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 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 distress

No facial trauma

Cervical airway stabilized with Philadelphia collar

GCS = 15

BreathingCTT inserted with sanguinous output initially noted at <500 cc

Good fluctuation

O2 sat at 98%

BreathingInitial 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

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 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 headL 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 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 Line

POEn: 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 DoneCBC

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 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 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 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 Survey

Airway

Breathing

Circulation

Disability

Exposure

Immediate Life-threatening injuries to be identified during

the primary surveyA – 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 patencyAsk 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 bleedingChest

Abdomen

Retroperitoneum

Long bones

External blood loss (street and sheets)

CIRCULATION

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

CIRCULATION

Spinal cord injury protectionSCI may cause hypotension – neurogenic shockTreat with crystalloids

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

DISABILITY

Perform 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 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 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-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

Thank You !

Case Conference

Gun Shot Wounds

Aldwin Ong

09 March 2011