Case Presentation

1. Jon Groner Trauma Medical Director CasePresentation

2. History • 11 year old male kicked by horse • Patient treated by local chiropractor (post injury days 1 and 2) • In office radiograph showed rib fracture and there was a visible hematoma noted on the right lateral chest and abdomen • Patient taken to Community hospital due to increasing abdominal pain (post injury day 3)

3. Initial exam at community hospital • HR 111, BP 128/93, R 18, T 98.3, SPO2 98%, GCS 15 • Respirations shallow • Breath sounds decreased • Abdomen distended and tender

4. Initial exam at community hospital • Interventions: • IV started and fluid bolus given (8 ml/kg crystalloid) • Labs drawn • CT chest/abdomen/pelvis • Morphine 2 mg IV • Oxygen administered by nasal cannula

5. The most likely major injury is: • Rib Fracture • Pulmonary Contusion • Liver Laceration • Bowel Injury • Pancreatic laceration 0 of 0

6. Initial exam at community hospital • Interventions: • IV started and fluid bolus given (8 ml/kg crystalloid) • Labs drawn HH 10.1/28.9, ALT 1511, AST 896 • CT chest/abdomen/pelvis • Morphine 2 mg • Oxygen administered by nasal cannula

7. Transferred to pediatric trauma center • HR 106, BP 140/96, R 28, T 97.8, SPO2 100% • Breath sounds decreased on right • Cap refill < 3 seconds • Abdomen full and tender • Chest x-ray without evidence of airway disease • HH 10/28.7, ALT 1434, AST 826 H/H=7.7/22

8. Pediatric Trauma Center • Imaging from outside hospital reviewed

11. This liver injury should be labeled: • Grade 1 • Grade 2 • Grade 3 • Grade 4 • Grade 5

14. This Chest CT with IV contrast is: • Normal • Abnormal • Not Sure

15. Pulmonary Embolism

17. CT scan findings • High grade liver injury (grade 5) • Pulmonary Embolism

18. Treatment for this liver injury should include: • Bed rest with serial hemoglobin and hematocrit levels • Transfusion • Immediate Operation • A & B • B & C

19. Proposed Treatment Plan • High grade liver injury (grade 5) • Transfusion, serial hemoglobin/hematocrit • Strict Bedrest • correct any coagulation deficits

20. Treatment for the Pulmonary Embolism: • Intravenous Heparin • Pulmonary embolectomy (interventional procedure) • Observation only, operation only if clinical deterioration occurs

21. Proposed Treatment Plan • High grade liver injury (grade 5) • Transfusion, serial hemoglobin/hematocrit • Strict Bedrest • correct any coagulation deficits • Pulmonary Embolism • Pulmonary Embolectomy (cath lab) • Anti-coagulate when the liver is no longer a threat

22. Hospital Course • Patient taken to cardiac catheterization lab for pulmonary embolectomy • Indications: life threatening pulmonary embolism in patient with contraindication to primary therapy (anticoagulation)

23. Cath lab results • 2 units PRBC given prior to procedure • Procedure note: • Patient suffered a grade 5 liver contusion with capsule intact but with significant compression of his retrohepatic IVC. This has led to development of thrombus below and within the retrohepatic IVC with PE to right hilar distribution. He has undergone successful angiojet.

24. Cath lab results • IVC venogram demonstrates some clot within the infrahepatic IVC and near occlusion of retrohepatic IVC due to liver compression. • Team elected to not proceed with dilating or stenting the retrohepatic IVC due to potential further embolus w/o capacity to anticoagulate at this early stage.

25. Hospital Course • Returned from cath lab • 4/4 2012 @23:30 Hemoglobin 8.3/Hematocrit 23.3 • 4/5/2012@04:45 Hemoglobin 6.6 – PRBC given

26. What is the next step? • Activate massive transfusion protocol • Immediate Operation • Repeat CT scan to assess for further bleeding • Give activated factor Vlla

27. Hospital Course: • Patient taken to CT to evaluate for possible ongoing hemorrhage • Findings: • Redemonstrated massive subcapsular hematoma associated with liver laceration. The hematoma compresses the right lobe of the liver completely effacing the intrahepatic IVC. • Increase in abdominal ascites. • Hypodensity is noted within the IVC in both external iliac veins raising the possibility of iliac and IVC thrombus.

28. CT #2

30. No PA clot

32. Hospital Course: • No further bleeding following transfusion of blood, platelets, and plasma • Patient transferred out of PICU to hospital floor • Patient allowed out of bed 7 days post injury • Both Hematology and CT surgery recommend starting anticoagulation due to known caval compression and history of pulmonary embolism • 9 days post injury, intravenous heparin (with close monitoring) is begun

33. The next day… • ACT called by RN • Patient turning gray. SPO2 decreased to 90%. Patient placed on 2L O2. Patient felt a “pop” followed by acute RUQ pain. Abdomen increasingly firm and distended. ISTAT = 8.7, BP decreased (90/70, 80/40), HR 120-130 • Interventions: • PRBC given (10 ml/kg) • Morphine given • Heparin stopped • Patient transferred to PICU

34. What is the next step? • Activate massive transfusion protocol • Immediate Operation • Repeat CT scan to assess for further bleeding • Give activated factor Vlla

35. PICU course • Patient sent for Abdominal CT #3 • Increase in size of the large right subcapsular hematoma and hematoma associated with right hilar liver laceration constricting the intrahepatic IVC • Increase in free intraperitoneal blood in the abdomen and pelvis • Clot is seen distending the infrahepatic IVC contiguously through the common iliac veins and external iliac veins to the common femoral veins.

39. Now what? Impression: Worsening liver hemorrhage despite optimal medical management • Laparotomy • Massive transfusion protocol • Continued observation

40. Patient to OR • Procedure: • Exploratory laparotomy • Drainage of subcapsular liver hematoma with fulguration and fibrin glue application to liver surface and parenchymal liver injury • Irrigation of abdominal cavity and placement of 2 closed suction drains • EBL: • 1000 ml clot and old blood evacuated, • 50 ml intraoperative blood loss • Fluids: • 3,500 ml crystalloid • 2 units PRBC

41. Post op course • Patient returned to floor • Appears to be improving • Heparin restarted due to IVC/Iliac clots • 1 day later: • Patient again becomes hypotensive and mottled • Heparin stopped, PRBCs and FFP given

42. The next step should be: • Massive transfusion protocol • Activated factor Vlla • Return Operating Room for repeat wash out • Not sure

43. OR #2 • Procedure: • Exploratory laparotomy with abdominal washout • Large hematoma evacuated • Abdominal packing with 2 laparotomy sponges in the right upper quadrant • Placement of a negative pressure dressing in incision (fascia left open for 2nd look and pack removal)

44. Hospital Course after OR #2 • Hematology/Oncology Consult: • Patient has developed recurrent bleeding and thrombocytopenia while on heparin and has a positive PFA4 Ab ELISA screening assay for HIT. • Mark patient as being allergic to heparin.

45. OR #3 • Procedure • Removal of abdominal wound VAC • Exploratory laparotomy with abdominal washout • Drain placement and primary closure

46. Hospital Course – post op OR #3 • Patient returns to PICU – over next 24 hours: • HH 8.6/25.8, PLT 81 • Urine output has remained at less than 1 ml/kg per hour despite fluid boluses • HR in the 80s and BP stable, but capillary refill > 3 seconds. • Repeat CBC with hgb 8.1, plt 81. Platelets and PRBC ordered. • Increased bloody output from drains. • New CT ordered

47. CT #4

50. Hospital Course – post op OR #3 • Impression: • Ongoing hemorrhage despite maximal medical and surgical therapy