Waldemar Machała Robert Brzozowski Katarzyna Rupenthal

1. Gunshot wound of the chest, abdomen and left arm(traversing gunshots). Analysis of emergency medicine, anesthesiology, surgery and intensive care procedures. • Waldemar Machała Robert BrzozowskiKatarzynaRupenthal Department of Anesthesiology and IntensiveCare TheMilitaryTeachingHospital-CSW MilitaryInstitute of Medicine, Warsaw Departmentof Combat Medicine Department of General, Oncological, Metabolical and ThoracicSurgery 5th Command Battalion Kraków The gen. bryg. Stefan Hubicki Military Center of MedicalEducation

2. Activities 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, 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, 2012. • Entry wound – covered with dressing. • Exit wound – secured with Asherman Chest Seal. • Right upper limb – not immobilized.

3. Activitiesinthe Trauma Roomgeneral 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.

4. Activities of theTraumaRoom team sustainedinjuries – chest

5. Activities of theTraumaRoom team sustainedinjuries – rightupper limb

6. Activities of theTraumaRoom team sustainedinjuries – rightupper limb

7. ActivitiesintheTraumaRoomprocedures • 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.

8. ActivitiesintheTraumaRoomprocedures • 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.

9. ActivitiesintheTraumaRoomprocedures • 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, FiO2: 0.5, VT: 650 ml; RR: 12/min.; ETCO2: 32-35 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.

10. Activitiesintheoperatingroomprocedures • 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.

11. Activitiesintheoperatingroomsurgicalprocedure • Emergencyclamshellthoracotomy. • Pericardiotomy, 100 cc of pericardialeffusionevacuated. • R hilarlungclamping. • Released of L lungmassivepleuraladhesions, 250 cc of pleuraleffusionevacuated. • RLL interstitialcontrolbleeding (GIA 90). • R diaphragminterruptedsuture.

12. Activitiesintheoperatingroomsurgicalprocedure • Emergencyexplorativelaparotomy. • Packing, bleedingcontrol. • Temporarily - by Foleyscatheterballoon - liver’sbleedingtamponade.

13. Activitiesintheoperatingroomsurgicalprocedure • Identification of organsinjury. • Disseminatedgranulomatous TBC process of the abdominalcavity. • Disseminatedgranulomatous TBC process of the lungs & pericardial fluid & L hydrothorax.

14. Activitiesintheoperatingroomsurgicalprocedure • Pericardialsacinterruptedsuture & pericardialdrainage. • Sternal wirefixation. • R & L drainchesttubes. • Chestwallsuture. Dressing. • Laparostomy, vacuum dressing. • Surgeryfinished: 0215 a.m. (time of surg.=175 min).

15. Activitiesintheoperatingroomorthopedicsurgery • GSW of the R armirrigation & debridement. • Comminuted R armfractureExternalFixationby Hoffmann II. • Orthopaedicsurgerytime: 65 min.

16. Activitiesintheoperatingroomprocedures • 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. 13 400 ml

17. Activitiesintheoperatingroomprocedures Istsurgery IIndsurgery

18. Activitiesinthe ICU afterthesurgicalprocedure • 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.

19. Reoperationin general surgery August8, 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.

20. Reoperationin general surgery August8, 2012 • Explorativelaparostomy. • Liver’spackingremoved. • Irrigation & control of abdominalcavity. • Abdominalwallsuture.

21. Patient’shistory • 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.

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