Survival After Emergency Department Pneumonectomy in a Rural Setting: Success of the Regional Trauma System

Keywords

Trauma, pneumonectomy, trauma centers, patient outcomes

Case Report

Traumatic pneumonectomy remains a highly morbid procedure, with mortality rates being reported as high as 100% due to right-sided heart failure, pulmonary insufficiency, and severe shock [1]. We present a case report of survival to discharge after emergency department (ED) pneumonectomy for a patient “in extremis” from multiple gunshot wounds. This case highlights the value of coordination between level I trauma centers and non-level I trauma centers in working together to improve patient outcomes.

Emergency medical services was called to scene to find an unresponsive 22-year-old male with eight gunshot wounds to the right chest, bilateral arms, right groin, and right leg. On scene, he had agonal respirations, a pulse rate of 70, and no obtainable blood pressure. On arrival to the ED at the American College of Surgeons-verified Level III trauma center, he was confirmed to be in PEA, for which he was immediately intubated, had IV access secured, and underwent placement of a right-sided chest tube. Ten minutes after arrival, the surgeon was at bedside at which time the right-sided chest tube had drained 1500mL of blood. An emergent thoracotomy was performed with right pneumonectomy for perforation of the right pulmonary artery. The patient received 14 units of PRBCs, 3 units of FFP, and 10 units of platelets. After the emergent pneumonectomy, the patient remained hypothermic, coagulopathic, and hypoxic so was transferred by helicopter to the regional Level I trauma center for continued care.

On arrival to the ICU, the patient was acidotic with a pH of 7.05, base deficit of 16, BP of 140/100 and pulse 96 requiring pressors. Echocardiogram demonstrated right heart dilation with generalized hypokinesis. Chest x-ray demonstrated pulmonary edema. He responded to diuresis and inotrope support, but with worsening respiratory failure. After a complex course, which included placement on the oscillator and nitric oxide for ARDS, he was eventually weaned and discharged home after a one-month hospital stay. This patient’s survival demonstrates the capability of an inclusive trauma “system” to provide high level trauma care, even in a rural community. The rural Level III trauma center brought an experienced general surgeon to the bedside within 10 minutes of arrival, capable of performing a thoracotomy and emergency pneumonectomy to control exsanguinating hemorrhage. Transfers from Level III centers to a Level I trauma center have demonstrated improved survival over transport from non-designated trauma centers in part due to early identification for needed intervention, stabilization and rapid transfer to the Level I center for advanced care as needed as demonstrated in this report [2]. The patient’s continued and ultimate survival is a product of a well-established regional trauma system, with rapid aeromedical transfer to the waiting Level I trauma center. At the Level I center, there were 24/7 in-house trauma and surgical critical care physicians who managed his turbulent and complicated post-pneumonectomy and profound sepsis course over the ensuing month to ultimate recovery and functional survival.

Article Info

Article Type

Case Report

Publication history

Received: Mon 16, Dec 2019
Accepted: Tue 24, Dec 2019
Published: Tue 31, Dec 2019

Copyright

© 2023 Ronald F. Sing . This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.JSCR.2019.01.04

Author Info

Kyle W. Cunningham Ronald F. Sing Sullivan A. Ayuso

Corresponding Author

Ronald F. Sing
Department of Surgery, Carolinas Medical Center, Charlotte, NC

Figures & Tables

References

1. Halonen Watras J, O'Connor J, Scalea T (2011) Traumatic pneumonectomy: a viable option for patients in extremis. Am Surg 77: 493-497. [Crossref]
2. Barringer ML, Thomason MH, Kilgo P, Spallone L (2006) Improving outcomes in a regional trauma system: impact of a level III trauma center. Am J Surg 192: 685-689. [Crossref]