Please opine: A Trauma Case

[sandeep jain]

Dear Navin,

I understand that this is not a simple case and you would have done all what it takes to manage such patients. However going through your case study, some points come to my mind, in retrospect.
1. Delayed diagnosis of bowel injury, complicating the case. I suppose there were no signs of peritonitis at presentation or on serial physical examination. 
2. Patients can develop acute tubular necrosis secondary to contrast used for CT scan, inspite of adequate resuscitation, which may be the case.
3. Repeated bowel perforations can be due to either missed SMV injury or iatrogenic partial thickness tears during handling of such oedematous and fraible bowel.

Dr.Sandeep Jain
Trauma Surgeon


--- On Wed, 6/11/08, navin goyal <drnavingoyal at yahoo.co.in> wrote:

> From: navin goyal <drnavingoyal at yahoo.co.in>
> Subject: Please opine: A Trauma Case
> To: trauma-list at trauma.org
> Date: Wednesday, June 11, 2008, 12:35 PM
> A middle age man&nbsp; to the Emergency h/o RTA on
> 18.05.08 . Patient
> was irritable on admission, with hematoma over right Eye ,
> tachycardiac&nbsp; ,
> maintaining Blood pressure , and oxygen saturation over
> 90%. Patient was
> investigated and C T scan of head , chest and abdomen was
> done. CT scan showed
> depressed # frontal bone, Liver Laceration and
> hemoperitoneum . Patient was
> initially resuscitated and conservative management was
> planned. He still had tachycardia and later on his
> urine outoput decreased. Considering his decreasing urine
> output and non
> resolving tachycardia he was taken for Surgery. On Opening
> the abdomen 2 liters
> of hemoperitoneum was found and there was perforation in
> the jejunum. No fresh
> bleeding from the liver was found . Perforation was
> repaired in layers. Frontal
> wound was debrided , depressed fracture was elevated ,
> sinus bleeding was
> occluded with surgicell / Gelfoam.
> 
> &nbsp;
> 
> &nbsp;Patient had normal
> recovery from these surgeries however urine Output
> decreases to nil. Service of
> Nephrologists was taken and patient was kept on
> hemodialysis. 
> 
> 
> &nbsp;
> 
> &nbsp;However three days
> thereafter patient showed increase in the abdominal girth ,
> illeus and
> distension with pus which was not fecal smelling coming out
> from the drain site.
> Patient was again taken up for the laprotomy and on opening
> gut was found
> edematous and distended , some pus pockets were found in
> the abdominal cavity ,
> which were cleaned. 
> 
> &nbsp;
> 
> Later after two days patient had bilious leak from the
> abdominal wound, this fluid was sent for biochemistry which
> showed very high
> level of amylase and Lipase . Suspecting leak from the
> intestine patient was
> again explored on 5 th day post surgery and this time he
> had two perforations in the ileum. One site was
> in the distal ileum and another at 1 feet distal to the
> previous jejunal perf
> site.&nbsp; No leak was present from the
> previous sutured site, . Proximal perforation which was
> small&nbsp; about 1 cm size , and at
> mesenteric border was repaired.&nbsp; Illeostomy
> was taken out from the site of distal perforation.
> Abdominal cavity was
> thoroughly lavaged and abdomen closed.
> 
> &nbsp;
> 
> 
> 
> 
> 
> Patient’s drain again showed bilious fluid coming from
> the
> peritoneal cavity through the drain on the third day .
> Illeostomy was showing minimal function.
> On &nbsp;exploring the
> abdomen , a new perforation near the previously sutured
> jejunal perforation at
> the mesentric border was found&nbsp; and another from
> the previously sutured site in jejunum.&nbsp; . Since
> the new
> perforation was very close to the jejunal repaired , part
> was resected and re
> anastomosis was done . . Abdomen was closed via
> tension wiring&nbsp; . 
> 
> &nbsp;
> 
> Four&nbsp; days after the surgery patient again showed
> leak form
> the wound site . 
> 
> At present , illeostomy is showing minimal to moderate
> function with , fistula fluid leaking from the wound site.
> Patient kidneys are
> still not functional and he is requiring hemodialysis
> support. . He is managed
> conservatively and is fed through RT @ 150 ml 2 hrly.He is
> requiring minimal
> ventilator support in the form of pressure support. He is
> conscious , Some leak
> of CSF fluid is present from the frontal wound. Parentral
> Nutrition is being
> added to support the patient. Lower part of the abdominal
> wound has been opened up to allow the fistula to drain out.
> Over a week has passed , fistula is showing no sign of
> decrease.
> 
> 
> What should be the next stratergy for this patient?Any
> explaination or suggestion for new developing perforation
> in the mesentric border of the intestine?
> 
> 
> &nbsp;
> 
> 
> 
> 
> 
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