anesth case1 sab

8/3/2019 Anesth Case1 SAB

1/21

Case #1ORIF L ankle/SAB

TAGALTAGANAS

TAN

TANTANCHULINGTE

TEO


2/21

General Data

R.F. 45/M, married, works as driver from CaviteNo known co-morbiditesConsulted at PGH-ER last 01/08/2012, 3:00AMfor multiple injuries secondary to vehicular crashDate of injury: 01/07/2012Time of injury: 11:00 pm

Place of injury: LagunaMechanism of injury: Vehicular crash (motorcyclevs car)


3/21

History of Present Illness

4 hours PTC, patient was driving a motorcycle,wearing a helmet and not intoxicated, whenhe suddenly collided with an approaching carin the highway curveNo noted loss of consciousness, no activebleeding, no vomitingThere is note L ankle pain


4/21

Review of Systems

(-) headache (-) palpitations (-) hematuria

(-) dyspea (-) chest pain (-) joint pain

(-) orthopnea (-) diarrhea/constipation (-) weight loss

(-) cough and colds (-) dysuria (-) bleeding problems


5/21

Past Medical History

No previous surgeries and hospitalization(-) hypertension, diabetes, heart illness,

cancer, allergies, bronchial asthma, PTB


6/21

Personal and Social History

Smoker for 15 years consuming packs perday

Occasional alcoholic beverage drinkerDenies use of illicit drugs(-) medications currently being taken

Married for 23 years with 3 children (2 inhighschool, 1 finished 2 nd year college)


7/21

Physical Examination

(01/08/2012) PGH-ER

Appearance Awake, coherent, wheelchair-bound

Vital Signs BP 130/80 PR 72 RR 18 Temp afeb

HEENT AS, PC, (-) CLAD, ANM, NVE

CVS AP, DHS, NRRR (-) murmur

Lungs ECE, CBS, (-) wheezes, crackles

Abdomen Soft, flat, NABS, (-) tenderness, organomegaly

Extremities FEP, PNB, CRT


8/21

Course in the Hospital

01/08/20123:00 AM

Patient consulted at the PGH-ER wherein he was admitted underSurgery-Patient was examined and assessed-- ATS and TeANA were given-- X-rays: L leg APL, L ankle mortis

A> Multiple injuries 2o to vehicular crasht/c ankle fracture, L

3:45 AM Patient referred to OrthoA> Open ankle (talus) dislocation with bimalleolus fracture, LP> for application of co-aptation splint once reduced

start Cefazolin 1g IV q8Gentamicin 240mg IV ODPen G 4Munits IV q6

for repeat Xrays: lateral ankle mortis, foot APOL post reduction


9/21

01/08/20127:30 AM

Ortho service roundsA> open talus dislocation, L ankle

bimalleolus fracture, L

ankle: fracture, open, incomplete, transverse, displace, medialmalleolus, L: fracture, closed, complete, comminuted, displaced, lateral

malleolus, L

P> for debridement of open woundfor possible ORIF

01/10/2012 s/p Debridement L foot, athrotomy, application of external fixator Llower extremity

Operative findings:-Fracture medial malleolus

-Valgus deformity-Comminuted fracture, lateral malleolus with distal fibula-NO nectoric tissue

NOTES: Surgery was uneventul. Patient tolerated well the procedure.No episodes of hypo/hypertension. Total blood loss: __


10/21

01/22/2012 s/p Repeat debridement, application of VAC, L ankle

Operative findings:-(+) necrotic tissue, skin overlying operative site- partially transected tendon

NOTES: Surgery was uneventul. Patient tolerated well the procedure.No episodes of hypo/hypertension. Total blood loss: __

01/26/2012 For repeat debridement, ORIF left ankle/SA


11/21

Pre-op Labs

Blood type: O+CBC (01/13/2012)

Hb 127

Hct 0.375

WBC 11.5 Neutrophil 0.779

Lymphocyte 0.123

Platelet Monocyte 0.076

Eosinophil 0.022


12/21

Uric Acid (01/19/2012): 0.25 LowElectrolytes (01/13/2012)

Glucose 5.52 (4.1-5.9)

BUN 2.50 (2.9-9.3) Low

Creatinine 80 (57-113)

Sodium 138 (135-144)

Potassium 4.0 (3.6-5.1)

Chloride 104 (101-132)


13/21

PT/PTT (01/15/2012)

PT reference 14.0

Patient s value 13.1

% Activity >1.0

INR 0.93

APTT reference 30.6

Patient s value 28.9


14/21

Urinalysis (01/26/2012)Color yellow Transparency clear

Specificgravity

1.010 pH 6.5

Sugar (-) Protein (-)

Microscopic

RBC 1-3/hpf Bacteria few

WBC 0-1/hpf Mucus thread (-)

Epithelial cells Rare Crystals/Cast (-)Special test

Bilirubin (-) Leucocytes (-)

Urobilinogen Normal Nitrite (-)

Ketone (-) Hemoglobin Trace


15/21

ECG


16/21

Wound tissue GS/CS (01/26/2012) GS: no PMN seen, G(-) bacilli 0-2

CS: thioglycolate broth (+) forEnterobacter

cloacae

S: Meropenem, PiperacillinI: none

R: Amox-Clav, Ampi, Ampi-Sulbactam, Cipro, Genta


17/21

Pre-op record

To be inserted by Lorraine


18/21

Intra-op record

To follow photoImportant

ASA 1 VS: 120/80, 100s, awake, 16, afeb Anesth CUA, SAB, Ortho Durban LP done at L3/4 using SNCE 25, (+) CSF, (-)blood

20mg Bupivacaine, 0.15 MOSO4 intrathecally OR time 7:00-12nn

Midazolam 1@7:15, 1@9am

Cefazolin 1g@8amKetorolac test dose @8:15, 30mg@8:45Demerol 25mg@9am, 25mg@9:30Start of induction at 7:15, operation @8:15End of anesth @11:45


19/21

Intra-op findings (+) soft callus, segmental fracture and

comminuted (+) shortening


20/21

Post-op Orders

To PACUMonitor VS q15 until stable, hourly thereafter02 inhalation at 5lpm with face mask

IVF: D5NR 1L x 8hMay have DAT once fully awake with strict aspirationprecautionMeds:

Ketorolac 30mg IV q6 x 24h Tramadol 50mg IV q8 prn for pain Celecoxib 200mg/tab, 1 tab BID x 3days then prn for pain


21/21

Flat on bed x 6h post opPatient was given MOSO4 intrathecally

Morphine precaution please WOF: vomiting, pruritus, hypotension (SBP

anesth case1 sab

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