A High Speed MVA with duodenal injury.

1. A Dangerous Safety Measure Alireza Haghshenass

2. Seatbelts

3. Injury 34 Year-Old Female Mechanism Brought in by helicopter retrieval team Restrained back-seat passenger (driver side) of a high-speed MVA (combined speed of 140 Km/h) Major deformity to the car Extricated by the retrieval team on to a spinal board Injuries: Severe Neck, Chest, Abdomen, and Left Lower Limb Pain (Obvious Closed #)

4. Injury Scene: Sweaty & Diaphoretic BP: 90/50 HR: 115 / min O2 Sat: 92% on Air GCS : 15/15 Treatment: IVC 18 G Left Forearm C-Spine Collar Spinal Board Morphine 10 mg Ketamine 20 mg Midazolam 1 mg Transfer to hospital as patient appeared stable

5. Emergency AMPL: No significant finding, mother of 1.5 year-old child also injured in the accident and was transferred to Westmead Children at the same time. Last meal : 6 hours ago and since then just a few cups of water and soft drink. Primary: A : Patent, C-Spine Collar In Situ, Talking B : Bilateral air entry tender to touch on left side, no subcutaneous emphysema O2 Sat 95% RA, RR 20 / min C : Warm, Well-perfused, capillary return < 2”, no obvious source of bleeding HR 120/min, BP 100/70 D : GCS 15/15, Pupils 2 mm bilateral sluggish reaction to light

6. Adjuncts Chest X-Ray Multiple left sided lateral rib #s Minor lucency seen at the lower chest wall laterally over the left hemidiaphragm, ? small pneumothorax

7. Adjuncts ECG : Sinus Tachcardia, Normal Axis U/A : Blood ++ / Protein + FAST : Not Done

8. Secondary Survey Head : NAD Face : NAD C-Spine : Collar In Situ, Mid-Cervical Spine Tenderness Chest : Paradoxical Chest wall movement on left side Abrasion, bruising, and tenderness obliquely across right clavicle, sternum, left breast, left lower chest wall Sash bruising all across the chest from the right base of the neck to the left lower abdomen

9. Secondary Survey Abdomen : Generalized tenderness with guarding Large tender lower abdominal abrasion (Lap bruising) Pelvis : tenderness over the left hipin continuation of the seatbelt bruising Upper Limbs : NAD Lower Limbs : Left leg deformity, tenderness, and bruising Abrasion right above the left knee Back : Tenderness around T3-4 level, no other spinal tenderness, anal tone good

10. Blood Test Results FBC : 131, 26.8 , 260 INR : 1.2 EUC : 138, 3.4, 6.2 , 68 CMP : 2.05, 0.82, 1.25 Lipase : 522 LFTs: Bili 14 ALT 77 AST 133 GGT 11 ALP 55

11. CT-Scan

12. CT-Scan

13. CT-Scan

14. CT-Scan Report: Sternal fracture with retrosternal haematoma Multiple left sided rib fractures with a small flail segment Left 5th - 9th Rib #s 7th – 8th Rib #s in 2 Segments Fracture of the T2 spinous process, likely resulting from significant flexion. No definite cervical spine fracture is identified. however ligamentous injury is not excluded. Superior endplate depression fracture of T10 without extension into the posterior elements. High grade injury to the third part of the duodenum, with evidence of perforation and retroperitoneal haematoma. There is suggestion of active haemorrhage within this haematoma. While the haematoma extends to the right renal hilum, no definate renal injury is identified, however delayed renal excretory phase CT is required to exclude a ureteric injury. Evidence of bowel injury, with thickening of a few mid abdominal jejunal loops, and marked thickening of the caecum. Haemorrhage is noted along the right paracolicgutter.

15. Lower Limb X-Rays Report: Transverse fractures through the mid shaft of both tibia and fibula noted. Alignment is near anatomical. No unusual features are noted. The visualised portions of the ankle and knee joints appear within normal limits.

16. Surgical Team Plan ?

17. Surgical Team Plan Major Trauma Call activated NBM, IVF, DVT Prophylaxis ABx ADT For laparotomy ± small bowel resection ± Whipple’s Left ICC with the view of PPV

18. Repeat Bloods FBC : 93, 15.7, 138 EUC : 136, 3.4, 4.9, 64 INR : 1.5 ABG : pH : 7.28 pO2 : 504 pCO2 :42 BE : -7 HCO3 : 19 Lactate : 1.2

19. OT Midline Laparotomy Haemoperitoneum Lesser Sac Opened : D3 Longitudinal 2 cm Serosal Tear Proximal Jejunum Perforation Distal Jejunum Mesenteric Tear Caecum and Transverse Colon Mesenteric Tear with Ischaemic Changes Expanding Right Retroperitoneal Collection

20. Repeat Bloods ABG : pH : 7.26 pO2 : 208 pCO2 :41 BE : -8 HCO3 : 18 Lactate : 1.3

21. OT D3 Serosal Tear Repaired Longitudinally Jejunum Resection X 2 Right Hemicolectomy Decision was made to abbreviate the laparotomy as the patient: More acidotic Increasing INR Expanding Retroperitoneal Collection was explored

22. ICU Treatment Commenced: 2 U Pack Cells 2 U FFP 4 U Cryoprecipitate After 1 hour: Improving blood gases with: Increasing pH : 7.29 Dropping BE : -6 HCO3 : 20 Repeat FBC : 109, 14.4, 142 INR : 1.2 EUC : 139, 4.4, 4, 62 LFTs : Unchanged CMP : 1.71, 0.7, 0.81

23. ICU 4 hours after admission: ABG: pH : 7.37 pO2 : 181 pCO2:36 BE : -4 Lactate : 2.7 12 hours after admission: FBC : 74, 6.2, 99 EUC : 139, 4.1, 4.4, 62 CMP : 1.85, 1.04, 1.17 INR : 1.5 Drain in right retroperitoneum : Cr : 1,378

24. ICU 36 hours: FBC : 85, 7.6, 11 INR : 1.6 4 U FFP Transfused Improvement in all markers then onwards

25. ICU

26. Timeline D2: ICU : Commence TPN General Surgery: No contamination No active bleeding Anastomosis Urology: Complete transection at the level of the lower pole Primary repair over 6Fr Stent

27. Timeline D3: ICC was removed D4 : Extubated D9 : Development of abdominal sepsis found on CT Commencement of Timentin and Clindamycin D11 : TPN was weaned off D12 : Abdominal wound collection Openned and Packed

28. Timeline D16 : ABx Stopped OT : Fixation of Tibia D19 : VAC Dressing of abdominal wound D23 : Rehab D33 : D/C

29. Damage Control Laparotomy

30. Damage Control

31. Damage Control Term used in the Merchant Marine, maritime industry and navies for the emergency control of situations that may hazard the sinking of a ship

32. History of DCL Was first described by John H. Pringle in 1908 Used to suture over gauze packing to control portal venous haemorrhage caused by trauma

33. History of DCL In 1913 William Stewart Halsted modified the Pringle’s technique and laid a rubber sheath between the gauze and the liver to protect the liver parenchyma

34. History of DCL Progress over decades and with the contribution of surgeons such as Kenneth Mattox the concept of abbreviated laparotomy prevailed.

35. History of DCL The term “Damage Control Laparotomy” was coined by Rotondo et al. in 1992 In this landmark report they explained the 3 phases of DCL: Expeditious surgical control of haemorrhage with temporary abdominal closure Rewarming and resuscitation in the ICU Definitive Surgical Repair

36. Bloody Vicious Cycle Hypothermia: Evaporative and Conductive heat loss Diminished heat production Metabolic Acidosis: Exacerbated by aortic clamping Vasopressors Massive transfusion Impaired myocardial performance Coagulopathy: Dilution Hypothermia Acidosis

37. DCS Indication to limit the operation time and proceed with DCS: T < 35° pH < 7.2 Base Deficit <15 or < 6 if > 55 Years INR/aPTT > 50% Normal The Goal: Limit haemorrhage without causing ischaemia Limit GI Spillage Small GI Injuries: a rapid whipstitch 2.0 nonabsorbable Complete transection or segmental damage: GIA stapler Pancreatic injury: packed and assessment of duct integrity is postponed

38. Control of Haemorrhage

39. Abdominal Closure