Indexing Title: RCHAN’s Medical Anectodal Report [04-1]

 MAR Title: Hypotension in a Major Vascular Injury

 Date of Medical Observation: April 17, 2004

 Narration:

A 46 year old man came in with a stab wound at the LUQ area with bowel evisceration transferred from Ospital ng Sampaloc. Patient came in pale stretcher borne with a BP of 90/60, CR=90 RR of 24 and was afebrile. Abdomen was flat, tender on all quadrants with guarding and rigidity. We directed the patient to the operating room. On opening up we evacuated 2.5 liters of hemoperitoneum. On exploration, we noted a 4 cm mesenteric laceration and a centrally expanding retroperitoneal hematoma. We also noted a 0.5 cm laceration on the duodenum and a 1 cm laceration on the transverse colon. We applied bobcock on the perforations to prevent spillage. We explored the expanding hematoma which revealed a 2 cm laceration on the infrarenal portion of the inferior vena cava which was actively bleeding. By that time, the BP dropped to 60/40. Fluids and Dextran were instituted. We noted that the patient’s blood was now pale and diluted. Blood loss was computed to be 6 L at that time. We applied proximal and distal control with vascular clamps over the vessel. We finally controlled the bleeding. We decided to transfuse the available bags of type-specific FWB (which took quite sometime before it was brought to the OR eventhough we asked for the blood bank for it prior to opening up the patient) before proceeding to repairing our injuries to stabilize the patient. We transfused 3 units of FWB initially. The BP went up to 110/70. We then proceeded to repair the inferior vena cava, the duodenum, the transverse colon and the mesenteric laceration. We also gave 2 more units of PRBC and 2 units FFP. The total blood loss was estimated to be 3 liters. Patient was discharged after 6 days with no complications.

Insights (Discovery, Stimulus, REINFORCEMENT):

We prioritized the vascular injury before repairing the other injuries because it needed to be controlled and to prevent further blood loss. We also decided to stabilize the patient’s condition after controlling the bleeding by transfusing the blood first rapidly which brought up the patient’s blood pressure and replaced the blood losses. It gave the patient a better fighting chance since all the major organs were now reperfused and all the factors that the blood contains that will aid in maintaining hemostasis were replenished. Since we transfused blood rapidly, we gave FFP for the platelets lost, again making our vascular repair more effective. And true enough, the patient survived the operation despite the increased incidence of mortality in major vascular injuries especially in OMMC and the amount of blood loss that the patient had.