| Abstract: ACS is increasingly recognized after massive trauma and damage control laparotomy. The indirect method of utilizing bladder pressure has become the standard technique for measuring intra-abdominal pressure. We present a case wherein the bladder pressure confused the clinical scenario, complicating the management of the patient.
An 18 y/o male presented S/P GSW to LLQ, and 2 GSW to the LLE. Vital signs upon arrival included a GCS of 15, BP 96/58, P 126 and RR 20. He received 3 liters of crystalloid and 2 units of packed red blood cells. Physical examination was remarkable for abdominal tenderness with both guarding and rebound. Significant findings upon exploration included a right retroperitoneal hematoma, perforation of the right internal iliac artery and vein, bleeding from pelvic bone, and multiple small bowel perforations. Right retroperitoneal exploration, ligation of the right internal artery and vein, ligation of multiple bleeding unnamed pelvic vessels, foley tamponade of pelvic bone bleeding, small bowel resection, and packing for damage control laparotomy and towel clip closure were performed.
Bladder pressures were 20 cm H20 with PIPs of 32 on standard CMV. 24 hours postoperatively his urine output decreased and Creatinine increased to 1.7. The reduced urine output was attributed to ATN. Bladder pressure at this time 49 cm H20 and PIPs were unchanged. Awaiting correction in the patient's coagulopathy, pack removal was planned for 36 hours postoperatively.
On the first post-trauma day, he was turned on his left side and his saturation dropped to 45%. He was returned to the supine position and his FIO2 was increased from 35% to 100%. His saturation transiently improved to 70% but then fell to 30% with SBP of 30.
With a tentative diagnosis of ACS, the towel clips were removed and his intraabdominal aorta was clamped, resulting in a SBP of 70 but no improvement in saturation. Intraoperatively it was noted that his foley catheter was kinked and not draining secondary to the retroperitoneal hematoma, so a suprapubic catheter was placed, which resulted in free-flowing urine. The elevated bladder pressures were attributed to kinking of the foley catheter. His abdomen was closed with a Bogata bag. Postoperatively, a CT demonstrated a massive saddle pulmonary embolus for which an IVC filter was placed
This case report demonstrates that despite the usefulness of obtaining bladder pressures to support a diagnosis of ACS, they cannot be interpreted as isolated findings.
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