AP Pelvis
Cystogram
(pelvic hematoma)
CXR (Lt hemo-
pneumothorax)
CXR
(S/P Lt Chest tubes)
ADMISSION DIAGNOSIS:
Blunt trauma status post bicycle versus automobile accident.
HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old white male who was struck by a car while riding his bicycle and he was thrown a long distance. He arrived with a Glasgow coma score of 8, being Ambu bag ventilated.
PAST MEDICAL HISTORY: Unknown.
PHYSICAL EXAMINATION: Pulse was 121, blood pressure of 106/54 which decreased to 90/50 and saturations 99%-. being Ambu bag ventilated. The HEENT examination revealed pupils to be 5 mm. and nonreactive bilaterally. Gag reflex was present. The mid face was stable. Tympanic membranes were clear. There was a tongue laceration, approximately 4 cm in size. The neck revealed no palpable deformity. The chest was clear throughout. There was large bruise on the right lower chest. The heart was tachycardiac with no murmurs. The abdomen was flat and soft. The pelvis was unstable with crepitus on the right. Rectal examination revealed no tone and heme positive guaiac. No gross blood. No bony spicules. The back revealed no deformity. Neurological examination revealed no focal deficits. Positive deep tendon reflexes. Flexion posturing to stimulus prior to paralysis. The extremities revealed a gross deformity of the right leg with external rotation. Distal pulses were present.
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AP Pelvis |
Cystogram |
CXR (Lt hemo- |
CXR |
HOSPITAL COURSE: The patient underwent rapid sequence intubation in the Trauma Center and also underwent an abdominal ultrasound which revealed fluid in the right upper quadrant. A Foley catheter was placed with gross hematuria. A cystogram was performed with no extravasation. The cystogram otherwise showed a classic pear-shaped bladder indicating a substantial pelvic hematoma.
A chest x-ray revealed a right pulmonary contusion and a pelvis x-ray revealed a shattered right pelvis. The patient subsequently underwent a CT scan of his head which revealed tight cisterns, a left subdural hematoma and a mass effect of the left ventricles.
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Head CT |
Pelvic CT |
Renal CT |
The small quantity of blood noted by abdominal ultrasonography was not felt to cause the patient's hemodynamic instability. The pelvic injury was identified as the most likely major source of bleeding and the patient was taken to angiography.
Pelvic angiography showed extravasation from a superior gluteal branch on the right. This was embolized and the BP stabilized. The spleen showed a lower pole avulsion without gross bleeding, and was embolized. The right kidney showed a lower pole avulsion without extravasation, and both were managed nonoperatively. The severe brain injury precluded further operative intervention with respect to the pelvic injury.
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Pelvic Embolization |
Spleen Injury |
Rt Renal Injury |
Following embolization the patient went to the Surgical Intensive Care Unit. The patient had episodes of hemodynamic instability and decreased saturations over the ensuing 24 hours.
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ARDS, Contusions |
In addition to undergoing the previously mentioned procedures a consultation by the oral maxillofacial surgery service, orthopedic surgery and neurosurgery were obtained. The patient was noted to have a right open comminuted mid shaft tibia/fibula fracture and a both column acetabular fracture on the right. A neurosurgical consultation resulted in placement of an intracranial pressure monitor via a right frontal bur hole. The patient's initial intracranial pressures were approximately 35 and he had increasing intracranial pressures over the ensuing 48 hours. This occurred despite Mannitol and further aggressive support. The patient's intracranial pressures increased to over 100 mmHg pressure and his pupils were noted to be fixed and dilated.
The family was then counseled regarding the likelihood brain death given the increasing intracranial pressures and fixed and dilated pupils with the remainder of the examination consistent with brain death. Organ procurement was then contacted and the patient's family agreed to undergo organ donation as a non-heart beating donor. The patient was subsequently taken to operating room on the third hospital day and was removed from the ventilator in the operating room. All pressors were discontinued and he was pronounced dead at 0408. The patient subsequently underwent organ procurement.