e-CASES: Hepatic fracture, Active hemorrhage
Patient struck by a foal in a field (impact of the hoof in the right hypochondrium).
At start of care by the emergency services, the patient was agitated, pale, faint, with pain in right hypochondrium, and with a mottled complexion. 92% saturation in ambient air, blood pressure: 170/100 mmHg, heart rate: 80/min. Pulmonary auscultation was symmetric. The patient was eupneic. Saturation rose under a high-concentration mask. Intravenous fluid therapy started, Morphine titration. Transfer to the university hospital.
On arrival at the emergency room: hemodynamics maintained (150/70mmHg), patient tachycardiac at 130/min, agitated, hematocrit 8.8g/dl. The patient was given 3mg of Hypnovel. The pressure dropped rapidly. Intravenous administration of 500ml of voluven.
Transfer to anesthesia-intensive care department due to hemodynamic instability:- orotracheal intubation and mechanical ventilation.- Continuation of vascular filling with 1 l of voluven and 500 ml of saline solution, administration of 3 red cell packs from emergency stock.- Abdominal ultrasonography revealed significant hemoperitoneum.
Transfer to scan.
Liver fracture involving segments VII, VII and V with active bleeding visible from the arterial phase. Appearance suggestive of arteriovenous fistulation with communication of the right hepatic artery and the middle and right hepatic veins in the form of pseudoaneurysms, significant hemoperitoneum. There is also a non-displaced fracture of the 8th right rib and non-traumatic bilateral isthmic lysis of L5.No other intra-abdominal posttraumatic lesions.Fortuitous discovery of a 14 mm left adrenal adenoma (0 Hounsfield spontaneous density units).Pancreatic calcifications compatible with a calcifying chronic pancreatitis aspect. Simple cortical cyst of the left kidney.
Hepatic fracture, Active hemorrhage
Decision taken to perform embolization after preparation of the patient and hemodynamic stabilization. The vascular examination revealed an active leak of contrast medium after catheterization of the right hepatic artery. This leak is in the early stages and arises from the bifurcation of the superior hepatic branch. Hyperselective catheterization of the branch at the source of the bleeding with fitting of fibered coils. Satisfactory post-embolization scan with no residual leakage.Diuresis is maintained, the intra-vesical pressures are approximately 14 mmHg, the abdominal perimeter remains stable at around 102 mm.
On the second day, kidney function deteriorated, the patient became oliguric and the vesical pressures rose. The gastrointestinal surgeon was contacted; he decided to perform laparostomy after lavage of the hemoperitoneum (abdominal compartment syndrome).
On day 5, the patient underwent further gastrointestinal surgery for peritoneal lavage. A biliary fistula was detected during surgery and drained with a Salem blade.
On D8, respiratory function deteriorated: massive bilateral pulmonary embolism detected on the CT scan and parieto-occipital ischemic area corresponding to a constituted ischemic stroke in the left PCA-MCA junction region.