A Difficult Case in Trauma Surgery

CHALLENGING CASE
IN TRAUMA SURGERY
LOU SMITH, MD, FACS,FICS
UNIVERSITY OF TENNESSE MEDICAL CENTER, KNOXVILLE
CASE PRESENTATION: SHOTGUN BLAST TO THE LEFT
ARM, NECK, CHEST AND ABDOMEN
34 year old married female with 2 children
Previously in good health
Was receiving the shotgun from her husband outside the window of a pickup truck when the weapon
unintentionally discharged into the left arm, neck, left chest and left abdomen.
Lived in a rural area. Prehospital ambulance arrived within 15 minutes, transport time approximately 30 minutes
due to location.
Interventions en route: Cervical collar/backboard, O2 by mask, one iv started. No fluids given. 1mg Morphine
given
Prehospital vital signs: P 120 R 34 BP 90/P 02 sat 90%
No pulse in the left arm, faint pulses in the remainder of the extremities.
Single 18g IV established in the right hand en route to hospital.
• Arrival observations
• Patient is speaking without hoarseness
• She is slightly confused. She knows she has been shot but only complains of “hard to breathe”; does not
answer questions about the events
• Breath sounds are present but slightly diminished on the left
• HR 130 BP 80/P Sat 93% on NRB resp rate 32
• Collar in place
• Scatter of shotgun fragments from the left elbow to the shoulder, few pellets in the neck (4), most of
the pellets enter the left chest and abdomen
• Which of the following is not an urgent need for this patient?

• A. ENDOTRACHEAL INTUBATION
• B. REMOVE COLLAR AND EVALUATE THE NECK FOR IMPENDING AIRWAY COMPROMISE, TRACHEAL
SHIIFT AND JUGULAR VENOUS DISTENTION
• C. PLACEMENT OF A LEFT CHEST TUBE
• D. CHEST XRAY
• E. ESTABLISH ANOTHER IV
• Obtained an emergent chest xray.

• Collar removal revealed only a few pellets in the neck without expanding hematoma, tracheal shift or
neck vein distention.
• Central venous IV established for administration of blood and fluids
• Emergency release O negative blood present in the emergency department prior to patient arrival
• What type of IV access should be established?

• A. Intraosseous catheter
• B. Left subclavian line
• C. Femoral central line
• D. Right subclavian line
• E. Left antecubital
• Right subclavian central line inserted.

• House officer noted that blood flowed back into the tubing of the line rapidly while obtaining the blood
for type and cross and CBC.
• Emergency release blood administered by high flow fluid warming pump.
VS now
• P 140
• R 32
• Sat 91%
• BP 75/P
• Pulse palpable only at the femoral and carotids
• Patient is more lethargic
• Emergency release blood started on high flow
warming pump at the time these VS obtained.
• What would you do next?

• A. Insert a left sided chest tube
• B. Go to the operating room for a thoracotomy
• C. Go to the operating room for a laparotomy
• D. FAST scan
• E. CT scan
CASE PRESENTATION:
SHOTGUN BLAST TO THE LEFT
ARM, NECK, CHEST AND
ABDOMEN
What we did:
A. Inserted a left sided chest tube: 300cc
output
B. Obtained a FAST scan
Two units of emergency release blood have been • What should you do now?
given. A. Emergency room thoracotomy
P 140 • B. Intubate the patient
BP 80/60 • C. Proceed to the operating room for
laparotomy
R 32
• D. Proceed to the operating room for a
O2 sat 91% on 100% mask
thoracotomy
GCS 12
• E. Perform a pericardiocentesis
• What we did:
• Operating room IMMEDIATELY AVAILABLE
• Prepped patient from chin to knees
• Median sternotomy
Through and through injury of the atrial appendage

• After the release of the pericardial tamponade, What next?

BP 90
• P110 A. Close the chest
• Patient now intubated and on the ventilator • B. Open the abdomen
• Patient has received 4 blood, 2 FFP, platelets • C. Explore the left arm circulation
have been ordered for administration • Take to the ICU for resuscitation
• Left chest tube output now 400cc total

• No chest tube on right. Sat 99% on 100% on the ventilator.
• Patient is oozing but not severely
• More blood has been ordered and there is a plan to give it.
• Upper median sternotomy site covered with IOBAN drape
• Abdomen opened
• Injuries:
 Ruptured diaphragm
 Ruptured spleen without active hemorrhage
 Hematoma on the tail of the pancreas
 Active hemorrhage from lesser curvature of the stomach
 Multiple small injuries to the stomach
 Small bowel transected about 15cm from ligament of Treitz.
• Patient condition
• BP 85/55 (arterial line now inserted on the right)
• On 5th unit of blood, 4th FFP, platelets still not
here • What should we do next?
• Temp 35.3C
• Ph 7.18
• Hgb 9
• Commit to a damage control approach

• None of the injuries ALONE are 100% nonsurvivable, but the physiologic state of the patient may cause
her to die.
• PRINCIPLES OF DAMAGE CONTROL

• #1 STOP THE BLEEDING
• #2 STOP THE SPILLAGE OF ENTERIC CONTENTS
• #3 ANYTHING ELSE that needs to be done----can it be delayed
• 1. STOP BLEEDING
 Ligate vessels in the lesser curvature
 Remove spleen
• 2. STOP SPILLAGE OF ENTERIC CONTENTs
 Staple bowel injuries. Do not attempt re-anastomosis in this setting
 Figure of 8 stitches to small punctures in the stomach X 6
 Place drain on the pancreas
• What should we do for THIS patient? • ANYTHING ELSE
 Repaired diaphragm (to support breathing) if patient not highly unstable
 Don’t address possible arterial injury in the arm: LIFE BEFORE LIMB
• STOP OPERATING
• Vacuum assisted closure
• ICU Care and resuscitation
• Patient condition on arrival to ICU
• P 115
• BP 90
• R on ventilator
• 6 units pRBCs, 4 FFP and one pack of pooled platelets given
• T 34
• INR 1.9
• Hgb 9.5
 ICU strategy
• Rewarm the patient
• Fluid resuscitation with blood and IV fluids
• Restore coagulation cascade with FFP, platelet, and cryoprecipitate as needed.
• Correct pH with all the above (no bicarb)
• Support on ventilator
• Takes 4 hours to resuscitate patient vital signs, rewarm and restore pH and coagulation parameters.
WHAT NOW?
• A. RETURN TO THE OPERATING ROOM AND CLOSE THE CHEST, ANASTOMOSIS OF SMALL BOWEL,
FORMAL REPAIR OF THE STOMACH AND REMOVAL OF THE TAIL OF THE PANCREAS
• ADDRESS THE LEFT ARM WHICH REMIAINS PULSELESS BUT HAS A FAINT MONOPHASIC DOPPLER SIGNAL
IN THE ULNAR AND RADIAL ARTERIES. FINGERS ARE COOL/CAP REFILL DELAYED, BUT NO OVERT
ISCHEMIA
• ADDRESS POTENTIAL NECK INJURIES BY EVALUTING ESOPHAGUS, TRACHEA, VERTEBRAE AND
VASCULATURE
 LIFE BEFORE LIMB.
 UNRECOGNIZED INJURY TO THE TRACHEA, ESOPHAGUS, VASCULATURE OR CERVICAL SPINE COULD BE
LIFE THREATENING
 CT OF THE NECK WITH CONTRAST SHOWED NO VASCULAR INJURY, BUT SUBCUT AIR IN THE NECK
 SINCE WE WERE ALREADY IN CT SCAN AND NO ADDITIONAL TIME OR DYE LOAD WAS NEEDED, WE ALSO
PERFORMED SIMULTANEOUS CT ANGIO THE LEFT ARM VESSELS. FILLING DEFECT IN THE MID BRACHIAL
ARTERY WITH RECONSTITUTION BELOW THE ELBOW.
 EGD AND BRONCHOSCOPY WERE NEGATIVE.
 PATIENT TAKEN TO OPERATING ROOM FOR EXPLORATION OF THE BRACHIAL ARTERY WHEN :
• T 36
• PH 7.32
• HGB 10.5
• INR 1.6
• BP 100
• P 100
• PLATELETS 55k BUT TRANSFUSION IN PROGRESS
• CLOSURE OF THE CHEST UNDERTAKEN AT 36 HOURS INTO THE HOSPITALIZATION

• ABDOMEN SERIALLY CLOSED OVER 5 DAY PERIOD.
• PATIENT SURVIVED. EXTUBATED ON POD #5 AFTER HER SERIAL ABDOMINAL CLOSURE

• WENT TO WARD ON HD#8
• DIED OF MASSIVE SADDLE EMBOLUS HD#11

A Difficult Case in Trauma Surgery

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A Difficult Case in Trauma Surgery

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CHALLENGING CASE

• Which of the following is not an urgent need for this patient?

• Obtained an emergent chest xray.

• What type of IV access should be established?

• Right subclavian central line inserted.

• What would you do next?

Through and through injury of the atrial appendage

• After the release of the pericardial tamponade, What next?

• Patient now intubated and on the ventilator • B. Open the abdomen

• Left chest tube output now 400cc total

• Commit to a damage control approach

• PRINCIPLES OF DAMAGE CONTROL

• CLOSURE OF THE CHEST UNDERTAKEN AT 36 HOURS INTO THE HOSPITALIZATION

• PATIENT SURVIVED. EXTUBATED ON POD #5 AFTER HER SERIAL ABDOMINAL CLOSURE

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