1) A 36-year-old man was in a motorcycle collision with a bus and suffered multiple severe injuries including a fractured right humerus, blunt abdominal trauma, and polytrauma. 2) In the operating room, the patient experienced significant blood loss of 500ml from a liver laceration and developed hemorrhagic shock. Vasopressors were administered. 3) During surgery, the patient developed ventricular tachycardia and required defibrillation, amiodarone, and cardioversion to restore normal sinus rhythm due to his injuries and hemorrhage.

1. BY THE GRACE OF GOD AND
ENCOURAGEMENT GIVEN BY OUR
HOD WE WERE ABLE TO GO AHEAD
AND HELPED US TO SAIL SAFELY

2. MORBIDITY and MORTAILITY
36 yr Niaz Ahamed
RTA With POLYTRAUMA
R shaft of humerus fracture
Blunt Trauma Abdomen
DOA -6/12/2017
Wt-80 kg
Ht -170cm
Team involved
Dr.Charles Assoc.Prof
Dr.Yasha SR
Dr.Daniel PG
Dr.Harith PG
Dr.Monisha PG

3. History
• H/o RTA two wheeler collision with bus at 3.pm
• h/o injury to the abdomen and Right upper limb
• h/o injury to the chest
• No h/o ENT bleed LOC, Seizure ,vomiting,Head
injury
• Shifted to Cuddalore GH,treated conservatively.
• Referred here for further management
• h/o k/c/o alcoholic,smoker
• No h/o any other comorbidities

4. Primary Survey
• Airway
Patent Airway
• Breathing
RR 24/min SpO2 100% room air
B/L AE + No adventitious sounds
• Circulation
PR 150 BP 140/90
• Disability
GCS 13/15 E4 V4 M5
Pupils b/l reacting to light
• Exposure
Deep lacerated wound over the Ant.Aspect of Right shoulder
Active bleeding + Compression bandage in situ
R arm Swelling
deformity
Bony crepitus
Radial Pulse was Present

5. Secondary Survey

6. FAST scan
• Fast Scan 1 at 4.00pm –No free fluid collection
noted
No solid organ damage

7. • Patient became irritatable
• Drop in GCS
Airway was secured with 8 size tube PCV at 5.00pm
• Fast Scan 2- Minimal free fluid collection in the Pelvic
region.
No fluid present in the Morrison's pouch and
splenorenal space
No evidence of pleural effusion and pericardial
effusion noted
Fluid was aspirated under aseptic precaution content
was blood
One unit O-ve
Two units of B+ve was transfused

8. • Monitor showed ST elevation lead II at 6.30pm
• 12 lead ECG showed II,III,aVf,V3-V6

9. Investigations
• Hb : 10.1 gm %
• TC : 23,600
• Platelet : 2,08,000
• RBS : 223mg/dl
• Urea 28
• Creatinine 1.75
• Na 136
• K 3.4
• Cl 108
• Blood Group : B positive
LFT
• alb :3.7
• Total P:5.5
• T.Billirubin 0.7
• Direct 1.8
• AST 986
• ALT 415
• ALP 56

10. Investigations
• PT 18.8
• INR 1.42
ABG
• PH 7.21
Pco2 39
Po2 295
HcO3 15.6
FiO2 100%
Investigations
CPK MB 155 U/L
Troponin IPositive

11. ANAESTHETIC PLAN
Peri-op Risk Factors
• Obese
• RTA with multiple
injuries(Poly trauma)
• Inferolateral MI
• Alcoholic
• Smoker
• Incision
• Increase risk of
Bleeding
• Prolonged surgery
• Hypothermia
• Vascular repair
• Hypovolemia
• Metabolic Acidosis
• Massive
transfusion
• HAEMORRHAGIC
shock
• Arrhythmias
• Cardiac arrest
Patient factors
Surgical factors
Anaesthesia factors
• Genral Anaesthesia
• Invasive Lines.
• Inotropes to be kept ready
• To release 4 units of PRBC
• Defibrillator.
• Body warmer and fluid warmer.
• Consent to be obtained.
• Taken Under ASA 5E

13. R IJV CVC ,L radial arterial ,Left arm 16G,L EJV 16 G
Machine Checked,Emergency Drugs ,Inotropes
Loaded ,Invasive Lines Kept ready
On table at 7.45 pm
Connected to monitor
ECG,IBP,SpO2
HR-120 IBP 132/76 Spo2 99%
Connected to circle
TV 550ml RR 14 PEEP 5cmh20
Inj Morphine 3mg and 6mg,Oxygen 6l and Des 3%
Incision was put at 8.30 pm
One unit NS and One unit of Plasmolyte
I
N
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R
A
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14. 500 ml of blood with 250 ml of clot
Liver Laceration present over VI segement 5x2cm
IBP 88/50 HR 130
INJ NORAD 4mg in 50mlInj Dopamine 200 mg in 50ml
I
N
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R
A
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P
9.00 pm Patient had episode of Ventricular Tachycardia with Pulse with heart rate to 180
Inj.Loxicard given 50mg still VT persisted another dose given at 9.10pm
VT persisted 9.20 pm Inj.Amiodarone 150mg given
VT persisted 9.30 pm 200J shock given VT reversed to
Ventricular Bigemini and reversed to sinus tachycardia
I/v/o Tense forearm on right side fasciotomy of forearm was done
Doppler examination was done triphasic waveform

15. Patient shifted To ICU BP 100/60 PR 110
2 Units of PRBC, 1 unit of FFP , 1 unit Platelets, 4 units NS
(570 ml) (99ml) (53ml)
3 sterile pads were placed over the Liver and b/l drain
Wash was given with NS to rule out any other Bleeding Points present
R shoulder debridement was done above elbow slap application was done
(1800ml)
1200 ml Blood loss NIL Urine Output
I
N
T
R
A
O
P

17. POD #1