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Cardiothoracic Surgery General Surgery

Gunshot injury to chest

60 year old male

Presentation:Gunshot to back

HPC:Patient with no known chronic illnesses was well until about 8 hours prior to presentation(around 12:30am) when he was allegedly shot from a long range (from one end of a school park) by armed robbers as he was patrolling an area of his community ,as part of a local community watchdog team activity.He was shot twice at his back and once on his left arm.He suddenly could not walk,fell down,and was also bleeding.He did not lose consciousness,but had chest pain and felt very weak.He was sent to a nearby hospital where he was resuscitated and referred to KATH for further management.

ODQ:Limb weakness+(both lower limbs), Loss of sensation+,Hemoptysis-

PMH and SH-No known chronic illnesses,no previous admissions or surgeries.

DH:Not on any long term medications.

FH:No known chronic illnesses.

SH:Farmer,lives in Obuasi,Alcohol-,Smoking-

Examination

O/E-Elderly man who is lethargic,in respiratory distress, pale++, anicteric, no C-Spine tenderness.

CVS:S1+S2+0,HR-134bpm,BP-80/50mmHg

RS: RR-22cpm,SPO2-98% on NRBM, Reduced air entry over right lung with dull percussion note.

ABD:Distended,generalized tenderness,tympanitic percussion note.

CNS:GCS:15/15,Pupils equal and reactive to light,Power in right lower limb:0/5 Power in left lower limb:3/5

Extremities:Puncture wound about 0.5cm by 0.5cm at themedial aspect of the proximal part of the left arm.No limb swelling or deformity.No weakness or limited range of motion in the both upper limbs.Distal pulses present .

Back:Puncture wound about 1cm by 2cm at the right infrascapular area about the level of T10/T11,bleeding with  extensive surrounding edema.Dressing applied,hemorrhage controlled.Another puncture wound about 0.5cm by 0.5cm over the left scapular not actively bleeding.

EFAST:Positive,reduced lung,sliding on the right,free fluid in the peritoneum.

Under aseptic conditions,size 24Fr(only size available) chest tube was passed in the right 5th intercostal space,anterior axillary line,afterlocal infiltration with Lidocaine.1700mls of blood drained initially.Chest tube was secured at 15cm and oscillating.

Urethral catheter was passed and drained bloody urine.

Working diagnosis:

Polytrauma sec. to gunshot with

1.Penetrating chest injury with massive right hemothorax

2.Penetrating abdominal injury with hemoperitoneum

3.Penetrating retroperitoneal injury with possible right kidney injury.

4.Thoracolumbar spine injury with paraparesis.

Patient was quickly prepared for an urgent exploratory thoracotomy and exporatory laparotomy.

POST OP DIAGNOSIS:

1.MASSIVE HAEMOTHORAX

2.MODERATE HAEMOPERITONEUM

FINDINGS:

1.Haemothorax-500mls

2.10cm right lower lobe lung deep avulsion injury to the lung with 3 pieces of free avulsed lung tissues.

3.10cm transverse rupture of right hemi-diaphragm with herniation of the greater omentum.

4.5cm superficial right lobe laceration with no active bleed.

5.Duodenal bruising with no active bleeding seen.

Operative details 

Under general anesthesia with cuffed endotracheal intubation , patient position on left lateral position and bony prominences well padded.

The right hemithorax cleaned with antiseptic solution and draped . A right thoracotomy incision made through the the 4th intercostal space from the posterior axillary to anterior axillary line . Rib spreader use to create access to the right lung . Minimal debridement done on the right lung and closed with absorbable sutures

A separate incison made in the 6th intercostal space to access the diaphragmatic laceration  . the laceration repaired with nylon 0 . The thoracostomy wounds closed routinely.

The entry wound explored , debridement and closed primarily

Patient reposition supine and abdomen prepared routinely and draped

A median abdominal incision used to access the peritoneum. Inspection led to the above findings. Abdomen closed routinely.

Patient was transfused two units of blood intraoperatively.

Postop vitals were stable

HISTORY OF 60-YEAR OLD MALE WITH GUNSHOT INJURY

PC:Gunshot to back

HPC:Patient with no known chronic illnesses was well until about 8 hours prior to presentation(around 12:30am) when he was allegedly shot from a long range (from one end of a school park) by armed robbers as he was patrolling an area of his community ,as part of a local community watchdog team activity.He was shot twice at his back and once on his left arm.He suddenly could not walk,fell down,and was also bleeding.He did not lose consciousness,but had chest pain and felt very weak.He was sent to a nearby hospital where he was resuscitated and referred to KATH for further management.

ODQ:Limb weakness+(both lower limbs), Loss of sensation+,Hemoptysis-

PMH and SH-No known chronic illnesses,no previous admissions or surgeries.

DH:Not on any long term medications.

FH:No known chronic illnesses.

SH:Farmer,lives in Obuasi,Alcohol-,Smoking-

 

O/E-Elderly man who is lethargic,in respiratory distress, pale++, anicteric, no C-Spine tenderness.

CVS:S1+S2+0,HR-134bpm,BP-80/50mmHg

RS: RR-22cpm,SPO2-98% on NRBM, Reduced air entry over right lung with dull percussion note.

ABD:Distended,generalized tenderness,tympanitic percussion note.

CNS:GCS:15/15,Pupils equal and reactive to light,Power in right lower limb:0/5 Power in left lower limb:3/5

Extremities:Puncture wound about 0.5cm by 0.5cm at themedial aspect of the proximal part of the left arm.No limb swelling or deformity.No weakness or limited range of motion in the both upper limbs.Distal pulses present .

Back:Puncture wound about 1cm by 2cm at the right infrascapular area about the level of T10/T11,bleeding with  extensive surrounding edema.Dressing applied,hemorrhage controlled.Another puncture wound about 0.5cm by 0.5cm over the left scapular not actively bleeding.

EFAST:Positive,reduced lung,sliding on the right,free fluid in the peritoneum.

Under aseptic conditions,size 24Fr(only size available) chest tube was passed in the right 5th intercostal space,anterior axillary line,afterlocal infiltration with Lidocaine.1700mls of blood drained initially.Chest tube was secured at 15cm and oscillating.

Urethral catheter was passed and drained bloody urine.

Working diagnosis:

Polytrauma sec. to gunshot with

1.Penetrating chest injury with massive right hemothorax

2.Penetrating abdominal injury with hemoperitoneum

3.Penetrating retroperitoneal injury with possible right kidney injury.

4.Thoracolumbar spine injury with paraparesis.

Patient was quickly prepared for an urgent exploratory thoracotomy and exporatory laparotomy.

POST OP DIAGNOSIS: 1.MASSIVE HAEMOTHORAX  2.MODERATE HAEMOPERITONEUM

FINDINGS:

1.Haemothorax-500mls

2.10cm right lower lobe lung deep avulsion injury to the lung with 3 pieces of free avulsed lung tissues.

3.10cm transverse rupture of right hemi-diaphragm with herniation of the greater omentum.

4.5cm superficial right lobe laceration with no active bleed.

5.Duodenal bruising with no active bleeding seen.

Patient made satisfactory recovery in the postoperative days .

Reducing the omentum stuck in the diaphragmatic laceration

Surgeons :

1.Dr Isaac Okyere ( Cardiothoracic and Vascular surgeon)

2. Dr  Edward Boateng ( General surgeon)

3. Dr Kafui      ( general surgery resident)

compiled by Drs Richard Ametih and Marian Quansah

 

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