Monday, April 11, 2005

Tales from the Trauma Service VIII...
I seem to be collecting transaxial gunshot wounds lately. The latest is a 20-ish black man shot by a known assailant at an unknown range and with an unknown weapon. Hemodynamically stable but with an impressive physical exam finding I will show you in a moment. Initial AP pelvis film and urethrogram:

The yellow line points to the paperclip marking the entry wound. He had a 15 mm/HG difference in systolic pressure between his legs, with the right greater than the left. So I have to worry about a rectal, vascular, and genitourinary injury. Off to the angio suite we go:

Looks like a pseudoaneursym, indicated by the black line, but wait....

Rapid filling of the left femoral vein (blue line). Here is another view:

So he has a traumatic arterio-venous fistula from the superficial femoral artery and vein Options include endovascular stent-grafting or operative repair. Given his age, I opted for the latter. He went to the OR for a rigid sigmoidoscopy, which was negative, the urologist performed a cystoscopy and drainage for this injury. WARNING:NOT SAFE FOR WORK OR MANY OTHER PLACES.
The edema, first thought to be from a urethral injury, was hematoma from blood tracking along the wound tract. The vein had severe damage. Both were repaired primarily.


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