Presentation on theme: "Waldemar Machała Robert Brzozowski Katarzyna Rupenthal"— Presentation transcript:
1Waldemar Machała Robert Brzozowski Katarzyna Rupenthal Gunshot wound of the chest, abdomen and left arm (traversing gunshots). Analysis of emergency medicine, anesthesiology, surgery and intensive care procedures.Department of Anesthesiologyand Intensive CareThe Military Teaching Hospital-CSWMilitary Institute of Medicine, WarsawDepartment of Combat MedicineDepartment of General, Oncological, Metabolical and Thoracic Surgery5th Command BattalionKrakówThe gen. bryg. Stefan HubickiMilitary Center of Medical Education
2Activities of the Trauma Room team circumstances of the trauma 30-year-old male: MN.Height: approx. 6’1’’.Body mass: approx. 121 lbs.BMI: 16.1 kg/m2.Details of the event – unknown: time 6:30 PM on August 5, 2012Gunshot: 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, 2012.Entry wound – covered with dressing.Exit wound – secured with Asherman Chest Seal.Right upper limb – not immobilized.
3Activities 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 (SpO2: 70%).Initial diagnosis:Traversing gunshot wound of the chest (right pleural cavity hematoma).Traversing gunshot wound of the right arm.Hypovolemic shock.Respiratory failure.
4Activities of theTrauma Room team sustained injuries – chest
5Activities of theTrauma Room team sustained injuries – right upper limb
6Activities of theTrauma Room team sustained injuries – right upper limb
7Activities in theTrauma Room procedures Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min.Clinical examination.Chest needle decompression (2nd right intercostal space at the midclavicular line).Start of instrumental monitoring (ECG, HR, SpO2, 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.
8Activities in theTrauma Room procedures Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min.Clinical examination.Chest needle decompression (2nd right intercostal space at the midclavicular line).Start of instrumental monitoring (ECG, HR, SpO2, 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.
10Activities in the operating room procedures Placing the patient on the operating table (10:00 PM).ASA physical status classification: IVE.Connecting to the anesthetic workstation:Oxygen + air + isoflurane (FiO2: 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.
11Activities 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.
12Activities in the operating room surgical procedure Emergency explorative laparotomy.Packing, bleeding control.Temporarily - by Foleys catheter balloon - liver’s bleeding tamponade.
13Activities 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.
14Activities 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: 0215 a.m. (time of surg.=175 min).
15Activities 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.
16Activities in the operating room procedures 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.3500 mL of crystalloids.1000 mL of colloids.2000 ml of FFP.250 mL of HyperHAES.ml
17Activities in the operating room procedures 21:4022:3200:2602:3307:4818:1707:3810:0211:5809:01pH7,2177,0247,2797,3177,4487,467,4417,4857,4647,568pCO2[mmHg]38,243,553,949,738,3374239,836,531,1pO217141706211098756155HCO3[mmol/l]15,511,325,325,526,526,328,6302628,4BE-12-20-2-12476Na144146145143142139136K3,83,53,33,94,24,74,43,7iCa1,081,260,971,121,291,271,151,1Glu[mg/%]237163241221171115567163Hct[%]282238414649,9505152Hgb[g/dL]9,57,512,913,915,617,717,3ACT[sek.]105122155INR1,81,31,51,71,9Ist surgeryIInd surgery
18Activities in the ICU after the surgical procedure Admission to ICU: time 3:30 AM on August 6, 2012.Thoracic epidural catherer – Th3-Th4.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, 2012.Oxygen therapy – face mask.Hemodynamically stable, cardiovascularly and respiratorily stable.Peristalsis normal (even lively).Enteral feeding and drinking – from 12:00 on August 6, 2012.
19Reoperation in general surgery August 8, 2012 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.
20Reoperation in general surgery August 8, 2012 Explorative laparostomy.Liver’s packing removed.Irrigation & control of abdominal cavity.Abdominal wall suture.
21Patient’s historyDischarged 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.