Shot in the Chest- Aortic Occlusion

A 30-year-old male sustained a gunshot wound to his left lower chest/ upper abdomen. On arrival, his heart rate was in the 50s with weakly palpable carotid and femoral pulses. Significantly hypotensive. Penetrating wound to the left lower chest wall with an occlusive dressing in place without ongoing hemorrhage.

Initial workup and management?

Assess mental status. Secure large-bore peripheral IV access and start massive transfusion. 

A rapid ultrasound of the chest and abdomen revealed fluid in the left chest, right upper quadrant, and no pericardial fluid. We placed a left chest tube with minimal output.

Still hypotensive…treatment options?

Resuscitative thoracotomy. Urgent OR if vitals improve with resuscitation. REBOA.

A rapid secondary survey revealed a previous midline laparotomy. This would likely impede rapid access for aortic control during laparotomy, so REBOA was placed through a right femoral artery cutdown. With inflation of the REBOA, he had a return of cerebral perfusion with spontaneous movement of his extremities.

He was transported emergently to the OR. We encountered massive hemoperitoneum and extensive dense intra-abdominal adhesions that prohibited easy access for a supra-celiac aortic clamp. There was ongoing hemorrhage despite REBOA.

Other options to control intra-abdominal bleeding?

• Procedures directed at source (compression of the liver, splenectomy, etc).

• Aortic occlusion above the injury- stops all perfusion below the level of occlusion. This can be done from the chest through a left anterolateral thoracotomy or below the diaphragm (supra-celiac clamp).

The patient underwent left thoracotomy for aortic cross-clamp. There were no obvious intra-thoracic injuries. Intra-abdominal injuries included a large Zone 1 retroperitoneal hematoma and left diaphragm injury, injuries to solid organs (liver and pancreas) and hollow viscus (stomach, small bowel, and colon).

Management of massive sub-diaphragmatic hemorrhage

Aortic occlusion decreases distal bleeding and redistributes blood volume to the myocardium and brain. This leads to a reduction in sub-diaphragmatic blood loss. Traditionally, this is accomplished through an open approach, either via thoracotomy or laparotomy. Concurrent with the expanding use of and comfort with endovascular approaches, endovascular occlusion of the aorta (REBOA) has been re-introduced as a less invasive approach.

General indications

• Traumatic life-threatening hemorrhage below the diaphragm (non-compressible torso trauma) in patients in unresponsive shock 

• Zone 1 (distal thoracic aorta)- control of severe intra-abdominal/ retroperitoneal hemorrhage, or for traumatic arrest. 

• Zone 3 (above aortic bifurcation)- severe pelvic, junctional, or proximal lower extremity hemorrhage.

Mixed results regarding clinical outcomes. Essentially the same time to aortic occlusion as resuscitative thoracotomy. Not shown to be significantly quicker at obtaining aortic occlusion than resuscitative thoracotomy.

Brenner M et al. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trauma Surg Acute Care Open. 2018;3(1):1-3.