Case ConferenceGun Shot Wounds

Aldwin Ong

09 March 2011

General data• N.A.• 43 y/o • Male• Married• Payatas, Quezon City • Primary Informant: Patient (Reliability:

60%)• Secondary Informant: Wife (Reliability

70%)

Chief complaint

• Multiple Gun Shot Wounds

Brief Clinical HistoryNOI: Gunshot WoundsTOI: 4:00 amDOI: 2/22/11POI: Litex, Commonwealth

History of present illness

5 hours PTA

Patient was on his motorcycle on his way back home, when he was “held up” and shot a few times from the back by an unknown individual while stopped.With helmet on, patient lost consciousness and fell off.EAMC- ER

History of present illness

EAMC Labs Done:CBC with PlateletBlood Typing

Management Done:TT and ATS givenDouble Line placedFoley CatheterizationNGT insertionCTT insertion, leftWounds Dressed

CBCHgb

129 g/LHct

0.37WBC 15.4

N0.59L0.32M 0.06

Plt601

BTO+

SMPCH

AirwayPatient was alert, coherent, answers in phrases, with mild respiratory distressNo facial traumaCervical airway stabilized with Philadelphia collarGCS = 15

BreathingCTT inserted with sanguinous output initially noted at <500 cc

Good fluctuationO2 sat at 98%

BreathingInitial PE at SMPCH:

VS: RR 22

Chest: CTT inserted at 5th ICS L Ant Axillary LinePOEn: L posterior axillary line, ≈4th ICS (+) Supraclavicular and suprasternal retractions, resonant lung fields, (+) Rhonchi, bilateral

Abdomen:GSW L mid-axillary line, ≈L2

CNS:GSW L posterior occipital region of head

CirculationInitial PE at SMPCH:

VS: HR 88 BP 110/70

HEENT:Flat neck veins

Chest:Adynamic precordium, normal rate, regular rhythm, distinct S1 & S2

Extremities:CRT < 2 secsFull and equal pulses

DRE:(–) blood per finger

DisabilityGCS 15(–) CN deficitsIntact Sensory5/5 motor strength all extremitiesNo gross deformities

ExposureNoted Points of Entry:

L posterior occipital region of headL posterior axillary line, ≈4th ICS L posterior axillary line, ≈L2

Secondary SurveyHISTORY

A – No known allergies. Denies alcohol intake.M – No medicationsP – No known illnesses. No previous surgeries or hospitalizationsL – Last Meal: 8 pm on the evening PTA (2/21/11)E – Driving motorcycle home after taking wife to her destination

Secondary SurveyHead-to-toe examination of orifices:

No epistaxisNo hemoptysisNo hemotympanumNo bleeding per rectum

Tertiary SurveyGeneral Survey:

Awake, alert, with some apparent cardiorespiratory distress.

Vital Signs:BP 110/70 HR 88RR 22 T 36.6C

Tertiary SurveyHEENT:

GSW measuring approx. 1 cm in diameter, (+) swelling, POEn: L occipital, head. Anicteric sclerae, pink palpebral conjunctivae. No gross facial deformities, no facial crepitus. Intact tympanum, no hemo-tympanum. Nostrils patent, midline septum, no epistaxis. Moist buccal mucosa, intact mandible, no trismus. No gross Neck veins not engorged. No TPC, No CLAD.

ChestCTT inserted at 5th ICS L Ant Axillary LinePOEn: L posterior axillary line, ≈4th ICS (+) Supraclavicular and suprasternal retractions, resonant lung fields, (+) Rhonchi, bilateral

Tertiary SurveyAbdomen:

Distended abdomen, no ecchymosis. GSW approx 1 cm in diameter with serrated edges and contusion collar, POEn: L mid axillary line, ≈L2 level. Normoactive BS, tympanitic periumbilical region, dull towards the abdominal flanks(+) Direct tenderness on light palpation, Left hemi-abdomen; (+) Rebound tenderness whole abdomen

DRE:No masses, lacerations, mucosal breaks. Good sphincter tone. No high riding prostate. No blood per rectum.

Extremities:No jaundice, no cyanosis, no apparent edema. CRT <2 secs. Full and equal pulses.

Tertiary Survey

• Cerebrum:• GCS 15• Conversant. Intact Sensorium.

Cerebellum:• No nystagmus, no tremors.• (–) Dysdiachokinesia

CRANIAL NERVES:I – Not testedII – 2-3mm briskly reactive to light, III, IV, VI – IntactV – IntactVII – (–) facial asymmetryVIII – No asymmetryIX, X – (+) gag reflexXI – IntactXII – Midline tongue

Tertiary Survey

• Sensory:• Intact.

• Motor: R L

5/5 5/5 5/5 5/5

• DTR: Normal reflexes

Tertiary Survey

Personal & Social History

• Denies smoking• Occasional alcoholic beverage

drinker• Denies illicit drug use

Personal & Social History

• Previously worked as a seaman• Stopped working to help take

care of youngest child who is disabled.

Acute Surgical Abdomen secondary to Multiple Gunshot Wounds: POEn

1) L Occipital2) 4th ICS L posterior axillary line3) L flank

s/p Closed Tube Thoracostomy, L for Hemothorax (2/22/11)

Admitting Diagnosis

Diagnostics DoneCBCUrinalysisCranial seriesCervical seriesCXR AP-LAbdominal AP-L

Operation DoneEmergency Exploratory Laparotomy, evacuation of hemoperitoneum, ligation of omental bleeders, debridement, CTT re-insertion (2/22/11)

Post-op DiagnosisHemoperitoneum secondary to omental bleeders secondary to multiple gunshot wounds: POEn

1) L Occipital2) 4th ICS L posterior axillary line3) L flank

s/p exploratory laparotomy, evacuation of hemoperitoneum, ligation of bleeders, debridement, CTT re-insertion, left, for Hemothorax (2/22/11)

Course in the wardsReferred to neurosurgical service and TCVSNeurosurgery service advised removal of slugTCVS advised observation and referral to orthopedic service regarding slug at the vertebral body of T8Ortho service advised observation and bed rest for 3 weeks, and application of spine brace.

Operation DoneExtraction of foreign body, mastoid process, temporal bone left, debridement of wound edges (2/26/11)

Final diagnosisForeign body, mastoid process, temporal bone, left secondary to multiple gunshot wounds: POEn

1) L Occipital2) 4th ICS L posterior axillary line3) L flank

s/p extraction, debridement of wound edges (2/26/11), s/p “E” Exploratory Laparotomy, Evacuation of Hemoperitneum, Ligation of bleeders for hemoperitoneum, debridement, CTT re-insertion, Left, for Hemothorax (2/22/11)

Case discussion

Trauma

Primary SurveyAirwayBreathingCirculationDisabilityExposure

Immediate Life-threatening injuries to be identified during

the primary surveyA – Airway obstruction, Airway injuryB – Tension pneumothorax, Open pneumothorax, Flail chest with underlying pulmonary contusionC – Hemorrhagic shock, Cardiogenic shock, Neurogenic shockD – Intracranial hemorrhage/mass lesionE – for remaining injuries

AIRWAYGuarantee patency

Ask questions like “What is your name?”

Indications for intubation:Decreased mental status (GCS 8 or less)Obstructed or partially obstructed airwayHemorrhagic shockIneffective respiration (flail chest)Combative patients (respiratory distress?)Potential for airway deterioration (e.g. high C-spine injury)

AIRWAYAssume a C-spine injury until the neck is cleared

Maintain inline stabilization or C-collarAssume that the patient has a full stomach and is at risk of aspiration

BREATHINGGuarantee adequate oxygenation and ventilation

All trauma patients should receive supplemental oxygen irrespective of the severity of injuryAirway patency alone does not assure adequate ventilationVentilation requires adequate function of the lungs, chest wall, and diaphragmAssess respiratory effort, breath sounds, and oxygen saturation (if pulse oxymetry is available)

CIRCULATIONAssure adequacy of tissue perfusion and control bleeding

Assess vital signsIdentify sites of bleeding

ChestAbdomenRetroperitoneumLong bonesExternal blood loss (street and sheets)

CIRCULATIONControl hemorrhage

Direct pressures on open woundLigation of bleedImmediate immobilization/reduction of fractures in long bones and pelvisSurgery

CIRCULATIONSpinal cord injury protection

SCI may cause hypotension – neurogenic shockTreat with crystalloids

ResuscitatePlace large bore peripheral IV access (minimum of 2 IV lines in hypotensive patient)

DISABILITYPerform a cursory neurologic exam

Assess Glasgow Comma ScaleIf patient is intubated or unable to verbalizeV = M(0.5) + E(0.4)

Assess sensory and motor function of the extremities

EXPOSURESearch for remaining injuries

Reassess vital signsIs the patient stable?Has the patient’s response to fluid infusion and early stabilization appropriate?

Look for areas where injuries are often missed, like axilla and perineum (this means removing the remaining clothing, if any).Logroll to visualize back

Secondary SurveyQuick History using the Mnemonic AMPLE

AMPLE Mnemonic:A – AllergiesM – MedicationsP – Past IllnessesL – Last MealE – Events preceding the incident/injury

Secondary SurveyDetailed head-to-toe physical examinationReassess

Tertiary SurveyDetailed, meticulous PE after definitive management

Criteria for admitting Injured Patient

1. Penetrating injuries to head, neck, torso, and extremities proximal to the elbow and knee

2. Flail chest3. Combination trauma with burns4. Two or more proximal long-bone fractures5. Pelvic fractures6. Open and depressed skull fracture7. Paralysis8. Amputation proximal to wrist and ankle

Criteria for admitting Injured Patient

9. Significant underlying medical disease- Cardiac disease or respiratory disease- Diabetes- Cirrhosis- Morbid obesity- Pregnancy- Immunocompromised- Bleeding disorders or in anticoagulation

Criteria for admitting Injured Patient

10.Mechanism of Injury- Ejection from automobile- Death in the same passenger compartment- Falls >20 feet- High speed auto crash > 50 km/h- Motorcycle crash of > 20 km/h- High impact collision (pedestrian vs train)- Separation of rider from motorcycle/bike- Pedestrian thrown, rollover, or run-over

11.Age <5 or >55

Psycho-socialTaking care of the family as the breadwinnerPatient has a disabled child

Public healthReferral systems between hospitalsInitial care in hospitalsPublic safety

Thank You !

Case ConferenceGun Shot Wounds

Aldwin Ong

09 March 2011