Background The management of penetrating thoracoabdominal trauma can be a vexing surgical challenge. Patients with penetrating thoracoabdominal injuries and hypovolemic shock usually warrant immediate surgical intervention. However, in selected hemodynamically stable patients with isolated right sided thoracoabdominal wounds, interventional radiologic angio-embolization may provide a non-operative alternative.
Methods We present a 19 year old man who sustained two gun shot wounds (GSW): A through and through injury to the right thoracoabdominal region two inches lateral and below the nipple and a second to the left lower extremity. On arrival to the emergency department (ED) he was normotensive, but tachycardic to 106 bpm. On physical exam, he had decreased breath sounds on the right and a right thoracostomy was performed.Left lower extremity pulses were present Initial hemoglobin was 12.0 mg/dL followed 11.3 mg/dL and 10.1 mg/dL. Focus sonography for trauma (FAST) scan demonstrated a small amount of free fluid in the abdomen. Computed tomography (CT) showed a Grade III-IV liver laceration involving the anterior and posterior segments of the right lobe of the liver with an area of active extravasation. CT clearly demonstrated that the missile trajectory only involved the liver.The patient was the taken to IR for hepatic arteriogram and embolization.
Results Arteriogram revealed active extravasation from a tertiary branch of the right hepatic artery, which was succesfully embolized
Conclusion Arteriogram also showed disruption of the left popliteal artery which was repaired surgically. The patient had an uneventful post procedure course and was discharged to home on hospital day four.
Conclusion This case illustrates the widening multi-disciplinary approach to the non-operative management of penetrating right sided thoracoabdominal injuries. In this case surgical intervention was avoided resulting in a decreased length of stay and decreased morbidity related to laparotomy and hepatorrhaphy.
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