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Leftovers
  1. David V Feliciano
  1. Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr David V Feliciano, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201-1595, USA; davidfelicianomd{at}gmail.com

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History

A 25-year-old man presented to the trauma center with a close-range shotgun wound to the left proximal thigh.

Examination

The patient was awake and alert with a heart rate of 120 beats per minute and a systolic blood pressure of 90 mm Hg. A pressure dressing on the left proximal thigh which was applied in the field was half-saturated with blood. No arterial pulses were palpable in the left foot.

Question

The most appropriate first step in the management of this patient in addition to resuscitation is:

  1. CT arteriography.

  2. CT of the abdomen.

  3. Duplex ultrasound distal to the wound.

  4. X-ray of the left groin and thigh.

Management

An X-ray of the left groin and thigh documented that all pellets were in the proximal thigh inferior to the left inguinal ligament. A blood specimen was sent for type and crossmatch (no massive transfusion protocol available at the time), a cephalosporin antibiotic was administered, and the patient was moved to the operating room.

Question

The preferred operative approach would be:

  1. Pass a retrograde endovascular balloon occlusion of the aorta (REBOA) device through the right groin.

  2. Make a left extraperitoneal renal transplant incision for proximal control.

  3. Apply an aortic compression device on top of the pressure dressing.

  4. Make a longitudinal incision in the left groin proximal to the wound.

Management

A longitudinal incision was made in the left groin to allow for proximal control of the left common femoral artery and distal control of the left femoral vein. After encircling both femoral vessels with vessel loops, a vascular clamp was applied to the left common femoral artery and the time was noted. Bleeding from the open wound decreased significantly. A separate longitudinal incision was then made distal to the open wound. After elevation of the left sartorius muscle, the mid-left superficial femoral artery …

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