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

Secondary Survey

FAST scan

• Fast Scan 1 at 4.00pm –No free fluid collection noted

No solid organ damage

• 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

• Monitor showed ST elevation lead II at 6.30pm

• 12 lead ECG showed II,III,aVf,V3-V6

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

POD #1