2023 FSA Podium and Poster Abstracts

P040: GSW TO THE RIGHT CHEST AND LIVER WITH AAST GRADE 5 LIVER INJURY AND AAST GRADE 5 RENAL INJURY
Kayla Yoshida, DO; Emily Chung, DO; David McDougal, DO; Orlando Gomez, DO; Victor Iturbides, MD; Nicholas Nedeff, MD; HCA Florida Kendall Hospital

Introduction / Background: AAST (American Association for the Surgery of Trauma) Grade 5 liver injuries have a significant mortality rate of 67-80%. These catastrophic injuries can exsanguinate a patient thus, prompt resuscitation and surgical intervention are both of dire importance.

Damage Control Resuscitation (DCR) is the strategic approach to the hemodynamically unstable trauma patient in hemorrhagic shock which focuses on balanced resuscitation, hemostatic resuscitation and the prevention of acidosis, hypothermia, and hypocalcemia. The anesthesiologist’s role within DCR is most imperative as the quick and efficient replacement of blood products can be the difference between life and death in the operating room and the ICU thereafter.

Methods: This report covers an emergent traumatic case involving a 26 year old male who presented as a Level 1 Trauma after a gunshot wound to the right chest. The patient was found to have massive right-sided hemopneumothorax with a GCS of 7. A chest tube was placed and he was emergently intubated by the trauma team; initial FAST exam was positive in the RUQ and a decision was made to emergently take the patient to the OR for exploratory laparotomy and possible thoracotomy. Massive transfusion protocol (MTP) was initiated. In the OR, the anesthesiology team immediately placed the patient on standard ASA monitoring and placed a left radial arterial line. IV access included a femoral central line and bilateral upper extremity 18-gauge IV catheters. Massive transfusion was started through the central catheter using the Belmont Rapid Infuser. MAPs were maintained above 60 mmHg with constant volume replacement as simultaneously blood was found to be hemorrhaging into the right retroperitoneal space. Over the course of the case, 29 blood products (14 PRBC, 10 FFP, 4 platelets, 1 Cryo) were administered in addition to 4g of calcium chloride and 1g of tranexamic acid. Once the trauma team identified the source of the bleeding to be near the hepatic artery, the interventional radiology team was called for emergent angiogram and possible embolization. The interventional radiology team identified active extravasation of contrast near the right hepatic veins and the right hepatic artery was embolized with gelfoam. Additionally, extravasation of contrast was found near the right kidney and a right renal artery stent was placed with adequate cessation of active bleeding.

Results: The patient was transferred in stable condition to the Trauma ICU for continuous monitoring. Later in the patient’s course, the bullet was found to be lodged within the spinal canal at L1 which was deemed non-operative per the neurosurgical team. The patient remained in the unit for three months after undergoing a partial hepatectomy as well as multiple plastic surgeries for ulcer wound preparation and grafting. He was transferred to a rehabilitation facility for paraplegic reconditioning.

Discussion: This case emphasizes the importance of proper DCR as well as efficient interdisciplinary collaboration in order to adequately resuscitate a trauma patient with AAST Grade 5 liver injury and AAST grade 5 renal injury.