Shiva Dindyal and Constantinos Kyriakides

A 19-year-old female was admitted to casualty following a road traffic collision. A witnessoftheincidentreportedthatshewasdrivinghercaratapproximately70km/h in wet conditions and the car skidded off the road when she turned a sharp bend. She collided with a tree and there were no other passengers involved. She was found in her severely damaged car, drowsy and restrained by her seat belt and the dashboard. The car windscreen had a “bulls-eye” on the driver’s side and she had a laceration to herforehead,whichwasprofoundlybleeding.Shecomplainedofdifficultyinbreathing and pain in her chest, abdomen and obviously deformed right leg. The paramed- icsattendedthescenewiththefire-servicewhohelpedextricateherformthewreckage then carefully immobilized her cervical spine.

She was immediately transported by helicopter to the nearest emergency department. There she was treated by the duty surgical trauma team.

Question 1

Which of the following interventions should be performed by the paramedics as their initial management?

A.  Reduction, splinting and immobilization of her right femur fracture B.  Intravenous cannulation and bolus fluid administration

C.  High flow oxygen administration D.  Administration of analgesia

Primary examination in casualty revealed a patent airway as she was talking but she was shortofbreath.Hertracheawasdeviatedtotherightside,theleftchestwashyper-resonant and devoid of breath sounds. Hemodynamically her heart rate was raised (109 beats/min) and blood pressure (120/75 mmHg) was within normal limits. Her abdomen was tender in the left hypochondrium and right femur had an open mid-shaft fracture. Routine trauma blood investigations were requested. Neurologically she was drowsy and becoming increasingly confused.

S. Dindyal ( )

Department of General Surgery, The Royal London Hospital, London, UK

had returned to values within normal ranges with a continuous fluid infusion and whole blood transfusion. A plain pelvic radiograph and clinical examination were normal.

Question 4

Which investigation or treatment should be performed next?

A.  Plain radiographs of the right femur then reduction, splinting and immobilization of her right femur fracture

B.  Computerized tomography of head, neck, chest, abdomen and pelvis C.  Emergency laparotomy and damage control surgery

D.  Diagnostic angiography

Imaging revealed that she had suffered from polytraumatic injuries. She had bilateral cerebral contusions, left clavicle and cervical vertebra (Fig. 15.2) fractures, multiple rib frac- turesincludingtheleftfirstribwithalefthemo-pneumothoraxandbilaterallungcontusions. Her thoracic aorta was disrupted and a pseudoaneurysm of the proximal descending vessel had formed (Figs. 15.3 and 15.4). Her abdominal imaging revealed a liver laceration, large splenic hematoma and free abdominal fluid suggestive of bleeding. Her pelvis was normal but she had an open, displaced fracture of her right femoral shaft.

Clinically she was becoming increasing more difficult to ventilate, and was deteriorating hemodynamically. Her left chest drain continued to swing and bubble however blood was also still draining. Her abdomen had become more distended. She was in hypovolemic shock and was no longer responding to intravenous fluid and blood administration. Her right thigh wound was becoming more tense and swollen.

An arterial blood gas revealed that she was suffering a metabolic acidosis, with a raised lactate, and her hemoglobin level had further dropped. She was taken immediately to the operating room.

She underwent an emergency laparotomy, splenectomy and packing of her liver. Her right femoral shaft fracture was debrided, irrigated, reduced then immobilized with a splint. An intracranial bolt was inserted for pressure measurements. The duty vascular surgeon was called to assess her transected thoracic aorta, he scrutinized the Computerized Tomographic chest imaging.

Question 5

Using Fig. 15.5 below, which is the correct list order of the commonest anatomical sites of traumatic aortic disruption starting with the most frequent to the least common in descending order?

A.  1, 2, 3, 4

B.  4, 2, 3, 1

C.  3, 1, 2, 4

D.  3, 1, 4, 2

E.  1, 4, 2, 3

Fig. 15.2 MRI showing a cervical vertebral fracture

Fig. 15.3 CT scan reconstruction showing a disrupted thoracic aorta with a pseudoaneurysm of the proximal descending vessel

Fig. 15.4 CT scan crosssectional slice showing a disrupted thoracic aorta with a pseudoaneurysm of the proximal descending vessel

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