Case for discussion

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Tim:

What do you think ultimately killed him? 
Retroperitoneal sepsis?  ARDS?  Ongoing bleeding? 

Ben Reynolds, PA-C
Pittsburgh, PA

--- "Hardcastle Tim, Dr <tch at sun.ac.za>"
<tch at sun.ac.za> wrote:

> Dear List
> 
> Over the past weekend we had a really frustrating
> case and I wish to share it with you. The patient
> eventually died, even with all the stops pulled that
> we could (Cash-strapped SA govt hospital, but a
> "level 1" teaching hospital nonetheless)!
> 
> 18 y/o male GSW entrance (R) lower posterior chest
> lateral scapular line, AXR reveals bullet in (L)
> upper quadrant, lateral AXR show bullet anterior.
> Taken for emergency laparotomy, minimal waiting
> time, minimal fluid pre-op.
> 
> Findings at laparotomy: Segment 7 liver thru-thru
> injury, not bleeding. Retroperitoneal haematoma RUQ,
> left till last because non-expanding, yet fairly
> large. Seven small bowel and three small large bowel
> injuries quickly repaired by single layer hand-sewed
> technique (we don't have funding for staplers in our
> government-owned hospital). Until this point he was
> very stable haemodynamically so no place for true
> damage control here.
> 
> The retropeitoneum then opened, and (R) renal vein
> and IVC anterior partial injuries found and
> controlled fairly easily, with only about total
> 1000ml bloodloss from start of procedure. Then for
> the difficult bit! The bullet had destroyed the
> ampulla of Vater and the head of the pancreas. Given
> that he would need a Whipple, the area was drained
> and the procedure terminated to stabilise the
> patient, assemble a team (it was 4 am) and go back
> in about 12 - 24 hours. He went to our trauma ICU
> area and recieved blood and other blood products to
> correct the deficits.
> 
> After 16 hours he was stable, but by no means normal
> and we attempted a definitive operation. After the
> duodeno-jejunal segment had been mobilised, he
> unfortunately became progressively inotrope
> dependant and we resected the sectioned small bowel
> with staples (now in elective surgery suite) and
> left the blind-ended distal small bowel and stomach
> on suction. We left drains to try and control the
> pancreatic fluid leak and bile leak, with the
> retroperitoneum already very lipid necrosed.
> 
> After another 24 hours we could see he would never
> stabilise to get the Whipple completed in the near
> future, so we took him back again and placed a
> t-tube in the bile duct and ligated this distal
> thereto to create a controlled biliary fistula, did
> a Stamm gastrostomy to drain the stomach and a
> feeding jejunostomy (Witzel) and left the
> retropeitoneal drains to create a controlled
> pancreatic fistula. 
> 
> Closure for the last two occations was by "sandwich"
> VAC pack - SA style.
> 
> He progressively deteriorated in terms of renal
> function / respiratory function / haemodynamic
> function and was "too unstable for dialysis" as per
> our Renal Unit. We therefore decided to call in the
> family, explain the inevitable prognosis, sedate him
> and let nature take its course. He passed away last
> night; 5 days post trauma.
> 
> I'm sure our American colleagues would have some
> fancy toys to have helped, so I'm keen to see if
> others would have done things differently.
> 
> Regards
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> General Surgeon (Trauma and ICU)
> ATLS and DSTC instructor
> Intern program Coordinator: Surgery
> Program Manager: Emergency Medicine (U.S.)
> Operational Head: Diana Princess of Wales Trauma
> Unit
> Department of Surgery Room 4064
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> 
> 2 Lorient Close
> Vredekloof, Brackenfell
> 7560, Western Cape,
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
> Home: +27219813098
> --
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