Severe crush trauma with hemorrhagic shock: Where to look for the source of bleeding?

Abstract text (incl. references and figure legends)

Introduction Crush injuries are always associated with multiple injuries. Outcomes are often poor due to the the severity of the injury, even with optimal treatment. Case presentation: 64-year-old male patient, crush trauma victim arrived intubated with severe hemodynamic instability after two episodes of cardiac arrest. EFAST was positive for left pneumothorax that was immediately drained. A trauma laparotomy was performed showing just a small amount of blood in right and left hypochondrium. Abdominal packing and of Bogota bag were performed with slight hemodynamic improvement. CT scan showed a right emo-pneumothorax and minimal pneumomediastinum. According to these finding a right pleural drainage was performed with leakage of abundant blood and air pressure. Therefore, the patient underwent urgent thoracotomy with evidence of diaphragmatic laceration through which there was a massive bleeding of probable hepatic origin due to disengagement and laceration of the right supra hepatic vein. Haemorrhagic control was obtained but the patient died immediately after due to another cardiac arrest. Discussion according to the ATLS the indications to emergency thoracotomy are: immediate drainage of 1500 ml of blood after chest drainage or initial blood <1500ml but persistence of bleeding (200 ml/hour 2 to 4 hours). In our case, upon arrival the thoracic drainage did not charge large quantities of blood such as to indicate a massive haemothorax. It was the persistence of of hemodynamic instability, despite the negativity of abdominal surgical exploration, that led to an urgent, albeit late, thoracotomy. Conclusion: trauma of the supra hepatic veins are rare ad often fatal. However we have to keep in mind that in high energy trauma the bleeding source may be charged to one body district but give sign of if in another body district in light of the associated injuries. Therefore an aggressive surgical approach is the only one that allows to decrease the mortality rate

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