Case 10-2007 A 55-Year-Old Man Impaled in a Rowing Accident

Robert L. Sheridan, M.D., George Velmahos, M.D., Ph.D., R. Malcolm Smith, M.D., and Richard Sacknoff, M.D. N Engl J Med 2007; 356:1353-1360March 29, 2007

Presentation of Case
A 55-year-old man was admitted to this hospital after being impaled by the prow of a racing shell in a rowing accident. The patient, who was in excellent health, was sculling on the Charles River in Boston when his boat collided head-on at approximately 7:20 a.m. with an eight-person shell moving in the opposite direction; both boats were estimated to be traveling at 12 to 16 km per hour. The initial contact between the vessels tore a rubber safety bumper from the larger boat, and the sharp prow of the larger craft entered the left side of the patient's lower back, above the iliac crest, and exited

the central portion of his lower abdomen above the pubis (Figure 1Figure 1Diagram of the Patient's Injury.). He then slipped off the larger vessel's prow and fell into the water. He did not lose consciousness and within 5 minutes was pulled from the water by the occupants of the larger boat and brought to shore. Emergency medical services (EMS) were called and were dispatched at 7:23 a.m., arriving at 7:36. On examination by EMS personnel, the patient was alert, in pain, and lying on his right side. The systolic blood pressure was palpable at 108 mm Hg, the diastolic pressure was not recorded, and the pulse was 72 beats per minute; the respirations were 16 breaths per minute. Capillary return was less than 2 seconds. The skin was cool and wet; the lungs were clear. There were lacerations on the lower back and abdomen, with loops of intestine protruding from the wounds. Oxygen was administered by face mask, and the patient was transferred by ambulance to the emergency department of this hospital, departing the scene at 7:44 a.m. While in transit, an intravenous line was placed, and 300 ml of normal saline was rapidly infused. The trauma center of this hospital was notified at 7:52, and the ambulance arrived at the hospital at 7:55.

The patient had a history of obstructive sleep apnea, a laparoscopic cholecystectomy, lumbar spinal fusion, tonsillectomy, and adenoidectomy. He had no allergies to medications. He was married, exercised regularly, and took no medications. He drank alcohol in moderation and did not smoke or use illicit drugs. The patient arrived at the trauma resuscitation area at 7:58 a.m., where he was met by the trauma team, members of which arrived between 7:55 and 8:10. The radiology service, clinical laboratories, blood bank, and operating room were alerted. On arrival, the patient was alert. The blood pressure was 120/60 mm Hg, the pulse 78 beats per minute, and the rectal temperature 36.1C; the respirations were 28 breaths per minute while the patient was breathing 100% oxygen with a non-rebreathing mask. The skin was cool and pale; carotid, femoral, and pedal pulses were 2+ bilaterally. There was a horizontal laceration in the left lower abdominal quadrant that was 10 cm in length and a laceration on the posterior left flank that was approximately 14

cm in length (Figure 2A and 2BFigure 2 Preoperative and Intraoperative Photographs of the Injury.). Loops of small bowel protruded from both wounds, with vigorous bleeding. Rectal examination was normal, and there was no blood in the rectum. There was no clinical evidence of injury to the spine, and the results of the remainder of the examination were normal.

Results of laboratory tests are shown in Table 1Table 1 Results of Hematologic and Serum Chemical Laboratory Tests.. The patient was placed on a warm blanket, and a urinary catheter was inserted; the urine was yellow and cloudy, with more than 100 red cells per high-power field. The trachea was intubated using a rapid-sequence-intubation protocol, with the addition of fentanyl, at 8:07 a.m. A chest radiograph was normal. A central venous line was placed, and warm crystalloid solution was infused. Tetanus toxoid was administered intramuscularly, and ampicillin and metronidazole were administered intravenously. The blood pressure rose to 140/77 mm Hg. The patient was taken to the operating room at 8:22.

General endotracheal anesthesia was induced with isoflurane and propofol. Intraoperative radiographs revealed the previous vertebral laminectomy at L5S1 and a comminuted fracture of the left ilium extending close to the left sacroiliac joint (Figure 3AFigure 3

Radiographic Images.). The patient was placed in a semilateral position to allow access to both wounds. The neck, torso, and thighs were prepped and draped. Blood and crystalloid solution were infused. The posterior wound was briefly examined, a fragment of bone from the iliac crest was removed, and the wound was packed so that the laparotomy could proceed. A midline abdominal incision was made. Exploration of the abdomen disclosed avulsion of approximately 60 cm of small intestine, with several full-thickness lacerations, and avulsion of the left colon, with multiple contusions (Figure 2C). The peritoneal cavity contained intestinal contents, fragments of muscle, wood, flecks of paint, and fluid that was presumed to be river water. There was vigorous bleeding from mesenteric vessels. Bleeding was controlled, followed by resection and primary anastomosis of the injured segments of the intestine and irrigation of the abdominal cavity and retroperitoneum with warmed crystalloid solution. The other abdominal organs, kidneys, ureters, and major nerves appeared to be intact. The anterior wound in the abdominal wall was dbrided, foreign material and muscle fragments were removed, and the wound was closed. To assess the extent of muscle damage, an incision was made in the skin to connect the entry and exit wounds. The wound in the lower back was examined; fragments of wood and necrotic muscle were removed, the wound was irrigated, and the retroperitoneum was closed behind the bowel. Lumbar nerve roots appeared to be stretched, and one was completely divided within the wound. Primary closure of the entire defect in the muscle was not possible, so a vacuum sponge was inserted, and the skin closed. Pathological examination of the excised tissue revealed a segment of small bowel, 19.5 cm in length, with two transmural lacerations that were 6.0 by 2.0 cm and 2.5 by 0.5 cm, and a segment of the colon, 6.0 cm in length, with a serosal injury that was 1.5 by 0.8 by 0.2 cm. Postoperatively, the patient was placed on bed rest with nasogastric suctioning and no oral intake. Ampicillin, levofloxacin, and metronidazole were administered intravenously. Narcotic analgesics and dalteparin were given. On the second hospital day, radiographs and computed tomographic (CT) scanning of the pelvis confirmed the presence of a fracture through the wing of the left ilium, with a slight posterior displacement of the iliac wing that did not enter the acetabulum (Figure 3B). On the third hospital day, 2 units of packed red cells were transfused. The patient was returned to the operating room, and the posterior wound was reassessed. No necrotic tissue or purulent drainage was found. A defect in the soft tissues forming the posterior abdominal wall was continuous with a triangular defect in the pelvic brim left by the prow of the boat, into which a

loop of bowel had herniated (Figure 3C). A local fascial flap was rotated into the defect to close it, and the flap was secured to the pelvis with sutures. During the next week, the patient gradually advanced to ambulation, and the nasogastric tube was removed; oral intake was resumed, and solid foods were gradually introduced. On the eighth hospital day, the posterior drain came out and was not replaced; the next day, intravenous antibiotics were discontinued, and oral antibiotics were administered. On the 10th hospital day, the maximum temperature was 37.4C; the abdominal incisions were clean, dry, and intact; and the abdomen was soft, not distended, and mildly tender, with bowel sounds present. The patient was discharged to his home.

http://www.nejm.org/doi/full/10.1056/NEJMcpc079004