# Clinical Cases: Trauma Surgery

## Case 1: Blunt Abdominal Trauma with Splenic Injury

### Patient Demographics
- **Age:** 28 years
- **Sex:** Male
- **Occupation:** Construction worker

### Chief Complaint
Patient brought by EMS after motor vehicle collision

### History of Present Illness
The patient was the restrained driver of a vehicle that was T-boned on the driver's side at approximately 40 mph. There was significant intrusion into the driver compartment. He was awake at the scene but complained of left-sided chest and abdominal pain. He was placed in a cervical collar and transported to the trauma center. He denies loss of consciousness.

### Prehospital Information
- GCS 15 at scene
- BP 98/68, HR 118
- 2 large-bore IVs placed
- 1L crystalloid infused en route

### Primary Survey (ATLS)
- **A (Airway):** Patent, speaking in full sentences, no stridor
- **B (Breathing):** Bilateral breath sounds, splinting on left, RR 24
- **C (Circulation):** BP 94/62, HR 122, pale, cool extremities, cap refill 4 seconds
- **D (Disability):** GCS 15, pupils equal and reactive
- **E (Exposure):** Left flank contusion, seat belt sign across abdomen

### FAST Examination
- **Positive:** Free fluid in left upper quadrant (splenorenal recess)
- **Positive:** Free fluid in pelvis (pouch of Douglas)
- No pericardial effusion

### Resuscitation
- Activation of massive transfusion protocol
- Blood products: 2 units PRBCs, 2 units FFP initiated
- Tranexamic acid 1g IV
- Vital signs after resuscitation: BP 102/68, HR 108 (transient responder)

### Secondary Survey
- **Head/Neck:** C-collar in place, no facial injuries
- **Chest:** Left chest wall tenderness, no crepitus, bilateral breath sounds
- **Abdomen:** Distended, diffuse tenderness, guarding, seat belt sign
- **Pelvis:** Stable to compression
- **Extremities:** Left knee contusion, no deformity

### Laboratory Results (Initial)
- Hemoglobin: 10.2 g/dL
- Lactate: 4.8 mmol/L
- Base deficit: -6
- INR: 1.1
- Platelets: 198,000/μL

### Imaging

**Chest X-ray:**
- Left lower rib fractures (ribs 9, 10, 11)
- No pneumothorax
- No hemothorax

**CT Abdomen/Pelvis with IV contrast (patient stabilized):**
- Grade IV splenic laceration with active extravasation (blush)
- Large hemoperitoneum
- No hollow viscus injury
- No renal injury
- No pelvic fracture

### Diagnosis
- Grade IV splenic laceration with active hemorrhage
- Left lower rib fractures

### Management Decision
Given:
- Hemodynamic instability (transient responder)
- High-grade splenic injury with active blush
- Large hemoperitoneum

**Decision:** Angioembolization vs. operative management
- Patient transiently stabilized with resuscitation
- Interventional radiology immediately available
- Proceed with splenic artery embolization

### Interventional Radiology
- Main splenic artery coil embolization performed
- Successful occlusion of bleeding vessel
- Patient monitored in surgical ICU

### Post-Embolization Course
- Hemoglobin stabilized at 9.8 g/dL (no further transfusions needed)
- Lactate normalized by 12 hours
- Serial abdominal exams: Improving
- DVT prophylaxis initiated at 48 hours

### Hospital Course
- ICU x 3 days
- Transitioned to floor
- Ambulating by day 4
- Discharged day 6

### Post-Splenectomy/Splenic Injury Considerations
- Spleen preserved (non-operative management successful)
- No OPSI (overwhelming post-splenectomy infection) prophylaxis needed
- Activity restrictions: No contact sports for 3 months
- Repeat imaging at 1 week: Stable

### Teaching Points
1. ATLS primary survey is systematic and life-saving
2. FAST exam rapidly identifies hemoperitoneum
3. Hemodynamically unstable patients with positive FAST → OR
4. Transient responders may be candidates for angioembolization
5. Non-operative management is standard for stable blunt splenic injury
6. Splenic artery embolization can salvage spleen in selected patients
7. Grade of injury and hemodynamic status guide management

### Clinical Image
![FAST Exam Positive](case_01_image.jpg)

**Image Description:** Focused Assessment with Sonography for Trauma (FAST) examination demonstrating free fluid (anechoic stripe) in the splenorenal recess (left upper quadrant view), indicating hemoperitoneum in the setting of blunt abdominal trauma.

**Attribution:** Image from Wikimedia Commons, Category:Trauma surgery. Source: https://commons.wikimedia.org/wiki/Category:Trauma_surgery

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## Case 2: Penetrating Abdominal Trauma

### Patient Demographics
- **Age:** 24 years
- **Sex:** Male
- **Occupation:** Unknown

### Chief Complaint
Brought by EMS with stab wound to the abdomen

### History of Present Illness
The patient was found outside a bar with a single stab wound to the left upper quadrant. Bystanders report an altercation. The patient is awake but confused and complaining of abdominal pain. The weapon (a folding knife, 4-inch blade) was recovered at the scene.

### Prehospital Information
- GCS 14 (E4V4M6)
- BP 82/54, HR 138
- Wound covered with sterile dressing
- Large-bore IV access, crystalloid running

### Primary Survey
- **A:** Airway intact, speaking
- **B:** Bilateral breath sounds, tachypneic (RR 28)
- **C:** BP 78/50, HR 142, weak thready pulses, cold and clammy
- **D:** GCS 13 (confused)
- **E:** Single stab wound in left upper quadrant, 2 cm in length

### Assessment
- Class III-IV hemorrhagic shock
- Penetrating abdominal trauma

### Immediate Management
1. Massive transfusion protocol activated
2. Permissive hypotension target (SBP 80-90) until OR
3. Blood products administered
4. Emergency department thoracotomy NOT indicated (has pulse)
5. Direct to OR for exploratory laparotomy

### Decision: OR vs. Further Workup
**Indications for immediate laparotomy:**
- Hemodynamic instability
- Peritonitis
- Evisceration
- Impalement (not this case)

Patient meets criteria → Emergent laparotomy

### Operative Procedure
**Exploratory Laparotomy (Damage Control):**

**Findings:**
- 1.5L hemoperitoneum
- Splenic hilum laceration (actively bleeding)
- Gastric perforation (anterior wall, near greater curvature)
- Diaphragm laceration (left hemidiaphragm, 3 cm)
- No other injuries on systematic exploration

**Procedures:**
1. Splenectomy (hilum injury, unable to salvage)
2. Primary repair of gastric perforation (two-layer closure)
3. Repair of diaphragm laceration (primary suture)
4. Thorough abdominal washout
5. Primary fascial closure (patient physiologically stable)

### Intraoperative Blood Products
- 6 units PRBCs
- 4 units FFP
- 1 unit platelets
- Ratio approximately 1:1:1

### Postoperative Course
- ICU admission
- Extubated POD 1
- Diet advanced POD 3
- Ambulatory POD 4

### Post-Splenectomy Prophylaxis
- Vaccinations administered before discharge:
  - Pneumococcal (PCV13 and PPSV23)
  - Meningococcal (MenACWY and MenB)
  - Haemophilus influenzae type b
- Patient education on OPSI risk
- Medical alert identification recommended
- Low threshold for antibiotics with febrile illness

### Discharge
- POD 5
- Oral antibiotics not routinely needed
- Follow-up with trauma surgery
- Social work consulted regarding circumstances of injury

### Teaching Points
1. Penetrating abdominal trauma with shock = immediate laparotomy
2. Stab wounds to the left upper quadrant can injure spleen, stomach, diaphragm, and colon
3. Systematic exploration of all abdominal organs required
4. Damage control principles when patient is physiologically compromised
5. 1:1:1 blood product ratio in massive transfusion
6. Post-splenectomy vaccination is critical (OPSI prevention)
7. Left-sided penetrating trauma: Always rule out diaphragm injury

### Clinical Image
![Exploratory Laparotomy](case_02_image.jpg)

**Image Description:** Intraoperative photograph during exploratory laparotomy for penetrating trauma demonstrating systematic exploration of the abdominal cavity. The surgeon performs a thorough evaluation of all organs following the established sequence to identify all injuries.

**Attribution:** Image from Wikimedia Commons, Category:Trauma surgery. Source: https://commons.wikimedia.org/wiki/Category:Trauma_surgery

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## Case 3: Damage Control Surgery for Severe Trauma

### Patient Demographics
- **Age:** 35 years
- **Sex:** Female
- **Occupation:** Nurse

### Chief Complaint
Brought by helicopter EMS after high-speed motor vehicle collision

### History of Present Illness
The patient was the unrestrained driver in a single-vehicle rollover at highway speed. She was found partially ejected from the vehicle with significant deformity to the front of the car. She was unresponsive at the scene. GCS was 6 (E1V2M3). She was intubated in the field.

### Prehospital Information
- GCS 6 → intubated
- BP 70/40 (after 2L crystalloid)
- Bilateral femur deformities
- Massive external hemorrhage controlled with tourniquets

### Primary Survey (on arrival)
- **A:** Intubated, tube confirmed
- **B:** Bilateral breath sounds, clear
- **C:** BP 72/40, HR 148, massive transfusion already initiated
- **D:** GCS 3T (sedated), pupils 3mm bilateral and reactive
- **E:** Multiple injuries: open book pelvis, bilateral femur fractures, large scalp laceration

### FAST Examination
- **Positive:** Large amount of free fluid in all quadrants
- Pericardium: No effusion

### Resuscitation
- Massive transfusion protocol ongoing
- Blood products: PRBCs, FFP, platelets (1:1:1)
- Calcium replacement (for citrate toxicity)
- Pelvic binder applied

### Laboratory Results
- pH: 7.18 (acidosis)
- Lactate: 8.4 mmol/L
- Base deficit: -12
- Temperature: 34.8°C (hypothermia)
- INR: 1.8 (coagulopathy)
- Fibrinogen: 120 mg/dL (low)

### The "Lethal Triad"
1. **Hypothermia:** 34.8°C
2. **Acidosis:** pH 7.18
3. **Coagulopathy:** INR 1.8

### Decision: Damage Control Surgery
Patient meets criteria for damage control approach:
- Severe physiologic derangement
- Multiple injuries
- Lethal triad developing
- NOT candidate for definitive repair

### Damage Control Laparotomy
**Findings:**
- 3L hemoperitoneum
- Grade V liver laceration (involving retrohepatic vena cava area)
- Mesenteric injury with active bleeding
- No hollow viscus injury identified

**Damage Control Procedures:**
1. Temporary packing of liver (perihepatic packing)
2. Mesenteric bleeding controlled with sutures
3. Abdomen left open - temporary abdominal closure (negative pressure wound therapy)
4. Total OR time: 35 minutes

**Goal:** Stop hemorrhage, prevent contamination, restore perfusion, LEAVE THE OR

### Orthopedic Intervention
- Bilateral femur external fixation (temporary)
- Pelvic binder continued

### ICU Resuscitation Phase
Goals:
1. **Warm:** Active warming (Bair hugger, warm fluids, warm environment)
2. **Correct coagulopathy:** Continue blood products, cryoprecipitate, correct acidosis
3. **Optimize perfusion:** Goal-directed resuscitation, vasopressors as needed

### Progress Over 48 Hours
- Temperature: 36.8°C
- pH: 7.38
- INR: 1.1
- Lactate: 1.6 mmol/L
- Hemodynamically stable on minimal vasopressors

### Planned Re-Exploration (48 hours)
**Take-back laparotomy:**
- Packing removed carefully
- Liver hemostasis achieved (bleeding stopped)
- Mesentery healing
- Bowel viable
- Abdomen closed (delayed primary closure)

### Subsequent Operations
- Day 5: Definitive femur fixation (intramedullary nails)
- Day 7: Pelvic fixation

### Hospital Course
- ICU x 10 days
- Transferred to floor
- Rehabilitation facility transfer Day 21

### Teaching Points
1. Damage control surgery = abbreviated surgery to restore physiology
2. Lethal triad (hypothermia, acidosis, coagulopathy) mandates damage control
3. Principles: Control hemorrhage, control contamination, temporary closure
4. Resuscitation in ICU to reverse physiologic insult
5. Planned re-exploration when patient stabilized
6. Staged definitive repairs when patient can tolerate
7. Damage control resuscitation parallels damage control surgery

### Clinical Image
![Damage Control Surgery](case_03_image.jpg)

**Image Description:** Temporary abdominal closure with negative pressure wound therapy dressing following damage control laparotomy. The open abdomen allows for re-exploration and prevents abdominal compartment syndrome while the patient undergoes physiologic resuscitation.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Trauma_surgery