A 26-year-old male was involved in a motor vehicle collision. He was
intubated in the field and transported to the ER with BP 90/64
mmHg and HR 112 bpm and was taken to the operating room after
positive FAST. He was found to have a grade V splenic injury
requiring splenectomy, a grade III right hepatic lobe injury with
persistent venous bleeding, and an injury to the base of the terminal
ileum mesentery which was resected and stapled. Packing with
laparotomy pads was able to achieve hemostasis and temporary
abdominal closure was done. In ER and OR he received 24 U PRBC,
22 U FFP, and 4 six-packs of platelets. Three hours later, peak
,inspiratory pressures have increased from 21 to 35, urine output has
decreased from 25 ml/hr to anuria, and vasoactive medications have
to be started to maintain BP. Hemoglobin is 12 g/dL with no
transfusion of PRBC since surgery. What is the next best step in
management?
A. Volume resusc
Give this one a try later!
Perform a right medial visceral rotation and ligate the vena cava.
Correct.
In the setting of an unstable patient with complete transection of the vena cava,
the best option is ligation. Repair of the vena cava is usually the preferred option;
however, this may not be feasible in the setting of damage control laparotomy in
an unstable patient with multiple injuries where prolonging the operative time
risks developing coagulopathy, acidosis, and hypothermia prior to control of all
major bleeding sources. A left medial visceral rotation is performed for aortic
exposure from the hiatus to the iliacs. A right medial visceral rotation is required
for caval exposure.
Resection with primary anastomosis
Correct.
Fecal diversion was credited with decreasing mortality from penetrating colon
injuries in World War II. Since that time, evidence has been steadily accumulating
that primary repair of the colon after penetrating injury is safe. In a recent meta-
analysis from the Cochrane Database of Systematic Reviews, pooled data from 5
prospective randomized trials noted fewer total complications, intra-abdominal
infections, total infections, and wound complications after primary repair versus
fecal diversion with a stoma. There was no difference in overall mortality
between the groups. All studies but 1 included patients traditionally considered
to be "high risk," i.e., patients with delay to operation, shock, significant
hemorrhage or transfusion requirement, fecal contamination, and significant
tissue loss. None of the studies' data included complications or hospital length of
stay due to colostomy takedown. Colostomy takedown has a reported
complication rate of 5% to 25%, can require postoperative hospital stays of over
15 days, and can add significantly to overall healthcare costs.
, Remove abdominal dressing at bedside with reapplication to allow for
worsening bowel edema
Correct.
This patient has developed abdominal compartment syndrome (ACS)
despite having an open abdomen. One must keep in mind that the
temporary abdominal closure can be restrictive and may require
modification over time. Volume resuscitation will exacerbate this patient's
primary problem without significantly improving preload. Diuresis is
inappropriate in light of this patient's recent major blood loss and ongoing
hemodynamic instability. Paralysis is sometimes necessary if the diagnosis
of ACS is in doubt, or the patient has ongoing ventilator dyssynchrony,
neither of which is present here. ECMO may yet be necessary for this
patient's pulmonary and/or hemodynamic support but does not address
the current primary issue.
Perform angioembolization of bleeding pelvic arteries followed by external
fixation of the pelvis.
Correct.
Pelvic arterial injury may be managed by open intraperitoneal exploration and
ligation of vessels, endovascular embolization or pre-peritoneal packing. In
recent years, endovascular control has become the preferred option for control
of pelvic hemorrhage in most patients, especially if they are relatively
hemodynamically stable. In some facilities, hybrid operating rooms may allow
this modality to be extended even to the unstable patient. Control of
hemorrhage should be accompanied or immediately followed by temporary
stabilization of the bony pelvis with external fixation devices.
Don't know?
2 of 23
Term
A 30-year-old man presents to the Emergency Department after
being struck by a motor vehicle; he was found pinned under the
vehicle and required 30 minutes of extrication. On arrival, his blood
pressure is 76/50 mmHg, pulse 132 beats/min, and he is slow to
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