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All great suggestions. I especially love the recommendations to start filling out the Medicaid application and also the referral to the primary care clinic. Ha! What a hoot! So, true. So, true.
Yes, fiberoptic intubations are neat and give you added detail to be able to look around and I would have pushed it if they had not been able to do it with the conventional laryngoscope and an ETT. Also, a cric would have been simple to just extend the incision down and over to the left. We could have converted the cric over to a trach subsequently.
Sadly, we do not have an esophageal scope in the OR for Anesthesia to look for a pericardial effusion. One is coming as we are starting a CT program, but right now it was out of our reach (another great idea).
Etomidate is a good med as is SUX but the truth is that the Anesthesiologist pushed the Norcuron IV on arrival to the OR.
So, as for the case . . .
We prepped chin to the knees and table to table (and with a foley placed by the intern). My chief resident and I went for the neck first as it was bleeding the most. We quickly cut down on the right carotid sheath (luckily, no injury to the carotid or the jugular). We explored the gapping hole in his right neck that got close to the right carotid sheath. The laceration went into the throat above the thyroid cartilage and you could see and feel the ETT passing through the vocal chords. It was the mucosa and the muscles that were bleeding into the pharynx/larnyx and had temporarily clotted until distrurbed by our first attempted intubation in the trauma bay. We closed the mucosa and muscles and left a drain, did a quick tracheostomy and then closed the skin after a few washouts with a bulb syringe.
At this point still a little hypotensive with SBP in the mid to upper 90's despite two units of blood and more on the way with FFP thawing. Had about two liters of crystalloid IV so far. So, at this point we did a subxiphoid pericardial window secondary to the hypotension and the right sternal stab wound. Lucky for us and the patient, the window was negative for blood.
At this point we went after the chest wounds and explored each as well as the right shoulder, concerned about an intercostal bleeder. Now, the chest tube on the right did not have any more blood coming out of it since placement, but in the back of my mind I was thinking about it being clotted off with blood. So, explored each wound on the right chest including the one next to the sternum. No bleeding from any of them but saw a laceration to the lung anteriorly which we sprayed with Tissel. Irrigation from each chest wound washout was coming out of the chest tube so I realized we were not clotted off.
Finally, went after the left axillary wound. Washed it out with saline bulb syringe and explored it. Could feel the axillary artery pulse through some fat but no injury or expanding hematoma or staining in the area. So, washed it out and stopped any miscellaneous bleeding and closed it with sutures deep and staples on the skin.
He was transfused a total of 5 units of packed RBC's and 4 of FFP, close to a 1 to 1 resuscitation of pRBC's to FFP. We got a post-op chest CT scan which did not show a vascular blush anywhere and an expanded right lung. Also, did a soft tissue CTA of the neck and vessels and it showed nothing that we did not already know. Figured we find out right away if we needed to go back and reoperate on an inominate artery or vein injury or if I had missed an injury somewhere else, so had the nurses hold the room until we called back from the CT scanner. As it was negative we released the room and went up to the Surgical ICU.
Next thing I know they were calling the trauma team to the trauma bay stat. We had a GSW to the abdomen that "walked in". Luckily they came in one after the other and not at the same time.
Dutch Matthews
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