major vessel firearm injury in medias tin um

8/8/2019 Major Vessel Firearm Injury in Medias Tin Um

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Major Vessel Firearm Injury inMajor Vessel Firearm Injury inMediastinumMediastinum

Presentation ByPresentation By

Surgical Unit IIISurgical Unit III


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Faryad Hussain

42 years of age42 years of age

Presented in emergency in state of shockPresented in emergency in state of shock

after three hours of Firearm wound onafter three hours of Firearm wound onsternum from low velocity weapon.sternum from low velocity weapon.

Conscious but DrowsyConscious but Drowsy

Markedly PaleMarkedly Pale

Rapid BreathingRapid Breathing


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ExaminationExamination

Pulse was very feeble 116/minPulse was very feeble 116/min

Temperature 97.4Temperature 97.4FF

Blood Pressure 60/NillBlood Pressure 60/Nill Respiratory Rate 28/minRespiratory Rate 28/min

Cold , clammy skinCold , clammy skin

Markedly paleMarkedly pale

SweatingSweating


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Chest Expansion and breathe soundsChest Expansion and breathe sounds

were reduced on left side.were reduced on left side.

Percussion note was inconclusive.Percussion note was inconclusive.

Needle thoracostomy was done but wasNeedle thoracostomy was done but was

not much of help.not much of help.


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Immediate resuscitation was startedImmediate resuscitation was started

wide bore i.v. cannula passed and fluidswide bore i.v. cannula passed and fluids

started.started.

Blood was arranged and two pintsBlood was arranged and two pints

transfused immediately.transfused immediately.

Following resuscitation, patients bloodFollowing resuscitation, patients blood

pressure and pulse started improvingpressure and pulse started improving


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Once the B.P. was improved with i.v.Once the B.P. was improved with i.v.

Fluids and blood transfusion, chest XFluids and blood transfusion, chest X--rayray

was taken.was taken. On Chest X RayOn Chest X Ray--PA view,there wasPA view,there was

mediastinal widening.mediastinal widening.

Pleural effusion on left side accompaniedPleural effusion on left side accompanied

by pneumothorax.by pneumothorax.


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After XAfter X--Ray, patient was rushed toRay, patient was rushed to

operation theatre and chest openedoperation theatre and chest opened

through midline sternotomy incision.through midline sternotomy incision.

Patient was operated within two hours ofPatient was operated within two hours of

presentation.presentation.


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Per operative FindingsPer operative Findings

Pulmonary Trunk was injured,with aPulmonary Trunk was injured,with a

laceration of about 1cm on its anteriorlaceration of about 1cm on its anterior

surface.surface.

There was hemopericardium which laterThere was hemopericardium which lateron turned out to be blood trickling downon turned out to be blood trickling down

into pericardium from intra pericardial partinto pericardium from intra pericardial part

of pulmonary vessel laceration.of pulmonary vessel laceration. There was left sided haemothorax.There was left sided haemothorax.

Pleura of left lung damagedPleura of left lung damaged


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Operative ProcedureOperative Procedure

Pulmonary trunk was repaired usingPulmonary trunk was repaired using

prolene 2/0.Pericardium was opened toprolene 2/0.Pericardium was opened to

find out the cause of hemopericardium.find out the cause of hemopericardium.

No intra pericardial vessel was damagedNo intra pericardial vessel was damaged

and myocardium was spared.and myocardium was spared.

Torn pleura on left side was repaired.Torn pleura on left side was repaired.


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Chest drain with under water seal placedChest drain with under water seal placedon left side.on left side.

Drain placed in superior mediastinum.Drain placed in superior mediastinum.

Pericardium repaired where it had beenPericardium repaired where it had beenopened for exploration.opened for exploration.

Haemostasis acquired and midlineHaemostasis acquired and midline

sternotomy wound closed with the help ofsternotomy wound closed with the help ofsteel wire and substeel wire and sub--cuticle prolene.cuticle prolene.


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Post Operative periodPost Operative period

Post op period was un eventful, thanks toPost op period was un eventful, thanks to

anesthesia and ICU colleagues for theiranesthesia and ICU colleagues for their

expertise and vigilance.expertise and vigilance.

Patient kept in ICU for 48 hours postPatient kept in ICU for 48 hours post

operatively for close monitoring.operatively for close monitoring.

Late post op period was without anyLate post op period was without any

significant event and patient left ward twosignificant event and patient left ward two

weeks after operation.weeks after operation.


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Follow UpFollow Up

Patient was followed on OPD basis andPatient was followed on OPD basis and

the only troublesome event was fistulathe only troublesome event was fistulaformation through sternotomy woundformation through sternotomy wound

which later on healed by itself onwhich later on healed by itself on

expectant management.expectant management.


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ConclusionConclusion

Immediate recognition of sinister eventImmediate recognition of sinister eventand prompt action saves the day, for theand prompt action saves the day, for the

patient and for the clinician.patient and for the clinician.

major vessel firearm injury in medias tin um

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