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SURGERY CASE PRESENTATION

GENERAL DATA
RE 44 y/o male married Roman Catholic Valenzuela City Admitted for the 1st time October 1, 2011

CHIEF COMPLAINT Air gun shot Wound

HISTORY OF PRESENT ILLNESS


NOI: Air gun shot wound POI: JBC, Maysan ,Valenzuela City DOI: October 01, 2011 TOI: 9:30 AM
Few minutes PTA , patient working in a gunshop store was hit with a pellet at his abdomen when a customer accidentally fired an airgun. He was immediately brought to the ER.

PAST MEDICAL HISTORY


(-) HTN (-) DM (-) Asthma (-) Allergy (-) previous hospitalization

FAMILY HISTORY
(+) Hypertension (+) Diabetes mellitus (-) Asthma (-) Allergy

PERSONAL AND SOCIAL HISTORY


Smoker- quit smoking Smoker Occasional alcoholic beverage drinker

PHYSICAL EXAMINATION
General Survey: Patient was confused, stretcher bound, cardio-respiratory distress Vital Signs: BP : palpatory 60mmhg - 80/70 90/50mmhg PR : 130 pm RR : 22cpm T : 36.2 C

PHYSICAL EXAMINATION
Skin: Cold, moist, pale skin HEENT: - pale palpebral conjunctiva - anicteric sclerae - no nasoaural discharge - no tonsillopharyngeal congestion - no cervical lymphadenopathy Chest and Lungs: - tachypnic, symmetrical chest expansion - no retractions - vesicular breath sounds Heart: - adynamic precordium - tachycardic but with regular rhythm - no murmur

PHYSICAL EXAMINATION
Abdomen: Abdomen:
Sligthly Globular Air gun shot wound at RLQ approx 3cm above the midinguinal point hypoactive bowel sounds rigid, guarding Direct and rebound tenderness at lower abdomen with involuntary guarding

PHYSICAL EXAMINATION
Perineum: Perineum:
Normal external genitalia

Rectal:
Good sphincteric tone, (-) pararectal tenderness nor masses, ((-) blood on tactating fingers.

Extremities: Extremities
Grossly normal extremities ,no edema, no cyanosis, rapid and weak pulses (very weak pulses at right femoral and right dorsalis pedis pulses)

PERTINENT FINDINGS
44 y/o male Clammy Gunshot Wound RLQ Point of entry: RLQ Point of exit: none Rigid abdomen RLQ

ADMITTING DIAGNOSIS
Severe Hemorrhagic shock 2r to air gun shot wound RLQ Acute abdomen due to perforated hollow viscous

BASIS:
1. Severe hemorrhagic shock:
Air gun shot wound (right iliac region) Palpatory BP of 60 mmhg; pulse rate of 112/min Pale palpebral conjunctiva Tachypnic Adynamic precordium Cold clummy skin on extremities

Pathophysiology
Hypovolemic Shock (Hemorrhagic Shock):
most common Most of the blood is lost from systemic and small veins (50%) ----> decrease cardiac return ----> low cardiac output ----> decrease blood pressure

Degree of Hemorrhagic Shock


First Degree Hemorrhagic Shock:
< 15% blood lost (<750ml blood) adrenergic constriction of blood vessels in the skin thirsty, feels cold normal BP, PR and urine output Normal level of consciousness

Degree of Hemorrhagic Shock


Second Degree Hemorrhagic Shock:
15 30% blood loss (750 1500ml) (+) above signs and symptoms > 100 HR Orthostatic hypotension low urine output
Due to aldosterone and ADH

Anxious level of consciousness

Degree of Hemorrhagic Shock


Third Degree Hemorrhagic Shock:
30 40 % (1500 2000) blood lost Hypotension >120 pulse rate Confused signs of M.I. ---> Q waves and depressed St-T segments

Degree of Hemorrhagic Shock


Fourth Degree Hemorrhagic Shock:
> 40 % (>2000 ml) blood lost Severe Hypotension >140 pulse rate Obtunded

Hyperventilation:
with spontaneous deep breathing there is a decreased intra-thoracic ----> increase ventricular end diastolic volume ----> increase cardiac output.

Collapse:
Displaced blood from extremity to the heart and the brain

Release of fluid from the interstitium into the vascular space:


Epinephrine causes constriction of the arterioles and precapillary sphincter ----> decrease intracapillary hydrostatic pressure ----> influx of H2O, Na & Cl

OLIGURIA - Renal conservation of body H2O and electrolyte


aldosterone anti-diuretic hormone (vasopressin) Cathecolamine effect to afferent arteriole to the glomerulus
)

BASIS
2. ACUTE ABDOMEN probably due to perforated hollow viscous:
History of air gun shot wound at right iliac region Development of signs of peritonitis:
Direct and rebound tenderness Board like rigidity of the lower abdomen Hypotension

(?) Probable organ injured ----------------

Admitted the pt. - - - NPO IVF: PNSS 1L Q6hr RA PLR 1L Q8hr in LA Diagnostics: 1. CBC with ABO typing 2. Abdomen X-ray supine and upright X3. FAST (Focus Abdominal Sonography in Trauma) (?) (?) (?) 4. CBG-203 CBG5. Serum electrolyte 6. CXR PA 7. 12 L ECG Therapeutics 1. Tetavax 2.Tetagam 3.Cefuroxime 1.5 Gm STAT ANST(-) now and then 750mg Q8 hours ANST(4. Ketorolac 30 mg (Tramadol) Q 8 ANST(-) ANST(-

PLAN

PLAN
Foley catheterization and connect to Urobag (for measuring urine output) No hematuria NGT Insertion done O2 inhalation 2-3 L/ min Prepare 4 units of FWB properly typed and crossmatched Transfuse 1unit of FWB once available For Exploratory Lap (done within 2 hrs)

CBC
WBC Neutrophil Lymphocyte Monocyte Eosinophil Basophil

Normal values
5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.200.20-0.40 0.020.02-0.08 0.010.01-0.03 00-0.02

10/01/2011
10:03AM

9.9 0.38 0.57 0.05 0.02 0.01

HGb
HCt RBC MCV MCH MCHC RDW Platelet MPV PDW

M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL

7.6
0.43 4.42 96.8 33 341 11.0 168 5.7 17.4

Serum electrolytes

RESULT
(10//01/2011)

N.V.

Na K Ca Cl

139 3.9 106 *1.09

138-146mmol/L 1383.6-5.0mmol/L 3.61.15-1.29mmol/L 1.1596-110mmol/L 96-

Chest portable AP/Abdomen Portable AP Gunshot interpretation

Chest portable AP/Abdomen Portable AP Gunshot interpretation

Chest portable AP/Abdomen Portable AP Gunshot interpretation


Heart is not enlarged Clear lung fields Diaphragm and sinuses are normal Intact bony thorax Chest leads in place Essentially normal chest Negative for pneumoperitoneum Bowel gas pattern is non obstructive and non-specific Mottled radiolucencies suggestive of fecal materials Flank stripes and psoas structures are intact (?) Foreign metallic slug acted in the right pelvic cavity

IMPRESSION:

FAST WHOLE ABDOMEN ULTRASOUND(portable)


Gunshot wound (RLQ) October 01, 2011 Interpretation: Hypoechoec material seen in the splenic and hepatic area. Suggestive of hematoma formation

OPERATIVE TECHNIQUES AND FINDINGS


Midline Incision carried down to the peritoneum Findings:  3.5L Fresh and clotted blood  Blood clots at the retroperitoneal area  External iliac artery incomplete laceration. Ileal wall has 6 perforation caused by the pellet Pellet lodged to the psoas major

OPERATIVE TECHNIQUES AND FINDINGS


Repair of laceration of external iliac artery Enterrhoraphy Segmental resection of ileum with end to end enteroenterostomy ----- enterorrhaphy of an incomplete bowel wall involvement Peritoneal lavage Jackson Pratt drain was placed Closure of surgical wound Dressing

OPERATIVE TECHNIQUES AND FINDINGS


SUMMARY
PRE-OPERATIVE DIAGNOSIS: PREDIAGNOSIS: Hemorrhagic Shock 2* to Air Gunshot Wound R Pelvis Operation Performed: Exploratory Laparotomy, Performed: Evacuation of Hemoperitoneum Repair of R External Artery Laceration Segmental Resection of Ileum with perforation and end to end Ileo-ileostomy. Anesthesia: G/A Anesthesia:

OPERATIVE TECHNIQUES AND FINDINGS


POSTPOST-OPERATIVE DIAGNOSIS: DIAGNOSIS:
1. Hemorrhagic shock 2* to Lacerated R Iliac artery. 2. Peritonitis 2* Multiple Perforations in the Ileum

HISTOPATHOLOGY
Submitted Specimen : Ileum

POSTPOST-OPERATIVE
Placed in ICU VS Monitoring q15min O2 inhalation 3-4LPM 3 Connect ET to T-piece apparatus T Diet: NPO temporarily IVF: 1. D5LR 1L x 8hrs 2. D5NM 1L x 8hrs 3. D5W 1L x 8hrs

POSTPOST-OPERATIVE
Therapeutics: Therapeutics: 1. Cefuroxime 750mg TIV q8h 2. Metronidazole 500mg IV q 8hr 3. Parecoxib 40mg (Dynastat) IV q

12 4. Ketorolac 30mg TIV q8h PRN for severe pain . Transfuse another unit (500ml) FWB, Type . Repeat hgb,hct, determination 6 hours post BT . Specimen to lab for histopath exam

THE END

st 1

Hospital day SURGICAL notes


* Request for ABG * Request for CBC 6 hours post BT * Monitor urine output * Monitor JP drain and NGT * Refer immediately if sudden drop in BP * Start Nexium 40mg IV q 12hr Anesthesia notes: * Extubation done * Watch out for DOB and desaturation * Suction secretions

6:oopm Stable vital signs fully awake

8:30 pm fully awake BP-120/70 mmHg CR-85 cpm RR- 20 Temp-37.0*C

2nd Hospital Day (Day 1 post-op)


Vital Signs: BP mmHg PR RR T

: 120/80 : 20 bpm : 76 cpm : 37.3 C

(-) Flatus (-) Bowel mov t (-) fever (-) N/V JP drain 220mL Adequate UO

Diet NPO IVF to follow: D5LRS 1L x 8hours D5 NM1L x 8hours D5LRS 1L x 8hours Request for Serum electrolyte tom AM. May transfer to ROC this afternoon Deep breathing exercise Therapeutics: Cont. Present meds May give Paracetamol (Aeknil) 300mg IV ANST ( ) Diphenhydramine IV
Refer for difficulty of breathing Suction secretions

CBC
WBC Neutrophil Monocyte Eosinophil Basophil HGb HCt RBC MCV MCH MCHC RDW Platelet MPV PDW 5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL

10/02/2011
07:58AM

13.2 0.75 0.13 0.10

Lymphocyte 0.20-0.40 0.20-

97 0.29 3.38 85 28.8 34 14.4 68 4.74

3rd

Hospital Day (Day 2 post-op)

Vital Signs: * transfuse 1 unit of PRBC BP : 130/80 mmHg properly typed and crossmatched PR : 20 bpm Post BT Hgb after 4 hours RR : 80 cpm Diet: maintain on NPO T : 36.7 C IVF: D5 LR 1L D5NM 1L (-) Flatus D5NSS 1L (-) Bowel mov t * cont. meds (-) fever Diphenhydramine IV Adequate UO Paracetamol (Aeknil ) IV for fever JP drain- 205mL

CBC
WBC Neutrophil Monocyte Eosinophil Basophil HGb HCt RBC MCV MCH MCHC RDW Platelet MPV PDW 5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL

10/03/2011
7:08 AM

11.4 0.75 0.14 0.08 0.01 0.01 94 0.27 3.21 85 29.3 346 13.8 0.68 5.11

Lymphocyte 0.20-0.40 0.20-

Serum electrolytes

RESULT
(10/03/2011)

N.V.

Na K Ca Cl

139 3.8 106 *114

138-146mmol/L 1383.6-5.0mmol/L 3.61.15-1.29mmol/L 1.1596-110mmol/L 96-

4th

Hospital Day (Day 3 post-op)


* Consume IVF on L U Ext. * Clear liquids * May remove NGT * Bladder training and remove IFC after urges * IVF D5 LR 1L each to run D5 NSS 1L for 12 hrs * Conti. meds

Vital Signs: BP : 130/80 mmHg PR : 20 bpm RR : 82 cpm T : 36. 9C (+) Flatus (+) Bowel mov t (-) fever (-) N/V Adequate UO

CBC
WBC Neutrophil Monocyte Eosinophil Basophil HGb HCt RBC MCV MCH MCHC RDW Platelet MPV PDW 5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL

10/04/2011
7:38AM

6.3 0.72 0.17 0.07 0.03 0.01` 102 0.30 3.48 85 29.2 343 13.8 86 5.11

Lymphocyte 0.20-0.40 0.20-

CBC
WBC g/L Neutrophil Monocyte Eosinophil Basophil HGb 175g/L HCt RBC 12/L MCV MCH MCHC 5.05.0-10.0 x 10 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 5.58888-96 2727-33pg 300300-360g/L

10/01/2011
10:03AM

10/02/2011
07:58AM

10/03/2011
7:08 AM

10/04/2011
7:38AM

9.9 0.38 0.57 0.05 0.02 0.01 146 0.43 4.42 96.8 33 341

13.2 0.75 0.13 0.10 0.01 0.01 97 0.29 3.38 85 28.8 34

11.4 0.75 0.14 0.08

6.3 0.72 0.17 0.07 0.03 0.01`

Lymphocyte 0.20-0.40 0.20-

94 0.27 3.21 85 29.3 346

102 0.30 3.48 85 29.2 343

RESULT RESULT Serum (10//01/2011) (10/03/2011) electrolytes

N.V.

Na K Ca Cl

139 3.9 106 *1.09

139 3.8 106 *114

138-146mmol/L 1383.6-5.0mmol/L 3.61.15-1.29mmol/L 1.1596-110mmol/L 96-

5th Hospital Day (Day 4 post-op)


Vital Signs: BP : 120/80 mmHg PR : 20 bpm RR : 76 cpm T : 36.3 C afebrile (+) Flatus (+) Bowel mov t w/appetite Tolerate to clear liquid *JP drain 25 cc May give several liquids IVF: D5LR 1L x 12hrs D5LR 1L x 12hrs Therapeutics: Shift IV meds to oral meds: 1.Metronidazole 500mg/tablet Q 8* hrs 2.Cefuroxime 500mg/tablet Q 6* hrs 3.Esomeprazole (Nexium)40mg/tab OD 4.Etoricoxib (Arcoxia) 120mg/tab. OD 4.Etoricoxib - Remove J-P drain J-

th 6
Vital Signs: BP mmHg PR RR T : 120/80

HD (5th POD)
Diet: DAT IVF to consume

: 80 bpm : 20 cpm : 37.0 C

Cont. Oral meds

(+) Flatus (-) Bowel Movt (+) soft abdomen (-) fever

th 7
Vital Signs: BP mmHg PR RR T : 120/80

HD

th (4

POD)

For discharge Home Medications: 1. Cefuroxime 500mg/tab q8h x 5D : 88 bpm 2. Metronidazole 500mg/tab q8h x 3D : 19 cpm : 36.5 C FollowFollow-up after 1 week at Surgery OPD

(+) Flatus (+) Bowel Movt (+) soft abdomen (-) fever

5. Release of vasoactive hormones: 6. Resorption of fluid from intracellular to extracellular space:


Epinephrine, cortisol and glucagon increases concentration of interstitial glucose ----> extracellular hyperosmolality ----> draws H2O from cell ----> hydrostatic pressure in the interstitium ----> forced H2O and CHON into the lymphatics -------------> oncotic pressure intravascular ----> attracts H2O intravascularly further

Algorithm for the evaluation of penetrating abdominal injuries