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Tue May 13 08:05:07 BST 2008

Johan

Cause of death is probably multifactorial and blunt cardiac injury may be
the cause, but I would hazard his drug use as a contributory factor and if
he's also taken cocaine that may produce the same response or compound the
problem.  While he was persistently shocked and bleeding prior to
splenectomy did he receive a lot of vasopressors?  This would give the same
picture if they were given for a long period without volume.

Finally you realise I presume that the aortic injury was not the cause of
his hypotension and the cause of hypotension should be sought elsewhere (the
laparotomy first and the aorta stented semi-electively in this patient
without traumatic brain injury).  There's a small possibility of cardiac
injury from the guidewires here too, though I guess that's unlikely.

I doubt this is cardiac herniation and, at the stage it was considered I
doubt opening the chest would have made any difference at all.

Karim

On 5/12/08, johan.malmgren at vgregion.se <johan.malmgren at vgregion.se> wrote:
>
> 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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What did this thx trauma die of?