MORTALITY REVIEW:
CRITICAL INCIDENTS
Dr Tengku Abdul Kadir Tengku Zainal Abidin
Supervised by: Dr Khairuddin Ismail
Patient History
• Mr MASR
• 17YO Malay male
• Alleged MVA MB vs car near UNISZA – unsure
mechanism, wearing helmet, unsure drug influence
• Brought to ED by JPAM
Arrival at ED
• Arrived at 1 am
• GCS E1V2M5 (8/15), pupils (R) 4 mm sluggish (L) 3 mm
reactive
• Haemodynamically: BP 70-90/40-60, HR persistently
tachycardic 110-160
• Intubated for airway protection by ED team
• Fluid resuscitation: Total 14 pints IVD, 8 pints whole
blood, 2 cycles DIVC then started on noradrenaline
infusion
Investigations
• FBC
• ABG: pH 7.14 pCO2 52 pO2 188 HCO3 17 BE -12 sO2
99
• FAST scan: Initially –ve x 4, then free fluid seen at
hepatorenal and splenorenal area
• Radiographs:
• CXR normal
• Pelvic x-ray: Dissociation of left SIJ 0.9 cm, pubic diasthesis 5 cm
 post pelvic binder pubic diasthesis 1.5 cm
• Left humerus: Comminuted # midshaft
• Left radial/ulnar: # distal 3rd radius with DRUJ disruption
• Left hand: # neck of 5th MCB, # base 3rd and 4th MCB
• CT brain normal
Clinical Findings
• Multiple abrasion and laceration wounds over face and
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scalp
No signs of basal skull fracture
Chest spring –ve
Abdomen distended over right side but soft
Deformed and oedematous left UL with puncture wound
over hand
Swelling and haematoma extending from RIF to midthigh
area, including bilateral scrotum
Problem List
Alleged MVA with polytrauma:
1. Severe head injury
2. Open book fracture
3. Intraabdominal injury
4. Open comminuted fracture midshaft left humerus
5. Open left Galeazzi fracture
6. Open fracture base of 3rd and 4th left MCB
7. Open fracture neck of 5th left MCB
Progress
• Primary team (surgical and orthopaedics) decided for
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operation
Surgical concerned of pelvic instability
Ortho: surgical should proceed in view of intraabdominal
injury as pelvis stabilised with pelvic binder + external
fixator may impede laparotomy
Case notified to anaes OT and confirmed OT at 6.07 am
by ortho and 6.30 am by surgical
Called to OT at 6 am and was sent stat
Vital signs during transfer supported by noradrenaline
double strength 10 ml/hour – BP 100/50, HR 100-127
Events in OT
• Arrived in OT 6.25 am
• Patient intubated on manual bagging, GCS 2T/15, pupils
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(R) 4 mm sluggish (L) 3 mm sluggish
Clinically very pale, poor perfusion, poor PV
Abdomen distended and tense
Sedation IV midamorphine 1 ml/hour, noradrenaline 10
ml/hour
CVL inserted in OT (USG guided)
Intra-operative Events
• External pelvic fixation by orthopaedics started at 7.25 am
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and exploratomy, splenectomy and abdominal packing by
surgical at 7.49 am
Intra-operatively, ventilated on PC FiO2 1 / PIP 14 / PEEP
8
BP 94-125/40-60 (MAP 36-50), HR 80-98  titrate up
noradrenaline to 25 ml/hour
Fluid resuscitation: 6 pints NS, 5 pints gelafundin, 1 cycle
DIVC, 8 pints WB (urine output not documented)
Surgery ended 8.50 am, EBL 3000 ml
Post-operative Events
• BP 120/49, HR 89 (IV noradrenaline 25 ml/hour)
• spO2 highest 93% on 100% O2
• Bradycardic then PEA at 9.25 am
• CPR 20 minutes, IV adrenaline total 10 mg, blood and
colloid pushed in
• Persistent oozing from laparotomy site spilling onto bed –
surgical informed
• Fresh blood from ETT
• Transferred to ICU with BP 120/77, HR 101
Arrival in ICU ~ 9:45am
• Arrived in ICU with IVI noradrenaline 35 ml/hour, IV
dopamine 10 ml/hour
• Cold peripheries, poor perfusion, very pale
• Pupils 7 mm bilaterally fixed and dilated
• Continuous bleeding from external fixation pin site and
laparotomy wound with abdomen distended
Deterioration ~10:00am
• Cardiac monitor: HR 80-90, NIBP 66/30
• Slowly bradycardic then PEA
• CPR commenced x 50 minutes
• Total IV adrenaline total 10 mg
• 1 pint crystalloid, 2 pints colloid, 3 pints WB pushed in; 1
cycle DIVC requested
• Noradrenaline increased to 60 ml/hour, dopamine 20
ml/hour
• Not reverted – asystole at 10:40am
• COD: Severe abdominal injury complicated with DIVC
and hypovolaemic shock
Pelvic XR before pelvic clamp
Pelvic XR after pelvic clamp
FBC pre operation – on arrival
PTTK, pre operation
ABG trend
Intraoperative monitoring
Intraoperative monitoring
Intraoperative monitoring
FBC pre and post OP.
Open for discussion…
• 1. Delayed operation.
• - time of resuscitation in ED
• - late pelvic fixation.
• - decision of operation
2. Intraoperation
- Difficulty of IVL, art line, call for help? adequate team?
- inform progress to sp? Communication.
- unstable hemodynamically
3. Degree of bleeding
- Diagnose severity of bleeding, %?, ABG,
- restore perfussion, control bleeding.
4. Pre op assessment,plan.
5. Communication to specialist, team to team