 0.3 cm aortic injury distal to left renal artery, controlled with Satinsky clamp (partial interruption). Mesenteric hematoma explored: 2 cm laceration of superior mesenteric vein just beneath uncinate, controlled with bull-dog clamps. Repair: superior mesenteric venorrhaphy (one-hour bowel ischemia), suture repair of aortic injury with Teflon pledgettes. Transfusion: 32 U PC, 15 U FFP, 6 Plt Temporary abdominal dressing with Bogotá bag due to visceral edema
7 POD 2: Return to OR for primary repair of fourth duodenum, repair of colonic injuries and two other jejunal enterotomies. POD 3: Return to OR for leak of colonic repair and creation of transverse colostomy. Application of plastic covering POD 10: Massive hemorrhage from open abdominal cavity. To OR for control. Retroperitoneal source not accessible due to bowel swelling. Partial control with packing. Emergency angiography revealed ruptured mycotic aneurysm of aorta. Emergency endoluminal stent placed for control. Transfusion: 34 U PC, 18 U FFP and 6 U Plt Laparostomy performed every 3-5 days for 6 weeks with reapplication of wound vac. Primary fascial closure eventually achieved. Patient maintained on mechanical ventilation via tracheotomy for four weeks. Required percutaneous drainage of intra-abdominal collections from region of ligament of Treitz and retroperitoneum. Developed low out-put duodenal fistula that closed spontaneously Discharged ~12 weeks after injury Colostomy takedown one year later 2 weeks post-stent 6 weeks post-stent
8 Case Presentation Inebriated young man fell five stories from roof on to abdomen, chest and face Admitted to ER in shock intubated with Head injury GCS 3 Maxillofacial injuries Massive subcutaneous emphysema Tense distended abdomen Near amputation right foot Laparotomy Operating Room Tension pneumoperitoneum Air coming from mediastinum underneath xyphoid with each positive pressure breath Non-bleeding small splenic hematoma Abdomen closed rapidly with tube draining mediastinum Flexible Fiberoptic Bronchoscopy Management of Airway Normal Our patient Neck exploration: Larynx and cervical trachea in tact Right thoracotomy: mediastinal pleura intact, complete transection of trachea
9 Unknown man admitted after high speed MVA HR 110 BP 100/70 GCS 7 Next Step? Case Presentation CT Scan Diagnosis? Next Step? Findings Exploratory Laparotomy Ruptured Left Hemidiaphragm Avulsion of mesentery from splenic flexure Ruptured Spleen Procedure Reduction and Repair of Left Hemidiaphragm Splenectomy Damage Control Colon Resection Distal Pancreatectomy Plastic Abdominoplasty On Call September 21, y.o 300 pound man admitted with multiple GSW s to the back In shock Breathing spontaneously, Bilateral breath sounds What next???
10 Direct to OR Bilateral tube thoracostomy Bright red blood in Foley Laparotomy Blood in Abdomen Findings at Laparotomy Moderate amount of blood on right side of abdomen GSW to liver Stool in Abdomen, hole in hepatic flexure Huge right sided retroperitoneal hematoma What now??? Right medial visceral rotation Findings: Exsanguinating hemorrhage controlled with packs BP 60 systolic Thru and thru injury of head of pancreas and duodenum What now??? Courtesy
11 Thru and Thru Injury to IVC/Right Renal Vein Additional Injury GSW to right kidney Severe Right nephrectomy after single shot IVP confirms functioning left kidney Next steps Management of pancreas? Management of duodenum? Management of colon injury?
12 Procedure Pancreas drained Duodenum repaired Damage control right hemicolectomy Liver packed Open abdomen management 20 units packed cells, 9 units FFP, 6 platelet packs, Factor VIIa Immediate post op course Hyperkalemia 7.2 Serum creatine rise to 2.0 Minimal blood requirement Return to OR on September 23, 2008 Extensive leakage of pancreatic secretions from injury in head of pancreas Saponification over duodenal suture line What next????? Pyloric Exclusion Ileostomy Wide drainage Abdominal Closure
13 46 yo man arrived ED 02:00 after witnessed 6-story fall, unknown whether intentional or accidental. Found naked on sidewalk with GCS 10, moving all extremities. Bystanders noted that fall was interrupted by utility pole support lines, patient then fell onto a car windshield that was shattered and finally he fell to ground. Field exam: multiple minor abrasions and lacerations on back, BP 90/P, HR 126 (irregular), R 20 (regular), O 2 sat 100%. Glucose 126 ED: BP 75/58, HR 110, saturations 100%. GCS noted 8, right pupil 5 mm and non-reactive, moved all four extremities, intubated following rapid sequence induction Brief asystole, required closed chest massage, received epinephrine and atropine, return of pulse with BP 86/58 and HR 151. Transfused 2 units packed cells. ER Exam: no external signs of head injury, white powder caked over oral mucosa, chest and abdominal exams normal, no deformity of extremities. Chest and pelvic x-rays obtained. FAST exam normal.
14 Patient displayed persistent hemodynamic instability with systolic pressures ranging and HR Received 2 additional units of blood and total of 3.5 liter crystalloid, repeat FAST exam normal. Transport to CT scan Muscle relaxants dissipated. Responded to NaHCO 3 improved mental status (responded to commands and right pupil became reactive). CT head and chest unremarkable. Initial Labs: pre-transfusion Hct 46. ABG 6.8/54/327, CK 7697, Na 149, HCO 3 11, Anion Gap 38, BUN 33, Cr 1.64.
15 CT abdomen and pelvis: No intra-abdominal abdominal injury, a round 6 cm foreign body noted in rectum. Transport to ICU. BP and HR normalized over several hours. Tertiary skeletal survey revealed possible new L-1 compression fracture and right calcaneus fracture. Old right clavicle and T12-L3 fractures confirmed. Urine tox screen positive for methamphetamine. CK peaked at 22, hours after injury: Transport to OR for rectal foreign body extraction and washout/suture back lacerations. Removal of dog toy featuring internal light Extracted with obstetrical forceps Final Diagnoses: Glass lacerations of back Methamphetamine toxicity Arrhythmias Seizure, arrived post-ictal Muscle damage Minor fractures (calcaneus, L-1) Rectal foreign body Extubated and transferred to Psychiatry
16 Initial Therapy Splenectomy Closure of stomach wounds Repair of hepatic artery
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Arterial Blood Gas Interpretation Routine Assessment Inspection Palpation Auscultation Labs Na 135-145 K 3.5-5.3 Chloride 95-105 CO2 22-31 BUN 10-26 Creat.5-1.2 Glu 80-120 Arterial Blood Gases WBC 5-10K
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