A case report on Bull Gore Injury

P. Snekapriya, N. Bhuvaneshwari

Department of Clinical Nutrition and Dietetics, Kauvery Hospital, Cantonment, Trichy

Correspondence: dietary.kcn@kauveryhospitals.com

Introduction

Bull gore injures or cattle horn injuries are defined as lesions resulting from a collision with the horns of a bull/cow. Treatment of this condition is focused on early diagnosis and surgical intervention. In the report, we have described the nutritional care for a 21-year-aged male, who had no previously known co-morbidities. He sustained abdominal injury from bull gore.

Case presentation

The patient was a 21 year aged male with no previously known co-morbidities. There was no family history of hypertension and diabetes. No known genetic history, no previous surgery.

The patient came with the chief complaint of bull gore injury. He was initially treated elsewhere, underwent laparotomy and came to us for further management. The patient was admitted and blood investigations were done (Hb, platelets, sodium, potassium, RFT, LFT, albumin). CE – CT abdomen and pelvis were done. After obtaining necessary per-operative assessment, patient underwent emergency laparotomy, posterior gastric perforation closure + revision of feeding jejunostomy. Post operatively patient was shifted to ICU and extubated on POD – 1. Patient had tachypnea, so required NIV support. He was treated with IV fluid, higher antibiotics, pain killers and PPI. He had low albumin level so, albumin (Normal Human Serum Albumin) was used and total parental nutrition (TPN) was given.

Patient improved symptomatically and was shifted to IMCU. USG chest showed bilateral moderate pleural effusion. Pulmonologist opinion was obtained and USG guided drainage was done, and drained fluid sent for culture and sensitivity. Patient was weaned off from NIV and maintained on O2 support, and shifted to ward. He gradually started on Feeding Jejunostomy feeds (JJ) and orals. Total parental nutrition (TPN) stopped. The patient developed breathlessness, tachypnea and fever, hence shifted to IMCU and started NIV support. Blood investigations were some, and blood and drain fluid were sent for culture sensitivity. Antibiotics changed according to culture and sensitivity. Pus discharged from the main wound, hence clips removed, pus drained and daily dressing done. Patient improved symptomatically, NIV support weaned off, shifted to ward and kept on O2 Support.

Then patient underwent I & D + wound wash. Daily wound wash was given, wound granulating and healthy.

Discussion

Post operatively he was shifted to ICU and extubated on POD – 1. Patient was on NPO for observation. The next day the patient had undergone Emergency laparotomy + bowel resection. After the procedure patient was on NPO for three days, RT aspirate was continued, at that time patient was on IV fluid support. Then we initiated Total Parental Nutrition (TPN). Three chamber bag was used. It is a 1000ml bag and it contain 763kcal, 30g of protein and 34g of fat. We started TPN 50ml/hr, 228.9 kcal and 9g of protein was achieved. Next day TPN was increased 75ml/hr and the target nutrients was achieved. Patient tolerated. We continued the same feed and introduced sips of water. TPN was stopped and Jejunostomy feeding (JJ) was initiated 30ml/2hr (clear liquid); slowly it was increased from 30ml to 60ml/2hr and started with supplement through the same. Gradually, Jejunostomy feeding (JJ) was increased to 70ml/2hr 1047kcal and 46.4g of protein the target nutrient was achieved. Trial oral clear liquid given, patient tolerated 30ml of oral clear liquid.

Gradually decreased the Jejunostomy feeding (JJ) to 60ml and oral normal liquid was increased from 30ml to 60ml. Patient tolerated oral liquid and we started small frequent amount of semisolid diet along with Jejunostomy feeding (JJ). Jejunostomy feeding (JJ) was stopped and started high protein semisolid diet with oral nutrition supplement. Patient tolerated oral feed and achieved 350kcal and 6g of protein. Gradually increase the oral intake. Next day patient was on NPO due to wound debridement and wound wash. we started semisolid diet. After the wound debridement patient did not pass stools for two days so, the intake decreased and calorie requirements could not be met. But patient passed stools and gradually increased intake amount. At the time of discharge patient tolerated 1629 kcal and 90g of protein.

Outcome

The patient was admitted with the chief complaints of bull gore injury. He underwent laparotomy procedure. WC provided careful and effective nutritional support. TPN was followed by feeding jejunostomy and gradually started on oral clear liquid. Patient tolerated orally and gradually increased the semisolid feeding. We achieved the target nutrients at the time of discharge and we prescribed high protein diet.

Ms. N. Bhuvaneshwari
Clinical Dietician

 

Ms. P. Snekapriya
Clinical Dietician

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