Case Report

Case report Femoral Artery Injury Trauma is the leading cause of death in the city where I was working in Iraq , because many trauma victims require immediate surgery , anaesthesiologist can directly affect the survival of these patients . In fact the role of the Anaesthesiologist is often that of primary resuscitator , while providing anaesthesia becomes a secondary activity . This case of bullet injuries directed towards femoral artery in young patient carries many interesting points , because of difficult work circumstances in Iraq under UN sunctions .

Introduction : Femoral artery injury can lead to massive haemorrhage and threaten extermity viability , also causing hypovolemic shock and then death . Shock in general is a syndrome asociated with inadequate oxygen transport to tissues and abnormal cellular metabolism . Hypovolemic shock occures when the intravascular volume is decreased by 15-25 % .

CASE REPORT 25 years old man was admitted to operating room as case of trauma to right femoral artery ( bullet injury ) with bleeding and hypovolemic shock . He was reffered immediately from emergency room in which there is 2 open viens with 2 cannula started and ringer 1000 ml IV infusion was started and sample for blood group and cross match also sent to blood bank . At admission to operation room the patient was pale , restlessness irritable , cold extremities , blood pressure was not detectable by ausculation method , no automatic blood pressure monitor was available , pulserate was not palpable by palpating the radial artery , no pulse oxymeter was available . ECG monitor showed tachycardia , heart rate 180/ min. Third open vein with third cannula was started and blood transfusion was started immediately . Once the patient was reffered to the surgical table , ECG showed bradycardia , loss of consciousness , both pupils where dilated , so immediate external cardiac massage was done , intubation with 100% oxygen was started and hydrocortizon 400 mg IV , ECG showed flat wave , so Adrenaline 1 mg IV then followed by Atropine 1.2 mg IV , then ECG showed tachycardia , pupils again started to react to the light , dexamethasone 8 mg IV , sodium bicarbonite 1 ml/kg IV ( 8.4 ) . The general anaesthesia was given : Ketamine 2 mg / kg IV . Suxamethonium 60 – 100 mg / kg IV infusion , O2 80 % , N2O 20 % . The Suxamethonium which was used was expired 5 months ago . No analgesia was given . No halothane was given . Blood transfusion 4000 ml IV . Calcium Gloconate 10 ml / 1000 ml blood IV . The operation was lasted for 4 hours . During operation second attack of cardiac arrest occurred . So immediate cardiac massage , then the patient responded . During operation and because of contineous suxamethonium overdose the patient was developing bradycardia , so small dose atropine IV 0.2 mg . During operation the electric power was cut , the generator did not work immediately but it took around 15 minutes , so this period was incomplete darkness , the only monitoring is palpation of radial pulse , which started to be palpable , and check the pupils by laryngoscopeblade , then after that , generator started to work again . operation was about to finish , BP 90/50 mm HG , suxamethonium infusion drip was stopped , mannitol 200cc IV . Urine output started to increase , the patient recovered completely , respond to verbal and painfull stimuli ( rapid response ) , spontaneous breathing , then Shifted to ICU for further management , the patient now is living with healthy limb .

Discussion : Many intersting points in this case : 1- First case of femoral artery injury ( bullet injury ) during 8 years working in anaesthesia and ICU as anaesthesiologist doctor . 2- Rapid management of this case , resuscitation immediately started and immediate refer of the patient from emergency room to operation room . 3- Contineous monitoring of the patient inspite of shortage of electronic monitor , no oxymeter was available , no automatic blood pressure monitors . 4- Early detection of both attacks of cardiac arrest and immediate treatment , otherwise any further delay can cause hypoxia and the brain damage which lead to death . 5- Usage of Suxamethonium instead of non- depolarizing muscles relaxant with risk of phase II block , and also was expired 5 months ago . The only complication which was ocuured bradycardia . 6- Cooperation between all operation room staff and experience of surgeons and anaesthesiologists in management of cases of trauma and shock .

REFERENCES : 1- Clinical Anaesthesiology , G . Edward Morgan ; Maged S. Mikhail 23- A practice of anaesthesia , Wylie and Churchill ; Davidson’s fifth edition .