Blunt traumatic injury in a pediatric patient treated with simultaneous damage control laparotomy, thoracotomy and transcatheter arterial embolization

Abstract

Abstract Background: The hybrid emergency room system (HERS) is a single trauma resuscitation room with computed tomography (CT) scanner, fluoroscopy, operating room, and angiography suite allowing surgeons and interventional radiologists (IRs) to obtain imaging studies and perform simultaneous major surgery and endovascular procedures in one room. We report a pediatric patient who suffered severe blunt trauma who underwent simultaneous damage control laparotomy with thoracotomy and endovascular treatment in the HERS. Case presentation: An 8-year-old male was struck and run over (chest and abdomen) by a vehicle. The patient was admitted to the HERS from the ambulance in hemodynamic shock. Focused Assessment of Sonography for Trauma revealed intraabdominal free fluid. Blood gas analysis showed lactic acidosis. The patient was intubated. The massive blood transfusion protocol was activated. Fluoroscopy confirmed no major injuries in the chest and pelvis and exploratory laparotomy was performed which revealed a liver injury (Abbreviated Injury Scale [AIS] 5) and splenic injury (AIS 2) with 1,000 ml of free intraabdominal blood. Perihepatic packing was performed. Simultaneously, IRs performed transcatheter arterial embolization of small branches of the right hepatic and subdiaphragmatic arteries. Subsequently, whole-body CT scan with intravenous contrast was performed which revealed a massive right hemopneumothorax with the extravasation of contrast medium from a right inferior pulmonary artery branch. Right anterolateral thoracotomy was immediately performed. A large laceration of the right lung S6 (AIS 4) was sutured (Injury Severity Score 42, Revised Trauma Score 1.9, TRISS Probability of survival 0.08). The chest and abdomen were temporarily closed, and the patient transferred to the ICU from the HERS. The right chest was closed on hospital day (HD) 2 and the abdomen closed on HD 3. The patient was extubated on HD 6. The postoperative course was complicated by. refractory right atelectasis. High-flow oxygen therapy and respiratory physiotherapy were continued. The patient was discharged home on HD26. Conclusions: The HERS may be useful not only for adult trauma patients but also for severely injured pediatric trauma patients. Protocolized trauma care in the HERS to facilitate collaboration among multiple disciplines and specialties is essential.