Thoracoabdominal Trauma Requiring Pulmonary Vein Repair and Splenectomy on Bypass

Abstract

Patients with blunt traumatic injuries concurrent in the abdomen and thorax present diagnostic and therapeutic challenges to trauma surgeons. Complex injury patterns require rapid evaluation and decision-making, with limited time for diagnostic investigation.1, 2 If surgical intervention is warranted, the body cavity with the most life-threatening injury should be explored first.2 Rare individuals requiring dual cavity intervention such as thoracotomy and laparotomy have been reported to have a mortality as high as 67 per cent.1 Blunt disruption of the pulmonary vasculature is a rare injury also associated with significant mortality. This injury pattern is generally considered to be caused by high energy deceleration forces, causing a tear in relatively fixed vascular structures.3, 4 Famously assumed to be the cause of death of Princess Diana in 1997, most patients do not survive to hospital presentation or surgical intervention, and few cases are reported in the literature.3, 4 This report presents a patient with blunt thoracoabdominal trauma who required multicavity surgical intervention. A 37-year-old man fell from a 30-foot scaffold onto asphalt. He was alert at the scene but was intubated by EMS for shortness of breath. On presentation to the trauma bay, the patient was hemodynamically stable. An initial chest X-ray demonstrated clear lung fields (Fig. 1), but a Focused Assessment with Sonography in Trauma (FAST) examination revealed some pericardial fluid as well as fluid in the splenorenal fossa. The patient remained hemodynamically stable during this time, and a CT scan was performed to further investigate these injuries. The pericardial effusion was redemonstrated on CT, which also confirmed a grade V splenic laceration (Fig. 2). The patient was then taken to the operating room for further evaluation. A pericardial window demonstrated scant return of blood, and the decision was made to proceed with a median sternotomy. After dividing the pericardium, lifting the heart produced exsanguinating hemorrhage. Massive transfusion protocol was initiated, and cardiovascular surgery was consulted intraoperatively. A 3-cm injury to the right inferior intrapericardial and intrapleural pulmonary vein was identified. The patient was placed on cardiopulmonary bypass and the venous laceration was repaired with 3-0 pledgeted Prolene sutures. A tear of the junction of the azygous vein and superior vena cava was also repaired. The patient remained hemodynamically unstable and was noted to have a tense abdomen. It was decided to proceed with exploratory laparotomy and splenectomy while the patient was still on bypass. After the spleen was removed, the patient had continued diffuse nonsurgical bleeding, and bypass termination was begun for heparinization reversal. At this point, the