S:

32 y/o F, with no PMHx, who presented to the ED via EMS s/p being struck by a motor vehicle with multiple blunt trauma and traumatic arrest. Patient was pulseless on the scene, but vitals returned after ACLS in the ED, however the patient coded twice again while there. CTs showed diffuse cerebral edema, right pneumothorax, multiple rib fractures, hip fracture, splenic lacerations and liver lacerations. 6-7 units of blood given in the ED. Patient was brought to the OR for laparotomy to control splenic and liver lacerations, with a plan to transfer to Bellevue after stabilization for the brain injury. While in the OR the patient remained hypotensive and was given pressors and massive blood transfusion protocol initiation. The patient had a splenectomy, as well as mesentery repair and perihepatic packing. An abdominal wound vac was placed with packing remaining.  Patient coded once prior to initial incision and once right before transfer to the ICU.

O:

VS: BP 70/44, HR 86 bpm, RR 18, Temp 97, O2 saturation N/A

Physical Exam:

Gen: intubated, not arousable, AxO x0

Skin: multiple abrasions to bilateral upper and lower extremities, skin cold to touch

HEENT: Laceration to left side of face, large laceration to scalp with staples in place, bilateral edematous eyes, NG tube in place

Cardiovascular: 1+ femoral pulses bilaterally, regular rate

Pulmonary: right chest tube in place

Abd: obese, distended

Labs:

9.06 | 9.2 | 205

           30.9

139 | 100 | 11             202

3.9  | 15    | 1.13

aPTT: 57.5

PT: 15.2

D-dimer: 17,428

Anion gap: 24

Albumin: 3.5

Total protein: 5.9

ALT: 284

AST: 257

Pro BNP: 273

Troponin: 0.409

Lactate: 12.0

CK: 940

Lipase: 110

Fibrinogen: 368

ABG:

pH venous: less than 7

PCO2: 91

PO2: 52

HCT: 29

Glucose: 241

Lactate: 10.6

Total Hgb: 9.6

Oxyhemoglobin: 64.4

Deoxyhemoglobin: 33.4

O2 saturation: 65.8

CXR: Small right pneumothorax. Due to a large amount of subcutaneous air along the right chest wall, the size of the pneumothorax may be underestimated.

Pelvis XR: Contour deformity of the right parasymphseal region, which represents osseous injury of indeterminate age. Multiple prominent bowel loops of indeterminate etiology.

CT abdomen/pelvis with IV contrast: large right pneumothorax. Shift of mediastinum to the left. Multiple right rib fractures. At least one acute left rib fracture possible multiple. Splenic rupture. Spleen appears severely ruptures with a possible small area of contrast extravasation within the region of the expected spleen. Splenic contours not well seen. Hematoma surrounding the spleen. Extensive laceration to right lobe of liver. No significant fluid or hematoma surrounding the liver.

Compression fracture of T12 that extends on the right and involves the lamina and superior articular process on the right. Transverse processes fractures on right at L1-L2, L3-L4. Pelvic fracture at right pubic symphysis. Multiple low-attenuation foci in both kidneys in the cortical areas. May represent small infarcts in the cortex of both kidneys.

CT head without contrast: diffuse cerebral edema. No focal infarcts, intracranial hemorrhage, contusions or mass effect. Moderate posttraumatic left fronto-parieto-occipital extracranial soft tissue swelling with small subgaleal hemorrhage and edema. No acute calvarial fractures.

CT cervical spine: nondisplaced fracture of right C4 articular process extending into its pedicle. No evidence of cervical spine subluxation.

A:

32 y/o F s/p pedestrian struck by motor vehicle with wound vac in place after laparotomy performed for splenectomy and perihepatic packing.

P:

Transfer from OR to ICU

Continue monitoring the patient

Continue massive blood transfusion protocol and IV fluids

Discuss critical condition with family

Bring patient back to OR once condition improves

Transfer to Bellevue for brain injury once patient is stabilized