TY - JOUR T1 - Wrong incisions JF - Trauma Surgery & Acute Care Open JO - Trauma Surg Acute Care Open DO - 10.1136/tsaco-2022-000935 VL - 7 IS - 1 SP - e000935 AU - David V Feliciano Y1 - 2022/04/01 UR - http://tsaco.bmj.com/content/7/1/e000935.abstract N2 - A 27-year-old man suffered a single stab wound to the left supraclavicular space. A pressure dressing applied in the field by the emergency medical service was saturated with dark blood when the patient arrived at the trauma center.The patient was agitated and thrashing about. His blood pressure was 70 mm Hg systolic, heart rate was 130 beats/min, and respiratory rate was 25 breaths/min with barely audible breath sounds on the left and normal breath sounds on the right.As resuscitation with crystalloid solutions and packed red blood cells was performed, an emergency chest X-ray showed a left hemothorax with a mediastinal shift to the right (figure 1). A left thoracostomy tube was inserted, and 1000 mL of dark blood was rapidly evacuated and autotransfused.Figure 1 Admission chest X-ray for patient #1 with stab wound to the left supraclavicular space.The patient was transferred to the operating room where, upon induction by the anesthesiologist, his systolic blood pressure decreased to 30 mm Hg. The surgeon chose to make a left supraclavicular incision to follow the track of the stab wound, but continued profound hypotension prompted conversion to a left ‘book’ thoracotomy incision; that is, a partial median sternotomy and left anterolateral thoracotomy in the fourth intercostal space were connected to the left supraclavicular incision. A 4 cm longitudinal laceration with active bleeding was visualized in the left subclavian vein at its junction with the crossover left innominate vein. An initial attempt to control the laceration in the vein was unsuccessful, and the mid-portion of the left clavicle was resected. Because of continuing hypotension, the descending thoracic aorta was cross-clamped. The left subclavian vein was eventually ligated proximally and distally around the laceration, but the patient had a cardiac arrest from intrapleural exsanguination and could not be resuscitated. Intraoperative transfusion included 34 units of packed red … ER -