Concluded Case

IRON NAIL ENTERED IN THE ABDO.

A ten years old school boy, fallen from the wall, unfortunately iron nail entered in the abdo. as we saw omentum came out from the abdo. Chief Complaints Severe abdo. pain č bleeding Chest pain Nasal bleeding Little bit pain in left parietal region History NAD Vitals Temp. 96°F BP 70/ 50 mmHg Pulse 128 bpm R/R 30 bpm O/F NAD Physical Examination Chest B/L clear Abdo. Soft Spo2 86% LL NAD UL NAD Investigations Advise for USG CT brain Awaited for other reports Management Conservatives management started Plan for under local č GA wound will be repaired.

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A case of hypovolemic shock with Penetrating abdominal injury It is,an acute emergency and if not acted on war footing we may loose,the patient Immediately resuscitate the patient- start 2 IV lines,- one with R.L or normal saline and other slowly with fresh blood transfusion. Meanwhile- get a Plain CT scan Head to rile out head injury- If CT is normal after an Ultrasonography abdomen- shift the patient to surgical O.T for urgent Exploratory laparotomy. Also give inj Tetglob 500 units stat , Parenteral antibiotics inj Piperacillin 4 gm +,Tazobactum 500 mg IV × 6 hourly along with inj Metrogyl infusion × 8 hourly . Catheterise the patient and monitor input output to maintain a urine output of more than 1 litre in 24 hours

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Unfortunate incidence From picture it appears iron nail the culprit object of injury has been pulled out and hence omentum is dragged out Better option was to keep nail in status co and could be removed under GA after due diligence Since nail was in lt hypochondrium hence like organ s hit are spleen colon and stomach and lt lower lobe of lung As sp02 seen is 86% suggest either organal damage or huge bleeding in peritoneal cavity Pt needs detail assessment Hrct ct brain ecg 2decho usg abd Beside lab investigations And need to compensate blood loss As pt stabilized will need surgical repair as per extent of injury Vital organs will need to be addressed accordingly and than the closure of wound after 100%hemostasis Followed by broadspectrum antibiotics Inj piperacillin+inj tazobactum Inj Ceftriaxozone Inj meteronidazole Inj tetanus toxoid Rest supportive treatment Vitals to be monitored

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It is a case penetrating abdominal injury by iron rod and through the wound omentum came out. Pt is in shock may be due to internal bleeding needs treated under close observation of the vitals To treat hypovolaemic shock IV drip 5% dextrose and normal saline if necessary blood transfusion to be given Blood for Hb% Str xray abdomen ,xray chest to rule out for any collection may be due to trauma causing low Hb saturation USG and CT scan to see any haemo peritoneum or any internal injury including blood vessel ,organs the to step accordingly if necessary by exploratiry laparotomy. If no injury detected then external wound may be repaired. Other injuries like nasal bleeding may be treated promptly. Vitals including intake output chart any any bleeding in urine to be watched.

Thanks Dr Dinesh Gupta.
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A case of hypovolemic shock with Penetrating abdominal injury It is,an acute emergency and if not acted on war footing we may loose,the patient Immediately resuscitate the patient- start 2 IV lines,- one with R.L or normal saline and other slowly with fresh blood transfusion. Meanwhile- get a Plain CT scan Head to rile out head injury- If CT is normal after an Ultrasonography abdomen- shift the patient to surgical O.T for urgent Exploratory laparotomy. Also give inj Tetglob 500 units stat , Parenteral antibiotics inj Piperacillin 4 gm +,Tazobactum 500 mg IV × 6 hourly along with inj Metrogyl infusion × 8 hourly . Catheterise the patient and monitor input output to maintain a urine output of more than 1 litre in 24 hours

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This patient is in shock Likely causes Abdominal solid organ injury Hollow viscus injury with perforative peritonitis Bleeding from omentum He need resuscitation with fluid and blood transfusion Coagulation disorder need to be corrected with fresh frozen plasma He needs urgent emergency exploratory laparotomy to find cause of low blood pressure and treatment of same Not to waste too much of time, quick stabilization and surgery is need of the hour.

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Management of hypovolemic shock Ionotropic support Volume resuscitation Surgical intervention to achieve hemostasis and repair the organ involved

Fluids and blood to be given with emergency laparotomy to achieve hemostasis and repair of injured organ

Thanks Dr. Pushker Bhomia, Dr.Dinesh Gupta,Dr. Parvez Alam, Dr. Shivraj Agrawal, Dr. Kute Ankush
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Serious accidental penetrating injury with Hemorrhagic shock? ATS Parental antibiotic Iv drip Ready for BT to combat Hemorrhagic shock. Admit pt in emergency ward. wound shud be repaired under GA by the Surgeon. May need Laparotomy after USG abdomen report. O2 inhalation stat & sos Bd. group,Hb% etc.

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Patient should be under close observation Pulse Temp Respiration & B P Complete haemostasis should be obtained Antibiotics I v I v fluid Blood transfusion according to HB level Plasma iv

Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Admit Hypotension R/0 internal bleed Opinion of surgeon

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