Full Text Online @ www.onlinejets.org Scenarios DOI: 10.4103/0974-2700.50753

Delayed presentation of shock due to retroperitoneal hemorrhage following a fall

Nader N N Naguib Department of General Surgery, Ain Shams University, Egypt

ABSTRACT During trauma the abdomen is one region which cannot be ignored. Due to its Complex anatomy it is very important that all the areas in the abdomen be examined both clinically and radiologicaly to rule out any abdominal bleeding as a cause of Hemorrhagic Shock Following Trauma. Our case justifies the above.

Key Words: Blunt , retroperitoneal hemorrhage, and Shock

INTRODUCTION rapid CT examination (without contrast) to rule out a ruptured aneurysm due to the lack of proper history. It was difficult to We present a case with unclear history that turned out to have maintain his vital signs that started to deteriorate again; so he an abdominal cause for his state of shock was rushed to theatre.

The CT scan showed a huge multi-locular abdominal cyst with CASE REPORT blood-dense fluid inside. The origin of the cyst was not clear due to its size. There was a tiny calcified structure floating in cyst A 53-year-old well-built man slipped on the floor and landed on cavity. Certainly, the possibility of a leaking was his back. He continued to suffer from sharp abdominal excluded. There was no other abnormal finding [Figures 1 and 2]. gradually increasing in severity for the following few days. The was localized in the epigastrium, left hypochondrium and At the laparotomy, a huge dark blue cyst was filling most of the back. As he overlooked his fall, his local doctor attributed the abdominal cavity and pushing the entire bowel to a small these pains to gastritis. compartment. Opening the cyst revealed dark blood clots and de-fibrinated blood. The cyst was multi-locular as shown on On the fourth day following his trauma, he presented to the the CT scan. The blood clots were removed and the loculi were Casualty Unit at Ain Shams University Specialized Hospital with traced down to the retroperitoneal space. The retroperitoneal shock and abdominal pain. He could not give relevant history space was full of blood clots of unidentified origin. There as his level of consciousness continued to deteriorate. None of was no active bleeding. A small branched atheroma taking the his family members who were accompanying him knew about shape of a blood vessel at its bifurcation was retrieved from his trauma. the cavity of the blood cyst. Its diameter was about 4 mm. It denoted the previous rupture of a retroperitoneal blood vessel His systolic blood pressure was 50-60 mmHg, and his heart at its bifurcation (a lumbar artery). This represented the calcified rate was 130 bpm. Inspection showed an abdominal mass. The structure identified at the CT scan. abdominal wall was tender and rigid on examination. The mass was fixed and not pulsating. The patient by this time received 15 units of blood and 12 units of fresh frozen plasma. As a consequence and due to the large Intensive resuscitation measures started immediately. Blood size of retroperitoneal and the fact that there was no was taken for cross match and investigations. The decision of active bleeding or identifiable bleeder and the patient started to exploration laparotomy was made. The patient was temporary show signs of coagulopathy, the decision was not to interrupt resuscitated, and on the way to the operating room, he had a the retroperitoneal hematoma. The cyst pseudo-wall, which Address for correspondence: actually was derived from the retroperitoneal wall, was closed by Dr. Nader N N Naguib, E-mail: [email protected] continuous vicryl suture to tamponade the remaining hematoma.

Journal of Emergencies, Trauma, and Shock I 2:2 I May - Aug 2009 139 Naguib: Late retroperitoneal bleeding

Figure 1: CT scan shows huge multi-locular blood cyst filling most of the abdominal cavity

Figure 2: CT scan; multiple cuts show the extent of the blood cyst at different levels

The patient was transferred to the ICU. He stayed there for his left kidney, he underwent an elective laparotomy. A smaller 3 days and was transferred to the ward. He was discharged 10 multi-locular blood cyst was identified, opened and evacuated. days after his laparotomy. More blood clots were removed and the cyst wall was left open for drainage. The abdomen was closed with two drains inside. One month later, a follow-up CT scan showed re-accumulation of some blood clots and mild left hydroureter and hydronephrosis. The patient went home on the fifth postoperative day. Following The patient was asymptomatic, but to avoid further pressure on his second laparotomy, he developed a infection. Some

140 Journal of Emergencies, Trauma, and Shock I 2:2 I May - Aug 2009 Naguib: Late retroperitoneal bleeding skin stitches were removed to help the pus draining. Six months Evaluating patients who have sustained blunt abdominal trauma follow up by abdominal ultrasound revealed no back pressure remains one of the most challenging aspects of acute trauma on the left kidney and absence of abdominal cysts or masses. care. Physical examination findings are notoriously unreliable as large amounts of blood can accumulate in the peritoneal and pelvic cavities without any significant or early changes in physical DISCUSSION examination findings.[6] Despite improvements in trauma care, uncontrolled bleeding For patients with blunt abdominal trauma, it might be worthy to contributes to 30-40% of trauma-related deaths and is the leading image the abdomen and pelvis to rule out a concomitant occult cause of potentially preventable early in-hospital deaths.[1] The abdominal . According to the European guidelines by the presence of the lethal triad of hypothermia, coagulopathy and Multidisciplinary Task Force for Advanced Bleeding Care, trauma acidosis represents a major risk for deterioration and adverse patients presenting with hemorrhagic shock and an unidentified outcome of polytrauma patients.[2] Resuscitation of the trauma source of bleeding should undergo immediate further patient with uncontrolled bleeding requires the early identification assessment.[7] Although it produces highly sensitive findings in of potential bleeding sources followed by prompt action to well-trained hands, FAST, unlike CT, is not specific to the site minimize blood loss, to restore tissue perfusion, and to achieve of origin and extent of injury.[8] CT scan often provides detailed hemodynamic stability.[1] The clinical symptoms of shock are the diagnosis in cases with misleading symptoms and thus determines three windows to the microcirculation, which can be assessed the need for operative intervention. The best CT imaging requires in terms of inadequate organ perfusion: level of conscious both oral and IV contrast.[9] Stuhlfaut and colleagues concluded (cerebral perfusion), pulse (peripheral perfusion) and urine output that acquisition of initial CT scans without oral contrast material (renal perfusion). These must differentiate whether a patient is helps us to meet both safety (definite risk of aspiration, and the hemodynamically normal or just apparently hemodynamically potential delay in patient care) and efficiency without sacrificing stable. Based on the response to initial resuscitation, the later diagnostic accuracy.[10] The decision to operate upon the patient group of patients is defined as either transient responders or in the reported case study was made because the patient was in nonresponders and is likely to require a surgical intervention for shock. The CT scan we conducted is a controversial issue. It was hemorrhage control.[2] done without contrast and without really having the appropriate time for a detailed radiological study. But because of the absence The problem may be “compensated shock,” in which cellular perfusion lags behind gross physiologic parameters. Not all of a detailed history of his trauma, we decided to exclude a trauma patients with tissue hypoperfusion as the result of ruptured aneurysm or other extra- abdominal cause of bleeding. massive hemorrhage arrive at the emergency department with signs of shock.[3] For patients with major isolated to the abdomen requiring emergency laparotomy, the probability of death shows There is no objective data describing the relationship between a relationship to both the extent of hypotension and the length the risk of bleeding and the mechanism of injury. Decreasing of time in the emergency department for those who were there [11] serial hematocrit measurements may reflect continued bleeding, for 90 min or less. Hill and colleagues observed a significant but patients with significant bleeding may maintain their serial decrease in mortality from shock by introducing an educational hematocrit.[1] Clinical studies have demonstrated that lactate program on trauma and by establishing a 60-min emergency levels and base deficit represent highly sensitive parameters for department time limit for patients in a state of hemorrhagic [12] recognition of “hidden shock” in traumatic hemorrhage.[2] shock. In our case study, it took less than 60 min to transfer this patient to the operating room including the time spared for The lack of a specific diagnosis should not delay resuscitation the CT scan. when hemorrhage is suggested by history, physical examination, or laboratory findings.[3] Retroperitoneal hemorrhage caused by blunt injuries still remains a challenge for the surgeons as there is always a risk of turning Nevertheless, the delayed presentation of an abdominal bleeding it into unstoppable bleeding. Muftuoglu et al., emphasized in a victim of a fall is rare. Wheaton and Tsalamandris presented that a treatment strategy must be determined by the surgeon, a 17-year-old boy with delayed manifestation of abdominal considering the ages, type of injury, accompanying diseases, bleeding 24 hours after a fall.[4] In this case, the patient presented additional organ injuries and especially the hemodynamic on the fourth day after his fall. stabilities of the patients. Perforated hollow viscous and hemodynamic parameters that cannot be stabilized are the Hematoma and bleeding in the retroperitoneal space are observed indications of operation.[13] In 1983, Stone and colleagues in 44% of patients with blunt abdominal trauma. Injuries missed described the techniques of abbreviated laparotomy, packing during the in-hospital secondary survey are responsible for a to control hemorrhage and of deferred definitive surgical repair mortality- rate up to 50% due to delayed treatment, while on until coagulation had been established.[14] Since then, a number the contrary, an early diagnosis does not carry high incidence of authors have described the beneficial results of this concept, of severe complications.[5] which is now called “damage control.”

Journal of Emergencies, Trauma, and Shock I 2:2 I May - Aug 2009 141 Naguib: Late retroperitoneal bleeding

Damage control was done in this case, and the peritoneum was safely extended to the first few hours after trauma.[20] sutured to prevent the spread of the hematoma. The patient was transferred to ICU, and later he had another elective surgery to The first 24 hours of resuscitation is strongly associated with deal with the back pressure on the kidney. increased morbidity and mortality. There is a post-traumatic therapeutic window of 24 h (the silver day), which if used Retroperitoneal bleeding secondary to interruption of lumbar efficaciously may dramatically influence the outcome of trauma and pelvic arteries are the most common cause of hemorrhagic patients.[21] shock from vertical deceleration injuries.[15] Siablis and colleagues reported a case survived after a fall and had a relatively small The established time-dependant management phases for trauma retroperitoneal hematoma detected during urgent splenectomy. patients in the first 24 h comprise the following: It was underestimated; 2 weeks later, the underlying laceration 1. Primary survey with baseline diagnostics and immediate life- of the lumbar artery led to the formation of a pseudo-aneurysm, saving procedures according to the ABC algorithm of the which then ruptured causing a large retroperitoneal hematoma ATLS protocol. and gradual complete femoral nerve palsy. Traumatic rupture of a 2. Damage control surgery in patients who are not responsive lumbar artery is a rare complication of a blunt abdominal trauma to the initial measures of resuscitation. that can lead to a potentially massive retroperitoneal hemorrhage and shock, or to subsequent pseudo-aneurysm formation and 3. Secondary survey, which can only be started in the [16] hemodynamically stable patients including a head to toe delayed retroperitoneal hematoma. In this case, the exact origin of bleeding was not identified as there was no active bleeding. examination and further radiologic work up. It was suggested that the cause of hemorrhage was a ruptured 4. Delayed primary surgery; surgical interventions which are not lumbar artery due to the floating calcified atheroma retrieved immediately required for resolving life threatening conditions from the blood cyst. The atheromatic surgical finding was shaped are performed after further evaluation of the stabilized as a blood vessel with a diameter of 4-5 mm, which indicated patients in the secondary survey.[2] the lining of a lumbar artery. Tertiary survey in the first 24 h can still miss injuries. Vigilance A mortality rate between 18% and 60% is observed in the and careful re-examination is required to minimize the impact patients with retroperitoneal hematoma. The main cause of of these injuries and to effect treatment as early as possible.[22] death is hemorrhagic shock. As a surgical strategy, exploring a retroperitoneal hematoma should be the last resort for the End points of resuscitation are as follows: surgeon if only there is severe active retroperitoneal bleeding 1. Stable hemodynamics without need for vasoactive or as opening of this closed system imposes “a chimney effect” inotropic stimulation and when the pressure on the bleeding tissues is taken-off; the 2. No hypoxemia or hypercapnia bleeding may become even more severe and lethal. Muftuoglu 3. Serum lactate < 2 mmol/l et al., reported in their study that more than half of the patients 4. Normal coagulation with a retroperitoneal hematoma died postoperatively due to the 5. Normothermia decision for retroperitoneal exploration.[13] Many collateral vessels 6. Urine output >1 ml/kg/h[23] supply any particular region of the retroperitoneum. This can explain why once a bleeding artery is under control, collateral supply to the same region could result in new bleeding. This is Conclusion one of the major reasons why the surgeons avoid exploration of the retroperitoneum in the setting of trauma. Also lumbar Bleeding in the retroperitoneal tissue can present late following arteries in particular are difficult to control operatively.[17] As blunt abdominal trauma. It can be massive and lead to damage control surgery was applied in our case, we did not risk hemorrhagic shock. It should be among the differential diagnosis further exploration of the hematoma. It is more important to in patients with clinical diagnosis of hemorrhagic shock even save the patient than to control the hematoma. in absence of evident history of trauma as rapid and prompt management decrease the mortality rate. Damage control Resuscitation is an ongoing process. Throughout the resuscitation surgery should be employed for patients presenting with deep and assessment phase the care providers need to keep an eye hemorrhagic shock and coagulopathy. Close observation and on the big picture - what are the patient’s injuries and what follow up is required as further management is likely required. is the highest priority? Transfer to definitive care, especially Further studies are required to investigate the need of follow up the operating room, should not be delayed by lower priority concerns.[18] imaging for trauma patients to detect the delayed complications at an early stage. Despite the lack of definitive scientific evidence, numerous research studies and requests for funding are based on achieving References the “Golden Hour” for all trauma patients.[19] In blunt polytrauma patients, this early phase of the golden hour is not restricted to 1. Spahn DR. Management of bleeding following : A European management within the first 60 min after injury only, but can be Guideline. Crit Care 2007;11:R17.

142 Journal of Emergencies, Trauma, and Shock I 2:2 I May - Aug 2009 Naguib: Late retroperitoneal bleeding

2. Stahel PF, Heyde CE, Ertel W. Current concepts of polytrauma 14. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy management. Eur J Trauma 2005;3:200-11. with onset during laparotomy. Ann Surg 1983;197:532-5. 3. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: Hemorrhagic 15. Buckman RF, Buckman PD. Vertical deceleration trauma. Surg Clin N shock. Crit Care 2004;8:373-81. Am 1991;71:331-41. 4. Wheaton DJ, Tsalamandris K. Delayed presentation of abdominal bleeding 16. Siablis D, Panagopoulos C, Karamessini M, Karnabatidis D, Margariti in a teenage boy after a fall. Am J Emerg Med 2000;18:78-82. S, Tepetes K, et al. Delayed diagnosis of a false aneurysm after lumbar arterial injury: Treatment with endovascular embolization: A case report. 5. Ambacher T, Riesener KP, Kasperk R and Schumpelick V. Transport Spine 2003;4:E71-3. management in blunt abdominal trauma: Case report of a patient with delayed diagnosis of splenic rupture. Zentralbl Chir 1999;124:1036-40. 17. Scalea OM, Glanz I, Goldstein IS, Duncan BO, Shaftan EW. Lumbar arterial injury: Radiologic diagnosis and management. Radiology 1987;165:709-14. 6. Udeani J, Ocampo HP. Abdominal Trauma, Blunt. E-Medicine. 18. Sherry E. Worldortho electronic textbook. Chapter 19. Available from: 7. Spahn DR, Cemy V, Coats TJ, Duranteau J, Mondejar EF, Gordini G, et al. http://www.worldortho.com. 1997. Management of bleeding following major trauma: A European Guideline. 19. Lerner EB, Moscati RM. The golden hour: Scientific fact or medical “urban Crit Care 2007;11:R17. legend”? Acad Emerg Med 2001;8:758-60. 8. Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez 20. Osterwalder JJ. Can the “Golden hour of shock” safely be extended in A. Hemoperitoneum as the sole indicator of abdominal visceral injuries: blunt polytrauma patients? Prospective cohort study at a level I hospital A potential limitation of screening abdominal us for trauma. Radiology in Eastern Switzerland. Prehosp Disast Med 2002;17:75-80 1999;212:423-30. 21. Blow O, Magliore L, Claridge JA, Butler K, Young JS. The golden hour 9. Salomone JA, Salomone JP. Abdominal Trauma, Blunt. E-Medicine. and the silver day: detection and correction of occult hypoperfusion within 10. Stuhlfaut JW, Soto JA, Lucey BC, Ulrich A, Rathlev NK, Burke PA, et al. 24 hours improves outcome from major trauma. J Trauma Injury, Infect Blunt abdominal trauma: Performance of CT without oral contrast material. Crit Care 1999;47:964-9. Radiology 2004;233:689-94. 22. D’Amours SK, Sugrue M, Russell R, Nocera N. Handbook of trauma care. 11. Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ. Time to The Liverpool Hospital Trauma Manual. 6th ed. 2002. ISBN 1 74079 027 8. laparotomy for intra-abdominal bleeding from trauma does affect survival 23. Parr MJ, Alabdi T. Damage control surgery and intensive care. Injury for delays up to 90 minutes. J Trauma Injury Infect Crit Care.2002;52:420-5. 2004;35:712-21. 12. Hill DA, West RH, Roncal S. Outcome of patients with hemorrhagic shock: An indicator of performance in a trauma centre. J R Coll Surg How to cite this article: Naguib NNN. Delayed presentation of shock Edinb 1995;40:221-4. due to retroperitoneal hemorrhage following a fall. J Emerg Trauma 13. Muftuoglu MA, Topaloglu U, Aktekin A, Odabasi M, Ates M, Saglam A. Shock 2009;2:139-43. The management of retroperitoneal . Scand J Trauma Resusc Received: 11.06.008. Accepted: 05-08-08. Emerg Med 2004;12;152-6. Source of Support: Nil. Conflict of Interest: None declared.

Journal of Emergencies, Trauma, and Shock I 2:2 I May - Aug 2009 143