Oct. 17, 2008, started out like many other cool fall days in Southern Nevada. But for one young Las Vegas resident, this day would present the greatest challenge of his life.
At approximately 12:30 p.m., members of the Clark County Fire Department (CCFD) were summoned to the aid of a 13-year-old bicycle crash victim. Ayren Perry had been riding his BMX bicycle on a residential street that afternoon. After several uneventful trips up and down the sidewalk, he looked down and saw a large rock. As he swerved to avoid it, he struck another large rock near his driveway. This impact jolted his front tire, causing the handlebars to turn hard to one side.
Locking his front wheel, Ayren flew over the handlebars, striking the end of a handlebar directly over his pubic symphysis and landing on it with the full force of his lurching body. The injury resulted in a 7.5 centimeter gaping hole torn open 3 cm below his umbilicus. He saw blood coming from the wound and he called for his father, who immediately called 9-1-1.
EMS Assessment & Treatment
On arrival, CCFD members quickly assessed the scene and situation. Beginning their primary survey, they noted that the patient was covered with an estimated 500 mL of blood and appeared pale and diaphoretic. He was phonating without difficulty and had no indication of pending airway compromise. His respiratory and thoracic assessment was equally unremarkable.
As the paramedics evaluated his circulatory status, however, they encountered their first red flag. Noting that Ayren showed signs of shock, they found thready, rapid pulses in his carotids and no discernable pulses in his arms or legs. His disability/neurologic evaluation showed him to have a GCS of 15 and no obvious motor deficits, although he stated at times he couldn_t feel his feet.
Because the metropolitan Las Vegas area has a dual-response system, the firefighter/paramedics were beginning their secondary exam just as a second EMS unit arrived. Ayren_s vitals at that time were: BP 66/26, pulse 158 bpm, respiratory rate 30, pulse ox 100% on 15 L O by non-rebreather mask.
Recognizing that their patient was presenting with penetrating abdominal trauma and shock, likely secondary to hypovolemia, the EMS crew acted swiftly and treated this patient in a rapid "load and go" fashion. Total scene time was estimated to be less than five minutes. Direct pressure was kept on the wound to prevent further exsanguination. En route to Nevada_s only Level 1 Trauma Center, the crew placed two 16 gauge IVs and initiated crystalloid infusion.
On arrival at the trauma center, the patient instantly received ATLS/PALS protocol-driven resuscitation. Initially, he was somewhat responsive to fluids, with his BP improving to 75/62 and his pulse slowing to 137. Unfortunately, he became increasingly lethargic within a few minutes of arrival. He deteriorated into pulseless V-tach, and external electrical cardioversion was performed. Nearly simultaneously, his airway was secured by orotracheal intubation.
Within minutes, he again lost his pulses. Having no success restoring his cardiovascular function through the previously successful means, the attending surgeon performed a resuscitative thoracotomy in the trauma bay. After cross-clamping the patient_s aorta and performing open cardiac massage for several minutes, he was able to restore spontaneous cardiac activity. Ayren was emergently transferred to the operating room (OR) (within 15 minutes of his arrival to the trauma center and 45 minutes of his injury).
On arrival to the OR, the patient again lost his pulses. During the operation, he experienced several episodes of V-tach and V-fib. These were corrected with internal paddle cardioversion/defibrillation.
Using a standard midline approach, the patient was incised from the sternal notch to the pubic symphysis. Noting that there was no evidence of a significant intraperitoneal source of bleeding, the trauma surgeons observed a large retroperitoneal hematoma in the right groin. It was so large that the surgical team was forced to gain exposure to the retroperitoneum by performing a second, more lateral incision over the groin. Next, they bluntly dissected along the oblique fascia to obtain adequate exposure to the suspected source of blood loss. The surgeons then identified the right iliac vein and found it to be almost completely severed. The iliac artery was fortunately intact. Both ends of the external iliac vein were subsequently ligated. After ensuring this was the major injury and no other surgically correctable causes of blood loss were present, the surgical team irrigated Ayren_s wounds and surgical sites. They then closed his wounds and placed a left-sided thoracostomy tube.
Next, he was transferred to the post-anesthesia care unit and subsequently placed in the pediatric ICU. During his recuperation, Ayren surmounted several obstacles to recovery. Due to the amount of fluids (including blood products) required during resuscitation and post-traumatic physiological changes, Ayren experienced significant pulmonary edema. His initial pH was 6.8 (pCO 55), and he required epinephrine in the initial hours after his surgery. Over the next several days, he was weaned off of the BP support. Pulmonologists, cardiologists and nephrologists were consulted to assist in his care. His wounds were subsequently closed in a delayed fashion and his chest tube removed. He was extubated.
Finally, he underwent physical therapy and was discharged on day 16. Currently, Ayren is at home with his family. He has returned to normal activity and is healthy and active.
This case illustrates the importance of early recognition of potentially devastating injuries and underscores the impact of rapid transport to the nearest center for the treatment of trauma in such cases. Without early recognition, rapid transport to an appropriately skilled staff and facility, and early resuscitation, Ayren would have undoubtedly succumbed to his injuries.JEMS
K. Alexander Malone,MD, FACEP, is an attending physician in the Department of Emergency Medicine at UMC of Southern Nevada. He also serves as the medical director for the North Las Vegas Fire Department.
J. E. Coates,DO, FACOS, is an assistant professor and program director of the Trauma/Surgical Critical Care Fellowship at the University of Nevada School of Medicine and the vice chairman of the Department of Trauma at UMC Hospital.
The authors wish to thank Assistant Chief Bruce Evans, NLVFD, for his assistance with this article.
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