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Case Conference Gun Shot Wounds Aldwin Ong 09 March 2011 General data • N.A. • 43 y/o • Male • Married • Payatas, Quezon City • Primary Informant: Patient (Reliability: 60%) • Secondary Informant: Wife (Reliability 70%) Chief complaint • Multiple Gun Shot Wounds Brief Clinical History NOI: Gunshot Wounds TOI: 4:00 am DOI: 2/22/11 POI: Litex, Commonwealth History of present illness 5 hours PTA Patient was on his motorcycle on his way back home, when he was “held up” and shot a few times from the back by an unknown individual while stopped. With helmet on, patient lost consciousness and fell off. EAMC- ER History of present illness EAMC CBC Hgb Hct WBC N L M Plt BT 129 g/L 0.37 15.4 0.59 0.32 0.06 601 Labs Done: CBC with Platelet Blood Typing Management Done: TT and ATS given Double Line placed Foley Catheterization NGT insertion CTT insertion, left Wounds Dressed O+ SMPCH Airway Patient was alert, coherent, answers in phrases, with mild respiratory distress No facial trauma Cervical airway stabilized with Philadelphia collar GCS = 15 Breathing CTT inserted with sanguinous output initially noted at <500 cc Good fluctuation O2 sat at 98% Breathing Initial PE at SMPCH: VS: RR 22 Chest: CTT inserted at 5th ICS L Ant Axillary Line POEn: L posterior axillary line, ≈4th ICS (+) Supraclavicular and suprasternal retractions, resonant lung fields, (+) Rhonchi, bilateral Abdomen: GSW L mid-axillary line, ≈L2 CNS: GSW L posterior occipital region of head Circulation Initial PE at SMPCH: VS: HR 88 BP 110/70 HEENT: Flat neck veins Chest: Adynamic precordium, normal rate, regular rhythm, distinct S1 & S2 Extremities: CRT < 2 secs Full and equal pulses DRE: (–) blood per finger Disability GCS 15 (–) CN deficits Intact Sensory 5/5 motor strength all extremities No gross deformities Exposure Noted Points of Entry: L posterior occipital region of head L posterior axillary line, ≈4th ICS L posterior axillary line, ≈L2 Secondary Survey HISTORY A – No known allergies. Denies alcohol intake. M – No medications P – No known illnesses. No previous surgeries or hospitalizations L – Last Meal: 8 pm on the evening PTA (2/21/11) E – Driving motorcycle home after taking wife to her destination Secondary Survey Head-to-toe examination of orifices: No epistaxis No hemoptysis No hemotympanum No bleeding per rectum Tertiary Survey General Survey: Awake, alert, with some apparent cardiorespiratory distress. Vital Signs: BP 110/70 HR 88 RR 22 T 36.6C Tertiary Survey HEENT: GSW measuring approx. 1 cm in diameter, (+) swelling, POEn: L occipital, head. Anicteric sclerae, pink palpebral conjunctivae. No gross facial deformities, no facial crepitus. Intact tympanum, no hemo-tympanum. Nostrils patent, midline septum, no epistaxis. Moist buccal mucosa, intact mandible, no trismus. No gross Neck veins not engorged. No TPC, No CLAD. Chest CTT inserted at 5th ICS L Ant Axillary Line POEn: L posterior axillary line, ≈4th ICS (+) Supraclavicular and suprasternal retractions, resonant lung fields, (+) Rhonchi, bilateral Tertiary Survey Abdomen: Distended abdomen, no ecchymosis. GSW approx 1 cm in diameter with serrated edges and contusion collar, POEn: L mid axillary line, ≈L2 level. Normoactive BS, tympanitic periumbilical region, dull towards the abdominal flanks (+) Direct tenderness on light palpation, Left hemi-abdomen; (+) Rebound tenderness whole abdomen DRE: No masses, lacerations, mucosal breaks. Good sphincter tone. No high riding prostate. No blood per rectum. Extremities: No jaundice, no cyanosis, no apparent edema. CRT <2 secs. Full and equal pulses. Tertiary Survey •Cerebrum: •GCS 15 •Conversant. Intact Sensorium. Cerebellum: •No nystagmus, no tremors. •(–) Dysdiachokinesia Tertiary Survey CRANIAL NERVES: I – Not tested II – 2-3mm briskly reactive to light, III, IV, VI – Intact V – Intact VII – (–) facial asymmetry VIII – No asymmetry IX, X – (+) gag reflex XI – Intact XII – Midline tongue Tertiary Survey • Sensory: • Intact. • Motor: • R L 5/5 5/5 5/5 5/5 DTR: Normal reflexes Personal & Social History • Denies smoking • Occasional alcoholic beverage drinker • Denies illicit drug use Personal & Social History • Previously worked as a seaman • Stopped working to help take care of youngest child who is disabled. Acute Surgical Abdomen secondary to Multiple Gunshot Wounds: POEn 1) L Occipital 2) 4th ICS L posterior axillary line 3) L flank s/p Closed Tube Thoracostomy, L for Hemothorax (2/22/11) Diagnostics Done CBC Urinalysis Cranial series Cervical series CXR AP-L Abdominal AP-L Operation Done Emergency Exploratory Laparotomy, evacuation of hemoperitoneum, ligation of omental bleeders, debridement, CTT re-insertion (2/22/11) Post-op Diagnosis Hemoperitoneum secondary to omental bleeders secondary to multiple gunshot wounds: POEn 1) L Occipital 2) 4th ICS L posterior axillary line 3) L flank s/p exploratory laparotomy, evacuation of hemoperitoneum, ligation of bleeders, debridement, CTT re-insertion, left, for Hemothorax (2/22/11) Course in the wards Referred to neurosurgical service and TCVS Neurosurgery service advised removal of slug TCVS advised observation and referral to orthopedic service regarding slug at the vertebral body of T8 Ortho service advised observation and bed rest for 3 weeks, and application of spine brace. Operation Done Extraction of foreign body, mastoid process, temporal bone left, debridement of wound edges (2/26/11) Final diagnosis Foreign body, mastoid process, temporal bone, left secondary to multiple gunshot wounds: POEn 1) L Occipital 2) 4th ICS L posterior axillary line 3) L flank s/p extraction, debridement of wound edges (2/26/11), s/p “E” Exploratory Laparotomy, Evacuation of Hemoperitneum, Ligation of bleeders for hemoperitoneum, debridement, CTT re-insertion, Left, for Hemothorax (2/22/11) Trauma Primary Survey Airway Breathing Circulation Disability Exposure Immediate Life-threatening injuries to be identified during the primary survey A – Airway obstruction, Airway injury B – Tension pneumothorax, Open pneumothorax, Flail chest with underlying pulmonary contusion C – Hemorrhagic shock, Cardiogenic shock, Neurogenic shock D – Intracranial hemorrhage/mass lesion E – for remaining injuries AIRWAY Guarantee patency Ask questions like “What is your name?” Indications for intubation: Decreased mental status (GCS 8 or less) Obstructed or partially obstructed airway Hemorrhagic shock Ineffective respiration (flail chest) Combative patients (respiratory distress?) Potential for airway deterioration (e.g. high C-spine injury) AIRWAY Assume a C-spine injury until the neck is cleared Maintain inline stabilization or C-collar Assume that the patient has a full stomach and is at risk of aspiration BREATHING Guarantee adequate oxygenation and ventilation All trauma patients should receive supplemental oxygen irrespective of the severity of injury Airway patency alone does not assure adequate ventilation Ventilation requires adequate function of the lungs, chest wall, and diaphragm Assess respiratory effort, breath sounds, and oxygen saturation (if pulse oxymetry is available) CIRCULATION Assure adequacy of tissue perfusion and control bleeding Assess vital signs Identify sites of bleeding Chest Abdomen Retroperitoneum Long bones External blood loss (street and sheets) CIRCULATION Control hemorrhage Direct pressures on open wound Ligation of bleed Immediate immobilization/reduction of fractures in long bones and pelvis Surgery CIRCULATION Spinal cord injury protection SCI may cause hypotension – neurogenic shock Treat with crystalloids Resuscitate Place large bore peripheral IV access (minimum of 2 IV lines in hypotensive patient) DISABILITY Perform a cursory neurologic exam Assess Glasgow Comma Scale If patient is intubated or unable to verbalize V = M(0.5) + E(0.4) Assess sensory and motor function of the extremities EXPOSURE Search for remaining injuries Reassess vital signs Is the patient stable? Has the patient’s response to fluid infusion and early stabilization appropriate? Look for areas where injuries are often missed, like axilla and perineum (this means removing the remaining clothing, if any). Logroll to visualize back Secondary Survey Quick History using the Mnemonic AMPLE AMPLE Mnemonic: A – Allergies M – Medications P – Past Illnesses L – Last Meal E – Events preceding the incident/injury Secondary Survey Detailed head-to-toe physical examination Reassess Tertiary Survey Detailed, meticulous PE after definitive management Criteria for admitting Injured Patient 1. Penetrating injuries to head, neck, torso, and 2. 3. 4. 5. 6. 7. 8. extremities proximal to the elbow and knee Flail chest Combination trauma with burns Two or more proximal long-bone fractures Pelvic fractures Open and depressed skull fracture Paralysis Amputation proximal to wrist and ankle Criteria for admitting Injured Patient 9. Significant underlying medical disease Cardiac disease or respiratory disease Diabetes Cirrhosis Morbid obesity Pregnancy Immunocompromised Bleeding disorders or in anticoagulation Criteria for admitting Injured Patient 10. Mechanism of Injury Ejection from automobile Death in the same passenger compartment Falls >20 feet High speed auto crash > 50 km/h Motorcycle crash of > 20 km/h High impact collision (pedestrian vs train) Separation of rider from motorcycle/bike Pedestrian thrown, rollover, or run-over 11. Age <5 or >55 Psycho-social Taking care of the family as the breadwinner Patient has a disabled child Public health Referral systems between hospitals Initial care in hospitals Public safety Case Conference Gun Shot Wounds Aldwin Ong 09 March 2011