Case Presentation and Discussion
On
Chest Trauma
Janix M. De Guzman, M.D.
General Data:
D.C. 20 y/o male, from Kasilawan, Makati
Chief Complaint:
“stab wound”
History of the Present Illness:
NOI: stabbing
TOI: 2:30am
DOI: December 15, 2003
POI: Pagkakaisa St, Kasilawan, Makati
Patient was playing chess while on a drinking session suddenly approached by unknown assailant and allegedly stabbed him on the back. Patient was then brought to our institution.
Physical Examination:
Ø conscious, coherent
Ø BP = 90/60mmHg CR = 82/min RR = 22/min
Temp. = 37.0OC
Ø Pink palpebral conjunctivae, anicteric sclerae
Ø Supple neck, no cervical lymphadenopathy
Ø Symmetrical Chest expansion, no retractions, no lagging
Decreased breath sounds, Base, Left Lung Field
Ø Stab wound 2 cm in length 8th ICS Paravertebral Line, Left with minimal bleeding
Ø Adynamic Precordium, good heart sounds, no murmur
Ø Flat Abdomen, normoactive bowel sounds, soft, no tenderness
Salient Features:
20 y/o Male
Stabbed wound 8th ICS, Paravertebral Line, Left
BP = 90/60
CR = 82/min
RR = 22/min
Decreased breath sounds, Base, Left Lung Field
Algorithm:
Stab Wound, 8th ICS, Paravertebral Line, Left
Clinical Diagnosis:
Stab Wound, 8th ICS, Paravertebral Line, Left
|
Clinical Diagnosis |
Certainty |
Treatment |
|
Penetrating |
85% |
Surgical |
|
Non- Penetrating |
15% |
Active Observation |
Note: ABC’s of emergency management done.
Paraclinical Diagnostic Procedure?
Yes.
To increase my certainty. Establish presence of air and/or fluid in left hemothorax.
Options:
|
Options |
Benefit |
Risk |
Cost |
Availability |
|
CXR upright |
+++ |
Radiation |
Php100 |
+ |
|
Ultrasound |
+ |
None |
Php300 |
+ |
|
CT Scan |
++++ |
radiation |
Php3000 |
- |
|
Needling |
+/- |
invasive |
Php50 |
+ |
Chest x-ray PA upright done:
Pretreatment Diagnosis:
Hemothorax, Left 2’ to Stab Wound, 8th ICS, Paravertebral Line, Left
Goals of Treatment:
Ø remove hemothorax
Ø full expansion of left lung
Treatment Options:
|
Options |
Benefit |
Risk |
Cost |
Availability |
|
Needling |
+/- |
+ |
50 |
+ |
|
Thoracostomy |
+++ |
+ |
500 |
+ |
|
Thoracotomy |
+++ |
+++ |
5000 |
+ |
Thoracostomy done:
Informed consent
Materials informed
Patient upright
Asepsis and antisepsis technique
Drapes placed
Incision placed level of 6th rib
Thorax entered at 5th ICS, MAL, Left
French 36 thoracostomy tube inserted
Initial output = 600cc blood
BP = 90/60mmHg CR = 90/min RR = 24/min
Decreased breath sounds, base left lung field
Repeat Chest x-ray PA upright requested:
Diagnosis:
Retained Hemothorax, Left; S/P CTT, 5th ICS, MAL, Left
Stab Wound, 8th ICS, Paravertebral Line, Left
Goals of Treatment:
Ø remove retained hemothorax
Ø achieve full expansion of left lung
Treatment Options:
|
Options |
Benefit |
Risk |
Cost |
Availability |
|
Active Observation with aggressive deep breathing exercises |
+/- |
- |
- |
+ |
|
Suctioning under Gen IV |
+++ |
+ |
1000 |
+ |
|
Thoracotomy |
+++ |
+++ |
5000 |
+ |
Patient brought to OR for suctioning of retained hemothorax:
700 cc old blood with clotted blood evacuated.
Intra-op Chest x-ray requested:
Goals Achieved:
Patient ready for transport to RR
However, 1 liter of fresh blood suddenly gushed from the reinserted CTT.
dyspneic
BP = 80/60 CR = 120 RR = 30
Neck veins engorged
Decreased breath sounds, LLF
Adynamic Precordium, good heart sounds
Patient prepared for Thoracotomy.
Informed consent
Materials prepared
Properly typed and crossmatched blood requested
3 unit WB properly typed and crossmatched transfused during OR
Patient positioned into right lateral decubitus after general anesthesia
Posterolateral thoracotomy done. Level of 6th ICS.
Findings Noted:
1 liter of fresh blood noted on left hemithorax
Transected posterior intercostals vessels actively bleeding on 8th ICS, Paravertebral Line, Left (Point of Entry of stab wound).
No other injuries noted.
Hemothorax evacuated
Transected posterior intercostal vessels ligated
NSS wash
Hemostasis checked
OS and Instrument count
Thoracostomy Tube inserted anterior and posteriorly
Rib approximated
Fascia closed layer by layer with vicryl O continuously.
Skin closed interruptedly.
Post-operative Care:
Immediately Post-op:
Nutrition
NPO
IV antibiotics
Ampicillin 500mg TIV q6
Gentamicin 80mg TIV q8
Adequate replacement of volume loss
1 unit PRBC properly typed and crossmatched transfused - RR
Adequate analgesia
CTEA – Bupivacaine 0.25% 5cc TEC q4 x 24hrs
Ketorolac 30mg TIV q6 x 8 doses
Respiratory support
Delayed extubation - x 24 hours
T-piece O2 inhalation at 8-10lpm
Moderate to high back rest
Secretions suctioned PRN
Monitoring
VS q15
UO q1
CTT output
1 day post-op:
Awake, alert
BP = 120/80 CR = 100 RR = 26
Symmetrical chest expansion, decreased breath sounds base left lung fields
CTT output
Anterior = 130cc
Posterior = 275cc
Nutrition
General Liquids with strict aspiration precautions
IVF and IV antibiotics continued
1 unit properly typed and crossmatched transfused
Hgb = 7.4 Hct = 22
Oral pain reliever ordered
Encouraged deep breathing exercises
Thora-bottle changed
VS q1, UO q1
2nd post-op day:
conscious, coherent
BP 110/70 CR = 88 RR = 24
Symmetrical chest expansion, clear and equal breath sounds
CTT output
Anterior = 30cc
Posterior = 50cc
Nutrition
Soft diet to DAT
IVF to 12hours; IV meds continued; Oral pain reliever continued
Deep breathing exercises continued
VS q 4
Foley catheter removed
CXR requested:
3rd Post-op day:
stable vital signs
SCE, CBS
CTT output
Anterior = 0
Posterior = 50cc
Started Ferrous sulfate 1 tab TID
4th Post-op day:
SCE, CBS
CTT output
Anterior = 0
Posterior = 50cc
Anterior CTT removed
5th Post-op day:
IVF discontinued
IV meds discontinued
Oral antibiotics started
CTT output
Posterior = minimal (<10cc)
CXR requested and noted
6th Post-op day:
Posterior CTT removed
7th Post-op day:
Discharged patient
Repeat x-ray noted prior to discharge.
