TY - JOUR T1 - Intrahepatic vascular trauma JF - Trauma Surgery & Acute Care Open JO - Trauma Surg Acute Care Open DO - 10.1136/tsaco-2021-000675 VL - 6 IS - 1 SP - e000675 AU - Melike Harfouche AU - David V Feliciano Y1 - 2021/01/01 UR - http://tsaco.bmj.com/content/6/1/e000675.abstract N2 - An 18-year-old man presented to the trauma center with four gunshot wounds to the following areas: left lower flank, left lower quadrant of the abdomen, left supraclavicular region and left scapula.The patient was awake but alternated between periods of agitation and lethargy. He had a heart rate of 140 beats/min, a blood pressure of 100/60 mmHg, a respiratory rate of 12 breaths/min, and appeared pale with cool and clammy skin. Breath sounds were clear bilaterally. His left supraclavicular wound did not exhibit any signs of overt bleeding, nor was there an expanding hematoma, and he had a palpable left radial pulse. His abdominal examination was significant for the gunshot wounds as described earlier and tenderness over the left flank.Large bore intravenous access was obtained, and transfusion with whole blood was initiated. A Focused Assessment for the Sonographic Evaluation of the Trauma Patient (FAST) documented a fluid stripe in the right hepatorenal fossa. A foreign body X-ray series was then performed (figure 1). The patient was taken to the operating room where an emergency exploratory laparotomy was performed. A moderate amount of hemoperitoneum and bile staining was noted in the lesser sac.Figure 1 Foreign body series demonstrating retained bullets in the right upper quadrant.The following injuries were noted: (1) anterior and posterior perforations of the stomach, (2) a through-and-through central injury to the left lobe of the liver, (3) a perforation of the right hemidiaphragm and (4) an injury to the edge of the inferior pole of the spleen. The right upper quadrant of the abdomen was packed with laparotomy pads, and this appeared to control the bleeding. The tip of the spleen was inspected again and found to be hemostatic. The gastric injuries were then oversewn with a 3–0 polydioxanone (PDS) suture. Because of a concern about the … ER -