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Case Conference Gun Shot Wounds

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: 6 0 %) Secondary Informant: Wife (Reliability 70%). Chief complaint. Multiple Gun Shot Wounds. Brief Clinical History.

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Case Conference Gun Shot Wounds

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  1. Case ConferenceGun Shot Wounds Aldwin Ong 09 March 2011

  2. General data • N.A. • 43 y/o • Male • Married • Payatas, Quezon City • Primary Informant: Patient (Reliability: 60%) • Secondary Informant: Wife (Reliability 70%)

  3. Chief complaint • Multiple Gun Shot Wounds

  4. Brief Clinical History • NOI: Gunshot Wounds • TOI: 4:00 am • DOI: 2/22/11 • POI: Litex, Commonwealth

  5. History of present illness 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. 5 hours PTA With helmet on, patient lost consciousness and fell off. EAMC- ER

  6. History of present illness Labs Done: CBC with Platelet Blood Typing EAMC • CBC • Hgb 129 g/L • Hct 0.37 • WBC 15.4 • N 0.59 • L 0.32 • M 0.06 • Plt 601 • BT • O+ Management Done: TT and ATS given Double Line placed Foley Catheterization NGT insertion CTT insertion, left Wounds Dressed SMPCH

  7. Airway • Patient was alert, coherent, answers in phrases, with mild respiratory distress • No facial trauma • Cervical airway stabilized with Philadelphia collar • GCS = 15

  8. Breathing • CTT inserted with sanguinous output initially noted at <500 cc • Good fluctuation • O2 sat at 98%

  9. 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

  10. Circulation • Initial PE at SMPCH: • VS: • HR 88 • BP 110/70 • HEENT: • Flat neck veins • Chest: • Adynamicprecordium, normal rate, regular rhythm, distinct S1 & S2 • Extremities: • CRT < 2 secs • Full and equal pulses • DRE: • (–) blood per finger

  11. Disability • GCS 15 • (–) CN deficits • Intact Sensory • 5/5 motor strength all extremities • No gross deformities

  12. Exposure • Noted Points of Entry: • L posterior occipital region of head • L posterior axillary line, ≈4th ICS • L posterior axillary line, ≈L2

  13. 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

  14. Secondary Survey Head-to-toe examination of orifices: • No epistaxis • No hemoptysis • No hemotympanum • No bleeding per rectum

  15. Tertiary Survey General Survey: Awake, alert, with some apparent cardiorespiratory distress. Vital Signs: BP 110/70 HR 88 RR 22 T 36.6C

  16. Tertiary Survey • HEENT: • GSW measuring approx. 1 cm in diameter, (+) swelling,POEn: L occipital, head. Anictericsclerae, 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

  17. 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, tympaniticperiumbilical 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.

  18. Tertiary Survey • Cerebrum: • GCS 15 • Conversant. Intact Sensorium. • Cerebellum: • No nystagmus, no tremors. • (–) Dysdiachokinesia

  19. 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

  20. Tertiary Survey • Sensory: • Intact. • Motor: R L 5/5 5/5 5/5 5/5 • DTR: Normal reflexes

  21. Personal & Social History • Denies smoking • Occasional alcoholic beverage drinker • Denies illicit drug use

  22. Personal & Social History • Previously worked as a seaman • Stopped working to help take care of youngest child who is disabled.

  23. Admitting Diagnosis • 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)

  24. Diagnostics Done • CBC • Urinalysis • Cranial series • Cervical series • CXR AP-L • Abdominal AP-L

  25. Operation Done • Emergency Exploratory Laparotomy, evacuation of hemoperitoneum, ligation of omental bleeders, debridement, CTT re-insertion (2/22/11)

  26. 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)

  27. 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.

  28. Operation Done • Extraction of foreign body, mastoid process, temporal bone left, debridement of wound edges (2/26/11)

  29. 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)

  30. Case discussion

  31. Trauma

  32. Primary Survey • Airway • Breathing • Circulation • Disability • Exposure

  33. 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

  34. 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)

  35. 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

  36. 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)

  37. 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)

  38. CIRCULATION • Control hemorrhage • Direct pressures on open wound • Ligation of bleed • Immediate immobilization/reduction of fractures in long bones and pelvis • Surgery

  39. 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)

  40. 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

  41. 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

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