Literary Grand Rounds Literary Grand Rounds Clinical VignetteClinical Vignette

Barry Crittenden, MDBarry Crittenden, MD

PGY2PGY2

March 18, 2009March 18, 2009

Chief ComplaintChief Complaint

The patient is a 30 year old female admitted The patient is a 30 year old female admitted as a trauma victim after being struck by an as a trauma victim after being struck by an automobile. automobile.

History of Present IllnessHistory of Present IllnessThe patient was standing on a street corner The patient was standing on a street corner when she was struck by an SUV. She was when she was struck by an SUV. She was pinned against a metal post by the vehicle. pinned against a metal post by the vehicle. At the scene, she lost consciousness, but At the scene, she lost consciousness, but maintained a pulse and spontaneous maintained a pulse and spontaneous respirations.respirations.Once she was able to be removed from the Once she was able to be removed from the post, bystanders applied pressure to her right post, bystanders applied pressure to her right leg.leg.EMS arrived within 10 minutes and rushed EMS arrived within 10 minutes and rushed the patient to Bellevue Hospital.the patient to Bellevue Hospital.

Additional HistoryAdditional History

Past Medical HistoryPast Medical History: none: nonePast Surgical HistoryPast Surgical History: myomectomy: myomectomySocial HistorySocial History: the patient is a singer-: the patient is a singer-songwriter in New York City. She denies songwriter in New York City. She denies any toxic habits.any toxic habits.Family HistoryFamily History: non-contributory: non-contributoryAllergiesAllergies: penicillin: penicillinMedicationsMedications: none: none

Physical ExamPhysical ExamGeneral: awake and alert, in severe painGeneral: awake and alert, in severe painVital signs: T 98.0 BP: 70/palp HR: 130 RR: Vital signs: T 98.0 BP: 70/palp HR: 130 RR: 32 O2 sat: 100% on NRB32 O2 sat: 100% on NRBAbdomen: large transverse laceration of her Abdomen: large transverse laceration of her lower abdomen with visible portions of her lower abdomen with visible portions of her bowel and bladder.bowel and bladder.Extremities: right leg partially amputated at Extremities: right leg partially amputated at the groin with active bleeding.the groin with active bleeding.Skin: pale and coolSkin: pale and cool

Remainder of physical exam was normalRemainder of physical exam was normal

Laboratory FindingsLaboratory Findings

CBC: WBC 3.9, Hgb 7.6, HCT 22.8, platelets CBC: WBC 3.9, Hgb 7.6, HCT 22.8, platelets 166 after initial resuscitation166 after initial resuscitationBasic metabolic panel: within normal limitsBasic metabolic panel: within normal limitsHepatic panel: within normal limitsHepatic panel: within normal limitsCreatine kinase: 1528Creatine kinase: 1528

Hospital CourseHospital CourseHospital Day 1: Hospital Day 1:

The patient was intubated immediately and taken The patient was intubated immediately and taken immediately to the operating room.immediately to the operating room.Massive volume resuscitation was initiated; she Massive volume resuscitation was initiated; she received a total of 10 liters of NS, 2 liters of LR, 30 received a total of 10 liters of NS, 2 liters of LR, 30 units of packed-RBCs, 15 units FFP and 5 units of units of packed-RBCs, 15 units FFP and 5 units of cryoglobulin.cryoglobulin.She underwent complete amputation of her right She underwent complete amputation of her right lower extremity.lower extremity.Consults in the operating room included Consults in the operating room included orthopedics, vascular surgery, urology, and orthopedics, vascular surgery, urology, and gynecology.gynecology.

Hospital Day 2: Hospital Day 2: The patient underwent a diverting loop colostomy The patient underwent a diverting loop colostomy and a right hip wound debridement and a right hip wound debridement

Hospital Day 4: Hospital Day 4: The patient underwent completion of her right hip The patient underwent completion of her right hip disarticulation by orthopedics with a partial wound disarticulation by orthopedics with a partial wound closure by plastic surgery closure by plastic surgery

Hospital Day 7: Hospital Day 7: The patient was weaned from the ventilatorThe patient was weaned from the ventilator

Hospital Day 8: Hospital Day 8: Psychology, physical therapy and rehab medicine Psychology, physical therapy and rehab medicine consults became involved in the patient’s careconsults became involved in the patient’s care

Hospital Hospital CourseCourse

Follow-upFollow-upThe pt began a challenging recoveryThe pt began a challenging recoveryMusic therapy helped with voice recovery Music therapy helped with voice recovery Diverting colostomy was reversed 4 Diverting colostomy was reversed 4 months latermonths laterDespite the extent of her lost limb, the Despite the extent of her lost limb, the patient is able to walk on a prosthetic limbpatient is able to walk on a prosthetic limbShe resumed a successful singing careerShe resumed a successful singing careerShe does public speaking and community She does public speaking and community service, including motivational work with service, including motivational work with other amputeesother amputees