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A 14-year-old man presented to the emergency department with intractable lower back pain and associated radiculopathy. He had been unsuccessfully treated in the past non-operatively for known lumbar disk herniation. He was seen and examined by the neurosurgery team and ultimately taken to the operating room for emergent microdiskectomy of L5–S1.
Postoperatively, the patient clinically deteriorated. He was lethargic, diaphoretic and was showing signs of shock. Initially, this was treated as a hypersensitivity reaction; however, a repeat labs noted a hemoglobin drop from 15.4 to >6.5. Massive transfusion protocol (MTP) was initiated, and the acute care surgery team was notified. On arrival of our service, the patient had a heart rate of 140, a blood pressure of 68/46 and was virtually unresponsive with a distended abdomen. He was reintubated and bedside ultrasound was performed which showed fluid in the pelvis. He was taken to the operating room for emergent laparotomy.
In the abdomen, there was a massive zone 1 retroperitoneal hematoma causing the intestinal contents to be pushed out of the abdominal cavity. Given the location of the hematoma, the decision was made to obtain proximal aortic control. The lesser sac was entered and supraceliac digital pressure was applied. Multiple attempts were made to pass a Crawford Clamp across the aorta; however, this was unsuccessful due to the body habitus of the patient and the remarkable size of the hematoma.
What would you do?
Continue digital pressure for proximal aortic control and explore the hematoma.
Emergent thoracotomy to obtain proximal aortic control in the chest.
Attempt endovascular balloon …