Unusual case of life threatening subcutaneous hemorrhage in a blunt trauma patient

Abstract

Introduction: Hemorrhage is the most common cause of shock in injured patients. Bleeding into the subcutaneous plane is underestimated cause of hypovolemic shock.

Presentation of case: Unrestrained male driver involved in a rollover car crash. On examination, his pulse rate was 144bpm, blood pressure 80/30mmHg, and GCS was 7/15. His right pupil was dilated but reactive. Back examination revealed severe contusion with friction burns and lacerations. A Focused Assessment Sonography for Trauma (FAST) was performed. No free intraperitoneal fluid was detected. CT scan of the brain has shown right temporo-parietal subdural hematoma and extensive hematoma in the deep subcutaneous soft tissues of the back. Decompressive cranicotomy and evacuation of the subdural hematoma was performed. On the 4th postoperative day, three liters of dark brown altered blood was drained from the subcutaneous plane.

Discussion: The patient developed severe hypovolemic shock and our aim was to identify and control the source of bleeding during the resuscitation. The source of bleeding was not obvious. Severe shearing force in blunt trauma causes separation between the loose subcutaneous tissues and the underlying relatively immobile deep fascia. This is known as post-traumatic closed degloving injury. To our knowledge this is the first reported case in the English Literature with severe subcutaneous hemorrhage in blunt trauma patients without any previous medical disease.

Conclusion: Bleeding into the subcutaneous plane in closed degloving injury can cause severe hypovolemic shock. It is important for the clinicians managing trauma patients to be aware this serious injury.

Keywords: Injury; Shock; Subcutaneous.