Full Recovery after Gunshot Wound to the Vena Cava and Aorta with Cardiopumonary Arrest
Darwin Ang MD FACS*, Alejandro Garcia MD, Matthew Delano MD, Jason Clark MD, Bogdana Trop MD,
Alexander Evans MD FACS
Prehospital and Trauma Resuscitation Room
(GSW to abdomen with one round CPR, no secured airway and non-functioning IV)
A 30 year old male was shot at 4 times and once in the umbilical region at close range. The patient was
found by the police on the ground where they initiated CPR. By the time EMS arrived, the patient had
regained vitals and was rushed to the trauma center which was a few minutes away. In the ED the
patient was hypotensive 80/60 and tachycardic. He had a 16 gauge IV in the left antecubital fossa;
however, the IV was not working and the patient did not have a definitive airway. The patient was
subsequently intubated and a subclavian line was placed. The patient was given 4 units of PRBC and 2
units of FFP via Level 1 Transfusion device and promptly rushed to the OR.
Operating Room
(laceration to the IVC x 3, right common iliac vein transection, lateral aortic injury, small bowel
perforation, small bowel mesenteric injury, cardiac arrest secondary to hemorrhagic shock and acidosis)
A quick sterile prep was performed from chin to thighs. A midline incision was started and blood under
tension was noted. Cell saver was used to harvest the blood products. The patient became asystolic.
The left chest was then opened via anterior lateral thoracotomy. Cardiac massage was initiated and the
aorta was cross clamped. ACLS protocol was initiated with several rounds of epi, calcium, and
bicarbonate. Cardiac massage effectiveness was gauged by rate, blood pressure, and end tidal CO2.
While open cardiac massage was performed by the scrub tech, attention was turned towards the
abdomen. There was an expanding lower midline retroperitoneal hematoma. Proximal and distal
control of IVC and aorta and the common iliacs were obtained after Cattell-Braasch maneuver. Once
isolation of the major vascular injuries was achieved, the patient was given 30 Joules of internal
defibrillation and spontaneous contractions returned. Total time CPR was over 30 minutes. The right
common iliac was completely transected and was ligated. The IVC had 2 anterior and 1 posterior
laceration and these were primarily repaired. The aorta had a single longitudinal laceration which was
primarily repaired. The patient also had a small venotomy in the left common iliac, injury to the small
bowel mesentery and injury to small bowel. The small bowel was resected and left in discontinuity. All
other bleeding was controlled with suture ligation or repair. The abdomen was left open and vacuum
packed and sent to the trauma ICU. Total blood volume lost was 10 liters. Six liters of cell saver was
returned to the patient.
Post-Operative Course
On post operative day 2 the patient went back to the operating room for reestablishing bowel continuity
and primary closure of the fascia. A nasojejunal tube was place for enteral feeds. On POD 6 the patient
was extubated. Neurosurgery was consulted for a comminuted fragment of the L5 vertebrae and
misalignment of L5 and S1 from the bullet. A TLSO brace was prescribed. Orthopedic surgery was
consulted for an ulnar nerve injury from one of the bullets. The patient underwent extensive physical
and occupational therapy. He recalled the events, tolerated a regular diet, and regained full cognitive
and neurologic function. On hospital day 20 he was discharged home with anticoagulation and home
physical therapy.
Summary of Injuries
1.
2.
3.
4.
5.
6.
7.
8.
IVC laceration, 2 anterior and 1 posterior
Distal aorta laceration
Transection of right common iliac vein
Comminuted fragmentation of L5 vertebrae
Subluxation of L5/S1
Small bowel perforation
Small bowel mesentery laceration
Right ulnar nerve injury
Summary of operations
1.
2.
3.
4.
5.
6.
7.
Primary repair of distal IVC
Primary repair of distal aorta
Ligation or right common iliac vein
Small bowel resection with ligation of mesentery
Anterolateral thoracotomy with aortic cross clamp and cardiac massage
Open abdominal VAC placement
Subsequent operation for the abdomen included washout, reestablishing bowel continuity,
primary closure of the fascia, and placement of nasal jejunal feeding tube.
8. Ulnar nerve graft and repair of muscle of the right hand.
Despite prolonged cardiopulmonary arrest, the patient was discharged home and had full cognitive and
neurologic function with the exception of his right hand.
Correspondence:
Darwin Ang, MD FACS