Severe Trauma due to train hit, needing emergent bilateral disarticulation of the lower limbs

Abstract text (incl. references and figure legends)

We present the case of a 50-year-old man with a past medical history of anxiety and reference to problems at work.

He was brought to the Resuscitation Room (RR) after being hit by a train, resulting in traumatic amputation of the left limb and partial amputation of the right limb with distal ischemia. Bilateral lower limbs (LL) tourniquet was applied, fluid resuscitation and tranexamic acid started and tracheal intubation was performed due to agitation and difficulty in pain management by the prehospital team.

Primary assessment at RR showed: severe head and face trauma with multiple fractures of the facial bones, calvaria and basal skull, with suspected liquor fistula and pneumocephaly; vertebromedullary trauma with L5 transverse process fracture; upper extremities trauma with left scapula and forearm fractures; pelvic trauma with complex pelvic ring fractures; and lower extremities trauma with left femur amputation and open right femur fracture.

Multidisciplinary trauma team, besides massive support, decided to perform bilateral amputation with disarticulation of the LL as a damage control strategy.

He was afterwards transferred to the Intensive Care Department with diagnosis of severe multiple trauma with hemorrhagic shock requiring multiple transfusion, rhabdomyolysis and multiple-organ failure (neurological, respiratory, cardiovascular, renal and hematological).

Intercurrent problems included type 2 acute myocardial infarction and ischemia and infection of the disarticulation stumps with secondary Enterococcus faecalis bacteremia, requiring antimicrobials and multiple surgical interventions.

Regardless the severity of the case, the care provided allowed an overall favorable evolution, allowing extubation on the 20th day and discharge to the ward on the 27th day.

The authors think that other strategies like the Resuscitative Endovascular Balloon Occlusion of the Aorta could be used in these situations and should be incorporated as resuscitative practices.

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