A 23-year-old Hispanic male sustained a single gun shot wound (GSW) to the left upper buttocks. He arrived to the Emergency Room in hemorrhagic shock with a systolic blood pressure of 73 and heart rate of 120. The patient had a patent airway, good breath sounds with adequate excursion but peripheral pulses were weak. He was able to move all extremities to command but was intermittently obtunded. There was a single GSW just above the left buttocks 5 cm lateral to the midline. The patient had diffuse abdominal tenderness and was in persistent shock. He was taken emergently to the operating room. No adjunct studies were performed in the Emergency Department except for the Focused Abdominal Sonography for Trauma examination that was positive for fluid. Approximately 2 L of blood was evacuated with lap pads at exploration. The bullet was retained in the low anterior abdominal wall on the ipsilateral side of the posterior GSW. There was continued active bleeding from deep within the pelvis. His aortic bifurcation and iliac veins were compressed but this did not arrest his bleeding. Venous bleeding continued from bony and soft tissue destruction. It was not well controlled with pelvic packing, gelfoam packing, foley catheter balloon tamponade, and iliac vein ligation. Bilateral internal iliac artery ligation was performed but the bleeding remained significant from a large bony defect. The patient continued to be hemodynamically unstable despite continued transfusions of red cells (15 units ultimately) and fresh frozen plasma. The decision for damage control laparotomy had been made early in the procedure but the pelvic bleeding eluded attempts at even reasonable surgical control for temporary closure and resuscitation. The left ureter had been identified and was found to be without apparent injury. Because the patient had continued bleeding that was not controlled by conventional means, and the patient’s clinical status was continuing to decline, one pack (1.75 oz.) of QuikClot, Absorbent Hemostatic Agent, was deposited in the large defect and packing was applied. This maneuver resulted in almost instant arrest of significant pelvic bleeding. There was a rapid improvement in hemodynamic parameters; however, the patient remained cold and coagulopathic. The remainder of the pelvis was packed and the uninjured left ureter was placed back in its normal position before the abdomen was temporarily closed and the patient transported to the Surgical Intensive Care Unit. The patient’s coagulopathy was corrected, there was no continued clinical bleeding and the patient’s physiologic parameters were more normal within the first 24 hours postoperatively. He was returned to the Operating Room where his packs were removed. There was only minimal bleeding noted. The remaining QuikClot was removed but there was a moderate amount of material left adherent to the surrounding tissues and deep within the pelvis. Quikclot was adherent to the ureter near the original injury site but it did appear intact. Tissues that were in contact with the material were viable. The patient did well postoperatively. He was transferred to the floor by postoperative day POD 2. He did not have evidence of bleeding and he complained only of left sided back and leg pain which was present preoperatively. He was tolerating a diet and was discharged on postoperative day 7. He was seen in a clinic visit and reported no other problems except for left sided back and leg pain as before. However, approximately 3 weeks postoperatively; he was evaluated and admitted for abdominal pain. Computed Tomography (CT) of the abdomen revealed left hydronephrosis and dilated ureter (Fig. 1). No ureteral extravasation was detected on CT. He was subsequently evaluated by urology and diagnosed with a ureteral injury with leak on anterograde cystourethrogram (Fig. 2). A nephrostomy tube was placed. Stent placement was attempted but was unsuccessful because of the size of the defect. Plans were made for elective operative repair. Two weeks later, he was evaluated emergently for abdominal pain and blood per his nephrostomy tube. He was found to have a hemoglobin of 7.2 g/dL (postoperative hemoglobin was 9.4 g/dL). He was found to be only in mild Submitted for publication August 21, 2006. Accepted for publication December 14, 2006. Copyright © 2009 by Lippincott Williams & Wilkins From the Department of Surgery, Division of Trauma/Surgical Critical Care (D.P., P.R.); and Department of Urology (S.C., C.B.), LAC USC Medical Center, Los Angeles, California. Address for reprints: Dr. David Plurad, MD, Department of Surgery, Division of Trauma/Surgical Critical Care, LAC USC Medical Center, 1200 North State Street, Los Angeles, CA; email: dsplurad@aol.com.
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Jul 18, 2023
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