Download - Case Conference Gun Shot Wounds
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Case ConferenceGun Shot Wounds
Aldwin Ong
09 March 2011
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General data• N.A.• 43 y/o • Male• Married• Payatas, Quezon City • Primary Informant: Patient (Reliability:
60%)• Secondary Informant: Wife (Reliability
70%)
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Chief complaint
• Multiple Gun Shot Wounds
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Brief Clinical HistoryNOI: Gunshot WoundsTOI: 4:00 amDOI: 2/22/11POI: Litex, Commonwealth
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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
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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
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AirwayPatient was alert, coherent, answers in phrases, with mild respiratory distressNo facial traumaCervical airway stabilized with Philadelphia collarGCS = 15
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BreathingCTT inserted with sanguinous output initially noted at <500 cc
Good fluctuationO2 sat at 98%
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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
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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
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DisabilityGCS 15(–) CN deficitsIntact Sensory5/5 motor strength all extremitiesNo gross deformities
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ExposureNoted Points of Entry:
L posterior occipital region of headL posterior axillary line, ≈4th ICS L posterior axillary line, ≈L2
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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
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Secondary SurveyHead-to-toe examination of orifices:
No epistaxisNo hemoptysisNo hemotympanumNo bleeding per rectum
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Tertiary SurveyGeneral Survey:
Awake, alert, with some apparent cardiorespiratory distress.
Vital Signs:BP 110/70 HR 88RR 22 T 36.6C
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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
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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.
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Tertiary Survey
• Cerebrum:• GCS 15• Conversant. Intact Sensorium.
Cerebellum:• No nystagmus, no tremors.• (–) Dysdiachokinesia
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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
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• Sensory:• Intact.
• Motor: R L
5/5 5/5 5/5 5/5
• DTR: Normal reflexes
Tertiary Survey
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Personal & Social History
• Denies smoking• Occasional alcoholic beverage
drinker• Denies illicit drug use
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Personal & Social History
• Previously worked as a seaman• Stopped working to help take
care of youngest child who is disabled.
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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
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Diagnostics DoneCBCUrinalysisCranial seriesCervical seriesCXR AP-LAbdominal AP-L
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Operation DoneEmergency Exploratory Laparotomy, evacuation of hemoperitoneum, ligation of omental bleeders, debridement, CTT re-insertion (2/22/11)
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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)
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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.
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Operation DoneExtraction of foreign body, mastoid process, temporal bone left, debridement of wound edges (2/26/11)
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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)
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Case discussion
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Trauma
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Primary SurveyAirwayBreathingCirculationDisabilityExposure
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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
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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)
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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
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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)
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CIRCULATIONAssure adequacy of tissue perfusion and control bleeding
Assess vital signsIdentify sites of bleeding
ChestAbdomenRetroperitoneumLong bonesExternal blood loss (street and sheets)
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CIRCULATIONControl hemorrhage
Direct pressures on open woundLigation of bleedImmediate immobilization/reduction of fractures in long bones and pelvisSurgery
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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)
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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
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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
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Secondary SurveyQuick History using the Mnemonic AMPLE
AMPLE Mnemonic:A – AllergiesM – MedicationsP – Past IllnessesL – Last MealE – Events preceding the incident/injury
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Secondary SurveyDetailed head-to-toe physical examinationReassess
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Tertiary SurveyDetailed, meticulous PE after definitive management
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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
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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
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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
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Psycho-socialTaking care of the family as the breadwinnerPatient has a disabled child
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Public healthReferral systems between hospitalsInitial care in hospitalsPublic safety
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Thank You !
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Case ConferenceGun Shot Wounds
Aldwin Ong
09 March 2011