GSW to abdomen

Patient Presentation
S.G., a 16 year-old male presents to the trauma bay s/p multiple GSWs (gun shot wounds) to abdomen.  He arrives AAO with a GCS of 15 c/o severe abdominal and back pain as well as light-headedness.  VS are as follows:  HR 120s, BP 80s/50s, O2sat 97% on RA with RR in 30s, afebrile but cool, clammy skin.  Upon assessment, 2 entrance wounds are observed (both in RUQ with one approximately midline) and there is minimal bleeding from the sites.  A positive FAST scan is reported.  Within 5 minutes of arrival, S.G. rapidly deteriorates: becoming less responsive and hemodynamically unstable.  B/L AC RICs (bilateral antecubital rapid-infusion-catheter) are placed and IVF are started via pressure bags as well as Levophed® and neo gtts hung.   Labs are as follows:  H/H 5/16, coags elevated, ABG was WNL following intubation.

Diagnosis
Hypovolemic shock secondary to GSW/hemorrhage

Treatment
Pt is intubated and transferred to the STICU where he codes upon arrival.  S.G. recovers but continues to arrest every few minutes despite pharmacological interventions.  The exact source of his bleeding was unknown; a bedside sternotomy is performed as well as an exploratory laparotomy.  It was established that the source was either a retrohepatic vena cava or a juxtahepatic venous injury.  With internal cardiac massage being performed, S.G. was transferred down the hall to the OR.  A Schrock shunt/atriocaval shunt via an ett was placed to bypass the site of injury for repair (a Schrock shunt is not common but usually involves placing a chest tube or endotracheal tube into the IVC to shunt venous blood past the damaged vessel site and return it to the heart).  S.G. arrested multiple times on the OR table, but recovered each time; he returned to the STICU for aggressive resuscitation.  S.G. received over 100 units of blood products within the first 24 hours of admission as well as multiple liters of IVF, mostly warmed via two Level 1 rapid infusers.  He would return to the OR later that evening for removal of the shunt and attempted repair of vascular injuries.

Outcome
S.G. had a long course of treatment in the ICU, including concerns of an anoxic brain injury secondary to multiple cardiac arrests and prolonged hypotension. He eventually woke up and was transferred to the floor and discharged less than 3 months later.  He returned to visit the unit; he made a full recovery.
Case created by Shanna Got, 2011.