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e-CASES: Thoracic Injuries, Subcapsular hemorrhage of liver, Pelvic injury

Histórico

Road traffic accident, light vehicle against plane tree, frontal impact, high speed (the patient who was the passenger was found in the driver's seat), release time: 1 hr 30, acute alcoholism and cannabis use.

 

Initial evaluation:

. Neurological: initial loss of consciousness, patient Glasgow = 15, no sensory or motor deficit,

. Haemodynamic: blood pressure: 11/7, heart rate: 120,

. Respiratory: Oxygen saturation: 94% in room air, respiration rate 20, signs of chest trauma on skin. No right breath sounds detected during auscultation,

. Abdominal: indeterminate abdomen,

. Maxillofacial: cut to upper lip,

. Orthopedic: open fracture of right wrist, lumbar pain, fracture of the left femur, fracture of the left humerus, symmetrical pulses detected.

 

Transfer to university hospital for continuation of treatment.

Descobertas

Cranioencephalic space:

No intra- or pericerebral traumatic lesions.

Fracture of the nasal bones.

 

Cervical spinal space

Stable, non-displaced and isolated linear fracture of the right wing of C7, with no gap in the posterior joint spaces.

 

Thoracic space:

Compressive right pneumothorax with passive parenchymatous compression on contact.
Moderate hemomediastinum with no aortic trauma.
Peripheral ground-glass pulmonary contusions of the lingula, left basal pyramid, and on the right pulmonary hemi-field.
Fracture of the middle arch of the 2nd and 3rd right ribs and the anterior costochondral junction of the 8th to the 12th right ribs.

 

Abdominopelvic space:

Non-enhanced hypodense subcapsular accumulation in segment VI of the liver (75 Hounsfield density units), compatible with subcapsular hematoma in this traumatic context.

Extensive sub- and retroperitoneal pelvic hematoma associated with a complex fracture (rupture of the pelvic girdle at 4 points) of the pelvis comprising:

- vertical fracture of both sacral wings, passing through the foramina, with an oblique horizontal fracture line on the 1st sacral piece;
- comminuted fracture of the right obturator frame (ilio- and ischiopubic branches);

- non-displaced T-shaped transverse fracture of the left acetabulum (with ischiatic crack), no intra-articular fragment, satisfactory joint congruence, no bone impaction.

 

No vascular or urological complications, under the reserve of insufficient filling of the bladder: the department has been advised to perform a plain abdominal X-ray after clamping the urinary catheter in the next 2 to 3 hours, to confirm satisfactory bladder continence and the absence of extravasation.

Associated fracture of the left transverse apophysis of L5.


Diagnóstico

Thoracic Injuries, Subcapsular hemorrhage of liver, Pelvic injury


Discussão

FOLLOW-UP:

 

- Intubation and mechanical ventilation

- Draining of pneumothorax

- Conservative treatment of pelvic fracture using support.


Pontos principais

Important points:

 

- WATCH OUT for pre-peritoneal air pockets; these should not be mistaken for pneumoperitoneum.

- ALWAYS look for vascular and urological complications in all cases of pelvic trauma. In this case, a cystoscan is preferable to a late phase scan to rule out any bladder lesions.



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