Effective management of a firearm injury with multiple intes
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A 30-year-old male rickshaw puller by occupation presented to the Emergency Department of tertiary care center with an alleged history of accidental firearm injury in an attempt to escape from the security officials. The patients were referred from a secondary health care center in view of incidental COVID-19 positive status. The patient had an entry wound, oval in shape with 2 cm diameter and inverted margins over the lateral aspect of the right abdomen. The exit wound was present on the lateral aspect of the left lower abdomen 1.5 cm in diameter, oval in shape, and everted margins.

Patients had a heart rate of 110 beats per minute, blood pressure of 110/90 mm of Hg, respiratory rate of 28 cycles per minute, spo2 94% at room air. He had no significant medical or family history. The patient had a history of alcohol consumption and smoking for past 10 years. Patient hematocrit level was 40.5%, hemoglobin 13.4 mg/dl, total leucocyte count was 7.22 × 103/l. Abdominal examination revealed generalized tenderness with guarding. Focused assessment with sonography for trauma (FAST) suggested free fluid in the pelvis. Contrast-enhanced computed tomogram (CECT) abdomen revealed features of bowel wall thickening involving small bowel loop, ascending colon, caecum, and sigmoid colon with peri colonic fat stranding and pneumoperitoneum suggestive of multiple bowel injuries.

Emergency exploratory laparotomy was performed by an additional professor and his team with 11 years of experience in trauma surgeries and care. Personal protective measures were followed as per institutional protocol. Intraoperative findings revealed multiple bowel perforations of size 2 × 2 cm at 110 cm, perforation of size 1 × 1 cm at 140 cm from the duodenojejunal flexure, another perforation of about 3 cm noted at the sigmoid colon with no associated solid organ injury. Primary repair was done for small bowel and colonic perforation. The operation was completed with loop ileostomy, to protect the integrity of primary repair sites. A 30 French abdominal drain was placed, which was removed on the 7th post-operative day. Peritoneal fluid culture and sensitivity revealed Klebsiella Oxytoca sensitive to Amikacin, ciprofloxacin, and meropenem.

Management of this patient was a challenging task for the entire team in a resource constraint situation like COVID 19 pandemic. The main challenge was how to transport this COVID positive patient from the COVID ward to OR because of the significant distance. So, the author decided to create a dedicated corridor and isolation ward with an intensive care facility adjacent to OR for safe transportation and post-operative care. Post-operatively patient's clinical condition deteriorated as the patient developed dyspnea, moderate hypoxia requiring oxygen supplementation by non-rebreathing face mask at a rate of 12 L/min, classified as moderate to the severe grade of COVID 19 confirmed case. The uphill task continued as the patient condition deteriorated from mild to moderate category of COVID 19 positive preoperatively to moderate to severe grade. As per national protocol for the management of COVID-19, the patient has treated with Enoxaparin 60 mg daily subcutaneously, intravenous Dexamethasone 6 mg IV once daily. Injection Remedisvir 200 mg intravenous on Day 1 followed by 100 mg daily for the next 4 days was administered.

The rest of the postoperative course was uneventful. However, the effective multidisciplinary approach and aggressive postoperative care resulted in the recovery of patients from COVID 19. This was a different experience for the team as they had to address both pulmonary complications related to COVID 19 and focussed post-operative care in the constraint resource. At the time of discharge patient was maintain spo2 at 99% at room air, respiratory rate of 16 cycles/min and had no febrile episodes for 8 days Patient was discharged on a postoperative Day 17 with satisfactory clinical improvement and training in ileostomy care. At follow up after eight weeks patient was doing well.