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Hi Guys,
This is a case where an intial case was made even more interesting with the aide of anesthesia. Patient is around 13 yrs old GSW to the shoulder area (entry within the deltoid muscle) and no exit wound.
Patient's initial mental status is diminished with responsiveness to pain.
Retrospect 20/20 hindsight i remember him only moving his left arm when transfering him from the EMT stretcher to the trauma bay table.
Patient gets tubed...by the PA in the ER. BTW its really unfortunate when you see ER personel not knowing what RSI is (im ok with or without cricoid pressure although i prefer cricoid pressure. Then when you see them not only ventilating the patient instead of preoxygenating the patient but instead 2 man ventilation with one guy (the new PA) holding the mask over the patients face with two hands and the resp therapist squeezing the heck out of the ambu bag only to fill the stomach with air...especially when the patient was still spontaenous...had not recieved the etomidate/sux yet . I usually dont interfere too much but at the same time when the patient aspirates, or now has bleeding in the airway and the ER staff then steps aside and ask..."where is anesthesia?" all in hopes to clean up the shyt that happened...very annoying esp at 3 am.
Anyways patient was tubed and goes to the SICU. About 1 hr later we get a call patient needs to come to the OR...losing blood from the b/l chest tubes.
The CT scan now shows bullet entering the right shoulder, pulmonary lac, hits the spine and goes to lacerate the other lung.
Patient enters the OR with relatively stable hemodynamics. Aline and RIJ central line...and the procedure continues with patient in the right lateral decubitus postion. Thoracotomy with fixation of pulmonary laceration and ligation of intercostal artery on the right side. Initial ABG shows the patient acidotic with pH 7.19 base excess -5.1
So we give the patient what he needs...fluids about 5 liters with the first 2.5 hours and 2 units PRBC as well as 1 U FFP...check the blood gas.
ABG: 7.17 with base deficit -7 Doesnt make sense
continue to give fluid and blood
In the mean time while they are still working on the left lung there seems to a large amount of output from the chest tube from the right lung.
By this time the left lung has been repaired and now patient is moved into the left lat decubitus position for repair of the right lung. Right thorax is opened up and pressures drop requiring pressors...kinda perplexed me since the patient had b/l chest tubes.
Trauma chief says..."ahhhh dude i see the central line coming out the SVC"
Thoracic attending says....no its now.....ohh yeah your right...just great.
Anyways somehow the RIJ central line had pierced through the SVC and drained alot of the fluid which was given through the cental line along with 1 of the 4 units of PRBC and 1UFFP into the chest and out the chest tube and also explained why the acidosis and base deficit was not getting better.
After fixing the pulmonary lac on the right side and ligating the intercostal artery...put one suture in the SVC as i pulled out the triple lumen cather with shame (although i wasnt the one who put it in)...still look like a jack.azz
Intersting case made all that much more interesting
At the end of the case...the thoracic attending, apart from that silly mistake it was great anesthesia provided...case went from 1130am to around 5:30 am...just woke up from my postcall nap and about to go on a walk with my wife and 8month old son
Part of life...just sharing
____________________________________________________________
http://www.02demand.com
online community of clinical excellence in anesthesia
This is a case where an intial case was made even more interesting with the aide of anesthesia. Patient is around 13 yrs old GSW to the shoulder area (entry within the deltoid muscle) and no exit wound.
Patient's initial mental status is diminished with responsiveness to pain.
Retrospect 20/20 hindsight i remember him only moving his left arm when transfering him from the EMT stretcher to the trauma bay table.
Patient gets tubed...by the PA in the ER. BTW its really unfortunate when you see ER personel not knowing what RSI is (im ok with or without cricoid pressure although i prefer cricoid pressure. Then when you see them not only ventilating the patient instead of preoxygenating the patient but instead 2 man ventilation with one guy (the new PA) holding the mask over the patients face with two hands and the resp therapist squeezing the heck out of the ambu bag only to fill the stomach with air...especially when the patient was still spontaenous...had not recieved the etomidate/sux yet . I usually dont interfere too much but at the same time when the patient aspirates, or now has bleeding in the airway and the ER staff then steps aside and ask..."where is anesthesia?" all in hopes to clean up the shyt that happened...very annoying esp at 3 am.
Anyways patient was tubed and goes to the SICU. About 1 hr later we get a call patient needs to come to the OR...losing blood from the b/l chest tubes.
The CT scan now shows bullet entering the right shoulder, pulmonary lac, hits the spine and goes to lacerate the other lung.
Patient enters the OR with relatively stable hemodynamics. Aline and RIJ central line...and the procedure continues with patient in the right lateral decubitus postion. Thoracotomy with fixation of pulmonary laceration and ligation of intercostal artery on the right side. Initial ABG shows the patient acidotic with pH 7.19 base excess -5.1
So we give the patient what he needs...fluids about 5 liters with the first 2.5 hours and 2 units PRBC as well as 1 U FFP...check the blood gas.
ABG: 7.17 with base deficit -7 Doesnt make sense
continue to give fluid and blood
In the mean time while they are still working on the left lung there seems to a large amount of output from the chest tube from the right lung.
By this time the left lung has been repaired and now patient is moved into the left lat decubitus position for repair of the right lung. Right thorax is opened up and pressures drop requiring pressors...kinda perplexed me since the patient had b/l chest tubes.
Trauma chief says..."ahhhh dude i see the central line coming out the SVC"
Thoracic attending says....no its now.....ohh yeah your right...just great.
Anyways somehow the RIJ central line had pierced through the SVC and drained alot of the fluid which was given through the cental line along with 1 of the 4 units of PRBC and 1UFFP into the chest and out the chest tube and also explained why the acidosis and base deficit was not getting better.
After fixing the pulmonary lac on the right side and ligating the intercostal artery...put one suture in the SVC as i pulled out the triple lumen cather with shame (although i wasnt the one who put it in)...still look like a jack.azz
Intersting case made all that much more interesting
At the end of the case...the thoracic attending, apart from that silly mistake it was great anesthesia provided...case went from 1130am to around 5:30 am...just woke up from my postcall nap and about to go on a walk with my wife and 8month old son
Part of life...just sharing
____________________________________________________________
http://www.02demand.com
online community of clinical excellence in anesthesia
