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Train Versus Pedestrian Resulting in Traumatic Hemipelvectomy
TRAUMA NOTEBOOK
TRAIN VERSUS PEDESTRIAN RESULTING TRAUMATIC HEMIPELVECTOMY
IN
Authors: Kathleen Whitney, RN, BSN, CEN, Linda Haynes, RN, BSN, MSN, PhD, and David Craig Smith, MD, FACS, Fort Worth, TX Section Editors: Maureen Harrahill, MS, ACNP-BC, and Angela Shannon, RN, MS, CEN
36-year-old man who worked in a train yard calmly told the 911 operator, “I’ve been run over by a train, and I think it cut me in half.” He had sustained massive pelvic and lower-extremity trauma when he fell off a train car and was run over. When paramedics and fire rescue arrived on the scene, they found a challenging extrication. The patient lay on his left side with the lower half of his body pinned beneath the wheels of the railroad car. Multiple unsuccessful attempts were made to free his legs while he continued to hemorrhage at an alarming rate. Luckily, before an amputation team arrived, they were able to free him by using inflatable airbags to lift the railroad car upward, off of him (Figure). The paramedics estimated that the patient lost 4 to 5 L of blood at the scene. After an extrication time of approximately 53 minutes, the patient was transported by air to the nearest level II trauma center. The patient arrived at the emergency department intubated with an 8.0 mm endotracheal tube and with a right subclavian central line placed by the transport team. He had an initial pulse of 115 beats/min and blood pressure of 60/40 mm Hg. The patient’s left leg was partially amputated, mangled, and disarticulated at the hip, remaining attached by only a muscle bridge. The near amputation extended upward to his waist level with avulsion of a large
A
Kathleen Whitney, Member, Tarrant County Chapter, is Staff Nurse, Emergency Department, Texas Health Harris Fort Worth Hospital, Fort Worth, TX. Linda Haynes is Trauma Research Nurse Clinician, Texas Health Harris Fort Worth Hospital, Fort Worth, TX. David Craig Smith is General Surgeon/Trauma Surgeon, Private Practice, TRACC, PA, and Medical Director of Trauma Services, Texas Health Harris Fort Worth Hospital, Fort Worth, TX. For correspondence, write: Kathleen Whitney, RN, BSN, CEN, 921 Harness Cir, Fort Worth, TX 76179; E-mail: [email protected]. J Emerg Nurs 2010;36:284-6. Available online 19 February 2010. 0099-1767/$36.00 Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.01.005
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amount of bone and other structures, leaving the left lower abdomen and pelvis with a gaping wound. The scrotum was partially degloved, exposing the left testicle. There was also a significant area of degloving to the right leg at the mid-thigh level, open fractures to the right foot, and a mangled right lower leg. All wounds were grossly contaminated with dirt and gravel. Upon arrival, the team placed additional intravenous lines, providing a total of 5 lumens through which to infuse blood products, crystalloids, and antibiotics. The trauma surgeon tied off exposed, bleeding vessels to slow the patient’s continued hemorrhage. Emergency nurses initiated infusion of 4 units of type O–negative packed red blood cells and initiated antibiotics, and the patient was transferred to the operating room within 18 minutes of arrival at the emergency department. Laboratory values showed an initial hemoglobin level of 4.3 g/dL and hematocrit of 13.7%. In the operating room, the surgeons completed the amputation of the left leg, ligated the left femoral artery and vein, and amputated the left testicle. They performed an above-knee amputation on the right lower extremity. The wounds were massively irrigated and the nonviable muscle and crushed bone debrided. They also performed an exploratory laparotomy, and no intra-abdominal injuries were identified. Because of the patient’s massive pelvic trauma, the surgeons divided the colon to set up for a colostomy during a future operation. The patient received a transfusion of 25 units of packed red blood cells, 3 units of platelets, 26 units of cryoprecipitate, and 11 units of fresh-frozen plasma on the day of admission. Discussion
Traumatic hemipelvectomy is a rare type of pelvic fracture, characterized by wide separation of the pelvic ring at the symphysis pubis and sacrum, along with rupture of the iliac vessels and disruption of the neurovascular bundle. 1,2 These fractures can be open or closed. Fortunately, they account for less than 2% of all pelvic fractures.1 This devastating injury is frequently the result of victims becoming entangled in farm equipment, industrial equipment, or the undercarriage of a vehicle.3 Commonly, the initial force impacts the victim’s knee, causing severe
VOLUME 36 • ISSUE 3
May 2010
Whitney et al/TRAUMA NOTEBOOK
FIGURE Train raised by airbags.
hyperabduction of the hip and disrupting the symphysis pubis and the sacroiliac joint.3 With multiple great vessels located within the pelvic cavity, these pelvic fractures have a high potential for massive hemorrhage and rapid exsanguination. Commonly associated injuries include genitourinary trauma, anorectal trauma, and injury to the ipsilateral lower extremity.2 Surviving patients have been plagued with chronic psychological trauma, phantom pain, and mobility issues.4 To date, there has been very limited success with prosthesis use, and many patients prefer to ambulate with crutches or use a wheelchair.4 In the acute setting the importance of rapid surgical intervention cannot be overstated. Control of hemorrhaging in these cases can be quite challenging, and intraoperative clamping of the abdominal aorta may be necessary.2 Close communication between all the team members from the surgical department, the blood bank, and the emergency department is essential to help ensure that the patient is taken to the operating room as rapidly as possible. Outcome of Our Case
The patient had a long and difficult recovery with multiple admissions and more than 20 subsequent surgeries. However, the postoperative period was remarkable for lack of sepsis in the face of his massive wound contamination. This may be potentially attributed to early infection prophylaxis, with antibiotics started immediately by the team in the emergency department. In addition, the team’s choice of using silver-impregnated dressings for wound management may also have helped prevent infection, tak-
May 2010
VOLUME 36 • ISSUE 3
ing full advantage of silver’s 3 mechanisms for infection control: binding with deoxyribonucleic acid to prohibit cellular reproduction, binding with chemical functionality on the cell wall, and binding with enzymes that are key for cellular respiration.5 Negative-pressure wound therapy was also used. This type of treatment has been shown to increase wound healing and reduce risk of infection by reducing the moisture in the wound and increasing cell proliferation.6 In addition, hyperbaric oxygen therapy was used to promote wound healing. Ultimately, the team was able to complete the wound closure using split-thickness skin grafts. The surgeons had to create a permanent end colostomy. The patient’s hospital course was complicated by issues involving his left kidney, which ultimately necessitated a nephrectomy. However, his right kidney continues to function well, and he remains continent of urine. The patient had complications from phantom limb pain, neuropathic pain, and polyneuropathy. Despite these complications, he progressed remarkably well with his rehabilitation regimen. He was custom fitted with a seating system that covered his entire left torso and fit into the remaining right buttock and leg, allowing him to sit independently. He was also fitted with a custom electric wheelchair that was built to allow him to sit comfortably without the prosthesis. This patient’s treatment was a multidisciplinary collaborative effort involving nursing; trauma surgery; orthopaedics; ear, nose, and throat; infectious disease; plastic surgery; rehabilitative services; and urology. The patient was discharged from the hospital 4 months after injury. After a lengthy rehabilitation, he has been able to return to work in a full-time capacity with the same company in a computer-related position. Conclusion
Traumatic hemipelvectomy is a rare but devastating injury. The key lesson for the trauma team was the power of a team working together, with the patient as the most important team member. Our patient not only survived but has self-sustaining employment and is a self-sufficient provider of his own care. He no long has phantom pain, and he shows no evidence of chronic psychological trauma. In fact, he has recently made his story public via numerous media sources including the popular press, the Internet, and televised interviews. Although our patient’s primary mode of transportation continues to be in a wheelchair, he has recently been successfully fitted with a prosthesis. A review of our patient’s case shows an individual who refused to
WWW.JENONLINE.ORG
285
TRAUMA NOTEBOOK/Whitney et al
give up. He is a truly extraordinary individual who survived an extraordinary trauma. REFERENCES
5. Ellis J. The many roles of silver in infection prevention [abstract]. Am J Infect Control. 2007;35(5):E26. 6. Jerome D. Advances in negative pressure wound therapy: the VAC instill. J Wound Ostomy Continence Nurs. 2007;34(2):191-4.
1. Labler L, Trentz O, Keel M. Traumatic hemipelvectomy. Eur J Trauma. 2005;31(6):543-50. 2. Reiger H, Dietl K. Traumatic hemipelvectomy: an update. J Trauma. 1997;45(2):422-6. 3. Ossewaarde S. Case study: traumatic hemipelvectomy. Int J Trauma Nurs. 1997;3(1):13-7. 4. Lawless M, Laughlin R, Wright D, Lemmon G, Rigano W. Massive pelvic injuries treated with amputations: case reports and literature review. J Trauma. 1997;42(6):1169-75.
Submissions to this column are encouraged and may be sent to Maureen Harrahill, MS, ACNP-BC [email protected] or Angela Shannon, RN, MS, CEN [email protected]
The "Triage Decisions" section is interested in articles about all facets of triage, including process change, case reviews, or general triage tips. These 3-5 page double-spaced articles can be sent via email to Andi Foley at [email protected] and/or Patricia Kunz-Howard at [email protected].
286
JOURNAL OF EMERGENCY NURSING
VOLUME 36 • ISSUE 3
May 2010
TRAIN VERSUS PEDESTRIAN RESULTING TRAUMATIC HEMIPELVECTOMY
IN
Authors: Kathleen Whitney, RN, BSN, CEN, Linda Haynes, RN, BSN, MSN, PhD, and David Craig Smith, MD, FACS, Fort Worth, TX Section Editors: Maureen Harrahill, MS, ACNP-BC, and Angela Shannon, RN, MS, CEN
36-year-old man who worked in a train yard calmly told the 911 operator, “I’ve been run over by a train, and I think it cut me in half.” He had sustained massive pelvic and lower-extremity trauma when he fell off a train car and was run over. When paramedics and fire rescue arrived on the scene, they found a challenging extrication. The patient lay on his left side with the lower half of his body pinned beneath the wheels of the railroad car. Multiple unsuccessful attempts were made to free his legs while he continued to hemorrhage at an alarming rate. Luckily, before an amputation team arrived, they were able to free him by using inflatable airbags to lift the railroad car upward, off of him (Figure). The paramedics estimated that the patient lost 4 to 5 L of blood at the scene. After an extrication time of approximately 53 minutes, the patient was transported by air to the nearest level II trauma center. The patient arrived at the emergency department intubated with an 8.0 mm endotracheal tube and with a right subclavian central line placed by the transport team. He had an initial pulse of 115 beats/min and blood pressure of 60/40 mm Hg. The patient’s left leg was partially amputated, mangled, and disarticulated at the hip, remaining attached by only a muscle bridge. The near amputation extended upward to his waist level with avulsion of a large
A
Kathleen Whitney, Member, Tarrant County Chapter, is Staff Nurse, Emergency Department, Texas Health Harris Fort Worth Hospital, Fort Worth, TX. Linda Haynes is Trauma Research Nurse Clinician, Texas Health Harris Fort Worth Hospital, Fort Worth, TX. David Craig Smith is General Surgeon/Trauma Surgeon, Private Practice, TRACC, PA, and Medical Director of Trauma Services, Texas Health Harris Fort Worth Hospital, Fort Worth, TX. For correspondence, write: Kathleen Whitney, RN, BSN, CEN, 921 Harness Cir, Fort Worth, TX 76179; E-mail: [email protected]. J Emerg Nurs 2010;36:284-6. Available online 19 February 2010. 0099-1767/$36.00 Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.01.005
284
JOURNAL OF EMERGENCY NURSING
amount of bone and other structures, leaving the left lower abdomen and pelvis with a gaping wound. The scrotum was partially degloved, exposing the left testicle. There was also a significant area of degloving to the right leg at the mid-thigh level, open fractures to the right foot, and a mangled right lower leg. All wounds were grossly contaminated with dirt and gravel. Upon arrival, the team placed additional intravenous lines, providing a total of 5 lumens through which to infuse blood products, crystalloids, and antibiotics. The trauma surgeon tied off exposed, bleeding vessels to slow the patient’s continued hemorrhage. Emergency nurses initiated infusion of 4 units of type O–negative packed red blood cells and initiated antibiotics, and the patient was transferred to the operating room within 18 minutes of arrival at the emergency department. Laboratory values showed an initial hemoglobin level of 4.3 g/dL and hematocrit of 13.7%. In the operating room, the surgeons completed the amputation of the left leg, ligated the left femoral artery and vein, and amputated the left testicle. They performed an above-knee amputation on the right lower extremity. The wounds were massively irrigated and the nonviable muscle and crushed bone debrided. They also performed an exploratory laparotomy, and no intra-abdominal injuries were identified. Because of the patient’s massive pelvic trauma, the surgeons divided the colon to set up for a colostomy during a future operation. The patient received a transfusion of 25 units of packed red blood cells, 3 units of platelets, 26 units of cryoprecipitate, and 11 units of fresh-frozen plasma on the day of admission. Discussion
Traumatic hemipelvectomy is a rare type of pelvic fracture, characterized by wide separation of the pelvic ring at the symphysis pubis and sacrum, along with rupture of the iliac vessels and disruption of the neurovascular bundle. 1,2 These fractures can be open or closed. Fortunately, they account for less than 2% of all pelvic fractures.1 This devastating injury is frequently the result of victims becoming entangled in farm equipment, industrial equipment, or the undercarriage of a vehicle.3 Commonly, the initial force impacts the victim’s knee, causing severe
VOLUME 36 • ISSUE 3
May 2010
Whitney et al/TRAUMA NOTEBOOK
FIGURE Train raised by airbags.
hyperabduction of the hip and disrupting the symphysis pubis and the sacroiliac joint.3 With multiple great vessels located within the pelvic cavity, these pelvic fractures have a high potential for massive hemorrhage and rapid exsanguination. Commonly associated injuries include genitourinary trauma, anorectal trauma, and injury to the ipsilateral lower extremity.2 Surviving patients have been plagued with chronic psychological trauma, phantom pain, and mobility issues.4 To date, there has been very limited success with prosthesis use, and many patients prefer to ambulate with crutches or use a wheelchair.4 In the acute setting the importance of rapid surgical intervention cannot be overstated. Control of hemorrhaging in these cases can be quite challenging, and intraoperative clamping of the abdominal aorta may be necessary.2 Close communication between all the team members from the surgical department, the blood bank, and the emergency department is essential to help ensure that the patient is taken to the operating room as rapidly as possible. Outcome of Our Case
The patient had a long and difficult recovery with multiple admissions and more than 20 subsequent surgeries. However, the postoperative period was remarkable for lack of sepsis in the face of his massive wound contamination. This may be potentially attributed to early infection prophylaxis, with antibiotics started immediately by the team in the emergency department. In addition, the team’s choice of using silver-impregnated dressings for wound management may also have helped prevent infection, tak-
May 2010
VOLUME 36 • ISSUE 3
ing full advantage of silver’s 3 mechanisms for infection control: binding with deoxyribonucleic acid to prohibit cellular reproduction, binding with chemical functionality on the cell wall, and binding with enzymes that are key for cellular respiration.5 Negative-pressure wound therapy was also used. This type of treatment has been shown to increase wound healing and reduce risk of infection by reducing the moisture in the wound and increasing cell proliferation.6 In addition, hyperbaric oxygen therapy was used to promote wound healing. Ultimately, the team was able to complete the wound closure using split-thickness skin grafts. The surgeons had to create a permanent end colostomy. The patient’s hospital course was complicated by issues involving his left kidney, which ultimately necessitated a nephrectomy. However, his right kidney continues to function well, and he remains continent of urine. The patient had complications from phantom limb pain, neuropathic pain, and polyneuropathy. Despite these complications, he progressed remarkably well with his rehabilitation regimen. He was custom fitted with a seating system that covered his entire left torso and fit into the remaining right buttock and leg, allowing him to sit independently. He was also fitted with a custom electric wheelchair that was built to allow him to sit comfortably without the prosthesis. This patient’s treatment was a multidisciplinary collaborative effort involving nursing; trauma surgery; orthopaedics; ear, nose, and throat; infectious disease; plastic surgery; rehabilitative services; and urology. The patient was discharged from the hospital 4 months after injury. After a lengthy rehabilitation, he has been able to return to work in a full-time capacity with the same company in a computer-related position. Conclusion
Traumatic hemipelvectomy is a rare but devastating injury. The key lesson for the trauma team was the power of a team working together, with the patient as the most important team member. Our patient not only survived but has self-sustaining employment and is a self-sufficient provider of his own care. He no long has phantom pain, and he shows no evidence of chronic psychological trauma. In fact, he has recently made his story public via numerous media sources including the popular press, the Internet, and televised interviews. Although our patient’s primary mode of transportation continues to be in a wheelchair, he has recently been successfully fitted with a prosthesis. A review of our patient’s case shows an individual who refused to
WWW.JENONLINE.ORG
285
TRAUMA NOTEBOOK/Whitney et al
give up. He is a truly extraordinary individual who survived an extraordinary trauma. REFERENCES
5. Ellis J. The many roles of silver in infection prevention [abstract]. Am J Infect Control. 2007;35(5):E26. 6. Jerome D. Advances in negative pressure wound therapy: the VAC instill. J Wound Ostomy Continence Nurs. 2007;34(2):191-4.
1. Labler L, Trentz O, Keel M. Traumatic hemipelvectomy. Eur J Trauma. 2005;31(6):543-50. 2. Reiger H, Dietl K. Traumatic hemipelvectomy: an update. J Trauma. 1997;45(2):422-6. 3. Ossewaarde S. Case study: traumatic hemipelvectomy. Int J Trauma Nurs. 1997;3(1):13-7. 4. Lawless M, Laughlin R, Wright D, Lemmon G, Rigano W. Massive pelvic injuries treated with amputations: case reports and literature review. J Trauma. 1997;42(6):1169-75.
Submissions to this column are encouraged and may be sent to Maureen Harrahill, MS, ACNP-BC [email protected] or Angela Shannon, RN, MS, CEN [email protected]
The "Triage Decisions" section is interested in articles about all facets of triage, including process change, case reviews, or general triage tips. These 3-5 page double-spaced articles can be sent via email to Andi Foley at [email protected] and/or Patricia Kunz-Howard at [email protected].
286
JOURNAL OF EMERGENCY NURSING
VOLUME 36 • ISSUE 3
May 2010