Gunshot wound to big red

• Published in: Trauma surgery & acute care open Vol. 5; no. 1; p. e000506
• Main Author: Feliciano, David V
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group LTD 13-08-2020; BMJ Publishing Group
• Subjects: Abdomen; Aneurysms; Blood pressure; Case of the Month; Coronary vessels; Diaphragm (Anatomy); Hematoma; Hypotension; Laparotomy; Ostomy; Pancreas; Sutures; Trauma; Trauma centers
• ISSN: 2397-5776; 2397-5776
• DOI: 10.1136/tsaco-2020-000506

Rapid infusion of packed red blood cells, crystalloid solutions, and 200 mEq of sodium bicarbonate over 10 min gradually improved the patient’s systolic blood pressure to 90 to 100 mm Hg. A closed suction drain was placed near the wounds in the head of the pancreas. Because of diffuse oozing (presumed nonmechanical bleeding), intra-abdominal packing with laparotomy pads was performed and a plastic silo bag was sewn to the skin edges of the midline abdominal incision. Discussion Injuries to the diaphragmatic, supraceliac, or visceral abdominal aorta are rarely seen in trauma centers, presumably because many patients exsanguinate at the scene. [...]the majority of patients with vital signs who arrive in the trauma center with an injury in this location will have a large midline supramesocolic hematoma exerting a tamponade effect.1 2 An increasing number of trauma centers around the world would have inserted a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) device in zone I in this patient with prehospital hypotension before transfer to the operating room.3 The patient described, however was treated in the pre-REBOA era. Originally described as part of a thoracoabdominal approach to elective repair of four thoracoabdominal aneurysms by DeBakey et al, this technique has now been widely used in elective and trauma vascular surgery to expose the proximal abdominal aorta for 65 years.6 Disadvantages of the left medial mobilization maneuver have been well described and include the following: (1) 5–7 min time period to perform the maneuver; (2) risk of iatrogenic injury to the spleen, left kidney, or posterior renal artery during mobilization of these structures; (3) creation of a fold in the visceral abdominal aorta caused by anterior rotation of the left kidney.7 In the patient described, the area of injury was in the supraceliac abdominal aorta. [...]there was no need, in retrospect, to mobilize the left kidney during the medial mobilization.