explore lap

[fuyuojo]

we had a patient who is a victim of gun shot wounds. the doctor did an explore laparotomy. on his first admission day, he had coffee ground drainage on his ngt. on his second admission day, he became restless, and moved side to side. he was also sweating profusely. before the graveyard shift ended, he suddenly vomitted coffee ground vomitus after being suctioned and had a cardiac arrest. after a few minutes, he died. is it possible that the bleeding inside his stomach caused the arrest? was it perhaps that the patient moved from his side that aggravated the condition thereby causing the cardiac arrest? i hope someone can enlighten me with this. thanks.

[psu_213, BSN, RN]

It could also be that the NGT was on suction and caused an electolyte imbalance (for instance, K+)...this could certainly cause an arrest.

[CRNA1982]

Did the pt. aspirate? This could lead to cardiac arrest. Coffee ground emesis is old blood. This would not cause him to die.....

[rkitty198, BSN, RN]

Coffee grounds emesis IS blood period! Old or not! It may not be old blood depending on where the bleeding is coming from. How are we supposed to know what killed the person with such little info? Sounds like we are missing vital info like bp, hct, ugh, and so forth. Sounds like he died from bleeding internally, with that vague description. I am very concerned that this patient went what sounds like 2 days of profound symptoms without any interventions and then just up and died! With these symptoms someone should have done something.

[rkitty198, BSN, RN]

It could also be that the NGT was on suction and caused an electolyte imbalance (for instance, K+)...this could certainly cause an arrest.

I have patients who are on ngt's for days without kcl in thier Ivs and they are able to maintain a balance of k. I wonder if it wasn't an issue with a post-op bleed from a perforation or an overwhelming infection.

I work surgical and see these symptoms mostly in people with hemorrhage.

[tokmom, BSN, RN]

Sounds like something ruptured and he died.

[CRNA1982]

Coffee grounds emesis IS blood period! Old or not! It may not be old blood depending on where the bleeding is coming from. How are we supposed to know what killed the person with such little info? Sounds like we are missing vital info like bp, hct, ugh, and so forth. Sounds like he died from bleeding internally, with that vague description. I am very concerned that this patient went what sounds like 2 days of profound symptoms without any interventions and then just up and died! With these symptoms someone should have done something.

Coffee grounds post-op day 1 are not uncommon at all; in fact it is expected after an ex-lap for GSW. So this is not a "Profound" symptom that any attending should be worried about. Furthermore, NG tubes to constant LIS may cause GI trauma and coffee grounds; which this pt. was more than likely experiencing. Any pt. that presents to the O.R. with a GSW to the abd and Ex-lap would be followed pretty closely post-op with frequent H+H checks. It is pretty much the standard of care to follow these basic lab draws post-op for these procedures and I'm pretty confident that they were performed in this scenario; even with the lack of information from the OP. Internal bleeding on post-op day two sounds like a zebra to me; especially since this pt. died so suddenly. Restlessness, followed by vomiting and suctioning sounds like possible aspiration or PE, resulting in cardiac arrest due to hypoxia. Coffee ground emesis is not overly concerning to me. I would be more concerned of an overly distended, hard abdomen s/p ex-lap day 2 during a basic assessment. Again, just my $0.02

[fuyuojo]

yes, his hgb hct values were normal post op day 1. his dx includes colon injury. he had 3 bullets that went through his transverse colon, as what i've seen on his operative report.

[canesdukegirl, BSN, RN]

Based on your second post, my guess is that he had free air in the colon which could have necrosed. If his injury was at the splenic flexure and the anastamosis was not repaired adequately, he could have experienced hypoperfusion, which would have led to the shocky symptoms you describe.

It is also entirely possible that he threw a clot. This would explain his shocky symptoms as well, as the thrashing around would make me think FIRST of hypoxia. The opiates that he was probably on would mask the true etiology of his hypoxemia if in fact he had thrown a clot.

[Up2nogood RN, RN]

Based on your second post, my guess is that he had free air in the colon which could have necrosed. If his injury was at the splenic flexure and the anastamosis was not repaired adequately, he could have experienced hypoperfusion, which would have led to the shocky symptoms you describe.

It is also entirely possible that he threw a clot. This would explain his shocky symptoms as well, as the thrashing around would make me think FIRST of hypoxia. The opiates that he was probably on would mask the true etiology of his hypoxemia if in fact he had thrown a clot.

The reslessness described would also have been my first clue that something was wrong.

[ckh23, BSN, RN]

Was he being orally suctioned and you triggered his gag causing him to vomit? Another possibility is that the increased pressure from the vomiting caused something to burst open. Or as someone else could have dislodged a clot.

[psu_213, BSN, RN]

I have patients who are on ngt's for days without kcl in thier Ivs and they are able to maintain a balance of k. I wonder if it wasn't an issue with a post-op bleed from a perforation or an overwhelming infection.

I work surgical and see these symptoms mostly in people with hemorrhage.

This was just one hypothesis I came up with, it certianly can be from blood loss.

On the other hand, I've had pts who have a K+ of 4.1, get and NG and next day K+ is down to 2.8...