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Waldemar MachałaRobert BrzozowskiKatarzyna Rupenthal Gunshot wound of the chest, abdomen and left arm (traversing gunshots). Analysis of emergency medicine,

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Presentation on theme: "Waldemar MachałaRobert BrzozowskiKatarzyna Rupenthal Gunshot wound of the chest, abdomen and left arm (traversing gunshots). Analysis of emergency medicine,"— Presentation transcript:

1 Waldemar MachałaRobert BrzozowskiKatarzyna Rupenthal Gunshot wound of the chest, abdomen and left arm (traversing gunshots). Analysis of emergency medicine, anesthesiology, surgery and intensive care procedures. Department of Anesthesiology and Intensive Care The Military Teaching Hospital-CSW The gen. bryg. Stefan Hubicki Military Center of Medical Education Military Institute of Medicine, Warsaw Department of Combat Medicine Department of General, Oncological, Metabolical and Thoracic Surgery 5th Command Battalion Kraków

2 Activities of the Trauma Room team circumstances of the trauma 30-year-old male: MN. Height: approx. 61. Body mass: approx. 121 lbs. BMI: 16.1 kg/m 2. Details of the event – unknown: time 6:30 PM on August 5, 2012 Gunshot: entry wound: left hypochondriac region. Exit wound: right pectoral region. A traversing gunshot of the right arm (humerus fracture). Brought to FOB Ghazni from the civilian hospital. In Trauma Room: time 9:45 PM on August 5, Entry wound – covered with dressing. Exit wound – secured with Asherman Chest Seal. Right upper limb – not immobilized.

3 Activities in the Trauma Room general condition Unconscious (GCS: 7 pts, i.e. 3/4; 1/6; 3/5). Non-invasive blood pressure (NiBP): undetectable. Heart rate (HR): 180/min. Pulse detectable only on carotid and femoral arteries. Respiratory failure (SpO 2 : 70%). Initial diagnosis: Traversing gunshot wound of the chest (right pleural cavity hematoma). Traversing gunshot wound of the right arm. Hypovolemic shock. Respiratory failure.

4 Activities of theTrauma Room team sustained injuries – chest

5 Activities of theTrauma Room team sustained injuries – right upper limb

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7 Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min. Clinical examination. Chest needle decompression (2 nd right intercostal space at the midclavicular line). Start of instrumental monitoring (ECG, HR, SpO 2, NiBP). IV access – 2x (1.2 mm and 1.4 mm) – left upper limb. Blood tests: blood group + Rh, morphology, biochemistry, gasometry. Fluids infusion: 1000 mL of Sol. Ringeri. 500 mL of 6% HAES. e-Fast (+++). Right pleural cavity drainage (drain No. 32 F) + active drainage: 1500 mL of blood. Activities in theTrauma Room procedures

8 Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min. Clinical examination. Chest needle decompression (2 nd right intercostal space at the midclavicular line). Start of instrumental monitoring (ECG, HR, SpO 2, NiBP). IV access – 2x (1.2 mm and 1.4 mm) – left upper limb. Blood tests: blood group + Rh, morphology, biochemistry, gasometry. Fluids infusion: 1000 mL of Sol. Ringeri. 500 mL of 6% HAES. e-Fast (+++). Right pleural cavity drainage (drain No. 32 F) + active drainage: 1500 mL of blood.

9 Endotracheal intubation, tube No. 9.0: Ketamine: 2 mg/kg (100 mg). Chlorsuccillin: 1.5 mg/kg (75 mg). Fentanil: 3 mcg/kg (0.2 mg). Mechanical ventilation, CMV, FiO 2 : 0.5, VT: 650 ml; RR: 12/min.; ETCO 2 : mm Hg. Right internal jugular vein cannulation – Seldinger. Cervical spine immobilization. Urine output monitoring (ml/kg/h). Nasogastric tube. Surgery qualification in emergency mode. Transport to operating room. Activities in theTrauma Room procedures

10 Placing the patient on the operating table (10:00 PM). ASA physical status classification: IV E. Connecting to the anesthetic workstation: Oxygen + air + isoflurane (FiO 2 : 0.35; MAC: 1-1.5). Fentanil (up to 5 mcg/kg) – up to 0.3 mg. Rocuronium: 0.6 mg/kg (40 mg). Pressure control in the intubation tube cuff. Activating Walking Blood Bank + Level I. Preparing the sterile field. Femoral artery cannulation - unsuccessful. Starting the operation. Left radial artery cannulation (start of BP monitoring). Starting the operation: 2 surgeons + 2 operating room nurses. Activities in the operating room procedures

11 Activities in the operating room surgical procedure Emergency clamshell thoracotomy. Pericardiotomy, 100 cc of pericardial effusion evacuated. R hilar lung clamping. Released of L lung massive pleural adhesions, 250 cc of pleural effusion evacuated. RLL interstitial control bleeding (GIA 90). R diaphragm interrupted suture.

12 Activities in the operating room surgical procedure Emergency explorative laparotomy. Packing, bleeding control. Temporarily - by Foleys catheter balloon - livers bleeding tamponade.

13 Activities in the operating room surgical procedure Identification of organs injury. Disseminated granulomatous TBC process of the abdominal cavity. Disseminated granulomatous TBC process of the lungs & pericardial fluid & L hydrothorax.

14 Activities in the operating room surgical procedure Pericardial sac interrupted suture & pericardial drainage. Sternal wire fixation. R & L drain chest tubes. Chest wall suture. Dressing. Laparostomy, vacuum dressing. Surgery finished: a.m. (time of surg.=175 min).

15 Activities in the operating room orthopedic surgery GSW of the R arm irrigation & debridement. Comminuted R arm fracture External Fixation by Hoffmann II. Orthopaedic surgery time: 65 min.

16 Mean arterial pressure (MAP) > 70 mm Hg. BIS < 50. TOF < 3 responses. Urine output > 1.5 mL/kg/hour. Normothermia (ReadyHeat). Fluids: 6500 mL of whole blood and RBCP. 150 ml (10 IU) of cryoprecipitate mL of crystalloids mL of colloids ml of FFP. 250 mL of HyperHAES ml Activities in the operating room procedures

17 : : : : : : : : : :01 pH7,2177,0247,2797,3177,4487,467,4417,4857,4647,568 pCO 2 [mmHg] 38,243,553,949,738, ,836,531,1 pO 2 [mmHg] HCO3 [mmol/l] 15,511,325,325,526,526,328, ,4 BE [mmol/l] Na [mmol/l] K [mmol/l] 3,83,53,33,53,94,23,94,74,43,7 iCa [mmol/l] 1,081,260,971,121,291,271,151,12 1,1 Glu [mg/%] Hct [%] , Hgb [g/dL] 9,57,512,913,915,617,71717,317,717 ACT [sek.] INR1,81,31,5 1,81,71,9

18 Admission to ICU: time 3:30 AM on August 6, Thoracic epidural catherer – Th 3 -Th 4. Trial dose: 4 mL of 2% lidocaine + 20 mcg of Adrenaline. Basic dose: ICU: 15 mL of 0.25% bupivacaine every 4 hrs. (e.g. 12, 16, 24, 4). 15 mL of 0.25 bupivacaine with 3 mg of morphine every 12 hrs. (e.g. 8, 20). Disconnecting from the respirator and extubation: time 7:30 AM on August 6, Oxygen therapy – face mask. Hemodynamically stable, cardiovascularly and respiratorily stable. Peristalsis normal (even lively). Enteral feeding and drinking – from 12:00 on August 6, Activities in the ICU after the surgical procedure

19 Balanced anesthesia: Induction: Propofol + FNT + cis-atracurium. Conduction: Oxygen + air + isoflurane (MAC: 1-1.5). TEA: 18 mL of 0.375% Bupivacaine. FNT + cis-atracurium. Recovery: Atropine. Neostygmine. Reoperation in general surgery August 8, 2012

20 Explorative laparostomy. Livers packing removed. Irrigation & control of abdominal cavity. Abdominal wall suture.

21 Discharged to the specialistic civilian hospital on August 9, 2012 at 1:00 PM (after 88 hrs of hospitalization in WEMSG, FOB Ghazni): Cannula in right internal jugular vein. Drain in right pleural cavity. Drain in left pleural cavity. Drain in abdominal cavity. Right arm external stabilizer. Urethral catherer. Tuberculosis. Patients history

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