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Mortality Review: Critical Incidents

Mortality Review: Critical Incidents. Dr Tengku Abdul Kadir Tengku Zainal Abidin Supervised by: Dr Khairuddin Ismail. Patient History. Mr MASR 17YO Malay male Alleged MVA MB vs car near UNISZA – unsure mechanism, wearing helmet, unsure drug influence Brought to ED by JPAM.

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Mortality Review: Critical Incidents

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  1. Mortality Review: Critical Incidents Dr Tengku Abdul KadirTengkuZainalAbidin Supervised by: Dr Khairuddin Ismail

  2. Patient History • Mr MASR • 17YO Malay male • Alleged MVA MB vs car near UNISZA – unsure mechanism, wearing helmet, unsure drug influence • Brought to ED by JPAM

  3. Arrival at ED • Arrived at 1 am • GCS E1V2M5 (8/15), pupils (R) 4 mm sluggish (L) 3 mm reactive • Haemodynamically: BP 70-90/40-60, HR persistently tachycardic 110-160 • Intubated for airway protection by ED team • Fluid resuscitation: Total 14 pints IVD, 8 pints whole blood, 2 cycles DIVC then started on noradrenaline infusion

  4. Investigations • FBC • ABG: pH 7.14 pCO2 52 pO2 188 HCO3 17 BE -12 sO2 99 • FAST scan: Initially –ve x 4, then free fluid seen at hepatorenal and splenorenal area • Radiographs: • CXR normal • Pelvic x-ray: Dissociation of left SIJ 0.9 cm, pubic diasthesis 5 cm  post pelvic binder pubic diasthesis1.5 cm • Left humerus: Comminuted # midshaft • Left radial/ulnar: # distal 3rd radius with DRUJ disruption • Left hand: # neck of 5th MCB, # base 3rd and 4th MCB • CT brain normal

  5. Clinical Findings • Multiple abrasion and laceration wounds over face and scalp • No signs of basal skull fracture • Chest spring –ve • Abdomen distended over right side but soft • Deformed and oedematous left UL with puncture wound over hand • Swelling and haematoma extending from RIF to midthigh area, including bilateral scrotum

  6. Problem List Alleged MVA with polytrauma: • Severe head injury • Open book fracture • Intraabdominal injury • Open comminuted fracture midshaft left humerus • Open left Galeazzi fracture • Open fracture base of 3rd and 4th left MCB • Open fracture neck of 5th left MCB

  7. Progress • Primary team (surgical and orthopaedics) decided for operation • Surgical concerned of pelvic instability • Ortho: surgical should proceed in view of intraabdominal injury as pelvis stabilised with pelvic binder + external fixator may impede laparotomy • Case notified to anaes OT and confirmed OT at 6.07 am by ortho and 6.30 am by surgical • Called to OT at 6 am and was sent stat • Vital signs during transfer supported by noradrenaline double strength 10 ml/hour – BP 100/50, HR 100-127

  8. Events in OT • Arrived in OT 6.25 am • Patient intubated on manual bagging, GCS 2T/15, pupils (R) 4 mm sluggish (L) 3 mm sluggish • Clinically very pale, poor perfusion, poor PV • Abdomen distended and tense • Sedation IV midamorphine 1 ml/hour, noradrenaline 10 ml/hour • CVL inserted in OT (USG guided)

  9. Intra-operative Events • External pelvic fixation by orthopaedics started at 7.25 am and exploratomy, splenectomy and abdominal packing by surgical at 7.49 am • Intra-operatively, ventilated on PC FiO2 1 / PIP 14 / PEEP 8 • BP 94-125/40-60 (MAP 36-50), HR 80-98  titrate up noradrenaline to 25 ml/hour • Fluid resuscitation: 6 pints NS, 5 pints gelafundin, 1 cycle DIVC, 8 pints WB (urine output not documented) • Surgery ended 8.50 am, EBL 3000 ml

  10. Post-operative Events • BP 120/49, HR 89 (IV noradrenaline 25 ml/hour) • spO2 highest 93% on 100% O2 • Bradycardic then PEA at 9.25 am • CPR 20 minutes, IV adrenaline total 10 mg, blood and colloid pushed in • Persistent oozing from laparotomy site spilling onto bed – surgical informed • Fresh blood from ETT • Transferred to ICU with BP 120/77, HR 101

  11. Arrival in ICU ~ 9:45am • Arrived in ICU with IVI noradrenaline 35 ml/hour, IV dopamine 10 ml/hour • Cold peripheries, poor perfusion, very pale • Pupils 7 mm bilaterally fixed and dilated • Continuous bleeding from external fixation pin site and laparotomy wound with abdomen distended

  12. Deterioration ~10:00am • Cardiac monitor: HR 80-90, NIBP 66/30 • Slowly bradycardic then PEA • CPR commenced x 50 minutes • Total IV adrenaline total 10 mg • 1 pint crystalloid, 2 pints colloid, 3 pints WB pushed in; 1 cycle DIVC requested • Noradrenaline increased to 60 ml/hour, dopamine 20 ml/hour • Not reverted – asystole at 10:40am • COD: Severe abdominal injury complicated with DIVC and hypovolaemic shock

  13. Pelvic XR before pelvic clamp

  14. Pelvic XR after pelvic clamp

  15. FBC pre operation – on arrival

  16. PTTK, pre operation

  17. ABG trend

  18. Intraoperative monitoring

  19. Intraoperative monitoring

  20. Intraoperative monitoring

  21. FBC pre and post OP.

  22. Open for discussion… • 1. Delayed operation. • - time of resuscitation in ED • - late pelvic fixation. • - decision of operation 2. Intraoperation - Difficulty of IVL, art line, call for help? adequate team? - inform progress to sp? Communication. - unstable hemodynamically 3. Degree of bleeding - Diagnose severity of bleeding, %?, ABG, - restore perfussion, control bleeding. 4. Pre op assessment,plan. 5. Communication to specialist, team to team

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