What did this thx trauma die of?

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Johan,

In view of the initial presentation with A. Fib and subsequent multiple
arrhythmias, Blunt Cardiac Injury is high on the list of the most important
factor that contributed to the patients death.  The other diagnoses you
mentioned probably contributed to the fatal outcome.

One question.  Why does your General Surgeon need a Chest Surgeon to open
the chest in such circumstances?

Mickey

 

My two agoras ("cents")

 

************************************************
Michael Stein MD
Director of Trauma, Attending Surgeon,
Department Of Surgery,
Rabin Medical Center, Beilinson Hospital,
Petach-Tikva, 49100
ISRAEL

 

Tel:   +972  3-937-7043
Fax:  +972  3-937-7042
E-Mail:   <mailto:mshtein at clalit.org.il> mshtein at clalit.org.il
************************************************

 

  _____  

From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of johan.malmgren at vgregion.se
Sent: Monday, May 12, 2008 9:50 PM
To: trauma-list at trauma.org
Subject: What did this thx trauma die of?

 

Opinions please about a case from this morning. Please excuse the lack of
details, I was only partially involved

 

37 y/o patient on amphetamine and benzo drives his motorcycle in 70 km/h
right into a truck. Stable in all ways prehosp apart from a atrial
fibrillation, 130 bpm.

Arrives in ER and is diagnosed with small hemo-/pneumothx right side, subQ
air right side, suspicious widened mediastine, left humerusfx. Still AFib
with pressure around 130/70. BG shows hgb about 95, lactate and pH normal.

Recieves a chest tube which drain some 100-200 ml blood. He's having some
problems keeping his saturation up and is intubated. Surgeon wants to have a
CT.

Once on CT the head and neck are fine, but just as the thx/abd is about to
start his BP is down to 95/50. So now everyone including the surgeon are
convinced that something is happening inside him, and a renewed BP is 65/30.
By this time he has by some way still recieved his CT and it shows a
ruptured thoracic aorta at the ductus level, subQ air right side and in
mediastine, mediastinal hematoma, lunglaceration, rib fx x4 and a contained
splenic hematoma.

 

Decision is made to stent the aortic rupture on the trauma OR. Stenting is
going fine although circulatory unstable. His abdomen is becoming more
distended and opened, and the splenic hematoma is no longer contained...
Fast splenectomy, but about the same time anesthesia has more and more
trouble. It turns out CVP is rising from 15 to 55-60, and the patient jumps
between this afib in 140 to bradycardia to and fro. Thoracic surgeons are
called in while the surgeon opens a diaphragmatic window, no tamponade. ECG
turns into widened QRS and then asystole. CPR is started without effect. TEE
shows no tamponade, and thoracic surgeon refuses to open chest with the
argument that "there's nothing we can do, only more harm".

Patient dies...

 

So, apart from so many other things to comment, I'm curious to what you
think actually killed the pt. The anesthesiology professor that handled him
thinks that his myocardial contusion was more devastating than they first
thought, and that he went into failure from transfusion overload. 

The surgeon also thinks that it was a plain myocardial contusion.

I'm thinking that if he had a contusion that actually killed him, wouldn't
you want at least a sternal fx and flail chest? How about coronary air
embolism that gave him a plain MI?

 

Suggestions and opinions please!

 

 

Johan Malmgren 
Resident, Anaesthesia, Critical Care & Traumatology
Dept of Anaesthesia and Critical Care
Sahlgrenska University Hospital
Gothenburg, Sweden
+46313428073 [Work]
+46707696961 [Mobile]

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