Ct trauma please help coding

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Date of Procedure: 2/1/2019
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Preoperative Diagnosis:
1. Traumatic arrest
2. Complex cardiac laceration, bi-ventricular apex, s/p primary (temporary) closure
3. S/p resuscitative (emergency department) thoracotomy
4. S/p motor vehicle crash
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Postoperative Diagnosis:*
1. Traumatic arrest
2. Complex cardiac laceration, bi-ventricular apex, s/p primary (temporary) closure
3. S/p resuscitative (emergency department) thoracotomy
4. S/p motor vehicle crash
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Procedure:
1. Mediastinal exploration
2. Open cardiac massage
3. Direct insertion of an 8Fr Cordis central line via the right atrial appendage
4. Epicardial right ventricular pacing wire placement
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Indications:
Yan, F is a middle aged caucasian woman who arrived to the emergency department in full traumatic arrest following a motor vehicle crash. Upon initial evaluation and management by the trauma team, cardiac tamponade was diagnosed in the trauma bay and a resucitative emergency department thoracotomy was undertaken. A complex biventricular apical laceration was diagnosed and quickly closed primary with skin clips. The descending aorta was cross clamped and measures were taken to transport the patient to the operating room. I was called to assist with mediastinal exploration, resucitation, and definitve cardiac repair.
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Anesthesia:
General.
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Wound Classification:
Contaminated.
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Findings:
The temporary biventricular closure was hemostatic. No additional great vessel or cardiac injuries were identified. Minimal and non-perfusing cardiac activity with good capture upon right ventricular pacing. We failed to achieve ROSC. Patient was pronounced deceased upon completion of the procedure.
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Procedure Details:*
The patient was identified in the trauma bay; her chest had been opened, and she was undergoing open cardiac massage. A 3-4cm jagged complex laceration of the biventricular apex was identified with skin clips. This was hemostatic. The heart was essentially empty and alternating between PEA and fine ventricular fibrillation in rhythm. Mass transfusion protocol and open cardiac massage was continued as the patient was transported to the operating room.
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Once in the operating room, the neck, chest, abdomen, and cephalad lower extremities were prepped in emergent fashion. The resuscitative thoracotomy incision was enlarged to a complete bilateral thoracosternotomy. The heart remained empty. A 4-0 prolene pursestring suture was placed on the right atrial appendage and an 8Fr cordis central line placed directly into the right atrium to assist with transfusion and restoration of volume. As volume was restored, the heart regained spontaneous intermittent activity. Ventricular fibrillation was identified and the heart was defibrillated with 50J DC current. Sinus bradycardia was restored as cardiac massage continued.
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The abdomen was opened by the trauma team. Please refer Dr. operative note describing this portion of their procedure. Simultaneously, a thorough mediastinal and bilateral pleural space exploration was undertaken as resuscitation continued. The surfaces of the left and right lung were smooth and glistening. There was no right or left pulmonary hilar injury. The was no injury or extrapleural hematomas identified at either the right or left pleural apex. There was a small pleual tear noted to the posterior basilar segment of the left lower lobe. This bleeding was controlled with packing and direct pressure. The anterior pericardium had been opened transversely. This was extended cephalad to its reflection on the ascending aorta. The ascending aorta was smooth and without injury, as was the main pulmonary artery. A clamp was across the descending thoracic aorta. There was no injury identified to the aortic arch in the left chest, or descending thoracic aorta. The SVC, IVC and right atrial surfaces were without injury as well. There were no additional right ventricular or left ventricular injuries identified. The patient progressed to PEA. Temporary right ventricular pacing wires were placed on the right ventricular with electrical capture, but without associated ventricular contractility despite adequate volume resuscitation. Cardiac massage continued. The patient again progressed to ventricular fibrillation and was defibrillated once more. PEA persisted. At this point, following >40min of operative resuscitation and no perfusing rhythm achieved, the decision was made to stop our efforts. The patient was pronounced deceased.
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At this stage, the procedure was discontinued.
 
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