Hemorrhagic Shock Caused by Closed Internal Degloving Injury: a Case Report

대한응급의학회지 제 30 권 제 5 호 � 증례� Volume 30, Number 5, 0ctober, 2019

Trauma Hemorrhagic shock caused by closed internal degloving injury: a case report

Hyung-Bin Kim1, Soon-Chang Park1, Sung-Hwa Lee1, Byung-Kwan Bae1, Young-Mo Cho1, Jae-Hoon Jang2, Sung-Wook Park1

Departments of 1Emergency Medicine and 2Orthopedic Surgery, Pusan National University Hospital, Busan, Korea

A closed internal degloving injury is a soft tissue injury, in which the subcutaneous tissue is ripped from the underlying fascia. In rare cases, a closed internal degloving injury can lead to hemorrhagic shock. A 79-year-old woman was brought to the emergency department following an auto-pedestrian accident, in which she was hit by a car. She was in a stupor and was hypotensive. The initial evaluation was unremarkable. During management, the patient required the transfusion of a large volume of blood, and vasoactive agent. Abdominal computed tomography revealed a large hematoma in her lower back and gluteal area and she was diagnosed with a closed internal degloving injury. Missed or delayed diagnosis of this type of injury may result in a significant increase in transfusion requirements and irreversible hemorrhagic shock.

Keywords: Soft tissue injuries; Degloving injuries; Hemorrhagic shock; Hematoma; Contusion

hemorrhagic shock. We present the case of a 79-year-old INTRODUCTION woman who presented with hemorrhagic shock due to closed internal degloving injury following an auto- Closed internal degloving injury, first described by the pedestrian accident. French surgeon Maurice Morel-Lavalle«e in 1863, is defined as a traumatic separation of the skin and subcutaneous tissue from the underlying fascia, which results CASE REPORT in a collection of hemolymphatic fluids between the subcutaneous fat and muscle fascia.1-3 A small hematoma or This report was approved by the Institutional Review seroma may resolve without treatment; however, a grow- Board of Pusan National University Hospital and informed ing hematoma or seroma can cause localized pain, consent was waived (H-1901-012-075) . swelling, or hypoesthesia. The average time to diagnose A previously healthy 79-year-old woman was brought this injury is reported to be between 3 days and 2 weeks to the emergency department (ED) after an auto-pedestri- from the date of injury.4-6 Kottmeier et al.7 reported that an accident. On arrival, she showed decreased mental the diagnosis is missed in up to 44% of patients with status with a Glasgow Coma Scale score of 9. Her initial closed internal degloving injury. Thus, the actual inci- vital signs included a systolic blood pressure (BP) of 50 dence of this injury is underreported and unknown. mmHg, undetectable diastolic BP, heart rate of 78 Clinically, closed internal degloving injury has been beats/min, respiratory rate of 14 breaths/min, and pulse associated with an increased risk of infection and skin oximetry of 95% on room air. Physical examination on necrosis due to compromised circulation of the overlying her head, chest, abdomen, and extremities showed no tissue.2,5,8 In rare cases, this type of injury can also cause external injuries. Focused assessment with sonography

책임저자: 박 성 욱 부산광역시 서구 구덕로 179 부산대학교병원 응급의학과 Tel: 051-240-7503, Fax: 051-253-6472, E-mail: [email protected] 접수일: 2019년 2월 22일, 1차 교정일: 2019년 5월 17일, 게재승인일: 2019년 6월 5일

468 Extensive soft tissue hematoma / 469

the transfusion, we inspected her back and recognized Capsule Summary extensive swelling in the lower back. But there were no abrasion, laceration, and signs of hematoma such as What is already known in the previous study ecchymosis or bruise. A closed internal degloving injury is not uncommon but Once BP was maintained above 90/50 mmHg, comput- is an easily overlooked injury in blunt trauma patients. ed tomography (CT) scans with intravenous contrast of This type of injury has been associated with an the head, chest, abdomen, and spine were performed. increased risk of infection and skin necrosis, but in rare The abdominal CT scan showed a large hematoma with cases can also cause hemorrhagic shock. contrast media extravasation in the subcutaneous tissue of her lower back and gluteal area (Fig. 1). Fluid collec- What is new in the current study tion in the right retroperitoneal space was also notable Closed internal degloving injury can be complicated by but the amount is small. Bleeding or Hematoma was not significant hematoma formation and lead to hemor- observed elsewhere. There was no evidence of cardiac rhagic shock. Missed or delayed diagnosis of this type of tamponade or pneumothorax, and extremity and spine injury may result in irreversible hemorrhagic shock. fracture either. We thought that the cause of her hemorrhagic shock was this soft tissue hematoma with an arterial bleed. We decided to apply a tight bandage around for trauma (FAST) examination revealed no pericardial her trunk to control the bleeding and admitted her to the effusion or intraperitoneal free fluid. Given the fact that intensive care unit with a BP of 103/62 mmHg and a she had been hypotensive for about forty minutes before hemoglobin 9.7 g/dL after transfusion. The following presenting to the ED, we considered hypovolemic shock day, emergency surgical debridement was undertaken as the etiology of altered level of consciousness. We because the patient had developed severe skin color were also concerned about possible traumatic brain change suggesting necrosis of the lower back (Fig. 2A). injury, although she had no obvious facial or head In the operating room, the non-viable skin was excised, wounds. We performed endotracheal intubation for air- which exposed a large hematoma in the lower back (Fig. way protection and administered 2 L of intravenous crys- 2B). The hematoma was removed, after which an exten- talloid fluid rapidly but she showed persistent hypotensive space was observed between the subcutaneous tis- sion (52/38 mmHg). Infusion of norepinephrine was sue and the underlying fascia of the back muscles. On started at 0.5 μg/kg/min. Emergent portable chest and postoperative day (POD) 9, the patient was still placed pelvis radiographs were unremarkable. Her initial labora- tory tests revealed a hemoglobin of 5.8 g/dL, and a platelet count of 117,000/mm3. The international normal- ized ratio (INR) and activated partial thromboplastin time (aPTT) were prolonged to 1.50 (reference range, 0.88-1.12) and 55.2 (reference range, 27.0-42.0 sec- onds), respectively. Liver and kidney function tests were within the normal range. The arterial blood gas analysis results were pH 7.27, pO2 396 mmHg, pCO2 34 mmHg, and base excess -10.4. Given the prolonged INR, aPTT, thrombocytopenia, and metabolic acidosis, we considered hemorrhagic shock with acute traumatic coagulopa- thy. She then received a transfusion of two units of packed red blood cell (RBCs) and fresh frozen plasma (FFP). Due to her persistent hypotension (80/60 mmHg) and anemia (6.1 g/dL), an additional seven units of Fig. 1. Contrast-enhanced abdominal computed tomography packed RBCs, two units of FFP, six units of platelets, showing a large subcutaneous hematoma (☆) in the and four units of cryoprecipitate were transfused. During lower back with contrast extravasation (arrows). 470 / Hyung-Bin Kim et al.

AB Fig. 2. (A) Skin color changes in the lower back. (B) The exposed subcutaneous hematoma from the same lesion after necrotic skin debridement. under ventilator care and showed improvement of the which typically will be deeper, less well defined, and consciousness but had slight confusion. Magnetic reso- less fluctuant.12 If closed internal degloving is composed nance image (MRI) of the brain was performed on POD primarily of blood, like our case, differentiating from 10, but the test revealed no definite signal-intensity hematoma may be impossible by physical examination. abnormalities. Tracheostomy was performed on POD 11 In addition to the mechanism of injury and physical due to pneumonia and pulmonary edema. The removal examination, characteristic location is also important in of the ventilator was made on POD 14, but the patient making the diagnosis of closed internal degloving injury. failed decannulation of tracheostomy due to dysphagia Commonly reported locations of closed internal deglov- and reduced ability to manage secretions. After the ini- ing injury include greater trochanter, pelvis, thigh, knee, tial surgery, the wound was debrided several times over gluteal, and lumbosacral regions.4 The imaging appear- the course of a few months and a skin graft was per- ance can vary according to the age of the extravasated formed to heal the large internal soft tissue defect in the blood and the composition of the collected fluid.13 lower back. The patient was transferred to a rehabilita- Diagnostic modality of choice is MRI. In the ED, CT can tion facility 4 months after presentation to the ED, at be used and a fluid collection abutting a fascial plane is which time she was alert but had tracheostomy due to suggestive of this type of injury. persistent muscle weakness, dysphagia, and large vol- In trauma patients with hemorrhagic shock, the source ume of pulmonary secretions. of bleeding should be promptly identified. The chest, abdominal cavity, and pelvic ring are common sources of blood loss in trauma patients. These sites are routinely DISCUSSION assessed by physical examination, radiographs of the chest and pelvis, and FAST. However, we failed to con- Closed internal degloving injury may occur when sider a soft tissue injury as the source of bleeding and high-intensity force, usually tangential to fascial planes, only performed a cursory examination of the patient’s produces a shearing force.9 Dead space created by injury anterior trunk. Our unawareness of the patient’s soft tis- fills with blood, lymph, liquefied fat, and debris. The sue injury contributed to the delayed identification of the hallmark physical finding in closed internal degloving bleeding source and transfusion of a large volume of injury is a superficial, soft fluctuant area, which may be blood products. Failure to suspect this type of injury and associated with ecchymosis, friction burns, and contour perform meticulous physical examination could cause deformity.10,11 This is slightly different from hematoma, missed or delayed diagnosis which may lead to a signifi- Extensive soft tissue hematoma / 471 cant transfusion requirement and irreversible hemorrhagic shock. CONFLICT OF INTEREST In the literature, there are only two reported cases of hemorrhagic shock from closed internal degloving No potential conflict of interest relevant to this article injury.14,15 In these cases, the patients were hemodynami- was reported. cally unstable and presented to the emergency department with an extensive subcutaneous hematoma in the flank and back. Skin necrosis was not observed in either ACKNOWLEDGMENTS case. Unlike in the previous cases, CT examination of our patient showed active contrast extravasation in the 본 연구는 2018년도 부산대학교병원 임상연구비 지원 hematoma of the closed internal degloving injury. In 으로 이루어졌음. light of this extravasation, we believe that the disruption of perforating arteries of the involved tissues at the time of the injury was more significant in our patient than in REFERENCES the previously reported cases, leading to a rapid filling up the dead space. Moreover, this rapid accumulation of 01. Morel-Lavalle«e M. 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