Surviving Thoracoabdominal

Penetrating Trauma:

Lawnmowers, Helicopters, and

Resuscitation

AKA ‘Miracle in a cornfield’

Donald Jenkins, MD. FACS DMCC

Division of Trauma, Department of Surgery

UT Health San Antonio

Patient History

• Otherwise healthy 52 y.o. male

• Mowing a field

• Right flank ‘bee sting’ sensation

• Discovered ‘down’ by neighboring farmer

• Transported to local hospital by EMS

• Profoundly hypotensive

• Pericardiocentesis performed with removal

of 30 ml’s of blood and improved SBP

Pre-Transfer Interventions

• Right Tube Thoracostomy

• Pericardiocentesis 15 mL

• 3 Liters of Crystalloid

• 4 units of Packed Red Blood Cells (PRBC)

En Route by Rotary Wing

• 4 units of PRBC

• 4 units of Plasma

• Highest HR 122 bpm

• Lowest BP 56 mmHg

• Lactate 3.6

• Pericardiocentesis repeated with

improvement in SBP

Labs• INR 1.1

• Lactate 2.64 mmol/L.

• pH 7.30

• PCO2 43 mmHg

• PO2 of 275 mmHg

• base deficit 5 mmol/L

• bicarbonate 21 mmol/L

• Hemoglobin 10.8 mg/dL.

Audience Response

• What next?

• A) CT scan

• B) Interventional radiology

• C) OR

• D) Other

Audience Response

• If OR, choice of procedure

• A) midline laparotomy

• B) sternotomy

• C) Right thoracotomy

• D) Other

Operation

• Median Sternotomy

• Right Atrial Laceration

• Transesophageal Echocardiogram

• Intraoperative Fluoroscopy

• Right Diaphragm Laceration

• Midline Laparotomy

• IVC injury

• Retrohepatic hematoma

Intraoperative Transfusion

• 9 units of PRBC

• 2 units of Cell Saver blood

• 3 units of platelets

• 6 units of fresh frozen plasma

• 2 units of cryoprecipitate

• 2 liters of crystalloid

• Blood loss 4 liters

• Patient stable and not bleeding; to ICU

Post-operative course

• Right chest tube puts out one liter in one

hour 6 hours after ICU admit

• New coagulopathy developed

• Blood pressure transfusion dependent

• CXR:

Audience Response

• Next step:

• A) OR

• B) IR

• C) OR to hybrid room

• D) place more chest tubes and correct

coagulopathy and observe

Operative Course

• ‘night call’ surgeon takes patient to OR 8

hours after ICU admission

• Extends midline incision across

costochondral junction for right thoracotomy

• ‘day surgeon’ called in from home to assist

• Bleeding source appears to be in right chest

• Bleeding source cannot be visualized but

seems to be medial posterior behind the

diaphragm

Audience Response

• Now what?

• A) open the diaphragm

• B) call IR in

• C) pack and get out

• D) other

Operative Course

• IR called in

• Palpation reveals injury likely to the 12th

intercostal artery at the spine

• Hemostatic gauze pack placed in medial

sulcus with temporary control

• Patient moved to hybrid OR

CeliacRadiologist decides celiac as most likely source

Circle denotes radiopaque sponge marker

SMARadiologist decides SMA as most likely source

First LumbarRadiologist decides to listen to the surgeon and

interrogates aortic intercostals

12th Intercostal

12th Intercostal Embolization

11th Intercostal

Hospital Course

• Off ventilator within 48 hours

• Out of ICU 48 hours after extubation

• Out of hospital 10 days after injury

• Hospital Stay 14 days

• 42 units PRBC

• 12 units of platelets

• 24 units of FFP

• 5 units of cryoprecipitate

Dismissal

3 Month Follow-up

The Projectile

Conclusion

• Fencing staples can be deadly when

propelled by 7 foot long field mower blades

• Field mower blades can exceed 1800 RPM

• The rotor speed of the helicopter the patient

was flow in was 500 RPM

• A bleeding source was missed in this case

and nearly cost the patient his life

1 Year After Injury