You are on page 1of 43

CASO

INTERESANTE
DR. JOSE MANUEL GODINEZ
DR. MARIO RECINOS

CIRUGIA - IGSS

DATOS GENERALES:
NOMBRE: K.E.C.A
EDAD: 9
AF: NA212155
FECHA/INGRESO: 31/12/2014
HORA : 19:00
ANTECEDENTES: DESCONOCIDOS

MOTIVO DE CONSULTA
HPAF EN MIEMBROS INFERIORES DE
30 MINUTOS DE EVOLUCION

HISTORIA DE LA ENFERMEDAD
HACE 30 MINUTOS, DESCONOCIDOS DISPARAN
PROVOCANDOLE HERIDAS POR ARMA DE FUEGO EN
MIEMBROS INFERIORES

BOMBEROS LO TRASLADAN A ESTA UNIDAD.

AL INGRESO P/A:45/25MMHG FC 95XMIN T36 FR25XMIN NORMOCEFALO TORAX SIMETRICO EXPANSIBLE ABDOMEN BLANDO DEPRESIBLE NO IRRITACION PERITONEAL NEUROLOGICO: GLASGOW 15 PUNTOS. .

HERIDA SANGRANTE.AL INGRESO MII: HPAF: ORIFICIO DE ENTRADA. HEMATOMA CRECIENTE. PULSO FEMORAL PALPABLE ¼. . POPLITEO Y PEDIO AUSENTES. CARA MEDIAL TERCIO MEDIO DE MUSLO IZQUIERDO. PIEL FRIA. CON DEFORMIDAD OSEA Y EDEMATIZADA. CARA LATERAL TERCIO MEDIO DE MUSLO IZQUIERDO. ORIFICIO DE SALIDA.

SIN HEMATOMA. . NO HEMORRAGIA ACTIVA Y PULSOS PERIFERICOS ¾.AL INGRESO MID: HPAF: ORIFICIO DE ENTRADA: EN CARA MEDIAL DE MUSLO DERECHO TERCIO MEDIO LATERAL ORIFICIO DE SALIDA: SALIDA EN CARA TERCIO MEDIO DE MUSLO DERECHO.

2 CREAT 0.95 GLUC 125 TP 13 HB 11.LABORATORIOS DE INGRESO WBC 8.4 TPT 23.23 NA 136 K 4.4 .5 HT 32% BUN 8 INR 1.

HEMORRAGIA ACTIVA DE MIEMBRO INFERIOR IZQUIERDO. HEMATOMA CRECIENTE. . A.IMPRESION CLINICA HERIDA POR PROYECTIL DE ARMA DE FUEGO EN MIEMBROS INFERIORES 1. B. HERIDA POR ARMA DE FUEGO EN SEDAL DE MUSLO DERECHO.

RAYOS X .

SALA DE OPERACIONES .

SALA DE OPERACIONES  INDICACION:  INESTABILIDAD HEMODINAMICA  HEMORRAGIA ACTIVA DE SITIO DE LESION MII  HEMATOMA CRECIENTE EN MUSLO IZQUIERDO  HERIDA POR PROYECTIL DE ARMA DE FUEGO EN MUSLO IZQUIERDO  INCISION: LONGITUDINAL CARA MEDIAL DE MUSLO IZQUIERDO .

 HEMATOMA CONTENIDO EN TEJIDOS BLANDOS. . CON HEMORRAGIA ACTIVA.  ARTERIA FEMORAL Y VENA SAFENA INTERNA SIN LESIONES EVIDENTES.SALA DE OPERACIONES  HALLAZGOS:  PERFORACION VENA FEMORAL SUPERFICIAL IZQUIERDA MAYOR DE 50%.

EDGAR RODRIGUEZ/DRA.SALA DE OPERACIONES  PROCEDIMIENTO:  EXPLORACION VASCULAR FEMORAL IZQUIERDA + LIGADURA DE VENA FEMORAL SUPERFICIAL IZQUIERDA + COLOCACION DE CATETER VENOSO CENTRAL SUBCLAVIO DERECHO CIRUJANO: DR. NATHALI HERNANDEZ ANESTESIOLOGO: DRA. . NORA LOPEZ ANESTESIA: GENERAL. SHUBERT QUIÑONEZ AYUDANTE: DR.

ORTOPEDIA  PROCEDIMIENTO:  COLOCACION DE FIJADOR EXTERNO DE FEMUR ANTEROLATERAL IZQUIERDO.  INDICACION:  FRACTURA DE TERCIO PROXIMAL DE FEMUR EXPUESTA POR HERIDA POR ARMA DE FUEGO CIRUJANO: DR. XET .

EVOLUCION .

EVOLUCION  INGRESA A UTI I  ATBS (CEFOTAXIME. FENTANYL)  AMINAS VASOACTIVAS (DOBUTAMINA)  EN NPO CON SOLUCIONES INTRAVENOSOS  VENTILACION MECANICA . AMIKACINA)  SEDACION (MIDAZOLAM.

33 TPT 23.15 HT 43% NA 137 PLT 234 K 5.3 CA 9 EVALUADO POR MEDICOS DE PEDIATRIA CAMBIA A: GENTAMICINA Y CEFEPIME .9 HB 15 BUN 12 INR 1.47 GLUC 110 TP 12.LABORATORIOS 01/01/2015 WBC 17.3 NEUT 86% CREAT 0.

32 HB 8.3 .78 GLUC 153 NEUT 27% CREAT 0.02 .03/01/2015 SE INICIA DIETA POR SNG SE TRANSFUNDE CELULAS EMPACADAS. WBC 9.9 BUN 9 HT 26% NA 136 PLT 96 K 4.

SE TRASLADA A ORTOPEDIA PEDIATRICA .EVOLUCION 04/01/2015 SE OMITEN AMINAS VASOACTIVAS UROCULTIVO: NEGATIVO A LAS 48 HORAS ASPIRADO TRAQUEAL: NEGATIVO A LAS 48 HORAS SE PREPARA PARA EXTUBAR 05/01/2015 SE RETIRA TUBO OROTRAQUEAL .

ADECUADA COLORACION. PULSOS FEMORAL. POPLITEO NO VALORABLE POR EDEMA Y DOLOR.EVOLUCION 06 -07/01/2015  PACIENTE CON BUENA EVOLUCION. TIBIAL Y PEDIO 3/3. SE DA EGRESO POR NO ACREDITAR DERECHO TRASLADO A HOSPITAL ROOSEVELT . TEMPERATURA Y LLENADO CAPILAR DISTAL. 3/3. SIN SIGNOS DE SINDROME COMPARTAMENTAL. MIEMBRO INFERIOR IZQUIERDO CON ESCASO EDEMA.

REVISION BIBLIOGRAFICA .

Swede JOURNAL OF VASCULAR SURGERY Volume 59. 2 Department of Surgical Sciences.Manejo de las lesiones vasculares en pediatría. Uppsala University. 2012 . Number 6S. Björn Kragsterman 1 Department of Vascular Surgery. Sweden. Uppsala. Section of Vascular Surgery. Stockholm. Karolinska Institute and Karolinska University Hospital. Carl Wahlgren.

MANEJO DE LAS LESIONES VASCULARES EN PEDIATRÍA.  Anatomical locations of vascular injuries included upper extremities [62%]. followed by penetrating [27%] and iatrogenic trauma [8%]. lower extremities [29%]. and neck [1%]. abdomen [7%]. . chest [1%]. RESULTS:  Blunt trauma [65%] was dominating.

 Reversed vein/venous patch (n ¼ 83) was the dominating graft material.MANEJO DE LAS LESIONES VASCULARES EN PEDIATRÍA. and synthetic grafts were only used in two open cases. .  The most common postoperative complication was arterial occlusion/thrombosis (n ¼ 11).

and the frequency of endovascular repair in the pediatric population is low . Conclusions:  shows that traumatic vascular injuries in children are associated with high limb salvage rates and low mortality.  The preferred repair techniques are venous patch and interposition graft.  Blunt trauma is most common and injuries are predominantly located to the upper and lower extremities.MANEJO DE LAS LESIONES VASCULARES EN PEDIATRÍA.

Manejo quirúrgico vs no quirúrgico en lesiones arteriales en extremidades. .

the axillary (4%). . and the external iliac (4%) arteries. the ulnar (9%). blunt trauma. shotgun and iatrogenic trauma.MANEJO QUIRÚRGICO VS NO QUIRÚRGICO EN LESIONES ARTERIALES EN EXTREMIDADES.  The most frequently injured vessels were the brachial (43%) and the common and/or superficial femoral (26%) artery followed by the popliteal (13%).  The mechanism of injury was penetrating lesion.

.

 An infant is unlikely to sustain a gunshot wound or complex trauma that would likely require open surgery.MANEJO QUIRÚRGICO VS NO QUIRÚRGICO EN LESIONES ARTERIALES EN EXTREMIDADES.  Conservative treatment consisting of heparin administration has been suggested. . with a tendency to spasm.  The diagnosis and management of arterial injury is more complex in children than in adults  Special technical problems are encountered when dealing with pediatric arterial injuries because the vessels are small and thin-walled.

ISQUEMIA DE MANO ASOCIADO A TRAUMA DE CODO .

cool.ISQUEMIA DE MANO ASOCIADO A TRAUMA DE CODO  Supracondylar fracture (SCF) of the humerus is common fracture the most  Children with SCF have a reported incidence of associated brachial artery injury of 8% to 10%.  Exploration of the brachial artery has been clearly indicated in the case of a pulseless. white hand. .

.

cool hand without detectable Doppler signals in the palmar arch.  We favor the thigh saphenous vein as a conduit because of its larger size and thicker walls. . but others have found the adjacent basilic vein to be a safe alternative with excellent long-term patency.ISQUEMIA DE MANO ASOCIADO A TRAUMA DE CODO  we recommend early brachial artery exploration in patients with profound hand ischemia defined as a pale.  We also recommend prompt exploration in patients who experience loss of wrist pulses or worsening Doppler signals after orthopedic fixation out of concern for entrapment.

Trauma cerrado femoropopliteo en niños .

 A lesion of a major artery of the limb. compartment syndrome . leading to gangrene.TRAUMA CERRADO FEMOROPOPLITEO EN NIÑOS  Vascular injuries resulting from blunt trauma are rare in Children approximately 1% of pediatric trauma Admissions in one multicenter experience. if not rapidly identified. may produce prolonged ischemia.

as it does in adults.TRAUMA CERRADO FEMOROPOPLITEO EN NIÑOS  Blunt trauma involving the popliteal artery. open revascularization can be performed when the endovascular technique fails. quick technique that allows immediate restoration of The blood flow  Moreover. if the repair is delayed by more than 6 hours. it may lead to a nonfunctioning limb or may necessitate amputation. .  The endovascular procedure is a minimally invasive.

.Manejo de la isquemia agudo en extremidades inferiores.

 Synthetic conduits. Autologous grafts. but they are more prone to infection.  If minimal vascular injury is present.  We advocate that vascular anastomosis performed with interrupted sutures be . primary repair should be the preferred technique. such as polytetrafluoroethylene graft. such as reversed saphenous vein. are preferred if primary repair is not feasible and have demonstrated the best long-term outcomes.MANEJO DE LA ISQUEMIA AGUDO EN EXTREMIDADES INFERIORES. can also be successfully used.

 Infants younger than 2. . In this age group. there is a great potential for rapid growth of adequate collateral circulation. and conservative management with anticoagulation may be attempted initially in a nonthreatened ischemic extremity.MANEJO DE LA ISQUEMIA AGUDO EN EXTREMIDADES INFERIORES.5 years.  Such complex lesions should be managed in tertiary specialized care facilities with a multidisciplinary team involving trauma and pediatric surgeons and pediatricians.

.

INTERPOSICION DE INJERTO DE SAFENA EN ESPIRAL F. ANGIOPLASTIA CON PARCHE VENOSO C. VENORRAFIA LATERAL B. ANASTOMOSIS TERMINOTERMINAL D. INTERPOSICION DE INJERTO *LIGADURA .REPARACIONES VENOSAS A.

SHUBERT QUINONEZ  JEFE DE CIRUGIA PEDIATRICA  5808-7966  DRA. DR. NICOLE MCCARTUR  JEFA DE RESIDENTES PEDIATRIA  4033-4549 GRACIAS!!! .