priorities? always abcde 1. 2.3.4.5. exposure · 9/21/2017 1 15 year old male with single gsw to...
TRANSCRIPT
9/21/2017
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15 year old male with single GSW to left chest
Always ABCDE1. Airway
2. Breathing 3. Circulation4. Disability5. Exposure
Priorities?
ABCDE
Airway: Pt. is able to talk
Breathing: Diminished Bilaterally per EMS
Bilateral needle decompression performed by EMS
Treatment?
Bilateral chest tubes placed
Circulation: BP 91/55, HR 128, RR 30, Sats 100%,
2+ pulses in all extremities, IV access obtained
Disability: GCS 15. No focal neuro deficits
Exposure: Solitary GSW wound in left axilla
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Next Steps
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Follow-up CXR
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Trans-mediastinal GSWWhat could be injured?
1. Heart
2. Aorta/Vena Cava
3. Lungs/Bronchi
4. Esophagus
5. Diaphragm
6. Spleen
7. Stomach
8. Liver
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Decision Making
How to evaluate for each possible injury?
CT scan?
Ultrasound?
OR?
Chest or Abdomen First?
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Trans-mediastinal GSWWhat could be injured?
1. Heart—He’s not dead! FAST scan to evaluate for fluid in the pericardial sac
2. Aorta/Vena Cava—He’s not dead! But could have traumatic pseudoaneurysm. CTA chest
3. Lungs/Bronchi—No air leaks in chest tubes. Bronchoscopy
4. Esophagus—Needs EGD and Esophogram
5. Diaphragm—No great test for this injury. Needs OR to assess
6. Spleen—FAST scan. CT scan. Operate
7. Stomach—EGD, CT scan, Operate
8. Liver—CT scan. Operate7
CT Chest
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CT abdomen
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Order of Operation
Low suspicion of intra-abdominal injury based on CT scan, FAST scan, and clinical exam
However, cannot rule out diaphragm injury.
Started with simultaneous laparoscopy to rule bilateral diaphragm injury, intra-abdominal hemorrhage, or organ injury and endoscopy
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No diaphragm injury, No intra-abdominal injury
Bronchoscopy normal
EGD--
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Trans-mediastinal GSWWhat could be injured?
1. Heart—No pericardial effusion
2. Aorta/Vena Cava—No great vessel injury by CTA
3. Lungs/Bronchi—Bilateral PTX resolved with chest tubes. No air leaks. Normal bronchoscopy
4. Esophagus—Distal esophageal injury
5. Diaphragm—No injury by laparoscopy
6. Spleen--No injury by laparoscopy
7. Stomach--No injury by laparoscopy
8. Liver--No injury by laparoscopy
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Esophageal RepairLeft Thoracotomy due to distal location
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Follow-up
Discharged to home tolerating a regular diet the following week
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Summary
Always ABCDE first
Address life threatening injuries first
Assess what can be injured by the mechanism of injury
Identify and treat injuries
Questions?
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