1. Trauma Transfer for Catastrophic IVC Injury NOT A VERY HAPPY NEW YEAR Stephen Clark Cardiothoracic Surgery Freeman Hospital Emma Farrow ED Consultant Cumberland Infirmary, Carlisle

2. Case Report Mr M - 23 years old New Years Eve Party Stab wound at 04.00 – Right back. Alleged indiscretions with Brothers wife. Pre-alert – 04.40. Trauma call activated Patient arrived Carlisle ED - 04:47 Isolated wound, right lower back Taken cocaine & alcohol, no PMH, No meds, NKDA All trauma team present, ED Cons arrived 04.55

3. Case Report On arrival - A – Clear, c-spine no concern B – RR-24, sats 100% on 15L, reduced A/E right base C - HR-95, BP 145/85, CRT 2 seconds, no external bleeding – Abdo soft, generally tender, no guarding – Pelvis NAD, No other injuries D – GCS-14 (E3, V5, M6) BM-7.6 E – Temp 36.5 2 inch laceration right lower back, muscle exposed

4. Interventions Oxygen IV access (orange, grey, green) – 1 litre N-Saline 6 units cross-matched Tranexamic acid discussed but not given at surgical registrars request Ready for CT 05:05 Erect CXR while awaiting CT– no free gas under diaphragm In CT 05:25 (slight delay for radiographer)

5. Further information Back to ED resus c/o surgical team ; Awaiting CT report BP normal & stable until – 07:00 HR 114, BP 129/70 – 07:10 HR 110, BP 91/60 CT report received 07:05

6. Laceration upper pole right kidney Blood in left hepatic space Gastric artery damage at coeliac axis. No chest injury

7. Further information Tranexamic acid given, 2 units blood given ; 2 units FFP ordered 07:40 Reviewed by surgical registrar “immediate surgery planned, anaesthetist informed” Transferred to theatre

8. From then on … Anaesthetics predicted problems – Ensured blood was available – Arterial and Central line placed – Fentanyl, Midaz, small amount of Thio and Sux Opened – Very little blood in abdo Retroperitoneal space opened, massive loss of volume

9. Carlisle Theatres Uncontrollable bleeding – Cardiac arrest on the table - suspected IVC laceration. Abdomen packed tightly for return to ITU to die. Stabilised. Contacted Cardiothoracic Consultant directly for ?IVC control in chest.

10. General Surgery Consultant called Theatre team and perfusionist called in Plan for direct transfer from ambulance to theatre Delayed transfer Surgeon called at 09.50. Patient arrived at FRH at 13.37. Ambulance called to Carlisle for transfer 11.52! Several calls from FRH to CIC during this time to find out where the patient was!

11. Newcastle Cardiothoracic Theatre Sternotomy performed to allow control of IVC in the chest Abdomen reopened – packs removed. Torrential bleeding and loss of blood pressure Right atrium cannulated with giving set for rapid transfusion Unable to maintain pressure – heparinised and crashed onto cardiopulmonary bypass Haemodynamic stability but unable to visualise bleeding as torrential blood loss continued

12. As luck would have it…. Cardiothoracic surgeon and hepatobiliary surgeon operate together frequently on advanced liver tumour resections using cardiopulmonary bypass 7 cases over 2 years using abdominal circulatory arrest technique

13. Theatre Decision made to crash cool to 18C and arrest circulation to the abdomen maintaining perfusion to the head and upper body from bypass flow allowing the heart to fibrillate.

14. Venous drainage DIAPHRAGM Arterial return LV Vent as Heart in VF Clamp IVC Clamp Aorta Head and upper body perfused at 18C with venous return from SVC only Abdominal organs unperfused at 18C Cardiopulmonary Bypass Cooling to 18C

16. Theatre Laceration to anterior and posterior IVC primary repair Haemostasis of caudate lobe injury with Aquamantys radiofrequency device Aorta and IVC unclamped. Rewarmed. Heart defibrillated. Weaned from cardiopulmonary bypass Chest and abdomen closed (packed, delayed closure) 32 units PBC’s 10 units platelets, 12 units FFP

17. Recovery Transfusion related lung injury Abdominal packs removed day 3 Upper abdomen not closed due to hepatic congestion – VAC dressing Ventilator associated pneumonia Weaned over 3 weeks and transferred to ward Discharged home 27 days after injury

18. Literature Few survivors described from this injury Hansen et al Abdominal vena caval injuries : Outcomes remain dismal Surgery 2000;128;572-8 Blunt retrohepatic IVC injuries – 75% mortality Shunts – difficult to place during massive exsanginating haemorrhage - 80-90% mortality Burch et al The atriocaval shunt. Facts and fiction Ann. Surg 1988;207;555-68 Cogbill et al Severe hepatic trauma – a multicentre experience of 1,335 liver injuries J. Trauma 1988;28;1433-8 5 case reports of using cardiopulmonary bypass and hypothermic arrest for retrohepatic venous injury between 1991 -2011

19. Comment If you cant be good, be lucky Direct referral to CT surgery – Involvement of MTC? Would that have been a good or bad thing? Transfer straight to theatre from ambulance with theatre staff, perfusion, anaesthetics, general surgery all present Delayed CT reporting and transfer but stable Decision for sternotomy before reopening abdomen Rapid loss of control but prepared Advanced cardiopulmonary bypass technique Practiced by liver and cardiac surgeon before