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Sun Sep 14 04:53:57 BST 2003

14 yo male MVA. Hypotensive and tachycardic on arrival to ER. Chest X-ray revealed left hemothorax, right side obviously normal. Initial left chest tube output is 400 cc. DPL is positive for gross hemoperitoneum. Laparotomy: A huge diaghragmatic tear extending from crura to the lateral chest wall, stomach, spleen, colon and KIDNEY in left thorax, a left sided retroperitoneal hematoma. Spleen was fractured. Splenectomy was done. Ongoing bleeding from left thorax dictated left thoracotomy and it was found that retroperitoneal blood was travelling from down to up to the thorax and to the abdomen through the diaphragmatic tear. MAP decreased to 30 mmHg at that time and aorta was cross clamped, a maneuver which increased BP to 120/70. Exploration was extanded and a total transection of the left renal vein just to the enterance to IVC was found and fixed. Operation was completed with a total whole blood transfusion of 9 units. 4 units of FFP were given. 

Postoperative serial Hb measurements are around 10 gr/dl; chest X-ray showed pulmonary edema on the RIGHT side, left side is OK. ABG analysis is pH: 7.29, pCO2: 43, BE: -6 but pO2:55, O2 sat: 75% (volume controlled, 100% O2, PEEP: 10 cm-H2O). Still hypotensive and CVP: 14 cm-H2O

What should we do regarding pulmonary menegament, fluids and inotropics ?
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