Transcript Tertiary Survey

Case Conference
Gun 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 History
NOI: Gunshot Wounds
TOI: 4:00 am
DOI: 2/22/11
POI: 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
CBC
Hgb
Hct
WBC
N
L
M
Plt
BT
129 g/L
0.37
15.4
0.59
0.32
0.06
601
Labs Done:
CBC with Platelet
Blood Typing
Management Done:
TT and ATS given
Double Line placed
Foley Catheterization
NGT insertion
CTT insertion, left
Wounds Dressed
O+
SMPCH
Airway
Patient was alert, coherent, answers in phrases, with
mild respiratory distress
No facial trauma
Cervical airway stabilized with Philadelphia collar
GCS = 15
Breathing
CTT inserted with sanguinous output initially
noted at <500 cc
Good fluctuation
O2 sat at 98%
Breathing
Initial PE at SMPCH:
VS:
RR 22
Chest:
CTT inserted at 5th ICS L Ant Axillary Line
POEn: 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
Circulation
Initial 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 secs
Full and equal pulses
DRE:
(–) blood per finger
Disability
GCS 15
(–) CN deficits
Intact Sensory
5/5 motor strength all extremities
No gross deformities
Exposure
Noted Points of Entry:
L posterior occipital region of head
L posterior axillary line, ≈4th ICS
L posterior axillary line, ≈L2
Secondary Survey
HISTORY
A – No known allergies. Denies alcohol intake.
M – No medications
P – No known illnesses. No previous surgeries or
hospitalizations
L – Last Meal: 8 pm on the evening PTA (2/21/11)
E – Driving motorcycle home after taking wife to her
destination
Secondary Survey
Head-to-toe examination of orifices:
No epistaxis
No hemoptysis
No hemotympanum
No bleeding per rectum
Tertiary Survey
General Survey:
Awake, alert, with some apparent
cardiorespiratory distress.
Vital Signs:
BP 110/70
HR 88
RR 22
T 36.6C
Tertiary Survey
HEENT:
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.
Chest
CTT inserted at 5th ICS L Ant Axillary Line
POEn: L posterior axillary line, ≈4th ICS
(+) Supraclavicular and suprasternal retractions, resonant lung fields,
(+) Rhonchi, bilateral
Tertiary Survey
Abdomen:
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
Tertiary Survey

CRANIAL NERVES:
I
– Not tested
II
– 2-3mm briskly reactive to light,
III, IV, VI – Intact
V
– Intact
VII
– (–) facial asymmetry
VIII – No asymmetry
IX, X – (+) gag reflex
XI
– Intact
XII
– Midline tongue
Tertiary Survey
• Sensory:
• Intact.
• Motor:
•
R
L
5/5
5/5
5/5
5/5
DTR:
Normal reflexes
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 Occipital
2) 4th ICS L posterior axillary line
3) L flank
s/p Closed Tube Thoracostomy, L for
Hemothorax (2/22/11)
Diagnostics Done
CBC
Urinalysis
Cranial series
Cervical series
CXR AP-L
Abdominal AP-L
Operation Done
Emergency Exploratory Laparotomy,
evacuation of hemoperitoneum,
ligation of omental bleeders,
debridement, CTT re-insertion
(2/22/11)
Post-op Diagnosis
Hemoperitoneum secondary to omental
bleeders secondary to multiple gunshot
wounds: POEn
1) L Occipital
2) 4th ICS L posterior axillary line
3) 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 wards
Referred to neurosurgical service and TCVS
Neurosurgery service advised removal of slug
TCVS advised observation and referral to orthopedic
service regarding slug at the vertebral body of T8
Ortho service advised observation and bed rest for 3
weeks, and application of spine brace.
Operation Done
Extraction of foreign body, mastoid
process, temporal bone left,
debridement of wound edges
(2/26/11)
Final diagnosis
Foreign body, mastoid process, temporal bone, left
secondary to multiple gunshot wounds: POEn
1) L Occipital
2) 4th ICS L posterior axillary line
3) 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)
Trauma
Primary Survey
Airway
Breathing
Circulation
Disability
Exposure
Immediate Life-threatening injuries to
be identified during the primary survey
A – Airway obstruction, Airway injury
B – Tension pneumothorax, Open pneumothorax,
Flail chest with underlying pulmonary contusion
C – Hemorrhagic shock, Cardiogenic shock,
Neurogenic shock
D – Intracranial hemorrhage/mass lesion
E – for remaining injuries
AIRWAY
Guarantee patency
Ask questions like “What is your name?”
Indications for intubation:
Decreased mental status (GCS 8 or less)
Obstructed or partially obstructed airway
Hemorrhagic shock
Ineffective respiration (flail chest)
Combative patients (respiratory distress?)
Potential for airway deterioration (e.g. high C-spine injury)
AIRWAY
Assume a C-spine injury until the neck is
cleared
Maintain inline stabilization or C-collar
Assume that the patient has a full stomach and
is at risk of aspiration
BREATHING
Guarantee adequate oxygenation and ventilation
All trauma patients should receive supplemental oxygen
irrespective of the severity of injury
Airway patency alone does not assure adequate ventilation
Ventilation requires adequate function of the lungs, chest
wall, and diaphragm
Assess respiratory effort, breath sounds, and oxygen
saturation (if pulse oxymetry is available)
CIRCULATION
Assure adequacy of tissue perfusion and control bleeding
Assess vital signs
Identify sites of bleeding
Chest
Abdomen
Retroperitoneum
Long bones
External blood loss (street and sheets)
CIRCULATION
Control hemorrhage
Direct pressures on open wound
Ligation of bleed
Immediate immobilization/reduction of
fractures in long bones and pelvis
Surgery
CIRCULATION
Spinal cord injury protection
SCI may cause hypotension – neurogenic shock
Treat with crystalloids
Resuscitate
Place large bore peripheral IV access (minimum of
2 IV lines in hypotensive patient)
DISABILITY
Perform a cursory neurologic exam
Assess Glasgow Comma Scale
If patient is intubated or unable to verbalize
V = M(0.5) + E(0.4)
Assess sensory and motor function of the
extremities
EXPOSURE
Search for remaining injuries
Reassess vital signs
Is 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 Survey
Quick History using the Mnemonic AMPLE
AMPLE Mnemonic:
A – Allergies
M – Medications
P – Past Illnesses
L – Last Meal
E – Events preceding the incident/injury
Secondary Survey
Detailed head-to-toe physical
examination
Reassess
Tertiary Survey
Detailed, meticulous PE after definitive
management
Criteria for admitting Injured Patient
1. Penetrating injuries to head, neck, torso, and
2.
3.
4.
5.
6.
7.
8.
extremities proximal to the elbow and knee
Flail chest
Combination trauma with burns
Two or more proximal long-bone fractures
Pelvic fractures
Open and depressed skull fracture
Paralysis
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-social
Taking care of the family as the
breadwinner
Patient has a disabled child
Public health
Referral systems between hospitals
Initial care in hospitals
Public safety
Case Conference
Gun Shot Wounds
Aldwin Ong
09 March 2011