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Difficulty: Very hardSurgical and Procedural Interventions

A 29-year-old man is brought to the emergency department after a high-speed motorcycle collision. He was ejected from the vehicle and found 30 feet away. On arrival, his airway is patent. He is confused and diaphoretic. Temperature is 36.2 C (97.2 F), pulse is 135/min, blood pressure is 85/50 mmHg, and respirations are 28/min. Primary survey reveals a rigid, distended abdomen and a grossly deformed right femur. A portable chest radiograph demonstrates a widened mediastinum with loss of the aortic knob contour. A focused assessment with sonography for trauma (FAST) is positive for free fluid in the hepatorenal and splenorenal recesses. The patient receives a rapid infusion of 2 units of uncrossmatched packed red blood cells, which improves his blood pressure to 105/65 mmHg. A CT scan of the chest, abdomen, and pelvis with intravenous contrast reveals a Grade III blunt thoracic aortic injury (pseudoaneurysm) just distal to the left subclavian artery, and a Grade IV splenic laceration with active contrast extravasation. While transferring the patient from the CT scanner to the stretcher, his blood pressure precipitously drops to 65/40 mmHg and his pulse increases to 150/min. He becomes unresponsive and is immediately endotracheally intubated. Which of the following is the most appropriate next step in the surgical management of this patient?

  1. Emergent exploratory laparotomyAnswer
  2. B
    Urgent thoracic endovascular aortic repair
  3. C
    Left anterolateral resuscitative thoracotomy
  4. D
    Angiographic embolization of the splenic artery
  5. E
    Resuscitative endovascular balloon occlusion of the aorta

Answer

The correct answer is emergent exploratory laparotomy.
The correct response is emergent exploratory laparotomy. This patient is experiencing profound, uncompensated hemorrhagic shock due to an actively bleeding, uncontained Grade IV splenic laceration. While he also has a Grade III blunt thoracic aortic injury (BTAI), this injury is currently contained as a pseudoaneurysm. In trauma patients with multiple life-threatening injuries, uncontained active hemorrhage takes absolute priority according to Advanced Trauma Life Support (ATLS) principles. The immediate surgical intervention required is an exploratory laparotomy to control the intra-abdominal bleeding. The contained BTAI should be managed with permissive hypotension (anti-impulse therapy) and delayed definitive repair (such as TEVAR) once the patient is hemodynamically stabilized and the active bleeding has been controlled.

Step-by-Step Solution

1
Evaluate the sources of hemorrhagic shock based on imaging and clinical deterioration.
The patient has uncontained intra-abdominal hemorrhage (Grade IV splenic laceration) and a contained blunt thoracic aortic injury (Grade III pseudoaneurysm).
Identifying the active source of exsanguination dictates the procedural priority in polytrauma.
2
Determine the immediate life threat driving the hemodynamic collapse.
The precipitous drop in blood pressure is driven by active uncontained bleeding from the spleen, not the contained aortic injury.
Contained aortic pseudoaneurysms are temporarily stable with permissive hypotension, whereas free intraperitoneal bleeding causes rapid exsanguination.
3
Select the appropriate surgical intervention.
Emergent exploratory laparotomy is chosen to perform a splenectomy and achieve immediate hemorrhage control.
Endovascular aortic repair requires heparinization which would be fatal with active splenic bleeding, and REBOA is contraindicated with proximal aortic injuries.

Key Concept

In polytrauma patients with concomitant blunt thoracic aortic injury (BTAI) and active intra-abdominal hemorrhage, emergent laparotomy to control uncontained bleeding takes precedence over the repair of a contained aortic pseudoaneurysm.
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Surgical and Procedural Interventions

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