Intracorporeal Use of the Hemostatic Agent QuickClot in a Coagulopathic Patient with Combined Thoracoabdominal Penetrating Trauma Franklin L. Wright, MS, Hong T. Hua, MD, George Velmahos, MD, Dave Thoman, MD, Demetrios Demitriades, MD, PhD, and Peter M. Rhee, MD, MPH, FACS J Trauma. 2004;56:205–208. T he clinical triad of acidosis, coagulopathy, and hypother- mia represent a significant therapeutic challenge in trauma patients. Hemorrhage and exsanguination can rapidly become uncontrollable, and a vicious cycle emerges, with significant overall mortality despite treatment. The con- cept of damage control surgery arose as a method of effec- tively controlling exsanguinating patients such that these un- derlying physiologic abnormalities may be corrected. 1 However, the key to success is to control major hemorrhage while delaying other nonessential procedures until the patient has been adequately resuscitated. This case represents the first reported intracorporeal use of a novel hemostatic agent, QuikClot (Z-Medica, Newington, CT), resulting in immedi- ate lifesaving hemorrhage control in a patient with hemor- rhage not amenable to conventional methods of hemostasis. CASE REPORT A 22-year-old man presented to the emergency depart- ment with multiple gunshot wounds to the back, abdomen, bilateral hips, and left thigh. On primary survey, the patient’s airway was patent; however, he was tachypneic, with a re- spiratory rate of 44 breaths/min. He had diminished breath sounds over the left lung field. His initial blood pressure was 118/88 mm Hg, with a pulse rate of 163 beats/min. The patient was awake and combative, moving all extremities purposefully. On complete exposure, he was noted to have gunshot wounds as follows: left back 2 cm medial to the left scapula, periumbilical region, right iliac crest, left iliac crest, left lateral hip, left buttock, and one anterior and one lateral wound to the left thigh (Fig. 1). In the emergency department, the patient underwent rapid sequence intubation. A left thoracostomy tube was placed, immediately yielding 800 mL of sanguinous output, which rapidly subsided and was subsequently autotransfused. A quick focused ultrasound examination failed to show free fluid in the pericardium or abdomen. A chest radiograph was taken and two large-bore intravenous catheters were placed. The patient’s initial hemoglobin level was 11.9 g/dL. Sec- ondary survey yielded no additional significant findings. Dur- ing initial resuscitation, the patient remained tachycardic and became hypotensive, with a systolic blood pressure of 90 mm Hg. Given the extent of the injuries and the clinical presence of shock, the patient was transported immediately to the operating room for an exploratory celiotomy, where a small amount of blood was evacuated from the peritoneal cavity. A pericardial window was performed, with no blood found in the pericardial sac. No major vascular injury was noted. Two enterotomies were found and repaired rapidly. In addition, a pelvic hematoma containing approximately 800 mL of blood was noted. This hematoma was explored and the bleeding was found to be from the bullet track of the left gluteal injury. Intraoperatively, the patient’s systolic blood pressure contin- ued to fall, from 90 mm Hg to 60 mm Hg. The chest radio- graph taken in the emergency department arrived in the op- erating room and revealed a residual left hemothorax (Fig. 2). His chest tube was noted to have an additional 1,000 mL of sanguinous output. A left thoracotomy was performed imme- diately and a massive left hemothorax was encountered. The patient had injuries to the upper lobe and lower lobes of the left lung. The heart, aorta, and major pulmonary vessels appeared intact. Hemorrhage from the upper lobe was quickly controlled with suture ligation, as the location of the track made it difficult to perform a stapled resection. A wedge resection of the lower lobe laceration was performed with a GIA stapler. Further hemorrhage was noted, coming from the massive posterior chest wall gunshot wound, with multiple rib fractures of T2 to T4. Submitted for publication July 9, 2003. Accepted for publication August 4, 2003. Copyright © 2004 by Lippincott Williams & Wilkins, Inc. From the Department of Surgery, Keck School of Medicine, University of Southern California (F.L.W., H.T.H., G.V., D.D., P.M.R.), and Navy Trauma Training Center, Los Angeles Medical Center (D.T., P.M.R.), Los Angeles, California. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Department of Defense at large. This article was prepared by a United States Government employee and, therefore, cannot be copyrighted and may be copied with restriction. Address for reprints: CDR Peter Rhee, MC, USN, MD, MPH, FACS, Navy Trauma Training Center, LAC+USC, 1200 North State Street, Room 6336, Los Angeles, CA 90033; email: prhee@nshs-sd.med.navy.mil. DOI: 10.1097/01.TA.0000074349.88275.C4 CASE REPORT The Journal of TRAUMA  Injury, Infection, and Critical Care Volume 56 • Number 1 205