Waldemar Machała Robert Brzozowski Katarzyna Rupenthal

Gunshot wound of the chest, abdomen and left arm(traversing gunshots).

Analysis of emergency medicine, anesthesiology, surgery and intensive care procedures.

Department of Anesthesiologyand Intensive Care

The Military Teaching Hospital-CSW

The gen. bryg. Stefan Hubicki Military Center of Medical Education

Military Institute of Medicine, WarsawDepartment of Combat Medicine

Department of General, Oncological, Metabolical and Thoracic Surgery

5th Command BattalionKraków

Activities of the Trauma Room team circumstances of the trauma

30-year-old male: MN.

Height: approx. 6’1’’.

Body mass: approx. 121 lbs.

BMI: 16.1 kg/m2.

Details of the event – unknown: time 6:30 PM on August 5, 2012

Gunshot: entry wound: left hypochondriac region.

Exit wound: right pectoral region.

A traversing gunshot of the right arm (humerus fracture).

Brought to FOB Ghazni from the civilian hospital.

In Trauma Room: time 9:45 PM on August 5, 2012.

Entry wound – covered with dressing.

Exit wound – secured with Asherman Chest Seal.

Right upper limb – not immobilized.

Activities in the Trauma Room general condition

Unconscious (GCS: 7 pts, i.e. 3/4; 1/6; 3/5).

Non-invasive blood pressure (NiBP): undetectable.

Heart rate (HR): 180/min.

Pulse detectable only on carotid and femoral arteries. Respiratory failure (SpO2: 70%).

Initial diagnosis:

Traversing gunshot wound of the chest (right pleural cavity hematoma).

Traversing gunshot wound of the right arm.

Hypovolemic shock.

Respiratory failure.

Activities of theTrauma Room team sustained injuries – chest

Activities of theTrauma Room team sustained injuries – right upper limb

Activities of theTrauma Room team sustained injuries – right upper limb

Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min.

Clinical examination.

Chest needle decompression (2nd right intercostal space at the midclavicular line).

Start of instrumental monitoring (ECG, HR, SpO2, NiBP).

IV access – 2x (1.2 mm and 1.4 mm) – left upper limb.

Blood tests: blood group + Rh, morphology, biochemistry, gasometry.

Fluids infusion:

1000 mL of Sol. Ringeri.

500 mL of 6% HAES.

e-Fast (+++).

Right pleural cavity drainage (drain No. 32 F) + active drainage:

1500 mL of blood.

Activities in theTrauma Room procedures

Activities in theTrauma Room procedures

Passive oxygen therapy – oxygen mask fresh gas flow 8 L/min.

Clinical examination.

Chest needle decompression (2nd right intercostal space at the midclavicular line).

Start of instrumental monitoring (ECG, HR, SpO2, NiBP).

IV access – 2x (1.2 mm and 1.4 mm) – left upper limb.

Blood tests: blood group + Rh, morphology, biochemistry, gasometry.

Fluids infusion:

1000 mL of Sol. Ringeri.

500 mL of 6% HAES.

e-Fast (+++).

Right pleural cavity drainage (drain No. 32 F) + active drainage:

1500 mL of blood.

Endotracheal intubation, tube No. 9.0:

Ketamine: 2 mg/kg (100 mg).

Chlorsuccillin: 1.5 mg/kg (75 mg).

Fentanil: 3 mcg/kg (0.2 mg).

Mechanical ventilation, CMV, FiO2: 0.5, VT: 650 ml; RR: 12/min.; ETCO2: 32-35 mm Hg.

Right internal jugular vein cannulation – Seldinger.

Cervical spine immobilization.

Urine output monitoring (ml/kg/h).

Nasogastric tube.

Surgery qualification in emergency mode.

Transport to operating room.

Activities in theTrauma Room procedures

Placing the patient on the operating table (10:00 PM).

ASA physical status classification: IVE.

Connecting to the anesthetic workstation:

Oxygen + air + isoflurane (FiO2: 0.35; MAC: 1-1.5).

Fentanil (up to 5 mcg/kg) – up to 0.3 mg.

Rocuronium: 0.6 mg/kg (40 mg).

Pressure control in the intubation tube cuff.

Activating Walking Blood Bank + Level I.

Preparing the sterile field.

Femoral artery cannulation - unsuccessful.

Starting the operation.

Left radial artery cannulation (start of BP monitoring).

Starting the operation:

2 surgeons + 2 operating room nurses.

Activities in the operating room procedures

Activities in the operating room surgical procedure

Emergency clamshell thoracotomy.

Pericardiotomy, 100 cc of pericardial effusion evacuated.

R hilar lung clamping.

Released of L lung massive pleural adhesions, 250 cc of pleural effusion evacuated.

RLL interstitial control bleeding (GIA 90).

R diaphragm interrupted suture.

Activities in the operating room surgical procedure

Emergency explorative laparotomy.

Packing, bleeding control.

Temporarily - by Foleys catheter balloon - liver’s bleeding tamponade.

Activities in the operating room surgical procedure

Identification of organs injury.

Disseminated granulomatous TBC process of the abdominal cavity.

Disseminated granulomatous TBC process of the lungs & pericardial fluid & L hydrothorax.

Activities in the operating room surgical procedure

Pericardial sac interrupted suture & pericardial drainage.

Sternal wire fixation.

R & L drain chest tubes.

Chest wall suture. Dressing.

Laparostomy, vacuum dressing.

Surgery finished: 0215 a.m. (time of surg.=175 min).

Activities in the operating room orthopedic surgery

GSW of the R arm irrigation & debridement.

Comminuted R arm fracture External Fixationby Hoffmann II.

Orthopaedic surgery time: 65 min.

Mean arterial pressure (MAP) > 70 mm Hg.

BIS < 50.

TOF < 3 responses.

Urine output > 1.5 mL/kg/hour.

Normothermia (ReadyHeat).

Fluids:

6500 mL of whole blood and RBCP.

150 ml (10 IU) of cryoprecipitate.

3500 mL of crystalloids.

1000 mL of colloids.

2000 ml of FFP.

250 mL of HyperHAES.

13 400 ml

Activities in the operating room procedures

Activities in the operating room procedures

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pH 7,217 7,024 7,279 7,317 7,448 7,46 7,441 7,485 7,464 7,568

pCO2 [mmHg]

38,2 43,5 53,9 49,7 38,3 37 42 39,8 36,5 31,1

pO2 [mmHg]

17 141 70 62 110 98 75 61 55 70

HCO3 [mmol/l]

15,5 11,3 25,3 25,5 26,5 26,3 28,6 30 26 28,4

BE [mmol/l]

-12 -20 -2 -1 2 2 4 7 2 6

Na[mmol/l]

141 144 146 145 143 142 141 139 141 136

K [mmol/l]

3,8 3,5 3,3 3,5 3,9 4,2 3,9 4,7 4,4 3,7

iCa [mmol/l]

1,08 1,26 0,97 1,12 1,29 1,27 1,15 1,12 1,12 1,1

Glu[mg/%]

237 163 241 221 171 115 56 75 71 63

Hct[%]

28 22 38 41 46 49,9 50 51 52 50

Hgb [g/dL]

9,5 7,5 12,9 13,9 15,6 17,7 17 17,3 17,7 17

ACT[sek.]

105 122 155

INR 1,8 1,3 1,5 1,5 1,8 1,7 1,9

Ist surgery IInd surgery

Admission to ICU: time 3:30 AM on August 6, 2012.

Thoracic epidural catherer – Th3-Th4.

Trial dose: 4 mL of 2% lidocaine + 20 mcg of Adrenaline.

Basic dose: ICU:

15 mL of 0.25% bupivacaine every 4 hrs. (e.g. 12, 16, 24, 4).

15 mL of 0.25 bupivacaine with 3 mg of morphine every 12 hrs. (e.g. 8, 20).

Disconnecting from the respirator and extubation: time 7:30 AM on August 6, 2012.

Oxygen therapy – face mask.

Hemodynamically stable, cardiovascularly and respiratorily stable.

Peristalsis normal (even lively).

Enteral feeding and drinking – from 12:00 on August 6, 2012.

Activities in the ICU after the surgical procedure

Balanced anesthesia:

Induction: Propofol + FNT + cis-atracurium.

Conduction:

Oxygen + air + isoflurane (MAC: 1-1.5).

TEA: 18 mL of 0.375% Bupivacaine.

FNT + cis-atracurium.

Recovery:

Atropine.

Neostygmine.

Reoperation in general surgery August 8, 2012

Reoperation in general surgery August 8, 2012

Explorative laparostomy.

Liver’s packing removed.

Irrigation & control of abdominal cavity.

Abdominal wall suture.

Discharged to the specialistic civilian hospital on August 9, 2012 at 1:00 PM (after 88 hrs of hospitalization in WEMSG, FOB Ghazni):

Cannula in right internal jugular vein.

Drain in right pleural cavity.

Drain in left pleural cavity.

Drain in abdominal cavity.

Right arm external stabilizer.

Urethral catherer.

Tuberculosis.

Patient’s history

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