Trauma M

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Trauma MM

• 9/25/07
• Uliyargoli.A

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• 25 M, healthy
• Sitting on his door steps
• Heard GSW
• Noted pain in his Rt side
• Brought himself to the hospital

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• AAOx3, GCS-15
• Pulse- 80, Bp110/60, RR-18,Sats- 98
• Decreased breath sounds Rt. Chest
• Noted to have a single ballistic injury wound in
  his rt. Flank above the iliac crest
• No evidence of any other injury
• No neurological deficits

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Cxray and abd xray
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• Chest tube inserted into Rt pleural space
• Approx 600ml of fresh blood drained
• Fall in Bp- 90/60, mild abd. distension and
  increasing abd. tenderness
• Pt emergently taken to the OR- within approx
  30mts of presentation to the ER

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• Massive transfusion protocol activated
• Intubated in OR
• Exploratory laparotomy- midline incision
• Approx 800-1000ml of intra-peritoneal blood
  including clots
• No active bleeding identified after initial
  packing
• Entire abd evaluated

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• Bullet entry wound entering the peritoneum in the
  rt flank noted
• Laceration of the Segment 5 of the Liver
  traversing the posterior aspect of the
  gallbladder. Laceration extending to anterior
  liver edge
• Exit wound through dome of liver
• Diaphragmatic wound in the posterior aspect of
  the rt diaphragm
• No evidence of any bowel or mesentric injury

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• The pleur-evac was next investigated and approx
  1200ml of blood had been drained
• Pt remained fairly stable so far with systolic in
  the 90s-100s.
• Liver lnjury attended to- Gallbladder dissected
  and removed. CBD Normal. Small lacerated portion
  of liver extending to edge removed
• Liberal use of argon and electrocautery to attain
  hemostais in liver bed.
• Temporary closure of abd obtained

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• Pleur-evac re-examined Had drained another 600
  ml in a short period of time
• Decision made to explore the Rt hemithorax
• Chest tube removed and incision extended to open
  chest along 4th rib space
• There was a gush of a large amount of blood and
  pt. Bp fell precipitously to the 50s

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• Attempt made to control pul. Hilum. Incision ext.
  across sternum dividing the sternum for better
  exposure
• Obtained control of bleeding with digital
  pressure across hilum
• Pt resuscitated and stabilised
• Active bleeding noted to be coming from a sizable
  defect in the Rt. inferior pulmonary vein easily
  controlled with digital pressure

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• Thoracic surgeon was called who evaluated the
  injury
• Pericardium opened longitudinally to try to gain
  vascular control. Pul vein encircled and repaired
  with 4.0 prolene. Complete hemostasis achieved.
  Pericardium closed with continuous sutures
• The Rt lung middle lobe was lacerated- this was
  repaired using endo-GIA stapler.
• Chest closed placing two chest tubes

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• Bld loss 4L. 14PRBC, 12 plts, 7FFP, 8L fluids
• Transferred to SICU- HDS, not on any pressors
• POD 1 and 2 remained relatively stable. UO was
  good
• Some bile like drainage noted from the drains on
  his open abdominal wound dressings

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• Return to OR after 48 hrs
• Bile staining of the GB bed and porta hepatis
  noted
• Identifying cystic duct stump, CBD was dissected
  and CBD opened . Injury to CBD ruled out.
• Small amt of drainage noted to be coming from GB
  bed
• JP placed into GB fossa area and abd closed
• Also intra-op positioning of Dobhoff tube into
  proximal jejunum attained

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• Pt remained HDS.
• Extubated the next day
• Transferred to the floor
• Continued to have increasing drainage from his JP
  drain tube average 100-125 ml that was
  distinctly bilious. Amylase was negative. Did not
  show any down ward trend over the next several
  days.

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• GI consult obtained for an ERCP and
  decompression.
• Also pt developed fever on pod 5 form his second
  surgery, with elevated WBC, and underwent a CT
  scan

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• The two chest tubes were removed on POD 5 and 6
• Pt continued to progress well with his incisions
  healing well, tolerating a diet and decreasing JP
  output.
• Pt was discharged on POD 7

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• 1 days after discharge apparently pt developed
  fever and cough and went to a different hospital.
  Was apparently treated for pneumonia with
  moxifloxacin as a inpatient for 4 days and then
  discharged home.
• Returned again after another 2 days with
  increasing SOB

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• Underwent a CT scan that showed a pericardial
  effusion and also an bedside echo positive for a
  significant pericardial effusion
• Transferred back to Sinai
• Pt underwent a CT scan and rpt echo

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• Underwent emergent sub-xiphoid pericardial window
• Drained 900ml of SS fluid drained
• Pericardial space drained with a Blake drain
• Pt subhepatic drain had now become very clear
  serous fluid and the drain was dcd.

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• Normal pericardial fluid- 15-50ml
• Aetiology- Secondary to injury or insult to
  pericardium
• Exudative fluids - secondary to inflammatory,
  infectious, malignant, or autoimmune processes
  within the pericardium.

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• Symptoms based on rate of accumulation, slow
  progression may accumulate upto 2.0L
• Becks triad- hypotension, muffled heart sounds,
  jugular venous distension . Pericardial rub,
  widened pulse pressure, tachycardia,