A CASE OF SUCCESSFUL TREATMENT OF THE PATIENT WITH THE GUNSHOT WOUND OF THE CHEST COMPLICATED BY SEVERE TRAUMATIC SHOCK
Kabanov City Clinical Hospital #1,
Omsk State Medical University,
Omsk, Russia
Currently, the importance of the problem of gunshot wounds with complications in view of traumatic shock is significant because of difficulties for diagnostics and treatment (both conservative and surgical), the features of the course of the pathology, which determines great amount of life threatening complications, and non-high percentage of positive clinical outcomes [1]. It requires continuous improvement of approaches to treatment of gunshot wounds complicated by severe traumatic shock at prehospital and hospital stages.
Therefore, the objective of the study is to reveal and define not only some organizational and tactical priorities of rendering emergency medical service and the key aspects of the disease, but also chronological sequence of development of organ and systemic violations in the patient with severe traumatic shock with the aim of optimization of intensive care and improvement of a clinical outcome.
The patient M., age of 37, suffered from a gunshot wounds to the left on June, 9, 2015, 12:35 a.m. The bystanders called emergency medical service. The emergency physician (12:45 a.m.) identified that the patient is unconscious (Glasgow Coma Scale = 8). Chest bleeding (in the left region) was of middle intensity. The skin was pale and cyanotic. The breathing was superficial and frequent (44 breaths per min). AP was 50/0 mm Hg, HR – 118 per min, shock index (SI) – 2.4. Oxygen saturation in capillary blood (SaO2) was impossible to determine. Blood loss was more than 2,500 ml (according to the data of system hemodynamics, clinical symptoms and estimation of external blood loss volume).
The patient received emergency aid: the dressing for the wounded regions, right subclavian vein catheterization according to Seldinger (central venous pressure [CVP] – negative), infusion therapy with volume of 2,000 ml (1,000 ml of isotonic sterofundin, 1000 ml of 4 % oxypolygelatin). After intravenous introduction of promedol (2 %, 1 ml) the tracheal intubation and artificial lung ventilation with Chirolog Paravent PAT (Chirana, Slovakia) were initiated.
There were no trends to improvement of clinical picture and systemic hemodynamics at the background of infusion therapy (AP = 60/0 mm Hg, HR = 118 per min, SI – 2, SaO2 – not determined, body temperature – 35.9ᵒ Ñ). Hemodynamics was controlled with the hemodynamic monitor MEC 1200 (Mindray, China) and the pulse oximeter MD 300 (Mindray, China). Vascular therapy with noradrenaline (3 µg/kg/min) was initiated. During transportation the emergency aid physician reported a message to Kabanov City Clinical Hospital #1, i.e. the thoracic surgeon and the anesthesiologist received the information about the diagnosis, severity of the patient’s state and the conducted anti-shock measures.
The patient was transported by the reanimobile to the admission department of Kabanov City Clinical Hospital (1:35 a.m.). The diagnosis was made (1:40 a.m.): “A gunshot chest wound to the left with penetration to pleural cavity and injuries to the lung and the ribs 3-6. Intrapleural bleeding. Hemopneumothorax to the left. Multiple foreign bodies in thoracic soft tissues to the left. Traumatic shock of degree 3”. Primary surgical preparation of the chest wounds, thoracotomy to the left, pulmonectomy and left pleural cavity draining (within 60 minutes) were realized at the background of total intravenous anesthesia (fentanyl + ketamine) with muscle relaxant in conditions of ALV with air oxygen mixture. The patient’s state was extremely severe at the moment of surgical treatment: skin surface were cyanotic and cold (body temperature – 36ᵒ Ñ), SaO2 – not determined, CVP – negative, systemic hemodynamics (AP = 70/40–60/30 mm Hg, HR = 110-118 per min, minute volume of blood circulation – 3.5 l/min, stroke volume (SV) – 30 ml, total peripheral vascular resistance (TPVR) 720 dyn×cm×s-5), which was estimated with non-invasive hemodynamic monitoring with MPR 6-03 (Triton Electronics, Russia), identified hemodynamic type of circulation even at the background of vascular support with noradrenaline (3.5 µg/kg/min) and infusion therapy (500 ml of isotonic sterofundin and 1,000 ml of 4 % oxypolygelatin). During surgery the patient received blood reinfusion from pleural cavity (1,000 ml). The total volume of blood loss was more than 3,000 ml (more than 50 % of circulating blood volume) according to the data of systemic hemodynamics.
At admission to the intensive care unit ALV was conducted with Chirolog Aura SV (Chirana, Slovakia) with CMV mode (Vt – 200 ml, MV – 2.9, FiÎ2 – 0.35 %). Infusion (isotonic sterofundin, 500 ml, 4 % oxypolygelatin, 1,500 ml, 1:3) and transfusion (fresh frozen single group plasma, 1,520 ml, single group packed red blood cells, 730 ml, 2:1) therapy with volume of 4,250 ml (table 1) was initiated, as well as antibacterial treatment (initial treatment – monotherapy with cefoperazone and sulbactam for 4 days, and henceforth, according to results of microbiologic examinations of the blood, meronem, 10 days, tigecycline, 7 days, levofloxacin (6 days) and symptomatic treatment (analgetics, sedative drugs, proton pump inhibitors). The blood analyses showed anemia (hemoglobin – 48 g/l; red blood cells – 1.3×109), hyperlactataemia (4.2 mmol/l) and events of DIC syndrome (antithrombin III – 39 %, APTT – 49.1 sec, SFC – 18 µg/100 ml) [1, 4]. The volume of initial urine output was 0 ml. Postsurgical non-invasive hemodynamic monitoring identified hypodynamic type of circulation confirmed by high HR (11 per min), low minute volume of blood circulation (3.8 l/min), systolic discharge (35 ml) and TPVR (840 dyn×cm×sec-5). It resulted in continuation of vascular support with noradrenaline using the infusion pump FmS (B. Braun, Germany), 3.5 µg/kg/min.
7 hours after admission to the ICU the patient demonstrated negative hemodynamics of general condition: arterial hypotension (AP up to 50/20 mm Hg), tachycardia (up to 126 per min) and discharge of 1,300 ml of transudate through the pleural drain. Besides, the chest X-ray examination showed left-sided hemothorax. After the gross conference the patient was taken to the operating room, where she received bleeding arrest and removal of hemothorax (within 45 min) at the background of total intravenous (fentanyl + ketamine) anesthesia with myorelaxants in conditions of ALV with air oxygen mixture. At admission to the ICU the patient demonstrated hemodynamic type of circulation, which was corrected with volemic and vascular support, and anemia (hemoglobin – 36 g/l, red blood cells – 1.1×109) and progressing DIC syndrome (antithrombin III – 33 %, APTT – 50 sec, SFC – 19 µg/100 ml). Therefore, the program of anti-shock therapy was supplemented with clotting recombinant factor VIIa (coagil), and the volume of fresh frozen single group plasma was elevated [3]. It favored arresting DIC syndrome by the end of the second day. It was confirmed by positive dynamics of antithrombin III (52 %), APTT (39 sec) and SFC (9 µg/100 ml). At the same time, the patient demonstrated restoration of hourly urination (up to 55 ml/hour) and normodynamic type of blood circulation instead of hypodynamic: minute volume of blood circulation (6.3 l/min), systolic discharge (57 ml), TPVR (1,130 dyn×cm×sec-5). It favored decrease in dosage of noradrenaline to 0.8 µg/kg/min.
At the same time, the examination of gas composition of arterial blood during ALV identified decreased (210) oxygenation index (OI = ÐàÎ2/FiÎ2). The parameters of ALV were modified: PEEP (5 cm H2O) was initiated, FiO2 was elevated (up to 0.5 %), and neurovegetative blockade was enhanced. The recurrent examination did not find any positive time trends of OI (200). The X-ray examination showed some infiltrates in the right lung. It testified ARDS according to the data of risk factors (traumatic shock) and acute initiation (within 72 min) of clinical signs of left ventricle insufficiency [1]. Also the patient showed severe multiple organ dysfunction (SOFA = 10), which developed with the following sequence: acute cardiovascular, renal insufficiency, hemostasiological, respiratory and liver insufficiency [5].
Devolution of shock was observed at 72 hours after initiation of intensive care (AP – 110/70 mm Hg, HR – 100 per min, body temperature – 36.7°C), as well as tissue hypoperfusion (decreasing lactate to 1.8 mmol/l), correction of anemia (hemoglobin – 73 g/l; red blood cells – 2.1×109) and urination normalizing (1,250 ml). It allowed stopping vascular support with noradrenaline. At the same time, the patient demonstrated transition from normodynamic type to hyperdynamic type of blood circulation (minute volume of blood circulation – 7.5 l/min, systolic discharge – 71 ml, TPVR – 1,498 dyn×cm×sec-5). It was associated with correction of hemocirculatory disorders and was confirmed by further decrease in venous blood lactate (up to 1.1 mmol/l). However, metabolic monitoring (indirect calorimetry), which was initiated simultaneously with hemodynamic monitoring, identified syndrome of hypermetabolism on the fourth day (the energetic requirements – 3,267 kcal during neurovegetative blockade – morphine + propofol + sibazon) confirmed by the increased levels of plasma glucose, albumin and urea (table 1).
| Table 1 | |||||||||||
| Blood loss and infusion transfusion therapy (ITT) at prehospital and hospital stages in the patient M. before rethoracotomy | |||||||||||
In this regard and also because of absent discharge of gastric contents through the nasogastral probe, the program of treatment was supplemented with enteral nutrition [2] with isocaloric (1 kcal per 1 ml) polysubstrate mixture with dietary fibers Nutricomp Diabet at the volume of 1,000 ml per day; Fms infusion pump (B. Braun, Germany) was used (40 ml per hour). Impossibility of introduction of higher volume of the mixture and its calorific density (for that time moment) was related to limited abilities to endure fluid load owing to ARDS [1, 2].
Therefore, on the fourth days the volume of infusion therapy was reduced to 1,500 ml (isotonic sterofundin). At the same time, helical computer tomography identified multiple foreign bodies (shotgun pellets) in the thoracic soft tissues to the left, and some changes in the right lung (the signs of ARDS). The echocardiographic, ultrasonic (general examination of the abdominal cavity) and multi-layer spiral CT did not find any pathologic changes. Hyperthermia was found on the fifth day (up to 39°C), as well as increasing count of leukocytes in the peripheral blood (up to 19.4×109/l), progression of cerebral (the events of agitation at the background of neurovegetative blockade), pulmonary (OI – 175), renal (the increasing level of creatinine to 165 mmol/l) and liver (the increasing level of bilirubin up to 45 mmol/l) insufficiency, and worsening metabolic disorders (the increasing level of glucose up to 8 mmol/l, lactate – to 2.6 mmol/l, energetic requirements – to 3,498 kcal). The organic systemic disorders witnessed development of secondary multiple organ insufficiency, which is common for severe sepsis [6]. Estimation of procalcitonin levels (7 ng/ml) confirmed development of severe sepsis of infectious genesis [6] as result of traumatic shock and not timely removed multiple foreign bodies (shotgun pellets) in the thoracic soft tissues to the left.
That’s exactly why on the fifth day of treatment the patient received more intense neurovegetative blockade, modified mode of ALV (PEEP increasing to 10 cm H2O, FiO2 – to 0.7 %), antibiotic therapy with consideration of microbiologic picture of the blood, decreasing volume of infusion therapy to 1,000 ml per day (isotonic sterofundin). The volume of enteral mixture was increased to 1,500 ml, because of absent discharge through the nasogastral probe. Besides, on the days 6, 8 and 10 the patient received some sessions of venovenous hemodiafiltration (the volume of ultrafiltrate – 1,000 ml) with PRISMA hemoprocessor (France). Tracheostomy was made on 7th day for continuation of ALV with the previous mode. Antibacterial therapy was modified on 14th day according to the data of blood microflora.
The realized curative measures favored regressing intensity of systemic inflammation by the moment of 15th day (table 2). It conditioned devolution of severe sepsis and decreasing intensity of multiple organ dysfunction, mainly, by means of improving function of the liver and kidneys. At the same time, the patient demonstrated persisting pulmonary (OI – 185) and cerebral (accidental agitation, GCS = 11 at the moment of refusal from sedative and narcotic measures) dysfunctions. It did not allow decreasing PEEP and oxygen level, and remove neurovegetative blockade from the treatment program. Within the same time intervals it was possible to increase the volume of enteral nutrition to 2,000 ml (2,000 kcal) and decrease (up to 500 ml) the volume of infusion therapy that favored further regression of systemic inflammation and syndrome of hypermetabolism (table 3).
| Table 2 | |||||||||||
| Dynamic changes of energetic requirements, SOFA data and biochemical parameters in the patient M. during treatment period | |||||||||||
| Note: the control examinations were conducted for 20 healthy volunteers. |
| Table 3 | |||||||||||
| Dynamic changes of energetic requirements, SOFA data and biochemical parameters in the patient M. during treatment period | |||||||||||
In its turn, on 17th day it conditioned improving function of the right lung (OI – 220) and, as result, decreasing intensity of MODS (table 3). PEEP and FiO2 were decreased at the background of positive time course of OI (up to 5 cm H2O and 0.4 % respectively). Moreover, on 19th day it was possible to realize transition to ventilation with the mode SIMV + PS (OI – 260). On 20th day the ventilation was realized with the mode CPAP + PS (OI – 280). At the same time, the patient demonstrated progression of systemic inflammatory response (table 3). MSCT of the brain and the abdominal cavity did not identify any pathologic changes, but it found right-side pneumonia and confirmed presence of multiple foreign bodies (the shotgun pellets) in the thoracic soft tissues to the left. Antibacterial therapy was modified on the basis of the results of the microbiological examination of the blood. Antibacterial therapy neutralized the events of systemic inflammation (table 3).
On the day 22 the patient was shifted to PS mode (OI – 300). At the same time, the patient demonstrated the significant decrease in her energetic requirements and serum urea levels, and increase in serum albumin (table 3) that testified correction of syndrome of hypermetabolism. On 25th day the patient was switched to independent breathing (OI – 340). On 28th day she was transferred to the thoracic surgery unit (the patient was in middle severity condition).
Therefore, owing to the features of the course of this pathology, patients with gunshot chest wounds with shock require rapid transportation (at the background of anti-shock therapy) to multi-field special medical facilities with wide possibilities of the modern medical diagnostic methods and technologies.
The conducted analysis of strategy and tactics of treatment of the patient M. with traumatic shock of degree 3 after thoracic gunshot wound allowed identifying the organizational tactical priorities of rendering emergency aid, as well as defining the key aspects of treatment of the disease, and chronologic sequence and structure of organ systemic disorders. That’s exactly why the organizational and tactical priorities of realization of emergency medical aid were minimizing time intervals: from the moment of initiation of anti-shock measures to hospital admission; from hospital admission to initiation of surgical treatment; from initiation of surgical treatment to bleeding arrest. The significant feature of surgical treatment of the gunshot wound was an impossibility of removing all shotgun pellets in the thoracic soft tissues that resulted in appearance of the causes of severe sepsis (especially at the background of traumatic shock of degree 3). Anti-shock therapy should be conducted at the background of hemodynamic and laboratory monitoring of homeostasis parameters – for productive correction of organ systemic dysfunctions, which appeared in the following chronological sequence: acute cardiovascular insufficiency, renal and cerebral insufficiency, hemostasis dysfunction, respiratory and liver insufficiency. SOFA is used for appropriate estimation of organ systemic dysfunctions, their time course and effects of intensive care because of the features of development (primary multiple organ dysfunction as result of traumatic shock) and the course (secondary multiple organ dysfunction as result of sepsis) of multiple organ dysfunction syndrome in this pathology. For decreasing intensity of systemic inflammation and sepsis (the leading pathogenetic factors of development and sustention of secondary organ system dysfunctions it is necessary to conduct antibacterial therapy according to results of microbiological monitoring of the blood and to carry out sessions of extracorporeal clearance of the blood (hemodiafiltration) from the moment of appearance and to regression of multiple organ dysfunction syndrome. Pulmonary dysfunction (ARDS) determining severity of general state is the leading organ dysfunction after development of severe sepsis. From pathogenetic point of view, for development of severe sepsis it is appropriate to conduct metabolic monitoring (simultaneously with hemodynamic monitoring) with use of techniques of nutritive (enteral) support for correction of hypermetabolism syndrome and adjuvant therapy of ARDS. ALV strategy and tactics for ARDS is based on time course of oxygenation index and the data of multispiral computer tomography.
CONCLUSION
1. Prehospital and hospital strategy and tactics of emergency aid for patients with thoracic gunshot wounds complicated by severe traumatic shock is realized from the perspective of succession and algorithmization.
2. Upon admission to the multidisciplinary hospital, from diagnostic point of view, it is appropriate to conduct diagnostic (general X-ray examination of the chest, clinical urine examination, examination of blood group and Rh factor) and curative (surgical and conservative treatment) measures concurrently.
3. The feature of the course of traumatic disease in patients with thoracic gunshot wounds complicated by severe traumatic shock is early transition of primary multiple organ dysfunction to secondary one, which is common for severe sepsis.
4. Daily dynamic estimation of multiple organ dysfunction syndrome with use of SOFA allows objective estimation of efficiency of realized intensive care and well-timed correction in case of low effectiveness.
5. Owing to the features of the course of the pathology it is appropriate to realize strategy and tactics of antibacterial therapy on the basis of microbiological monitoring of the blood.