M M Conference

1
MM Conference

• 11/28/2006

2
HPI

• PB- 5 year-old F with Hx of congenital femoral
  deficiency and R fibular hemimelia (hypoplasia of
  the fibula). Previously undergone R femoral
  lengthening with an Orthofix device applied to R
  femur and a extension device to the R tibial
  region
• Was in route with her mother from Kentucky to
  Baltimore to have the external fixator removed,
  when they were involved in a single car rollover
  MVC
• Both mother and child were belted
• Both were airlifted to JHH Trauma center

3
HPI

• No reported LOC, brought in on BB with C-collar
• Trauma team at JHH evaluated and cleared both
  patients after negative examinations and normal
  CT scan of the head, neck, chest and abdomen.
• After Trauma clearance, the child was transferred
  the same day to Sinai Hospital for her intended
  Orthopedic Procedure

4
HPI

• Next morning, the pt. developed increasing
  generalized abdominal pain
• General Surgery was called for evaluation

5
Physical Exam

• Vitals- Temp- 36.6 P- 120 BP-104/59 100 O2
• Gen- AAO x 3, Mild distress. Answered
  appropriately
• HEENT- L eye strabismus
• CVS- S1 S2 RRR
• Lung- B/L CTAB
• Neuro- no focal deficit
• ABD- Firm, ND, LLQ tenderness, BS- active,
  rebound in LLQ
  ecchymosis (? Seatbelt bruise) in LLQ
• EXT- R LE Ext. Fixator- in place palpable LE
  pulses

6
Labs

• Na-137, K-3.6, CL-104, CO2-24, BUN-6, CREA-0.28,
  Glucose 103 Ca-8.6
• WBC-8.7, HGB-10.8, HCT-32.0, Plts-295
• PT-12, INR-1.2, PTT-32.1
• Urine output- 1.0 L/24 hrs

7
A/P

• 5 y/o F s/p MVC with acute onset abdominal pain
  with peritoneal signs and ecchymosis in the LLQ
• Plan
• To OR for DPL and possible Exploratory Laparotomy
• Followed by Orthopedic procedure

8
Operative Procedure

• DPL
• Open technique
• No signs of Gross blood
• Aspirate was not clear
• WBC-none
• RBC-no result
• Exploratory Laparotomy
• Four quadrant exploration followed by running of
  bowel
• No signs of active bleeding or perforated viscus
• Thorough irrigation
• Closure of abdomen

9
Operative Procedure

• Orthopedic procedure
• Closed reduction with application of the external
  fixation apparatus to R tibial region
• Removal of the external fixation apparatus to the
  R femur and tibia
• Prophylactic rodding of Right femur with Rush rod
• EBL- 150cc

10
Postoperative Course

• POD1
• Vitals- stable
• Hgb/Hct-9.1/27.7
• Abd- soft, ND, incisional tenderness, negative
  rebound
• POD2
• Vitals- stable
• Hgb/HCt-9.0/27.1
• Abd- soft, ND, incisional tenderness

11
Postoperative Course

• POD3
• Vitals- stable
• Hgb/Hct-9.1/27.8
• Abd- same
• return of bowel function
• Started and tolerated diet
• D/Ced on POD8
• Uncomplicated postoperative course from general
  surgery point of view

12
Complication

• Negative Laparotomy
• What could have been done differently?
• Ct scan vs observation
• pt stable, but displayed exquisite LLQ tenderness

13
Diagnostic Peritoneal Lavage

• DPL
• One the most sensitive test available for
  determination of intra-abdominal injury
• Indication
• used for blunt trauma
• ex. Falls, MVC, or severe blow to abdomen
• often patients are unstable

14
Diagnostic Peritoneal Lavage

• 2 approaches
• OPEN
• small infraumbilical incision (about 1/3 the
  distance from umbilicus to pubic symphysis)
• linea alba is sharply incised
• catheter pierces through peritoneum
• syringe placed on catheter
• Closed
• small periumbilical incision
• cannula used to penetrate both fascia and
  peritoneum
• flexible guidewire is then passed through cannula
• cannula then removed, and a catheter is then
  passed through guidewire
• syringe placed on catheter

15
Diagnostic Peritoneal Lavage
16
Diagnostic Peritoneal Lavage

• DPL
• If gt10cc of gross blood can be aspirated
• if lt10 cc aspirated then
• 1 liter of normal saline is instilled
• if RBC count gt100,000 is aspirated
• if detection of bile or fecal matter
• In equivocal cases, amylase and alkaline
  phosphatase levels could be analyzed
• WBC is not considered a valid indicator of
  intraperitoneal injury

17
Diagnostic Peritoneal Lavage

• Discussion
• Why to do it?
• Usually has a high sensitivity to evaluate for an
  intra-abdominal injury from blunt trauma
• Especially useful in unstable patients or
  unresponsive patients
• Open or Closed?
• Literature supports use of both
• Closed is quicker, but may have difficulty
  passing guidewire if cannula is not placed
  properly
• should then be converted to open
• Open is slower, but everything is under direct
  vision

18
Diagnostic Peritoneal Lavage

• Problems?
• Surgeons have little experience in performing DPL
• Hematology departments have trouble analyzing
  the sample
• Misses retroperitoneal bleeds, contained hematomas

19
HPI

• KH- 24 y/o M involved in a MVC
• Belted front seat passenger hit from behind by
  another vehicle
• Head through windshield?
• Found walking at scene
• brought in as an Echo code on 10/27 at 2025
• GCS 15, LOC
• called as a priority 1 in field

20
HPI

• Primary survey
• Right hip pain
• Secondary Survey
• AMPLE
• Allergies-none
• Meds-none
• PMHx-none
• Last meal- 4 hours prior
• Events- MVC
• limited ROM Right Lower extremity
• tenderness of Right hip on palpation

21
Diagnostics

• Chest X-ray- no acute process
• Pelvis X-ray- Right acetabular fracture
• CT Head- No intracranial abnormality seen
• CT C-Spine- No subluxation or fractures noted
• CT Right Hip- Right Acetabular fracture
• Fracture involves anterior and posterior border
  of acetabulum
• multiple small bony fragments in joint space

22
Events

• Orthopedic Sx called at 0100
• Orthopedic Sx responds at 0105
• Orthopedic attending advises that patient should
  be transferred to Shock Trauma for definitive
  treatment
• Trauma Service called at 0130 for evaluation
• Trauma team agreed with plan to transfer patient

23
Events

• ED called on-call trauma surgeon at Shock trauma
• after several hours, trauma surgeon calls back
  and accepts he patient
• No Beds available at that time
• By 1800 on 10/28 Trauma team at Sinai consulted
  about situation regarding patient
• Refer to Orthopedic surgery due to 24 hrs period
  elapsing

24
Events

• Orthopedics resident contacted at that time
• At 1930 the Orthopedic resident still had not
  come to the ED for admission/evaluation of the
  patient
• At 2000- Shock Trauma has an available bed and
  the patient is then transferred to the facility

25
Complication

• Delay in care
• In hospital for 24 hrs without primary service
• Problems
• Should be Delta code?
• Who is responsible for non Delta code patients
  with isolated injuries?
• Who was responsible for this patient?