Our patient is a 35-year-old female. She was the restrained front seat passenger in a car vs. tree RTA at 80 km/h. Her seatbelt was worn with the shoulder strap sitting under her left axilla. The car had no airbags and was right hand drive. The accident occurred in urban South Australia. The 2 other occupants sustained minor injuries. She had a past surgical history of only bilateral breast implants, took no regular medications and had no pre-existing medical conditions. She was heavily intoxicated at the time of the RTA. She denied any previous drug use. She has no significant family or psychiatric history.
She was retrieved from the scene to a tertiary trauma centre via ambulance. Primary survey showed a patent airway, equal air entry, tachycardia of 110 bpm and blood pressure of 130/60. She had multiple superficial abrasions, a generally tender abdomen, an unremarkable chest X-ray, and a negative Focused Assessment of Sonography in Trauma (FAST) scan. She was taken immediately for Computer Tomography (CT) imaging from the trauma bay. Imaging showed a moderate volume of free intra-abdominal fluid (Image 1), a distended stomach with transection of the gastroduodenal junction (Image 2, Image 3, Image 4), and splenic injury (Image 5). Upon transfer from CT machine to barouche the patient became haemodynamically unstable with a blood pressure of 80/40 and tachycardia at 130. She was transfused with red blood cells and taken immediately to the operating theatre for exploratory laparotomy.
The patient underwent Rapid Sequence Induction (RSI) and midline laparotomy was performed. The on-call Trauma Surgical Consultant performed the procedure with the on-call Surgical Registrar assisting. She required 10 min of supracoeliac aortic compression until haemodynamic stability was secured. Subcapsular splenic injury with uncontrollable bleeding was identified and managed with splenectomy. Bleeding from a posterior paracaval liver laceration was controlled with packing. Once rapid bleeding was controlled systematic examination of the abdominal viscera revealed a complete shearing transection of the gastroduodenal junction. The pyloric sphincter was seen periodically relaxing and spurting alcohol smelling gastric contents into the abdomen. Pylorus and duodenum were stapled off and an orogastric tube was placed. Further examination showed a 13 cm seromuscular injury of the transverse colon with associated contusion. This was repaired primarily. Systematic examination incorporating all viscera including retroperitoneal structures did not demonstrate further injury. Extensive washout was performed, and the patient's abdomen was packed with a negative pressure dressing. She was transferred to the Intensive Care Unit (ICU) still intubated and sedated with a view to re-look laparotomy in 48 h.
Secondary survey and imaging identified an L3 chance fracture, multiple lower left sided rib fractures and a humeral fracture. She remained stable in the ICU and was managed with intravenous broad-spectrum antibiotics and received a total of 8 units of red blood cells intra and post operatively. Re-look laparotomy was performed 48 h following the initial injury. This was performed by the same Trauma Surgeon with assistance from Senior Hepatobiliary and Colorectal Surgeons. Packing was removed and there was no bleeding identified. The gastric and duodenal stumps were healthy and gastro-jejunal anastomosis was performed. The transverse colonic contusion had worsened, middle colic vascular injury was identified and resection with stapled anastomosis was undertaken with defunctioning loop ileostomy. Her liver laceration was no longer bleeding and repeat systematic examination did not demonstrate further injury. After further washout her abdomen was closed.
After several days in ICU she was transferred to the ward where she remained for a period of 4 weeks. Her admission was complicated by a post-operative ileus. The humeral fracture was managed by open reduction and internal fixation. The patient was unable to recall the events of her initial trauma and multiple operations. She was an active participant in her rehabilitation and maintained good spirits throughout her admission. She received formal trauma counselling, stomal therapy education and was discharged home once deemed safe by a multidisciplinary team. She did not appear to be suffering from any long term physical or psychological disabilities as a result of her injuries. While she struggled initially with stoma management, she learned to manage this independently after several days of education. Her stoma was reversed 6 months after discharge.
Written consent was obtained from the patient prior to the creation of this report. This work has been reported in line with SCARE 2018 criteria.