surviving thoracoabdominal penetrating trauma: lawnmowers
TRANSCRIPT
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Surviving Thoracoabdominal
Penetrating Trauma:
Lawnmowers, Helicopters, and
Resuscitation
AKA ‘Miracle in a cornfield’
Donald Jenkins, MD. FACS DMCC
Division of Trauma, Department of Surgery
UT Health San Antonio
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Patient History
• Otherwise healthy 52 y.o. male
• Mowing a field
• Right flank ‘bee sting’ sensation
• Discovered ‘down’ by neighboring farmer
• Transported to local hospital by EMS
• Profoundly hypotensive
• Pericardiocentesis performed with removal
of 30 ml’s of blood and improved SBP
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Pre-Transfer Interventions
• Right Tube Thoracostomy
• Pericardiocentesis 15 mL
• 3 Liters of Crystalloid
• 4 units of Packed Red Blood Cells (PRBC)
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En Route by Rotary Wing
• 4 units of PRBC
• 4 units of Plasma
• Highest HR 122 bpm
• Lowest BP 56 mmHg
• Lactate 3.6
• Pericardiocentesis repeated with
improvement in SBP
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Labs• INR 1.1
• Lactate 2.64 mmol/L.
• pH 7.30
• PCO2 43 mmHg
• PO2 of 275 mmHg
• base deficit 5 mmol/L
• bicarbonate 21 mmol/L
• Hemoglobin 10.8 mg/dL.
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Audience Response
• What next?
• A) CT scan
• B) Interventional radiology
• C) OR
• D) Other
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Audience Response
• If OR, choice of procedure
• A) midline laparotomy
• B) sternotomy
• C) Right thoracotomy
• D) Other
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Operation
• Median Sternotomy
• Right Atrial Laceration
• Transesophageal Echocardiogram
• Intraoperative Fluoroscopy
• Right Diaphragm Laceration
• Midline Laparotomy
• IVC injury
• Retrohepatic hematoma
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Intraoperative Transfusion
• 9 units of PRBC
• 2 units of Cell Saver blood
• 3 units of platelets
• 6 units of fresh frozen plasma
• 2 units of cryoprecipitate
• 2 liters of crystalloid
• Blood loss 4 liters
• Patient stable and not bleeding; to ICU
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Post-operative course
• Right chest tube puts out one liter in one
hour 6 hours after ICU admit
• New coagulopathy developed
• Blood pressure transfusion dependent
• CXR:
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Audience Response
• Next step:
• A) OR
• B) IR
• C) OR to hybrid room
• D) place more chest tubes and correct
coagulopathy and observe
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Operative Course
• ‘night call’ surgeon takes patient to OR 8
hours after ICU admission
• Extends midline incision across
costochondral junction for right thoracotomy
• ‘day surgeon’ called in from home to assist
• Bleeding source appears to be in right chest
• Bleeding source cannot be visualized but
seems to be medial posterior behind the
diaphragm
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Audience Response
• Now what?
• A) open the diaphragm
• B) call IR in
• C) pack and get out
• D) other
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Operative Course
• IR called in
• Palpation reveals injury likely to the 12th
intercostal artery at the spine
• Hemostatic gauze pack placed in medial
sulcus with temporary control
• Patient moved to hybrid OR
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CeliacRadiologist decides celiac as most likely source
Circle denotes radiopaque sponge marker
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SMARadiologist decides SMA as most likely source
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First LumbarRadiologist decides to listen to the surgeon and
interrogates aortic intercostals
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12th Intercostal
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12th Intercostal Embolization
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11th Intercostal
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Hospital Course
• Off ventilator within 48 hours
• Out of ICU 48 hours after extubation
• Out of hospital 10 days after injury
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• Hospital Stay 14 days
• 42 units PRBC
• 12 units of platelets
• 24 units of FFP
• 5 units of cryoprecipitate
Dismissal
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3 Month Follow-up
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The Projectile
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Conclusion
• Fencing staples can be deadly when
propelled by 7 foot long field mower blades
• Field mower blades can exceed 1800 RPM
• The rotor speed of the helicopter the patient
was flow in was 500 RPM
• A bleeding source was missed in this case
and nearly cost the patient his life
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1 Year After Injury