An 61 year old man presented to the ED in obvious shock, pale, unrecordable blood pressure, after collapsing at home. History was initially limited, but he was known to have had a bone marrow biopsy earlier in the day at another hospital.
Temperature 35 C
Pale, sweaty, altered conscious state,
BP - initially unrecordable, HR 106,
On log roll, dressing over bone marrow biopsy site (L side)
His initial FAST and bloods (pre-biopsy, and post collapse and attendance in ED).
He was treated with blood products (Packed cells and FFP), targeting a BP around 90mmHg which coincided with recovery to baseline mentation
+ What does the CT scan show.
Active bleeding from a branch of the left internal iliac artery into a large left psoas / retroperitoneal haematoma. There is also a very large ascending aortic aneurysm.
+ Post CT the patient once again became hypotensive. What are the disposition options?
The ideal next step is transfer for angio-embolisation by interventional radiologist.
The patient is unlikely to survive open laparotomy.
Transferred to interventional radiology suite for embolisation of the L internal iliac vessel.
The angiography demonstrated a pseudoaneurysm arising from the anterior division of the L internal iliac artery. A 5 x 22mm covered advanced V12 stent was placed, which successfully excluded the pseudoaneurysm.