Presentation
A horse fell on him.
Patient Data
Shattered spleen with active arterial bleeding (AAST grade V). Large perisplenic haematoma.
Renal lacerations spanning the entire parenchyma, with detachment of anterior part of the inferior pole and active arterial bleeding (AAST grade IV). Large perirenal haematoma. The left kidney enhances less than its right counterpart.
Right sternoclavicular joint dislocation and cartilaginous fracture of the 1st sternocostal synchondrosis. Small accompanying retrosternal haematoma.
Fractured 1st-12th (all) right ribs; 1st, 5th, 9th, 11th and 12th fractured in 2 places. Posterior fracture of 11th and lateral of 12th are comminuted. Minimal pneumothorax around lung apex, minimal haemothorax. Subcutaneous emphysema adjacent to upper ribs.
Fractured 1st-11th left ribs. 3rd-5th fractured in 2 places. Fracture of 1st rib is comminuted.
Minimal bilateral pneumothorax and haemothorax.
Bilateral subcutaneous emphysema in the chest - adjacent to upper ribs on right and more widespread on the left.
Fracture of left transverse process of L2 vertebra.
The right CFA was punctured using the Seldinger technique, after administering local anaesthesia under sterile conditions. The coeliac trunk-splenic artery was catheterised with a catheter on a guidewire. Angiography revealed several foci of bleeding in the spleen. The splenic artery was embolised at its middle third by 6 mm and 8mm coils with a satisfactory angiographic result.
Next, the left renal artery was catheterised. Many parenchymal filling defects were demonstrated, more prominent in the inferior part of the kidney. During one of the injections, extravasation from the inferior pole was demonstrated, in agreement with the CT angiogram. Selective catheterisation of the bleeding branch was performed and embolisation with a Tornado® 2/3 embolisation coil. Satisfactory angiographic result.
Haemodynamic improvement at the end of the procedure.
Haemostasis was carried out with ExoSeal® and manual pressure.
Case Discussion
Bystanders reported to the evacuating paramedics that the person fell off a horse, which fell on him.
Arrived at the ER fully conscious. BP 90-100/65-70 mmHg, pulse 120/min, 25 breaths/minute.
Among traumatic findings, CT angiography showed a shattered spleen and a grossly lacerated left kidney, both with significant arterial bleeding (AAST grade V and IV, respectively). The head and neck (not shown) were unharmed.
Embolisation of the ruptured splenic artery and of a segmental left renal artery was carried out.
Disclaimer:
I, Dr Yair Glick, have no actual or potential ethical or financial conflict of interest in relation to the aforementioned devices. This case is not intended to be a personal endorsement or recommendation of these products.
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