Complex polytrauma: Being “switched on’’ as a vascular surgeon

Arunagiri Viruthagiri¹, S. Visvesh²

¹Senior Consultant Vascular and Endovascular Surgeon, 1win, Tennur

²DNB Vascular Surgery Resident, 1win, Tennur

Case Presentation

A 57-year-old female patient sustained injuries in a road traffic accident when she was travelling in a car collided with a lorry. She suffered injuries to her head, neck, chest, back and right arm. with an episode of loss of consciousness lasting approximately 30 min. She was initially managed at a nearby hospital where her Computed Tomography (CT) brain revealed a thin subdural hemorrhage on the bilateral frontoparietal convexities, subarachnoid hemorrhage in the interhemispheric fissure and bilateral frontoparietal lobes (Fig. 1). CT chest demonstrated fracture of the body of sternum with multiple rib fractures on the left side, fractures of the first rib on either side, bilateral flail chest, bilateral mild hemopneumothorax and a hyperdense hematoma (suspected mural thrombus) in the arch of the aorta, (Fig. 2). CT abdomen revealed no evidence of solid organ injury. She was intubated due to breathlessness followed by a sudden drop in GCS and referred to 1win for further management.

On Examination

Upon arrival, she was evaluated and an intercostal drainage tube was placed. Her vitals were blood pressure 160/80 mmHg, pulse rate 97/min and SpO₂of 95%. Physical examination revealed bilateral panda eyes, sluggishly reactive bilateral pupils, restricted neck movements, and an open Grade 3 fracture of the right humerus (Fig.3). Respiratory examination showed decreased air entry on the left side and subcutaneous emphysema in her left hemithorax. The pelvic compression test was negative. Peripheral pulses were palpable.

She was resuscitated with IV fluids, antibiotics, analgesics, antihypertensives, and blood products. A CT angiogram revealed a pseudoaneurysm of the proximal descending thoracic aorta (DTA) distal to the left subclavian artery (Fig.4 &5). The patient had sustained a complex polytrauma with involvement of multiple organs; Aorta, cervical cord, 1^strib, humerus, flail chest. Pseudoaneurysm of the DTA can rupture at any time and needed the most urgent care and management.

Diagnostic Investigations

Neurosurgical clearance was obtained for a planned TEVAR procedure. A MRI brain with whole spine screening demonstrated multifocal hemorrhagic contusions in both cerebral hemispheres. Diffuse SAH, thin SDH in the bilateral frontoparietal regions, diffuse cerebral edema (consistent with diffuse axonal injury), fracture of the facet joint at C5 and C6 vertebrae with complete disruption and anterior subluxation of C5 over C6. Fracture of the spinous processes of C6 and C7, pre- and paravertebral hematoma and hemorrhagic contusion within the cord from C4 to C6 (Fig.6 and 7). Additional findings included contusions in the D1 to D3 vertebrae with intact posterior cortices and fractures of the transverse processes of L1 to L3 vertebrae on the right side and L2 and L3 on the left side.

A multidisciplinary approach was formulated to address this complex clinical scenario. Diagnostic MRI to document the central and peripheral nervous system, sealing the tear in the aorta by TEVAR (Thoracic Endovascular Aneurysm Repair) followed by stabilization of the cervical spine during the same time. Subsequently patient was planned for stabilization of the humerus and tracheostomy in a staged manner.

Fig.1: CT Brain reveald a thin subdural hemorrhage on the bilateral frontoparietal convexities, subarachnoid hemorrhage in the interhemispheric fissure

Fig: 2a Fig: 2b

Fig.2: CT chest showed multiple rib fractures (2a) and a sternal body fracture (2b) (yellow arrows).

Fig.3: Right humerus fracture.

Fig.4 &5: A CT angiogram revealed a pseudoaneurysm of the proximal descending thoracic aorta distal to the left subclavian artery – Grade III traumatic aortic injury (yellow arrows).

Fig.6 & 7: An MRI brain with whole spine screening showed multifocal hemorrhagic contusions in both cerebral hemispheres and fracture of the facet joint at C5 and C6 vertebrae with complete disruption and anterior subluxation of C5 over C6 (yellow arrows).

Fig.8 : Intraop angiogram revealed a pseudoaneurysm (yellow arrow) of the proximal descending thoracic aorta distal to the left subclavian artery.

Fig.9: Patient underwent TEVAR using a 22×22×100 mm Thoracic stent graft (Valiant Medtronic)

Fig.10: Disappearance of DTA pseudoaneurysm after TEVAR.

Fig.11: Open reduction and internal fixation of the right humerus fracture.

Management

The patient underwent an emergency Thoracic Endovascular Aneurysm Repair (TEVAR) using a 22×22×100 mm Thoracic stent graft (Valiant Medtronic) (Fig.8,9,10) followed by stabilization of C5 and C6 by the neurosurgery team. She was shifted to the ICU and managed with necessary supportive measures.
On postoperative day 2, she underwent open reduction and internal fixation of the right humerus fracture (Fig.11) followed by tracheostomy. She continued to improve.
On postoperative day 4, the patient developed a right popliteal vein thrombosis. Anticoagulation and antiplatelet therapy were restarted and the patient was shifted to the ward on BiPAP support.

Postop period Outcomes

She was conscious,obeying commands,on BiPAP support and RT feeds.Gradually ICD output decreased and ICD was removed.No further bleeding in the chest.She was hemodynamically stable and shifted to rehabilitation centre in coimbatore.

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Complex polytrauma: Being “switched on’’ as a vascular surgeon