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History
A 25-year-old man presented to the trauma center with gunshot wounds to the left shoulder and left lower quadrant.
Examination
The patient was combative and diaphoretic with a systolic blood pressure of 100 mm Hg and a heart rate of 132 beats per minute. He had a single gunshot wound to the soft tissue of the superior aspect of the left shoulder, with normal pulses at the left wrist and a normal neurological examination in the left upper extremity. His abdominal examination was significant for a gunshot entrance wound in the left lower quadrant and diffuse peritonitis. The right femoral pulse was not palpable.
Management
After blood was drawn for type and cross-match, a surgeon-performed ultrasound was ‘negative’ for a hemopericardium and a left hemopneumothorax. A massive transfusion protocol was initiated, and a cephalosporin antibiotic was administered. On the first set of arterial blood gases, the pH was 7.11 with a base deficit of −17.5. After transport to the operating room, the patient was intubated, a midline exploratory laparotomy was performed and 2 L of hemoperitoneum were evacuated. There were multiple enterotomies in the small bowel, transection of the right external and internal iliac arteries and near transection of the right spermatic cord. Intestinal clamps were rapidly placed at the sites of enterotomies. Progressive hypotension mandated manual compression of the supraceliac abdominal aorta. A vascular clamp was then applied to the right common iliac artery, and the distal end of the right internal iliac artery was clamped and ligated. As the distal end of the right external iliac artery had retracted under the inguinal ligament, the midline abdominal incision was extended obliquely across the inguinal ligament into the right groin. A vascular clamp was then applied to the distal end of the right external iliac artery. The right spermatic cord was ligated. …