View Full Version : Great Case Yesterday

03-12-2008, 07:52
20 year old GSW to right back (.38 cal) with bullet palpable just above his xyphoid process. Okay, the trajectory says it hit something in his abdomen and he needs an operation. Hit IVC with 2 holes (in and out) just below renal veins, hit duodenum on its edge and came out pancreatic head, through and through liver and stopped just above xyphoid. Alot of blood in abdomen as expected.
My issues: keep patients mean arterial pressure in the 55-60mmHg range, DO NOT over resuscitate with IVF...give blood.

Now for my editorial: it is my firm belief that had this guy received the typical 4-8 liters of IVF, he' have bled to death. His BP higher would make him bleed faster, the IVF would dilute his coagulation factors and with no clot, he hemorrhages to death. The medics that brought him in with a BP of 70-80 gave a total of 200mL IVF in the 25 minutes it took from scene to trauma bay.

Good news, finished the case at 5pm yesterday, he's leaving the ICU today to the stepdown area. Never got below 35.9 degrees, never got a pH below 7.34, and no coagulopathy in the OR.

This ties into the last thread's discussion and I believe is such an important point to make for all of the medics/docs/PAs, etc.....more may not be beneficial and may be harmful (resus fluids)....until the bleeding is controlled


Red Flag 1
03-12-2008, 09:35

In my residency with the Air Force, we were providing anesthesia for total joint replacement. Total joint replacement at that time was relatively new and there were no guides and cutting jigs that are in use today. Blood loss was always a problem and cases could take up to, and sometimes over, 4hrs. One of the ways we would address blood loss was to help prevent it buy using deliberate hypotention. In addition to the depressant effects of volitile agents we would add an alpha blocking agent such as Pentolinium, Regitin, or Sodium Nitropresside. I liked the Nipride because it was easy to control and it was neat to have the foil wrapped IV bag up @ the head of the table. All hypotensive cases were done with direct hemodynamic monitoring as a matter of course. We were also using this technique on several other cases like mulit-level lamies, etc.

Nice case you had !! I'll bet the IVC was fun.

RF 1

03-12-2008, 20:23

The typical medic is taught to give two large bore (14's) IV's and run the fluids so as to replace the lost volume.

I had an LN, PSD guy, IED victim with shrapnel through the upper legs bilat and abdomen, along with burns over 30% of the same area. Of course the guy was screaming bloody murder, and we managed to get IV access on one arm only. We had about 15 minutes of a ride to the TIF facility and we only ran 150 to 200 mL during that time. He was bleeding fairly profusely out of the holes in his abdomen and we didn't want to cause the problem you discussed.

He made it through surgery, but not the flight to B'dad. Tough break that. We did all we could as first line guys, and at least I can feel good about that.


Doc Dutch
03-12-2008, 20:46
Huge case. Great outcome. Good job. Love the low volume resus.

Questions: How did you control the injury to the duodenum and how what did you do for the pancreatic injury? How did you evaluate the pancreatic duct or will you it in the future? ERCP?

This is my most favorite topic of discussion with my resident staff. Keep us posted on his progress.

Again, great save and kudos, sir!


03-13-2008, 15:40
Doc Dutch,

Duodenum was an injury just to the undersurface/edge....single hole in the bottom (I REALLY HOPE!!) and up through head of pancreas. Used "flo-seal" applied right into the pancreatic injury. No obvious fluid coming up c/w major duct leak but that's not good enough. Based on his injuries and wanting to be done this operation I did not cut off the tail to get access to the duct and dye test him and likewise did not go after the ampulla and do a contrast study. I am a fan of post op ERCP if needed and just drained the hell out of it, let my duodenum repair heal then if I get into any problems, let GI do an ERCP and stent or at least do a sphincterotomy to drain it. I took the minimalist route because of the combo of injuries.
No whipple for this boy atleast not on the 1st go round, maybe in a delayed fashion if needed and fully resuscitated, warm, etc......
Out of the unit and getting an UGI with gastroview tomorrow. Out of bed today, already on jejunal tube feeds...I feed everyone within 12-24 hours of becoming 'stable'. His drains so far minimal and sending for amylase in the AM.
Sometimes it's good to be lucky and in this case having the IVC injury be contained and not freely hemorrhaging, I could set it up for potential success.....he's not out of the hospital yet!

1st pic is duodenumm flipped up to injury repair site, had proximal control with vessel-loop but did not open tissue over IVC yet, 2nd on is IVC isolated, gonadal vessels on top ligated and if you look carefully, just superior to the black silk tie is the 1.3 cm repaired lac, vertical orientation

Doc Dutch
03-15-2008, 19:38
Incredible. I salute you.

To all, trust me, this is the work of a master surgeon.

Again, congrats, ss!

Doc Dutch

01-05-2010, 22:25
How did this young man do? Was this a soldier or civilian? I just did my first whipple yesterday since finding this site and did a search thinking someone here may have talked about a trauma whipple. Mine required a side-bite of the PV.

Do you remember the triad parameters/labs going in? Did you fix the back wall IVC injury through the front? What was your tube and drain arrangement? Pyloric exclusion or duodenal diverticularization? Seems like it was a fairly small duodenotomy. Floseal work? Develop fistula?

Agreed, this area is tiger country and you did an outstanding job. Not as hard to save as retrohepatic caval injury but takes more thinking and fraught with more postop complications and decisions.