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A 27-year-old man presented to the trauma center with a close-range shotgun wound to the proximal right thigh.
The patient was awake and alert with a heart rate of 120 beats per minute, a systolic blood pressure of 80 mm Hg, and a base deficit of −10. The pressure dressing over a 7 cm diameter blast cavity in the mid-anterior proximal right thigh was saturated with blood and replaced. No exit wound was noted, and no arterial pulses were present in the right foot.
As a blood specimen was drawn for type and crossmatch, resuscitation with crystalloid solutions was initiated (no massive transfusion protocol available at the time). The X-ray of the right groin and thigh documented that almost all pellets were in the thigh itself (figure 1). After administration of a cephalosporin antibiotic, the patient was moved to the operating room.
Skin preparation and draping was from the umbilicus to the bilateral toenails, and the right foot was placed in a plastic bag. The open shotgun wound was too proximal to allow for the placement of a tourniquet or blood pressure cuff, so continuous pressure was applied. An 8 cm longitudinal incision in the right inguinal area was made proximal to the area of the shotgun wound. The right common femoral artery was exposed and an angled DeBakey vascular clamp was applied. A vessel loop was placed around the right common femoral vein as well. A separate 8 cm longitudinal incision was then made in the medial right thigh distal to the area of the shotgun wound. Both the superficial femoral artery and the femoral vein were clamped in this location as was the distal femoral vein in the groin.
The incisions were extended into the shotgun wound cavity. Multiple vessels in …
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