A previously healthy 18-year-old man suffered a frontal collision in a traffic accident.
Initially conscious, abdomen painful, O2 saturation by pulse oximetry 98% and systolic blood pressure (SBP) 90 mmHg.
During the transfer, the patient presented hemodynamic instability and decreased level of consciousness, so orotracheal intubation was performed, with clinical suspicion of hemorrhagic shock due to closed abdominal trauma.
Upon admission, a positive abdominal lavage was performed; an emergency puncture was performed to the operating room where a sphincterectomy was performed due to rupture of the spleen and suture of 4 hepatic fissures.
Hypotension and abundant bleeding from abdominal drains, significant anaemia (haemoglobin 6.2 g/dl) persisted during the postoperative period, therefore surgical reintervention was performed with fresh non-renaline blood gas/fused units.
The electrocardiogram (ECG) showed Q wave in II, III and aVF and sinus tachycardia at 170 lat/min. Creatinine kinase (CPK), 2,510 pg/l; isoenzyme B
cardiac output, left ventricular ejection fraction (LVEF) was measured at 20 h after admission: left ventricular systolic pressure was slightly dilated, left ventricular systolic function was preserved, pulmonary valves were normal and mitral regurgitation was maintained.
Increased pro-BNP up to 16,930 pg/ml, and it was decided to place a Swan-Ganz catheter that showed a mean cardiac output (CO) of 5.5 l/min; mean pulmonary artery resistance of 249 cm × 13 cm × 52 cm;
PO2 in mixed venous blood (distal), 51.8 mmHg (SvO2 86%); PO2 in right atrium blood (approximately), 40 mmHg (SvO2 75%), reason why medication is suspected
Nine patients were transferred to the operating room 60 hours after admission to remove intra-abdominal compression gauze.
Physical examination revealed a pro-tomesosystolic murmur II/ VI with a wide left ventricular border and a left ventricular septal defect with a new TTE showing severe dilatation of the right ventricular cavity and pulmonary hypertension with preserved septum.
The most evident systolic murmur (IV/VI); pro-BNP, 16,930 pg/ml; TnT, 0.707 ng/ml.
An urgent surgical closure of the apical septal defect (4 cm) was performed with placement of a tapered device under extracorporeal circulation. The patient showed progressive hemodynamic improvement with a paulatine decrease of amines 2,476 pg/ml after removal.
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The postoperative control TTE confirmed complete repair of the VSD with a tapering component.
The patient was extubated on the tenth day and admitted to the hospital ward after 15 days with a pro-BNP of 5,548 pg/ml and TnT of 0,230 ng/ml and discharged at 23 days.
