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BY THE GRACE OF GOD AND ENCOURAGEMENT GIVEN BY OUR
HOD WE WERE ABLE TO GO AHEAD AND HELPED US TO SAIL SAFELY
MORBIDITY and MORTAILITY
36 yr Niaz Ahamed
RTA With POLYTRAUMA
R shaft of humerus fracture
Blunt Trauma Abdomen
DOA -6/12/2017
Wt-80 kgHt -170cm
Team involved
Dr.Charles Assoc.Prof
Dr.Yasha SR
Dr.Daniel PG
Dr.Harith PG
Dr.Monisha PG
History• H/o RTA two wheeler collision with bus at 3.pm
• h/o injury to the abdomen and Right upper limb
• h/o injury to the chest
• No h/o ENT bleed LOC, Seizure ,vomiting,Headinjury
• Shifted to Cuddalore GH,treated conservatively.
• Referred here for further management
• h/o k/c/o alcoholic,smoker
• No h/o any other comorbidities
Primary Survey• Airway
Patent Airway
• BreathingRR 24/min SpO2 100% room airB/L AE + No adventitious sounds
• CirculationPR 150 BP 140/90
• DisabilityGCS 13/15 E4 V4 M5 Pupils b/l reacting to light
• ExposureDeep lacerated wound over the Ant.Aspect of Right shoulderActive bleeding + Compression bandage in situR arm Swelling
deformityBony crepitusRadial Pulse was Present
• Patient became irritatable
• Drop in GCS
Airway was secured with 8 size tube PCV at 5.00pm• Fast Scan 2- Minimal free fluid collection in the Pelvic
region.
No fluid present in the Morrison's pouch and splenorenal space
No evidence of pleural effusion and pericardial effusion noted
Fluid was aspirated under aseptic precaution content was blood
One unit O-ve
Two units of B+ve was transfused
Investigations
• Hb : 10.1 gm %• TC : 23,600• Platelet : 2,08,000
• RBS : 223mg/dl• Urea 28• Creatinine 1.75• Na 136• K 3.4• Cl 108
• Blood Group : B positive
LFT
• alb :3.7• Total P:5.5• T.Billirubin 0.7• Direct 1.8• AST 986• ALT 415• ALP 56
Investigations
• PT 18.8• INR 1.42
ABG • PH 7.21
Pco2 39Po2 295
HcO3 15.6 FiO2 100%
Investigations
CPK MB 155 U/LTroponin IPositive
ANAESTHETIC PLAN
Peri-op Risk Factors
• Obese• RTA with multiple
injuries(Poly trauma)• Inferolateral MI• Alcoholic• Smoker
• Incision• Increase risk of
Bleeding• Prolonged surgery• Hypothermia• Vascular repair
• Hypovolemia• Metabolic Acidosis• Massive
transfusion• HAEMORRHAGIC
shock• Arrhythmias• Cardiac arrest
Patient factors
Surgical factorsAnaesthesia factors
• Genral Anaesthesia• Invasive Lines.• Inotropes to be kept ready• To release 4 units of PRBC • Defibrillator.• Body warmer and fluid warmer.• Consent to be obtained.• Taken Under ASA 5E
R IJV CVC ,L radial arterial ,Left arm 16G,L EJV 16 G
Machine Checked,Emergency Drugs ,Inotropes Loaded ,Invasive Lines Kept ready
On table at 7.45 pm
Connected to monitorECG,IBP,SpO2HR-120 IBP 132/76 Spo2 99%
Connected to circle TV 550ml RR 14 PEEP 5cmh20
Inj Morphine 3mg and 6mg,Oxygen 6l and Des 3%
Incision was put at 8.30 pm
One unit NS and One unit of Plasmolyte
INTRAOP
500 ml of blood with 250 ml of clot Liver Laceration present over VI segement 5x2cm
IBP 88/50 HR 130
INJ NORAD 4mg in 50mlInj Dopamine 200 mg in 50ml
INTRAOP
9.00 pm Patient had episode of Ventricular Tachycardia with Pulse with heart rate to 180
Inj.Loxicard given 50mg still VT persisted another dose given at 9.10pm
VT persisted 9.20 pm Inj.Amiodarone 150mg given
VT persisted 9.30 pm 200J shock given VT reversed toVentricular Bigemini and reversed to sinus tachycardia
I/v/o Tense forearm on right side fasciotomy of forearm was done
Doppler examination was done triphasic waveform
Patient shifted To ICU BP 100/60 PR 110
2 Units of PRBC, 1 unit of FFP , 1 unit Platelets, 4 units NS (570 ml) (99ml) (53ml)
3 sterile pads were placed over the Liver and b/l drain
Wash was given with NS to rule out any other Bleeding Points present
R shoulder debridement was done above elbow slap application was done
(1800ml)1200 ml Blood loss NIL Urine Output
INTRAOP
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