Case Archive
 
Trauma Surgery, Anesthesiology
Ref. # 115501

A 20-year-old man was hit by two bullets and taken to the ER. Despite contradictions in the description of the area of entry and course of travel of the principle wound, the bullet appeared to have entered the man's abdomen from the right, severely damaging the liver and spleen. At exploratory surgery the spleen was removed, the liver repaired with drainage, and the bullet removed from the left chest wall. The next day the trauma surgeon noted "the muscular skeletal examination is unremarkable…neurological examination is not possible in this (sic) pharmacologically paralyzed patient." Nine days later lower extremity numbness was questioned. A CT scan showed blast transpedicular fractures of the first lumbar vertebra with encroachment of the spinal canal. The patient experienced bleeding from the liver injury as well as abscesses. Due in part to a delay in securing hospital placement, five weeks later he was transferred to a rehabilitation hospital. During three days there he experienced continued bleeding and a perihepatic abscess and was transferred back to the initial hospital. At surgery the patient sustained cardiac arrest on induction of succinylcholine. He was resuscitated with 4 mg of epinephrine and 2 mg of Atrophine, after which he went into electromechanical dissociation, became asystolic, and was resuscitated. Post-op ischemic anoxic encephalopathy was noted. During hospitalization over the next five months, which included several transfers, the patient's course included severe decubitus ulcer and contractures. He progressed to verbalizing single words and was placed in an extended recovery unit. A medQuest trauma surgeon reported the nine-day delay in diagnosis of the spinal cord injury was not below the standard of care because the other injuries took precedence. Immediate neurosurgical intervention more likely than not would have only minimally improved the paraplegia. The use of succinylcholine constituted negligence, as it is contraindicated in patients with lower extremity paraplegia. It caused the patient's cardiac arrest, which in turn led to the anoxic encephalopathy. The patient more likely than not could have returned to an employable status if not for the cardiac arrest. Lastly, the decubitus ulcer indicated negligent nursing care. A medQuest anesthesiologist independently concurred that the use of succinylcholine was negligent and caused the cardiac arrest.




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