Gunshot wound of the chest, abdomen and left arm
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Gunshot wound of the chest, abdomen and left arm (traversing gunshots). Analysis of emergency medicine, anesthesiology, surgery and intensive care procedures. Waldemar MachałaRobert Brzozowski Katarzyna Rupenthal. Department of Anesthesiology and Intensive Care

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Waldemar MachałaRobert Brzozowski Katarzyna Rupenthal

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Waldemar macha a robert brzozowski katarzyna rupenthal

Gunshot wound of the chest, abdomen and left arm(traversing gunshots). Analysis of emergency medicine, anesthesiology, surgery and intensive care procedures.

  • Waldemar MachałaRobert BrzozowskiKatarzynaRupenthal

Department of Anesthesiology

and IntensiveCare

TheMilitaryTeachingHospital-CSW

MilitaryInstitute of Medicine, Warsaw

Departmentof Combat Medicine

Department of General, Oncological, Metabolical and ThoracicSurgery

5th Command Battalion

Kraków

The gen. bryg. Stefan Hubicki

Military Center of MedicalEducation


Activities of the trauma room team circumstances of the trauma

Activities of the Trauma Room team circumstances of the trauma

  • 30-year-old male: MN.

  • Height: approx. 6’1’’.

  • Body mass: approx. 121 lbs.

  • BMI: 16.1 kg/m2.

  • Details of the event – unknown: time 6:30 PM on August 5, 2012

    • Gunshot: entry wound: left hypochondriac region.

    • Exit wound: right pectoral region.

    • A traversing gunshot of the right arm (humerus fracture).

  • Brought to FOB Ghazni from the civilian hospital.

  • In Trauma Room: time 9:45 PM on August 5, 2012.

    • Entry wound – covered with dressing.

    • Exit wound – secured with Asherman Chest Seal.

    • Right upper limb – not immobilized.


  • Activities in the trauma room general condition

    Activitiesinthe Trauma Roomgeneral condition

    • Unconscious (GCS: 7 pts, i.e. 3/4; 1/6; 3/5).

    • Non-invasive blood pressure (NiBP): undetectable.

    • Heart rate (HR): 180/min.

    • Pulse detectable only on carotid and femoral arteries. Respiratory failure (SpO2: 70%).

    • Initial diagnosis:

      • Traversing gunshot wound of the chest (right pleural cavity hematoma).

      • Traversing gunshot wound of the right arm.

      • Hypovolemic shock.

      • Respiratory failure.


    Activities of thetrauma room team sustained injuries chest

    Activities of theTraumaRoom team sustainedinjuries – chest


    Activities of thetrauma room team sustained injuries right upper limb

    Activities of theTraumaRoom team sustainedinjuries – rightupper limb


    Activities of thetrauma room team sustained injuries right upper limb1

    Activities of theTraumaRoom team sustainedinjuries – rightupper limb


    Activities in thetrauma room procedures

    ActivitiesintheTraumaRoomprocedures

    • Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min.

    • Clinical examination.

    • Chest needle decompression (2nd right intercostal space at the midclavicular line).

    • Start of instrumental monitoring (ECG, HR, SpO2, NiBP).

    • IV access – 2x (1.2 mm and 1.4 mm) – left upper limb.

    • Blood tests: blood group + Rh, morphology, biochemistry, gasometry.

    • Fluids infusion:

      • 1000 mL of Sol. Ringeri.

      • 500 mL of 6% HAES.

  • e-Fast (+++).

  • Right pleural cavity drainage (drain No. 32 F) + active drainage:

    • 1500 mL of blood.


  • Activities in thetrauma room procedures1

    ActivitiesintheTraumaRoomprocedures

    • Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min.

    • Clinical examination.

    • Chest needle decompression (2nd right intercostal space at the midclavicular line).

    • Start of instrumental monitoring (ECG, HR, SpO2, NiBP).

    • IV access – 2x (1.2 mm and 1.4 mm) – left upper limb.

    • Blood tests: blood group + Rh, morphology, biochemistry, gasometry.

    • Fluids infusion:

      • 1000 mL of Sol. Ringeri.

      • 500 mL of 6% HAES.

  • e-Fast (+++).

  • Right pleural cavity drainage (drain No. 32 F) + active drainage:

    • 1500 mL of blood.


  • Activities in thetrauma room procedures2

    ActivitiesintheTraumaRoomprocedures

    • Endotracheal intubation, tube No. 9.0:

      • Ketamine: 2 mg/kg (100 mg).

      • Chlorsuccillin: 1.5 mg/kg (75 mg).

      • Fentanil: 3 mcg/kg (0.2 mg).

  • Mechanical ventilation, CMV, FiO2: 0.5, VT: 650 ml; RR: 12/min.; ETCO2: 32-35 mm Hg.

  • Right internal jugular vein cannulation – Seldinger.

  • Cervical spine immobilization.

  • Urine output monitoring (ml/kg/h).

  • Nasogastric tube.

  • Surgery qualification in emergency mode.

  • Transport to operating room.


  • Activities in the operating room procedures

    Activitiesintheoperatingroomprocedures

    • Placing the patient on the operating table (10:00 PM).

    • ASA physical status classification: IVE.

    • Connecting to the anesthetic workstation:

      • Oxygen + air + isoflurane (FiO2: 0.35; MAC: 1-1.5).

      • Fentanil (up to 5 mcg/kg) – up to 0.3 mg.

      • Rocuronium: 0.6 mg/kg (40 mg).

      • Pressure control in the intubation tube cuff.

  • Activating Walking Blood Bank + Level I.

  • Preparing the sterile field.

  • Femoral artery cannulation - unsuccessful.

  • Starting the operation.

  • Left radial artery cannulation (start of BP monitoring).

  • Starting the operation:

    • 2 surgeons + 2 operating room nurses.


  • Activities in the operating room surgical procedure

    Activitiesintheoperatingroomsurgicalprocedure

    • Emergencyclamshellthoracotomy.

    • Pericardiotomy, 100 cc of pericardialeffusionevacuated.

    • R hilarlungclamping.

    • Released of L lungmassivepleuraladhesions, 250 cc of pleuraleffusionevacuated.

    • RLL interstitialcontrolbleeding (GIA 90).

    • R diaphragminterruptedsuture.


    Activities in the operating room surgical procedure1

    Activitiesintheoperatingroomsurgicalprocedure

    • Emergencyexplorativelaparotomy.

    • Packing, bleedingcontrol.

    • Temporarily - by Foleyscatheterballoon - liver’sbleedingtamponade.


    Activities in the operating room surgical procedure2

    Activitiesintheoperatingroomsurgicalprocedure

    • Identification of organsinjury.

    • Disseminatedgranulomatous TBC process of the abdominalcavity.

    • Disseminatedgranulomatous TBC process of the lungs & pericardial fluid & L hydrothorax.


    Activities in the operating room surgical procedure3

    Activitiesintheoperatingroomsurgicalprocedure

    • Pericardialsacinterruptedsuture & pericardialdrainage.

    • Sternal wirefixation.

    • R & L drainchesttubes.

    • Chestwallsuture. Dressing.

    • Laparostomy, vacuum dressing.

    • Surgeryfinished: 0215 a.m. (time of surg.=175 min).


    Activities in the operating room orthopedic surgery

    Activitiesintheoperatingroomorthopedicsurgery

    • GSW of the R armirrigation & debridement.

    • Comminuted R armfractureExternalFixationby Hoffmann II.

    • Orthopaedicsurgerytime: 65 min.


    Activities in the operating room procedures1

    Activitiesintheoperatingroomprocedures

    • Mean arterial pressure (MAP) > 70 mm Hg.

    • BIS < 50.

    • TOF < 3 responses.

    • Urine output > 1.5 mL/kg/hour.

    • Normothermia (ReadyHeat).

    • Fluids:

      • 6500 mL of whole blood and RBCP.

      • 150 ml (10 IU) of cryoprecipitate.

      • 3500 mL of crystalloids.

      • 1000 mL of colloids.

      • 2000 ml of FFP.

      • 250 mL of HyperHAES.

        13 400 ml


    Activities in the operating room procedures2

    Activitiesintheoperatingroomprocedures

    Istsurgery

    IIndsurgery


    Activities in the icu after the surgical procedure

    Activitiesinthe ICU afterthesurgicalprocedure

    • Admission to ICU: time 3:30 AM on August 6, 2012.

    • Thoracic epidural catherer – Th3-Th4.

      • Trial dose: 4 mL of 2% lidocaine + 20 mcg of Adrenaline.

      • Basic dose: ICU:

        • 15 mL of 0.25% bupivacaine every 4 hrs. (e.g. 12, 16, 24, 4).

        • 15 mL of 0.25 bupivacaine with 3 mg of morphine every 12 hrs. (e.g. 8, 20).

  • Disconnecting from the respirator and extubation: time 7:30 AM on August 6, 2012.

  • Oxygen therapy – face mask.

  • Hemodynamically stable, cardiovascularly and respiratorily stable.

  • Peristalsis normal (even lively).

  • Enteral feeding and drinking – from 12:00 on August 6, 2012.


  • Reoperation in general surgery august 8 2012

    Reoperationin general surgery August8, 2012

    • Balanced anesthesia:

      • Induction: Propofol + FNT + cis-atracurium.

      • Conduction:

        • Oxygen + air + isoflurane (MAC: 1-1.5).

        • TEA: 18 mL of 0.375% Bupivacaine.

        • FNT + cis-atracurium.

    • Recovery:

      • Atropine.

      • Neostygmine.


    Reoperation in general surgery august 8 20121

    Reoperationin general surgery August8, 2012

    • Explorativelaparostomy.

    • Liver’spackingremoved.

    • Irrigation & control of abdominalcavity.

    • Abdominalwallsuture.


    Patient s history

    Patient’shistory

    • Discharged to the specialistic civilian hospital on August 9, 2012 at 1:00 PM (after 88 hrs of hospitalization in WEMSG, FOB Ghazni):

      • Cannula in right internal jugular vein.

      • Drain in right pleural cavity.

      • Drain in left pleural cavity.

      • Drain in abdominal cavity.

      • Right arm external stabilizer.

      • Urethral catherer.

      • Tuberculosis.


    Waldemar macha a robert brzozowski katarzyna rupenthal

    http://www.machala.info


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