Presentation
High speed MVA.
Patient Data
Chest
Endotracheal tube tip 35 mm above to the carina. NGT tip is projected with the stomach but above the expected position of the left hemidiaphragm, indicating diaphragmatic rupture and herniation of abdominal contents into the chest.
Opacification of the left mid and lower zones, consistent with pulmonary contusions. Left haemothorax and deep sulcus sign indicating a pneumothorax. Marked rightward mediastinal shift. The right lung appears clear. No right-sided pneumothorax or pleural effusion.
Multiple left-sided displaced posterior and lateral rib fractures. Subcutaneous emphysema within the left chest wall.
Pelvis
Pelvic binder and bilateral femoral splints noted. Severely comminuted displaced fractures of the left hemipelvis and left acetabulum with medial displacement of the left femoral head. The fractures extend into the widened left sacroiliac joint and pubic symphysis. Displaced fractures of the right superior and inferior pubic rami. Right hip joint alignment is normal.
Case Discussion
The patient was profoundly shocked with a positive FAST and proceeded straight to theatre ("red blanket") for emergency damage control laparotomy which found a large extraperitoneal haematoma, left diaphragmatic rupture with small bowel and the spleen in the chest and a left liver capsular tear. Extraperitoneal packing was performed and the decision was made to keep the abdomen open and proceed immediately to IR for bilateral IIA gelfoam embolisation and proximal splenic embolisation.
Post laparotomy and IR trauma CT panscan then identified:
Left flail chest with small haemopneumothorax
Left diaphragmatic rupture
AAST grade IV splenic laceration involving the splenic hilum
AAST grade III liver laceration
pelvic fractures
bladder rupture
Same day relook laparotomy repaired a complex intraperitoneal and extraperitoneal bladder rupture.
Day 2 relook laparotomy repaired the diaphragm rupture and closed of the laparotomy incision.
There were numerous orthopaedic procedures for several long bone fractures of the upper and lower limbs.
The patient had a long ICU and ward admission and recovery.
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