Morbidity and Mortality Conference

1
Morbidity and Mortality Conference

• 10/24/2006

2
HPI

• MS- 14 y/o Female
• transferred from an outside hospital
• Sustained injury to epigastric region while
  playing soccer
• Knee to chest
• Stated she felt winded
• Removed herself for rest of the game
• After the game
• Continued abdominal pain
• Felt lightheaded
• Experienced one episode of nausea and vomiting

3
HPI

• Went to Emergency Room at outside facility
• Patient tachycardic with three more episodes of
  emesis
• Ct scan AP (Oral with no IV contrast) obtained
• Some free abdominal and pelvic fluid with several
  loops of thickened bowel with a few foci of air
  that was not clearly intraluminal and a small
  bowel contusion which could not be ruled out
• Patient stablized and eventually transferred to
  Sinai Hospital at request of accepting Surgical
  Attending

4
HPI

• Directly admitted to PICU
• Vitals-Tc 38.2 P 105 BP 100/56 O2 sat 98RA
• GEN- AAO x 3, mild distress
• CVS- S1 S2 Sinus Tachycardia
• Lung- CTAB
• ABD- Firm, epigastric tenderness, mild
  distention, active bowel sounds, negative
  rebound aggravated by movement, alleviated by
  lying still

5
HPI

• CT Scan AP (Oral without contrast)
• Physiologic free fluid, no free air, thickened
  loops of small bowel
• A/P
• NPO, IVF
• Serial Abdominal exams
• Repeat Ct scan in 24 hrs

6
Hospital Day 2

• Tmax 38.7 P-110 BP-100/50 O2sat-97
• ABD- Firm, continued mild distention, generalized
  tenderness, hypoactive bowel sounds, negative
  rebound
• Based on fever and increased tenderness, Upper GI
  series performed
• Posttraumatic edema and wall thickening with
  extravasation of contrast into the wall

7
Hospital Day 2

• Radiology- revised reading of CT AP with
  correlation of outside CT AP and UGI series
• Bowel wall edema with in the jejunum with tear in
  the wall of the jejunum (most likely) leaking
  fluid and contrast material
• Patient taken to the Operating Room for an
  Exploratory Laparotomy

8
BON

• PostOp Dx- Jejunal Perforation ( 2 cm)
• Procedure- Resection of jejunal perforation with
  primary anastomosis
• EBL-minimal
• Complications- none
• Drains- none
• Specimen- jejunum

9
Post Op Course

• POD 1- Hemodynamically stable
• POD 2- NGT d/ced
• POD 4-7- Bowel function returns diet started
  and advanced as tolerated
• POD 8- Tolerating Regular diet, afebrile, pain
  controlled
• Discharged Home

10
Complication

• Delay in diagnosis
• What could be done differently?
• Based on mechanism and clinical exam patient
  could be taken to Operating Room
• Decision to OR in this case was skewed by
  radiological assessment