Trauma M

1
Trauma MM Conference

• 7/22/08

2
Trauma MM

• JJ
• 19 y/o M s/p GSW x 3 while at home by an intruder
• Specifically areas injured are left hand, left
  shoulder and torso
• Brought in on bb and c-collar. No acute distress.
  C/o Left upper extremity and chest pain
• GCS 15, no LOC
• Arrived at 1345 6/18/08

3
Trauma MM

• Primary Survey
• Airway- intact
• Breath Sounds- Equal B/L
• Cirulation- 18 in R antecubital
• BP-125/70 HR-83
• Disability- Left Hand, Left Shoulder decreased
  ROM
• Exposure-Full

4
Trauma MM

• Secondary Survey
• HEENT-Head-NC/AT Eyes-PERRL Ears-NT Nose-NT
  Mouth-NT Occlusion-Normal Facial Bones-NT
• Neck- Trachea-midline No creptiance No JVD No
  C-spine tenderness
• Chest- GSW to R torso, Left shoulder
• BS- Diminshed on R, Clear on Left
• Abd- Soft, NT, ND BS-active
• Pelvis- Stable

5
Trauma MM

• Secondary survey (cont.)
• Spine-No tenderness
• Back-No lesions
• Ext-
• LUE
• pain with abrasion
• Gunshot wound entrance to dorsal aspect at 1st
  metacarpal exit at base of 4th metacarpal
• sensation was intact, ROM decreased, warm to
  touch, good cap refill
• Other ext-normal
• Left Shoulder-
• Entry at lateral aspect of Deltoid, no exit wound
• Edematous, no sub q emphysema
• Neuro-No focal deficit

6
Trauma MM

• Labs
• Na-136 K-3.6 Cl-104 CO2-21 BUN-14 Crea-1.1
• Gluc-275
• Wbc-14.4 Hgb-12.3 Hct-34.1 Plt-279
• Etoh-lt10

7
Trauma MM

• Radiology
• CXR- bullet fragments seen overlying posterior
  aspect of 1st and 2nd rib
• Left Hand- comminuted fracture of 2nd mid
  metacarpal, spiral fx through the distal 1/3 of
  3rd metacarpal
• Left shoulder-nondisplaced distal clavicle
  fracture questionable acromoclavicular
  separation
• Left humerus- no fracture
• Left forearm- no fracture

8
Trauma MM

• Radiology
• CT Thorax and upper abd-
• bullet in anterior surface of soft tissue at
  right neck base
• 2nd bullet in anterior soft tissue near left
  clavicle near AC joint
• air in the superior mediastinum, extending to the
  base of the neck
• No Free air in abdomen
• Inflitrate in L UL c/w contusion

9
Trauma MM

• Consults
• Ortho-
• S/p GSW with Left 2nd and 3rd metacarpal fx Left
  nondisplace clavicle fx
• Wounds irrigated and splinted
• Transfer to Union or Shock trauma for hand
  surgery
• Shock trauma accepted patient no beds available
  at that time
• Trauma and Orthopedic attendings aware
• Plan to admit to Trauma and await transfer
• If no transfer an ID to be performed by Ortho in
  early AM

10
Trauma MM

• 3/18 2130
• Pt transferred to floor at 2130. No signs of
  distress. No new complaints
• 3/18 2250
• Red Surgery- Pt sleeping, no reported complaints.
  
• D/w with Ortho resident that pt still here
• Ortho plan for washout of hand in AM
• 3/19 0030
• Shock Trauma bed available
• Transferred to shock trauma

11
Trauma MM

• Upon arrival
• Pt complained of chest pain, mild distress
• History reviewed
• CT Head, C-spine, Chest Abd performed
• Air in the superior mediastinum noted

12
Trauma MM

• 6/19 Shock Trauma Work Up
• CT Head Neck with angiography
• Left Vertebral artery thrombosis
• Esophagus- no leak noted
• Bronchoscopy-negative
• EGD- Proximal esophagus at 20cm-transmural
  hematoma in the wall of the esophagus with some
  exudate on the mucosa.
• No loss of insufflation
• No apparent full thickness perforation noted
• However, full thickness injury could not be ruled
  out
• Plan
• Given the findings, and no absolute elimination
  of the possibility of an esophageal injury- a
  diagnostic exploration was performed
• OR for Neck exploration

13
Trauma MM

• Date of Procedure 6/20/08
• Post Op Dx- GSW to neck
• Procedure- Left neck exploration repair of
  esophagus
• Details of Procedure-
• Carotid sheath examined- intact
• Posterior lateral injury of the esophagus at the
  level of the thoracic inlet
• Hematoma noted- evacuated
• Transmural injury
• Closed in two layers

14
Trauma MM

• Transferred to ICU postoperatively
• Hemodynamically stable
• Eventually discharged
• Follow up with Shock Trauma

15
Trauma MM

• Complication
• Missed diagnosis- esophageal injury

16
Esophageal Injury

• Esophageal tear is defined as a breach of
  esophageal wall, whether due to a mucosal tear,
  perforation or rupture.
• An esophageal tear allows upper GI contents to
  egress from the esophageal lumen into the soft
  tissues of the neck, the mediastinum and pleural
  space, the peritoneal cavity, and possibly
  multiple sites, depending on the location of the
  injury.
• Cervical soft tissue infections, mediastinitis,
  pleuritis, or peritonitis ensue, followed by
  systemic sepsis and death if the condition
  remains untreated.
• Esophageal perforations or tears almost always
  require surgical correction, though a small and
  contained esophageal tear is occasionally managed
  expectantly.

17
Esophageal Injury

• Esophageal tears are estimated to occur in 1 of
  patients with blunt trauma, but they are far more
  common with penetrating or iatrogenic trauma.
• Esophageal rupture carries a high mortality rate
  secondary to rapidly developing mediastinitis.
• Survival improves dramatically if the esophageal
  injury is recognized and treated within 24 hours
  of its occurrence

18
Esophageal Injury

• Clinical presentation of esophageal tears/rupture
  includes hematemesis, chest pain, dysphagia,
  odynophagia and rapid onset of sepsis, fever,
  tachycardia, hypotension and shock.
• Patients often complain of sudden, sharp
  epigastric pain radiating to the interscapular
  area. Dyspnea, cyanosis, and shock are late
  symptoms

19
Esophageal Injury

• Diagnostic Modality
• CT findings of esophageal rupture include focal
  extraluminal air collections at the site of tear
  and a hematoma of the mediastinal or esophageal
  wall
• CT findings in esophageal tear/perforation can be
  summarized as follows Extraluminal air in the
  mediastinum/surrounding the esophagus is the most
  reliable sign and when taken in conjunction with
  the clinical presentation has 92 accuracy.

20
Esophageal Injury

• Esophageal perforations that are treated
  surgically within 24 hours have good results.
• The outcome obviously depends on comorbidity and
  to whether postoperative pulmonary complications
  occur.
• Even with prompt therapy, the mortality rate is
  high, varying from 30-50.

21
Esophageal Injury

• With delay in diagnosis, the mortality rate
  exceeds 90. Mortality rates from perforation
  caused by instrumentation are lower than other
  causes (15-20), although clearly still notable.
• Vertebral osteomyelitis has been reported in
  association with penetrating and after blunt
  traumatic esophageal rupture.