Mortality Meet

Case Presentation

Dr Prashant Shukla - Fellow Trauma Surgery

1
 Basic details
ATMIST

• 18 year old; Male

• Time of injury - 8:30 pm of Day 0
• Mechanism of injury - RTA - head on collision with a road roller while riding bike.
• Injuries - 3 cm elliptical abrasion with adjoining contusion at right upper abdomen
• Vital signs – P – 124/min, BP –129/82 mm Hg, SpO2 – 98% on room air
• Treatment given – injectable analgesic & IV fluids.
• Reached trauma centre BHU at 5:30 am of Day 1
• Complain of Progressively increasing abdominal pain
 Primary survey
Airway & cervical spine control

• Air exchange - present

• No added sounds
• Control & immobility of cervical spine maintained
• Airway patent & protected
• Patient anxious
 Primary survey
Breathing

• Breath sounds - bilateral air entry equal

• Chest wall movements - bilaterally equal & symmetrical.
• No tracheal deviation
• Neck veins - not distended
• RR - 24/min ( thoraco-abdominal)
• No external chest injury, surgical emphysema, bony crepitations
• Spo2 - 96% on room air
• 0xygen support started
 Primary survey
Circulation & haemorrhage control

• Mentation - patient is conscious

• Skin colour & temperature - normal
• Pulse - 138/min
• Blood pressure - 122/78 mm Hg
• Shock index - 1.13

• B/L 16 G cannula inserted- Resuscitation started with 1L warm crystalloid - vitals: P -

96/min, BP - 124/76 mmHg - Responder
 Primary survey
Disability

• Pupils - bilateral equal & reactive

• GCS - 15/15
• All extremity movement - normal
• Voice - normal
 Primary survey
Exposure & environment

• Temperature - normal
• Spinal examination - normal
 Secondary survey
Resuscitation continued; vital parameters improved
• AMPLE history -
• No allergies, No medications currently taking & No significant past medical history
• Last oral intake 2 hrs before injury
• Immediate transport post injury to nearest primary health care facility from where
referred to trauma centre BHU.
• Head to toe examination -
• Abdomen - soft, tenderness & guarding present at right upper abdomen, DRE - normal
• E-FAST - positive - free fluid at Morrison pouch detected.
 CECT abdomen
Moderate haemoperitoneum

Fluid in the lesser sac.

Uncinate process of pancreas showing edema and
Heterogenous enhancement with pancreatic-duodenal, right perinephric fat stranding.
 Blood work up
Day 1

Creatinine 2.2 mg/dl Haemoglobin 13.5 g/dl

Urea 78 mg/dl Haematocrit 44.6%
Sodium 140.2 mmol RBC 4.85 * 1012 / L
Potassium 4.2 mmol/L WBC 6.86 * 103 / uL
Chloride 106.5 mmol/L DLC 81 / 7.6 / 8.4 / 2.7 / 0.3
Total bilirubin 1.1 mg/dl PLT 215 * 103 / uL
Direct bilirubin 0.7 mg/dl INR 1.72
Indirect bilirubin 0.4 mg/dl Amylase 1930.4 U/L
SGPT / ALT 35 U/L
Lipase 1506 U/L
SGOT / AST 67 U/L
Calcium 10.2 mg/dl
ALP 124 U/L
Total protein 6.6 g/dl Phosphorous 3.9 mg/dl

Albumin 3.2 g/dl HIV/HBsAg/HCV Non reactive

 Blood work up
Day 2

Creatinine 5.4 mg/dl Haemoglobin 12.6 g/dl

Urea 139 mg/dl Haematocrit 41.6%
Sodium 151.2 mmol RBC 4.63 * 1012 / L
Potassium 6.0 mmol/L WBC 11.90 * 103 / uL
Chloride 109.3 mmol/L DLC 59.6 / 28.5 / 7.6 / 3.3 / 1.0
Total bilirubin 1.3 mg/dl PLT 139 * 103 / uL
Direct bilirubin 1.1 mg/dl pH 7.250
Indirect bilirubin 0.20 mg/dl PaCO2(mm Hg) 36.2
SGPT / ALT 963 U/L
PaO2(mm Hg) 26.5
SGOT / AST 1795 U/L
HCO3 15.5
ALP 120 U/L
Total protein 4.2 g/dl BE -10.8
Albumin 1.9 g/dl Lactate 8.90
 Day 2 - 10:00 am
Patient deteriorated at ED

• Pulse - 170/min
• BP - 120/60 mm Hg
• Spo2 - 100 % on 2L O2 /min
• Patient unconscious - GCS - E1V1M1 - intubation done
• Sudden cardiac arrest - 3 cycle of CPR given - inj adrenaline given.
• Patient immediately shifted to emergency OT for exploration
• 2 cycle of CPR given in OT
 Operation record
Planned for damage control surgery

• On exploration
• 1.5 litre bilious contaminated intraperitoneal fluid present.
• 2*2 cm of perforation present over third part of duodenum - grade II
• Procedure done
• Peritoneal lavage with tube drainage of duodenum with closure of abdomen with
baggota bag done
• Operative time - 35 min
• Patient shifted to ICU
 Post operative course
POD - 0 ( DAY 2 post injury )
12pm 8pm
HR (per min) 170 148
BP (mm Hg) 116/70 ( inj Norad 20 mcg/min ) 110/78 ( inj Norad 16 mcg/min )
Temp (F) 102 100.7
RR / SpO2 20 / 100 24 / 100
Mode SIMV PSV
FiO2 80 40
PEEP (cm H20) 5 5
PS (cm H20) 18 18
pH 7.096 7.25
PaCo2 43.1 31.6
PaO2 348.2 287
HCO3 12.9 13.7
BE -16.0 -12.2
Lactate - 7.81
RBS 41 ( inj D-25% 100 ml stat ) 47 ( inj D-25% 100 ml stat )
Urine ouput 60 ml over last 4 hrs 300 ml over last 8 hrs
Drain output - 50 ml (ss)
 DAY 3
POD 1
2am 4pm
HR (per min) 136 116
BP (mm Hg) 128/74 ( inj Norad 24 mcg/min ) 108/58 ( inj Norad 24 mcg/min )
Temp (F) 99 99.1
RR / SpO2 12 /100 12 / 92
Mode SIMV SIMV
FiO2 40 80
PEEP (cm H20) 5 5
PS (cm H20) 18
pH 7.24 7.16
PaCo2 29.2 38.2
PaO2 206.4 329
HCO3 12.4 13.4
BE -13.5 -14.3
Lactate 6.9 8.04
RBS - 160
Urine ouput 250 ml over last 6 hrs Nil for last 12 hrs
Drain output 100 ml (ss) 700ml (ss)
 Blood work up
POD 1 / Day 3

Creatinine 6.9 mg/dl Haemoglobin 11.9 g/dl

Urea 176 mg/dl Haematocrit 41.1%
Sodium 143.4 mmol RBC 4.58 * 1012 / L
Potassium 7.0 mmol/L WBC 10.44 * 103 / uL
Chloride 107.0 mmol/L DLC 82 / 10.6 / 4.0 / 1.8 / 1.6
Total bilirubin 4.0 mg/dl PLT 62 * 103 / uL
Direct bilirubin 3.1 mg/dl INR 5.84
Indirect bilirubin 0.90 mg/dl
SGPT / ALT 3270 U/L
SGOT / AST 7969 U/L
2 units PC & 4 units FFP were transfused
ALP 443 U/L
SLED was done as per nephrology advise.
Total protein 4.3 g/dl
Albumin 2.3 g/dl
 DAY 4
POD 2
11am

HR (per min) 118

BP (mm Hg) 88/48 ( inj Nora 30 mcg/ml + inj vasopressin 0.04 U/min)

Temp (F) 100

RR / SpO2 28 / 99

Mode PRVC

FiO2 80

PEEP (cm H20) 5

PSV (cm H20) -

RBS 54

Urine ouput Nil over last 12 hrs

Drain output 200 ml

 Day 4
POD - 2

• Patient developed sudden hypotension & bradycardia —-> cardiac arrest

• ACLS protocol followed
• Patient declared dead at 1:15 pm.
 Summary

• 18 year old male patient with alleged history of RTA presented with abdominal pain and
class II Haemorrhagic shock & e-FAST suggestive of free fluid in the Morrison pouch.
• CECT abdomen suggestive of moderate heamoperitoneum & fluid in the lesser sac,
Uncinate process of pancreas showing edema and heterogenous enhancement with
pancreatic-duodenal, right perinephric fat stranding.
• Patient deteriorated eventually and was explored with evidence of third part of duodenal
perforation (Grade II) and damage control surgery was done.
 Discussion
Duodeno-pancreatic trauma

• Incidence -
• Duodenum - 1.5-11%
• Pancreas - 5-6%
• Blunt rupture of duodenum leads to minimal symptoms-
• retroperitoneal location,
• low bacterial count, and
• neutral pH contents.
• Clinical signs - highly non specific & delayed.

Feliciano DV. Abdominal trauma revisited. Am Surg. 2017;83:1193.

 Duodeno-pancreatic trauma
Diagnosis

• Initial amylase value does not differentiate between patients with perforated and non-
perforated Duodenal injury
• A normal amylase level does not exclude Duodenal injury.
• Measuring amylase and lipase levels every 6 h is recommended.
• Accuracy may be improved if they are measured more than 3 h after injury
• Amylase can also be elevated in head, hepatic, and bowel injuries and in alcohol abuse
and after hypo-perfusion of the pancreas

Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y,
Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R; WSES-AAST Expert Panel. Duodeno-pancreatic and extrahepatic biliary
tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019 Dec 11;14:56. doi: 10.1186/s13017-019-0278-6. PMID: 31867050; PMCID: PMC6907251.
 Duodeno-pancreatic trauma
Work up
• Missed blunt Duodenal injury on CECT rates up to 27% have been described
• Up to 40% of Pancreatic injury can be missed or misdiagnosed on abdominal CT-scan
obtained within 12 h of injury.
• Pancreatic injury becomes more evident 12–24 h after trauma.
• A repeat CT-scan with curved multi-planar reconstruction and specific pancreatic phase
(35–40 s from iodine contrast injection) can help in diagnosing pancreatic ductal (PD)
injuries
• Minor injuries may be more evident on MRI than on CT-scan

Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y,
Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R; WSES-AAST Expert Panel. Duodeno-pancreatic and extrahepatic biliary
tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019 Dec 11;14:56. doi: 10.1186/s13017-019-0278-6. PMID: 31867050; PMCID: PMC6907251.
 Duodeno-pancreatic trauma
Diagnostic laparoscopy

• Not been specifically studied for the evaluation of pancreatic-duodenal injuries.

• The duodeno-pancreatic anatomy and the retroperitoneal location increase the risk of
missed injuries

Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y,
Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R; WSES-AAST Expert Panel. Duodeno-pancreatic and extrahepatic biliary
tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019 Dec 11;14:56. doi: 10.1186/s13017-019-0278-6. PMID: 31867050; PMCID: PMC6907251.
 Duodeno-pancreatic trauma
Treatment - DI

• Hemodynamic stability without definitive evidence of full thickness laceration of dictates NOM with
• serial abdominal exams,
• bowel rest, and
• nasogastric tube decompression
• OM
• DCS
• Primary repair
• Pyloric exclusion

Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y,
Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R; WSES-AAST Expert Panel. Duodeno-pancreatic and extrahepatic biliary
tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019 Dec 11;14:56. doi: 10.1186/s13017-019-0278-6. PMID: 31867050; PMCID: PMC6907251.
 Duodeno-pancreatic trauma
Treatment - PI

• NOM is the treatment of choice in presence of Haemodynamic stability.

• Proximal lesions - endoscopic intervention
• OM
• Drainage
• Distal pancreactomy +/- splenectomy
• Staged PD.

Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y,
Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R; WSES-AAST Expert Panel. Duodeno-pancreatic and extrahepatic biliary
tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019 Dec 11;14:56. doi: 10.1186/s13017-019-0278-6. PMID: 31867050; PMCID: PMC6907251.
 Lesson
Take home message

• Specific injury patterns in the pancreas and duodenum often have variable expression
at early posttraumatic multidetector CT: They may be hardly visible, or there may be
considerable exudate, hematomas, organ ruptures, or active bleeding.
• Repeated CT should be considered for patients in stable condition when there is a
strong suspicion of duodeno-pancreatic injury despite normal findings at admission
CT.
• Don’t use the lethal triad as a guide to bailing out.
 Thank you
For every complex problem, there is a solution that is simple, neat & wrong. - H.L. Mencken