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

2-
3- A practice of anaesthesia , Wylie and Churchill ; Davidson’s fifth
edition .