MANAGEMENT TACTICS FOR A PATIENT WITH MULTIPLE GUNSHOT WOUNDS
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
According to WHO data, each year about 3.5 million people die after injuries. About 18 % of all lethal cases are associated with firearm. Use of firearm takes the second place among all lethal cases in individuals at age of 10-34 [1]. At the present time gun wounds are characterized with more pronounced morphofunctional changes, specific severity and multiplicity. Despite of achievements in modern medicine, we do not observe decrease in mortality within the last 10-15 years [2, 3, 4].
Gunshot wound is an individual type of combat surgical injury as result of impact of injuring bullets of firearm and explosive devices. But, unfortunately, gunshot wounds are possible not only at war, but also in times of peace. Emergent medical aid for patients with gunshot wounds firstly consists in some diagnostic and curative measures, which are immediately performed for restoration of support of vital functions, prevention and, if necessary, treatment of dangerous complications including multiple organ insufficiency [5, 6].
The patient S., age of 45, suffered from three gunshot wounds in the head, the chest and the abdomen at his place of employment. The critically ill patient with traumatic shock was admitted to the Mezhdurechensk Central City Hospital. The following surgical interventions were conducted: primary surgical preparation of open gunshot non-penetrating fracture of the frontal bone to the right, primary surgical preparation of the gunshot wound in the right superciliary region, enucleation of the left eye, laparotomy, nephrectomy to the right, cholecystectomy, liver wound suturing, draining, primary surgical preparation of the thoracic gunshot to the left, left pleural cavity draining. After surgical intervention the patient was transferred to the intensive care unit. Within the first 24 hours anti-shock therapy was performed. At the background of the therapy the patient demonstrated relative stabilization of his state (AP = 130/70 mm Hg, HR = 122-125 per min). The patient was on drug sedation and ALV.
Considering severity of the patient’s state (ISS = 50, an extremely severe injury), increasing ARDS, high risk of renal insufficiency and, as result, need for high tech specialized aid, the patient was transferred by the reanimobile from Mezhdurechensk Central City Hospital to Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky. The distance is 300 km. The time of transportation was 3 hours and 25 minutes. During transportation the standard monitoring was performed (AP, RR, ECG, SpO2, HR, Ò0), all values were within the references. During transportation stable state was provided by means of intensive care measures with the techniques developed by our center [7, 8, 9]. Controlled mechanical ventilation was initiated. For decreasing risk of complications ALV with low respiratory volume was initiated (Vt – 5-6 ml/kg, Pmax – 30-35 cm Í2Î, ÐÅÅÐ 5 mbr, FiO2 – 0.5). Infusion therapy was conducted with hydroxyethyl starch 130/04 (HES 130/04 – 800 ml + 0.9 % NaCl – 900 ml). The patient’s state did not worsen during his transportation.
The patient was in critical state at the moment of admission to the intensive care unit in Clinical Center of Miners’ Health Protection (Fig. 1). Consciousness was absent mainly because of drug sedation. There was anophthalm to the left (after enucleation of the left eye). The patient suffered from obesity of degree 4, the body weight was more than 160 kg. The skin surfaces were pale, dry and clean. There was a bedsore in the sacral region.
Figure 1
ThepatientS. with multiple gunshot wounds at admission to the ICU
Intermittent positive pressure ventilation (IPPV) was initiated (Fr -18, PEEP 5 mbr, FiO2 – 0.5). Auscultation confirmed harsh breathing, weakness in the inferior departments and singular rales that disappear after cough. The drains included poor hemorrhagic discharge from the left pleural cavity. There was no exhaust air.
The cardiac tones were clear and rhythmical. Hemodynamics was stable. AP was 140/70 mm Hg, HR – 105-110 per min, central venous pressure – 110 mm H2O.
The abdomen increased owing to subcutaneous fat and bloating. It was soft during palpation. The dressings were saturated with bile. Peristaltic noises were absent. Urine output was through the catheter. Despite of diuresis stimulation with saluretics (furosemide), we observed tendency to decreasing.
Local examination: along the middle abdominal line one could observe a laparotomy wound sutured with interrupted sutures. The retroperitoneal space (right renal bed) was drained with two silicone tubes, which were delivered through the counterpuncture along the posterior axillary line. Three sponges and two silicone tubes were installed in the gall bladder bed and were output through the counterpuncture in the right hypochondrium. In the liver wound three sponges and two silicone tubes were installed with output through the upper edge of the wound.
After admission the patient was examined by the surgeon, the neurosurgeon, the traumatologist and the cardiologist. Some clinical biochemical, radiologic, endoscopic and electrophysiological examinations were made. The results of the examinations were used for confirming the diagnosis and designating further medical diagnostic measures.
The diagnosis: “Polytrauma. Gunshot non-penetrating blunt wound of the right supraorbital region. Open gunshot fracture of frontal sinus to the right, of upper wall of the right wall, of cribriform bone with transition to the base of anterior cranial fossa. Brain contusion of middle severity. A penetrating wound of the left eye with an injury to its layers (the state after primary surgical debridment of the wound, revision of wound canal, raining, enucleation of the left eye).
There was a non-penetrating perforating wound of thoracic soft tissues to the left. The state after thoracotomy to the left and left pleural cavity draining.
A gunshot (bullet) penetrating abdominal wound with an injury to the left lobe of the liver, the gall bladder and the right kidney. Retroperitoneal hematoma. Hemoperitoneum. The state after laparotomy, suturing for the liver wounds. The state after cholecystectomy, nephrectomy to the right and abdominal cavity draining”.
Complications: biliary peritonitis.
At admission the laboratory examinations showed anemia, leukocytosis, hyperenzymemia, increasing levels of nitric waste (table 1).
| Table 1 | |||||||
| Dynamics of laboratory values in the patient S. with multiple gunshot wounds | |||||||
After presurgical preparation (4 hours after admission) the patient received some surgical interventions: underflap revision in the frontal region of the head, draining, relaparotomy, revision, sanation, redraining of abdominal cavity and the retroperitoneal space, application of laparostom. During relaparotomy all gauze sponges were removed out of the abdominal cavity. Revision identified an extensive pulmonary defect of liver tissue in the region of porta and bile leakage. As result, after sanitation the liver wound was packed with the greater omentum. There were no injuries to intrahepatic ducts in the region of the defect. On the third day we conducted relaparotomy, revision and abdominal sanation. On the fourth day during reprogrammed relaparotomy one could observe bile leakage from the liver wound. As result, we conducted external draining of ductus choledochus for decompression of bile passages. On the days 5-6 after the injury the patient received sanitation relaparotom. The laparostom was closed on the day 6 after correction of abdominal inflammatory events.
Additionally, the following diagnostic procedures were conducted:
1. Cranial radiography in two planes (at admission): fractures of the cranial vault were not found. Brain and pulmonary MSCT were not conducted because of excessive body weight (more than 160 kg).
2. Echo-encephaloscopy (at admission) – no displacement of median structures of the brain.
3. Fiberbronchoscopy (at admission): blood aspiration. Bilateral diffuse endobronchitis of the second degree.
4. ECG (at admission) – sinus tachycardia; metabolic changes in myocardium.
5. X-ray examination of the chest (3rd day after the injury) – clinical picture of acute respiratory distress syndrome (ARDS) of degrees 2-3. Some signs of minimal hydrothorax on both sides. Some hypostatic changes in the lungs. Extension of heart contours in diameter. ARDS disappeared on 11th day. The lungs were without infiltrative changes.
6. Echocardiography (at admission and on 8th day) – without significant changes. Myocardial contractility is satisfactory. Some changes in the aortic valve. Some sclerotic changes in the bicuspid valve.
7. Duplex scanning of vessels of the lower extremities (9th day): occlusive thrombosis of medial sural veins and fibular veins to the right. Non-oclusive thrombosis in the deep femoral vein. On 13th day we observed repatency of the clot and restoration of perfusion in the left deep femoral vein.
Intensive care included antibacterial, infusion and antienzymic therapy, respiratory support with various modes (IPPV, SIMV, ASB), correction of disorders of coagulation potential, prevention of deep venous thrombosis and thromboembolic complications, prevention of stress ulcers and gastrointestinal bleeding, early nutritive support.
On 10th day tracheostomy was made owing to need for long term respiratory support and constant sanation of tracheobronchial tree.
Owing to severity of the patient’s state and presence of only one kidney we offered a possibility for decompensation of his state by means of such aggressive surgical tactics. However there were no other variants. All surgical interventions were conducted only after collegial discussion of the patient’s state in concordance with damage control concept [3], i.e. the treatment was based on the complex approach and staged correction of identified injuries and disorders of vital functions of the body.
The patient’s state worsened on 6th days after the injury. It consisted in rapid progression of clinical course of multiple organ insufficiency: respiratory (by means of increasing ARDS), renal-liver insufficiency (decreasing function of the single kidney). Considering increasing water-electrolytic disorders and intoxication syndrome (table 1), the decision was made about initiation of renal replacement therapy (RRT) [10]. The criteria for initiation of RRT were osmolarity > 300 mOsm/kg, plasma natrium > 150 mmol/l, average molecules > 1 c.u. The offered criteria were the early predictors of developing renal insufficiency.
There were 30 RRT sessions including 28 hemodialysis sessions with AK-200 ULTRA, and 2 sessions of long term low flow renal replacement therapy with hemodiafiltration mode with Prisma-flex device.
10 procedures of hemodialysis were conducted each day, followed by 20 procedures of hemodialysis and hemodiafiltration – every second day.
Hemodialysis was conducted by venovenous contour (dual-lumen catheter) with use of bicarbonate dialysate. The duration of the first session was 2 hours, the subsequent ones – 4-8 hours. Heparinization was selective, before a dialyzer (a hemofilter), dosing through the infusion pump, 5-10 units of heparin during the session. The rate of filtration was 220-240 ml/min. According to indications about 1.8-4.8 l of ultrafiltrate were removed.
Continuous monitoring of clinical biochemical parameters was conducted, as well as consideration of introduced fluid, physiological losses and daily diuresis (table 1).
On 54th day the positive trends of acute renal insufficiency were found. It was associated with restoration of excretory system and concentration function of kidneys (tables 1, 2).
| Table 2 | |||||||||
| Dynamics of restoration of renal excretory function in the patient S. with multiple gunshot wounds | |||||||||
X-ray examination showed disappearance of ARDS (Fig. 2, 3). Also clot recanalization and restoration of perfusion in the left deep femoral vein were observed.
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Figure 2 Rg – thechestbythepatientS. with multiple gunshot wounds at admission to the ICU. ARDS of degrees 2-3 |
Figure 3 |
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Despite of use of anti-bedsore matrass beginning from the first day of admission to ICU, the patient demonstrated development of the bedsore (10×12 cm) in the sacral region. According to our opinion it is associated with the excessive body weight (160 kg) and absent possibility for early activation of the patient. Dressing for the bedsore was changed each day. A possibility for activation of the patient appeared on 30th day after clot recanalization and restoration of perfusion in the left deep femoral vein. During the treatment the size of the bedsore decreased to 3×5 cm. Active epithelialization of the defect was noted at the moment of discharge from the hospital.
ICU stay was 71 days. ALV period was 20 days. 10 surgical interventions were conducted. After stabilizing the patient’s state and restoration of renal function the patient was treated in the surgery department. 132 days after admission the patient was discharged, and his state was satisfactory. The body weight was 96 kg (Fig. 4).
Figure 4
The patient S. at the moment of discharge
Therefore, the offered laboratory criteria for early diagnostics of renal insufficiency allowed timely changing the complex of medical diagnostic measures with additional incorporation of the extracorporeal methods of detoxication (hemodialysis). Despite of presence of the single kidney, it allowed full restoring renal function and preventing development of chronic renal insufficiency with further chronic hemodialysis.
CONCLUSION
The presented case of treatment for the critically ill patient is based on the complex approach and staged correction of identified injuries and disorders of vital functions by means of high tech techniques, but it is possible only in special multi-field hospitals.
The efficiency of renal replacement therapy directly depended on timely diagnostics of water electrolytic and metabolic disorders. The indication for initiation of dialysis techniques is hypernatriemia, which is resistant to correction (plasma levels of natrium are 150 mmol/kg), hyperosmolarity (above 300 mOsm/kg) and average molecules > 1 c.u.