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Gunshot wound to big blue
  1. Melike Harfouche,
  2. David V Feliciano
  1. Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
  1. Correspondence to Dr David V Feliciano, Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; davidfelicianomd{at}gmail.com

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History

A 29-yearold man presented to the trauma center with a single gunshot wound to the right costal margin.

Examination

The patient was alert and responsive on arrival, but became increasingly lethargic throughout the assessment. His initial vital signs were a heart rate of 100 beats per minute, a systolic blood pressure of 80 by palpation and a respiratory rate of 20/min. His abdominal exam was significant for a single gunshot wound to the right costal margin at the midclavicular line, and his abdomen was distended and tense to palpation.

Question

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

  1. Massive transfusion and abdominal CT scan.

  2. Surgeon-performed FAST (focused assessment for the sonographic evaluation of trauma) examination.

  3. Transfer to operating room.

  4. Emergent hepatic arteriogram.

Management

A massive transfusion protocol was initiated, packed red blood cells were administered, and the patient was taken directly to the operating room where he underwent endotracheal intubation. After the administration of a cephalosporin antibiotic, a midline exploratory laparotomy was performed. A significant hemoperitoneum was evacuated. After evisceration of the small bowel to the right, the infrarenal abdominal aorta was cross-clamped because of profound hypotension. A large right retroperitoneal hematoma was exposed by a right-sided medial mobilization maneuver. After visualizing a 5 cm longitudinal anterior split in the infrarenal inferior vena cava (IVC) with a corresponding 2 cm posterior perforation just above the confluence of the common iliac veins, vascular cross-clamps were applied to both common iliac veins and the infrarenal IVC. There was still significant back-bleeding from the lumbar veins. After an attempt to repair the significant anterior laceration in the IVC, it became obvious that the IVC would be significantly narrowed. In addition, the patient remained profoundly hypotensive. At this point, both common iliac veins, the infrarenal IVC just above the perforations, and several …

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