Saving Life and Limb: Multidisciplinary Management of Complex Penetrating Trauma

A 20-year-old man presented in extremis after gunshot wounds to the right thorax, right upper abdomen and left forearm. Resuscitation per ATLS protocol included intubation, bilateral chest tubes and massive transfusion through coordinated efforts of trauma surgery and emergency medicine. Direct pressure was applied to the left forearm for pulsatile bleeding. The patient was taken immediately for operation.

Laparotomy was performed by trauma surgery while vascular surgery explored the left upper extremity. The abdomen was packed and systematically examined. The right liver lobe was transfixed by a missile and a balloon tamponade device was fashioned and deployed within the tract to control active hemorrhage. The missile tract continued into the retroperitoneum and a mesenteric hematoma at the hepatic flexure required partial colectomy. A lateral duodenal injury underlying this hematoma was repaired in two layers. Medial visceral rotation was completed for ongoing retroperitoneal hemorrhage followed by right nephrectomy for hilum injury. The remaining missile tract through psoas muscle was hemostatic. A right thoracotomy was performed for ongoing hemorrhage from the right chest tube. Wedge resections of the upper and lower lobes and a formal middle lobectomy were completed. Vascular surgery identified a brachial artery injury near the bifurcation and performed a repair with ipsilateral basilic vein. On postoperative day two, after resuscitation led by critical care intensivists, the patient was stable for completion right hemicolectomy, ileocolic anastomosis, cholecystectomy secondary to missile tract proximity, removal of balloon tamponade and abdominal closure.

The course was complicated by left forearm compartment syndrome on postoperative day two, requiring emergent volar and dorsal forearm fasciotomy and subsequent skin grafting by hand surgery. The patient was discharged home four weeks after admission with moderate sensory and motor deficits of his left hand. The patient survived these critical injuries through effective communication and collaboration among the involved disciplines.

Figure 1. CT image demonstrating open abdomen with balloon tamponade of liver injury

Figure 2. Balloon tamponade device consisting of rubber catheter and penrose drain