case conference gun shot wounds aldwin ong 09 march 2011
TRANSCRIPT
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 Labs Done:CBC with PlateletBlood Typing
Management Done:TT and ATS givenDouble Line placedFoley CatheterizationNGT insertionCTT insertion, leftWounds Dressed
CBCHgb
129 g/LHct
0.37WBC 15.4
N0.59L0.32M 0.06
Plt601
BTO+
SMPCH
AirwayPatient was alert, coherent, answers in phrases, with mild respiratory distress
No facial trauma
Cervical airway stabilized with Philadelphia collar
GCS = 15
BreathingCTT inserted with sanguinous output initially noted at <500 cc
Good fluctuation
O2 sat at 98%
BreathingInitial 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
CirculationInitial 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 headL 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 SurveyHEENT:
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.
ChestCTT 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 SurveyAbdomen:
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
CRANIAL NERVES:I – Not testedII – 2-3mm briskly reactive to light,
III, IV, VI – IntactV – IntactVII – (–) facial asymmetryVIII – No asymmetryIX, X – (+) gag reflexXI – IntactXII – Midline tongue
Tertiary Survey
• Sensory:• Intact.
• Motor:
R L
5/5 5/5
5/5 5/5
• DTR: Normal reflexes
Tertiary Survey
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 Occipital2) 4th ICS L posterior axillary line3) L flank
s/p Closed Tube Thoracostomy, L for Hemothorax (2/22/11)
Admitting Diagnosis
Diagnostics DoneCBC
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 Occipital2) 4th ICS L posterior axillary line3) 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 diagnosisForeign body, mastoid process, temporal bone, left secondary to multiple gunshot wounds: POEn
1) L Occipital2) 4th ICS L posterior axillary line3) 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)
Case discussion
Trauma
Primary Survey
Airway
Breathing
Circulation
Disability
Exposure
Immediate Life-threatening injuries to be identified during
the primary surveyA – 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 patencyAsk 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 bleedingChest
Abdomen
Retroperitoneum
Long bones
External blood loss (street and sheets)
CIRCULATION
Control hemorrhageDirect pressures on open woundLigation of bleedImmediate immobilization/reduction of fractures in long bones and pelvisSurgery
CIRCULATION
Spinal cord injury protectionSCI may cause hypotension – neurogenic shockTreat with crystalloids
ResuscitatePlace large bore peripheral IV access (minimum of 2 IV lines in hypotensive patient)
DISABILITY
Perform a cursory neurologic exam
Assess Glasgow Comma ScaleIf patient is intubated or unable to verbalizeV = M(0.5) + E(0.4)
Assess sensory and motor function of the extremities
EXPOSURESearch for remaining injuries
Reassess vital signsIs 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 extremities proximal to the elbow and knee
2. Flail chest3. Combination trauma with burns4. Two or more proximal long-bone fractures5. Pelvic fractures6. Open and depressed skull fracture7. Paralysis8. 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
Thank You !
Case Conference
Gun Shot Wounds
Aldwin Ong
09 March 2011