Utkrisht Shah

DC 25 years old male Filipino Roman Catholic Gill Puyat

 NOI: Gun Shot Wounds

POI:Gill Puyat Station

DOI: 10/22/12

TOI: 11:30 pm

Airway: Not obstructed, in mild respiratory distress

Breathing Respiratory rate 24 spontaneous breathing clear breath sounds, no retraction

C irculation : BP 140/90, HR 111

Site of bleedings cleansed and packed with sterile gauze.

Disability GCS 15 (E4, V5, M6) weak looking, responds well to verbal stimuli.

Exposure Removed all clothes to identify for other possible sites of trauma and bleeding.

A - No known allergies M - No medications P - No known history of previous surgery and hospitalization. L - 10:30pm E few hours PTA,patient was in a drinking spree with his friends when allegedly two unknown assailants fired gun shots at him.

Multiple Gun Shot Wounds

Few hours PTA,patient was in a drinking spree with his friends when allegedly two unknown assailants fired gun shots at him. Patient was then taken to the nearest hospital at St Ana but was transferred to our institution for further management.

No HPN, DM, asthma, PTB, heart disease and cancer. No known allergies with food and drug.

Father: inguinal hernia Mother: none Siblings: None

technician Smoker2 pack years, on and off for 10 years Occasional consumer of alcoholic beverages. Patient denies use of illicit drugs.

General: no weight loss, no anorexia, no fever, no chills, no fatigue Skin: no jaundice, no pruritus, no rashes, no pallor Head: no headache, no dizziness Eyes: no change of vision, no pain, no discharge Ears: no hearing loss, no discharge, no pain

Nose: no obstruction, no discharge, no congestion, no epistaxis Mouth and Throat: no dysphagia, no hoarseness, no lesion Chest/Lungs: no chest pain, no dyspnea, no cough, no sputum, no hemoptysis, no shortness of breath Cardiovascular: no chest pain, no palpitation, no murmur, no arrhythmia

Gastrointestinal: no abdominal pain, no nausea, no vomiting, no diarrhea, no constipation Genito-urinary: no dysuria, no frequency, no urgency, no hematuria Musculoskeletal: (-) muscle pain, no joint swelling or redness, no stiffness, no weakness Nervous System: no LOC, no seizure, no dizziness

General Survey: Patient came by stretcher cart(via ambulance ), weak looking, responds to verbal stimuli, in mild respiratory distress

Vital Signs BP: 140/90 RR: 24cpm,

HR: 111bpm T: 36.4C

Bw:59kg, Ht: 165cm, BMI: 21.67

SKIN: multiple abrasion wound in both upper extremity.

HEENT: hair distribution equally, pale palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light (3mm), no change of vision and hearing, moist lips and tongue, no deviation of the uvula, no neck stiffness, no cervical lymphadenopathies, thyroid gland is normal size

Chest/Lungs: Equal expansion,clear breath, no retraction Heart: Adynamic precordium, no murmurs, regular rhythm , tachycardic Abdomen: flat, soft,tender, normoactive bowel sound, (+) GSW Left hemi abdomen no POEx

Extremities: multiple abrasions on upper extremities (+) GSW POE: right deltoid, POEx: right medial aspect arm (+) GSW POE:left anterior thigh medial aspect, POEx:left gluteal area Neurologic: no dizziness, no loss of conscious

25 years old Male GSW BP: 140/90 HR: 111bpm RR: 24cpm, T: 36.4C Pink palpebral conjunctivae

(+) GSW Left hemi abdomen no POEx (+) GSW POE: right deltoid, POEx: right medial aspect arm (+) GSW POE:left anterior thigh medial aspect, POEx:left gluteal area

Multiple gun shot wounds POE1 Left hemi abdomen no POEx POE2: right deltoid, POEx2: right medial aspect arm POE3:left anterior thigh medial aspect, POEx3:left gluteal area

Wound cleaning and packing . Tetanus toxoid and IgG administered. Monitored vital sings every 15 minutes For CBC, CXR, XR Abdomen and pelvis

WBC Hemoglobin Hematocrit Segmenters lymphocytes monocytes

17,000/cu mm 13.37gms/dl 40 % 73 % 26 % 1%

Chest XR: No significant findings Plain abdomen and pelvis: foreign body (slug) left gluteal region, can not rule out incomplete fracture at left iliac bone X ray right humerus: A comminuted fracture is se en at middle third of right humerus. The surrounding tissue appears prominent suggestive of soft tissue swelling

Wound dressing done, using betadine and sterile gauzes. Pressure dressings applied. IVF: LR 1L X 8 Patient admitted, vitals monitored every 15 minutes, patient prepared prepared for surgery.
Blood transfusion: PRBC blood 3units

For Ex LAP

+ multiple GSW with segments of jejunum 50 cm LOT, 40 cm LOT, 80 cm LOT(4 Points of entry/ exit) + 500 cc of blood evacuated + slug at left gluteal area no noted GSW at spleen, colon, rectum

Basillic vein identified , isolated and cut Feeding tube inserted and checked for patency Skin closed

S: (+) Pain 4/10 Severity on site of surgery.

O: BP: 140/90 HR: 111bpm RR: 24cpm, T: 36.4C Awake, comfortable responds to verbal stimuli, in mild respiratory distress. Patient unable to extend right thigh, partial wrist drop

A:Multiple gun shot wounds

POE1 Left hemi abdomen no POEx POE2: right deltoid, POEx2: right medial aspect arm POE3:left anterior thigh medial aspect, POEx3:left gluteal area

S/P EX LAP, segmental resection of small bowel with EEA, Ligation of muscle bleeders, insertion of JP drain, wound debridement of multiple gun shot wounds, removal of FB, protosigmoidoscopy slug.

PLAN:NPO IVF: D5W+ Tramadol drip (D5W 240 cc+ Tramadol 200mg)X 10 gtts/min. TF: D5ER 1 LX8 Monitor urine I/O 1 hr, refer if >30 cc/hr VS q2, deep breathing exercise

Metronidiazole 500 mg IV q8 Cefuroxime 750 mg IV q8 Pantoprazole 40 mg IV OD

WBC Hemoglobin Hematocrit Segmenters lymphocytes Eosinophil

7,200/cu mm 10.8gms/dl 32 % 74 % 22 % 4%

BUN Cr Na+ K+ Blood typing

7 0.66 142 3.0 A+

S: (+) Pain 5/10 Severity on site of surgery.

O: BP: 130/80 HR: 80bpm RR: 20cpm, T: 36.8C Awake, comfortable responds to verbal stimuli.Abdomen soft slIghtly distended, hypoactive bowel sounds, afebrile

A:Multiple gun shot wounds

POE1 Left hemi abdomen no POEx POE2: right deltoid, POEx2: right medial aspect arm POE3:left anterior thigh medial aspect, POEx3:left gluteal area

S/P EX LAP, segmental resection of small bowel with EEA, Ligation of muscle bleeders, insertion of JP drain, wound debridement of multiple gun shot wounds, removal of FB, protosigmoidoscopy slug. s/p venous cut down left Basillic vein

PLAN:NPO IVF: D5W+ Tramadol drip (D5W 240 cc+ adol 200mg)X 10 gtts/min. TF: D5ER 1L X 8 Monitor urine I/O 1 hr, refer if >30 cc/hr VS q2, deep breathing exercise Hold tramadol drip

Tram

Metronidiazole 500 mg IV q8 Cefuroxime 750 mg IV q8 Pantoprazole 40 mg IV OD

S: (+) Pain 4/10 Severity on site of surgery.

O: BP: 150/80 HR: 88bpm RR: 21cpm, T: 37.6C Awake, comfortable responds to verbal stimuli, abdomen slightly distended, hypoactive bowel sounds

A:Multiple gun shot wounds

POE1 Left hemi abdomen no POEx POE2: right deltoid, POEx2: right medial aspect arm POE3:left anterior thigh medial aspect, POEx3:left gluteal area

S/P EX LAP, segmental resection of small bowel with EEA, Ligation of muscle bleeders, insertion of JP drain, wound debridement of multiple gun shot wounds, removal of FB, protosigmoidoscopy slug. s/p venous cut down left Basillic vein

PLAN:NPO IVF: D5W+ Tramadol drip (D5W 240 cc+ Tramadol 200mg)X 10 gtts/min. TF: D5ER 1L X8 Monitor urine I/O 1 hr, refer if >30 cc/hr VS q2, deep breathing exercise Removal of IFC, patient advised to ambulate

Day 4- + flatus, patient advised to sit up and ambulate, alternate D5NMK with Sterofundin. may wet lips. Shift IV antibiotics to oral tablets. Ie Cefuroxime 500 mg tab q8 Metronidiazole 500 mg tab q8 Day 5- soft diet. Patient may go home and follow up on 10th day post OP.

1.

2.

Lack of a definitive treatment should not impede the application of the indicated treatment. Detail history is not essential to benign the evaluation of an acutely injured patient. Treat the greatest threat to life.

Primary survey (ABCDE) Resuscitaton Secondary survey Definitive management Tertiary survey-secondary survey after a definitive management

Treatment priorities A: airway maintenance + c-spine protection B: breathing & ventilation C: circulation & hemorrhage control D: disability- neurologic exam E: exposure/ environment control

- Patency/ obstruction - Severe head injury -> definitive airway - Airway: patency . maxillofacial trauma . neck trauma

- Jaw thrust/ chin lift - Naso/ oropharygeal airway - LMA (laryngeal mask airway) - Defintive airway(cuff in trachea) . oro/ naso tracheal intubation . surgical cricothyroidectomy, thracheostomy

- Indication . Provide patent airway . Deliver supplemental oxygen . Support ventilation . Prevent aspiration

- Cricothyroidectomy/tracheostomy - indication : unable to intubate (severe maxillofacial injury, failed intubation)

Life threatening conditions - Tension pneumothorax - Flail chest with pulmonary contusion - Massive hemothorax - Open pneumothorax - Cardiac tamponade

1.

History (AMPLE)

- Allergies - Medications - Past illness - Last meal - Events preceding the incident

2. Physical exam

- detailed meticulous head to toe exam - finger and tubes in all orifices - radiology (NO XRAY in primary survey) - look, listen, feel everywhere

 Kinematics is the science of motion. In h

uman movement, it is the study of the p ositions, angles, velocities, and accelerat ions of body segments. In gunshot woun ds (GSW) we can use this to determine th e extent of injury from the forces and mo tion involved

There are 3 primary factors that determine the extent of injury in GSW. 1. Frontal Area. 2. Velocity. 3. Distance

Frontal area is the surface area of the bullet th at strikes an object. Factors that increase front al area are: Profile. Tumble. Fragmentation.

A pointed bullet if crushed & deformed as the r esult of striking the human body, will have a m uch larger frontal area than before its shape wa s changed. A hollow point bullet is a good exa mple of this. It flattens & spreads on impact, st riking more tissue, creating a larger cavity & gr eater injury.

A bullets center of gravity is located nearer to the base than to the nose of the bullet. When t he nose of the bullet strikes an object it slows r apidly. Momentum continues to carry the base of the bullet forward causing an end-over-end motion or tumble. Tumble

Bullets with soft noses or vertical cuts increase damage by breaking apart on impact. The mas s of fragments produced creates a larger fronta l area than a solid bullet and energy is disperse d rapidly into the tissues. A shot gun injury is t he ultimate example of fragmentation.

Velocity is a key factor to the overall extent of GSW injuries. According to the kinetic energy equation: (kine tic energy = mass/ 2 x velocity2) Doubling the m ass doubles the energy, however doubling the velocity quadruples the energy. Therefore a small-caliber bullet traveling at hig h speed can produce a more extensive injury th an larger caliber bullet traveling at a lower spe ed.

Firearms are classified according to energy lev el as either: Medium velocity weapons or High velocity weapons.

These weapons are guns that have short barrel s,cartridges that contain small amounts of gun powder and muzzle velocities of less than 1500 feet / second. Example: All Hand guns & some rifles.

High velocity weapons include assault and hun ting rifles with a muzzle velocity of more than 1500 feet / second. These weapons use larger cartridges. As the a mount of gunpowder in the cartridge increases the speed of the bullet increases.

Distance is also important in severity of injury. Air resistance slows the bullet. Therefore incre asing the distance decreases the velocity result ing in less kinetic energy. Unfortunately most victims of GSW injuries are from close range.

Thorax- Gunshot wounds to the thorax may re sult in severe injury to the pulmonary & vascula r systems.

Pulmonary- If the lungs are penetrated by a bul let, the pleura & pulmonary parenchyma are di srupted producing a pneumothorax. On occasi on, the pulmonary defect allows air to continu e to flow into the thorax that cannot be expelle d. The subsequent increase in pressure may ev entually cause collapse of the lung creating a t ension pneumothorax.

Vascular- GSW injuries may result in massive in ternal & external hemorrhage. For example, if the pulmonary artery or vein, vena cava, or aorta is destroyed, exsanguination may occur rapidly. Other injuries include hemothorax, myocardial rupture, or pericardial tamponade

 GSWs to the extremities are occasiona

lly life threatening & may result in disa bility. Any GSW to the extremity should be ev aluated for bone injury, motor sensory integrity, & presence of adequate bloo d flow.

Special considerations include vascular injury with bleeding into soft tissues & damage to muscle, bones, & nerves.

There are several scoring systems in place to di fferentiate patients who would benefit from pri mary amputation versus those patients for wh om salvage of the limb should be attempted.

Mangled Extremity Syndrome Index- Involves point scales for degree of skin, nerve, vascular & bone injury,injury severity, age, concurrent medical conditions & time to vascular repair. (R equires surgical intervention for accurate deter mination)

Predictive Salvage Index- Use with lower extre mities, this system assigns points for the level of an injury, degree of bone & muscle injury & i nterval before arrival in the operating room. Limb Salvage Index- Based on duration of isch emia & severity of injury to artery, bone, muscl e, skin, nerve & deep veins.

SKELETAL SOFT TISSUE INJURY

Low energy(simple fracture , pistol gunshot wound)-1 Medium energy(open, multiple fractures, dislocation0-2 High energy ( rifle GSW)-3 Very high energy trauma and gross contamination-4

Limb ischemia Pulse reduced or absent but perfusion normal-1 Pulseless, paraesthesia's, diminished capillary refil-2 Cool, paralyzed, numb-3 Score doubled for ischemia> 6 hours

Shock Systolic BP> 90 -0 Hypotensive transiently 1 Persistent hypotension 2

Age Less than 30-0 30-50: 1 > 50- 2

Mangled Extremity Syndrome Index : 3

The trauma ex-lap is the most comprehensive ex-lap , usually undertaken after evidence of internal ble eding (a positive FAST, or other overwhelming evide nce for internal hemorrhage). Ex-lap can lead immediately to a number of other procedures, including splenectomy, hepatic resectio n, repairs of the vena cava, repairs of the aorta, repai rs of the iliac arteries or veins, distally and bowel repair, small bowel resection and nephrectomy.

The skin is incised with a surgical knife. The incisi on is then deepened through the subcutaneous f at (see the image below). Electrodiathermy in co agulation mode provides a bloodless access thro ugh this layer. The linea alba is identified as a glis tening layer deep to the subcutaneous tissues.

Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in 2 straight artery forceps placed close to each other at right angles to the incision. Use careful palpation to ensure that no bowel or omentum is picked up in the artery forceps. In reoperations, extreme care is necessary because the underlying bowel may be adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the incision appropriately.

The steps of exploration depend on the initial fin dings and are governed by the principles of syste matic survey and priority for life-saving maneuve rs.

fracture in which the bone involved in the fracture is broken into several pieces. At least three separate pieces of bone must be present for a fracture to be classified as comminuted.

Most common in elderly people or in people with conditions which weaken the bones, such as osteogenesis imperfecta or cancer. A comminuted fracture can also occur as the result of tremendous force, such as a car accident or a severe fall.

This type of fracture is usually easy to diagnose with an X-ray to look at the site of the suspected fracture.

Complications of comminuted fractures can include infection, compartment syndrome, vascular necrosis, and nonunion, in which the pieces of bone fail to join together.