JISCMail - ACAD-AE-MED Archives

Well, the USS abdo was negative, no further investigations were undertaken at the time, the clinical signs were accepted as being due to the pelvic injury (SpR in telephone consult with Consultant). She was taken to theatre where ex-fix's were put on pelvis, right femur, left tib/fib. Fasciotomies to left lower leg.

During the ortho procedure by Cons Orthopod (after pelvis fixed I think) she became increasingly difficult to ventilate and CVS unstable. At this point the abdomen was noted to be distended. The General Surgeon was recalled and a laparotomy was performed. This showed a tear to the small bowel mesentary, with lots of free blood in the abdomen. This was resected and the abdomen closed. If a DPL had been performed initially, with that pelvic fracture, would it not have been positive anyway????

She was taken to ITU for post op care and developed pulmonary complications early. 12 hours post op she was on an FiO2 of 80%, pressure limited (controlled) ventilation, 20cm over 7.5 of PEEP, 1:1 ratios (figure from memory). She also had clotting abnormalities (from time of admission in fact) having had >15 units blood. We predicted that she would get much worse before improving, but in fact made a steady recovery. She was extubated on day 6. Long term prognosis for mortality is good, for morbidity, poor.

She was not anaesthetised until reaching theatre. In retrospect, this could have been done earlier, though appropriate concerns were raised at the time about losing a tamponade effect from the abdomen with no means of going directly to theatre. Blood gases in A+E showed a metabolic acidosis with respiratory compensation, oxygenation was adequate. Anaesthetic SpR not happy to put to sleep, decision confirmed by anaesthetic consultant later. I must say that I still disagree and think we would have been better and kinder to anaesthetise her earlier.

Never got scanned, it should have been but scanner not immediately available, no signs of external head injury and concious level rose with resuscitation in A+E. Local Scanner was dangerous and distant place, judgment call regarding risks (IC lesion vs death in the doughnut) therefore not scanned. Patient went straight to theatre for splintage/haemmorrhage control etc. Getting her to scan without an anaesthetic would have been very difficult. Post op she was taken straight to ITU for further care, deemed too unwell for scan initially (???). Still, it should have been done soon after.

The most practical idea sounds like skin traction with weights over the end of the bed as all that kit was available in the department. A steinman pin would have taken longer to organise but would be just as good, although it is more invasive for this temporising procedure.

As is the case in many UK hospitals. Major Trauma is a rare disease and few places are genuinely slick at manageing it. Of interest - the only consultant to see this patient in the first 50 minutes was an A+E one. (This case was not at my current hospital)