interesting trauma more more interesting

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anesthesia11230

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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 11:30pmam 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
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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



saw this happen at my institution last month. R IJ was placed and later found to be through and through the vasculature at the confluence with the subclavian. the difference that this one was placed by a very deft cardiac anesthesiologist - i.e. it can happen to anyone.
 
Even the thoracic surgeon was telling me afterwards that when he places triple lumen catheters over guidewire he advances the catheter 1 in and checks to see if the guide wire slides back and forth smoothly. Does this every inch until the catheter is fully placed. If I had heard this prior to the unfortunate incidence I would have thought this was totally uneeded and ridiculous. I have a slightly different take on it now.

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Patient came in with 20G in left arm and a very good 16 G on right arm. Im usually content with good running peripheral IV's. After having just finished a cardiac rotation and placing central lines everyday I jumped on the opportunity when the attending said place a central line.

I made one stick although didnt hit anything plus the patient had b/l chest tubes so no fear of ptx. I turn my back for a second to get a 4x4 and I see the attending fishing around the neck with the needle. First stick was arterial. Next i say lets use a finder needle...which may be for the conservatives...i always prefer using a finder needle.

He gets the RIJ and from there on it was a pair of 2 hands jamming this thing in without any finese or precision and thats part of the problem. There really was no hurry. Patient was hemodynamically stable on the vent being ventilated. IVs established and another resident working on an A-line.

Think this could have been prevented with primarily "coolness in mind"
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What kind of central line did you put in?

Were you able to aspirate blood when you put it in? I'm wondering if the wire perforated the svc, or if the catheter did it later?

Lastly, why were you giving blood through a small central line lumen when you had a good peripheral?
 
Used a triple lumen catheter. Issue was it was a 13 yr old kid and the catheter was intially advanced to 20 cm. The blood flow back upon aspiration was not adequate. I pulled the catheter back to about 15cm and hear the attending over my shoulder saying, "What are you doing???". Anyways let him get his hands back on the scene as if he never let his hands off. So I went back to the storage room to get another central line and I see the attending had already made another stick and was advance the already used and kinked guide wire. Then the new catheter from the central line kit i just got was used and advanced.

I think advancing the new catheter with the "used/kinked" guidewire is where the problem took place. When advancing a flexible catheter with a kinked guidewire just the slight kink probably butted the catheter along the vessel wall and with alil force (prob alot of force with the stress response at 1am) it punctured the vessel wall.

Even after the catheter was placed...blood was able to be aspirated with 2 of the 3 lumens. Ironically were able to get a CVP reading of about 12.

Later when we discovered the problem i believe the puncture through the vessel wall was thought to be near the subclavian vein. We obviously stopped using the central line at that time but kept it in place as it was preventing any bleeding from the puntured site.

Later the surgeon placed a guide wire through the catheter from the chest cavity...i got ahold of the guide wire from my side and we slowly pulled the catheter out from my side. He made one suture and continued to close.

To answer you question why we used the central line for giving blood. When the fluid warmer was changed into the central line we ended up giving 1 U PRBC through it then.
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What a mess!!

Poor technique was the cause. No doubt. Sounds like the svc was perforated by the wire. Was it the brown port that did not aspirate? Which port were you using for cvp? How far in was the 2nd catheter introduced?

Less important but I'm curious: Why did you change catheters? Why do a new stick? How big was this 13y/o?

Sorry to question you so much. I supervise residents and I'm trying to learn from your misfortune.
 
I went for a new central line kit as things were getting "messy" and lets say nonsterile. The second catheter was advanced to 20 cm in a rather large 13 yr old but still a considered the size of a very small adult.

The catheter was again advanced to 20 cm because the attending had initally advanced the first catheter to 20cm before I pulled it back to 15 cm which i along with the trauma chief and thoracic attending felt was more appropriate.

He insisted the 2nd catheter be placed 20 cm. Upon aspirate there was poor blood return as mentioned previously. We used the brown port for CVP readings which indicated 12 mmHg

Most of this happening was from a junior attending. Once the patient was induced and lines were placed. I managed the patient with a junior resident from midnight -5am with the attending showing up once around 2:45am

I enjoy the managing the patient but lets say i slept all day saturday (postcall) and had a unneeded argument with the wife due to my lethargic afluent affect. Life of residency just really sux at times on the personal side 🙂
 
Great case, and nice job.

When I was reading your original post of the case I couldn't help but to think that placing a central line in the SVC distribution was going to lead to a problem since you had a GSW to the chest and no exit wound along with pulmonary and spinal injuries. I was thinking I would have placed it in the groin. I don't doubt the attendings cowboy manners may have been the culprit but are you sure that the bullet didn't have anything to do with it?
 
Thats actually a great point that hasnt come up yet has not crossed my mind. Patient had a wild bullet from the left shoulder without any evidence of an exit wound. Thought I was bright enough of not putting an A-line in the left arm but should have applied the same logic towards staying away from relative nearby anatomy although its still the contralateral side...point still taken. Appreciate that lil pearl.

As far as bullet remnants contributing to the inadvertant venous puncture...not sure. They clearly saw the catheter tip through the vessel wall. Interesting speculation as to fragments or microvasculature trauma from a wild bullet contributing to this situation. I would like to think so although i think the reality was...poor technique 🙁
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