Case Report: 24 yo W/M pedestrian vs light-rail train. BIBA (brought in by ambulance) at ER at 12:35, hypotensive and tachycardic (SBP palpable in neck <90, HR ~ 160), obtain CXR and AP Pelvis x-ray. CXR shows evidence of pulmonary contusion, ? tracheal shift & left chest vented. Pelvis x-ray shows pubic symphysis diastasis.
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At 12:45 pt in OR where patient under goes exploratory laparotomy (negative), bilateral chest tube placement, fixation of pubic symphysis diastasis, and reduction of Left hip dislocation. At this time other injuries identified (noted and definitively diagnosed later) include pipkin 1 fracture left hip, left patellar dislocation with avulsion fracture of superior lateral pole, and right olecranon fracture. He had 2000 cc EBL, 5500 cc crystalloid, 10u PRBC, 1u FFP, 300cc Urine. Post-op lab Hct 24, Plt 64K, PH 7.12, pO2 312, pCO2 56
At 14:25 patient is taken to CT (head CT) intubated, chemically paralyzed. Head CT shows small bilat temporal lobe contusions, small subarachnoid hemorrhage, no mid-line shift, open cisterns.
Lab at 16:00 Hct 24 (after 3 more units of PRBC)
At 17:30 pt in angiography actively bleeding obturator artery emboli zed.
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Lab 1800 Hct 17, Plt 91K, INR 1.26, PTT 44.3
More transfusions given. At 23:00 INR, PTT corrected, at 0400 (Day 2) PH corrected, platelet count still dropping throughout initial 24 hours. After 24 hours, 40 u PRBCs. Patient develops abdominal compartment syndrome, requiring open packing of abdomen. Patient stabilizes by Day 3. He is unresponsive. At Day 7 managing team considers withdrawing support, patient begins to respond.
Subsequent management: ORIF R elbow, repair L patella, STSG Abdominal wall, excision of pipkin fragment (Pipkin 1). CT of Pelvis shows stable impacted sacral fx.
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No further operative treatment of pelvis (~ 4 week f/u AP Pelvis).
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