Severe multiple injuries with ulcer perforation in one case: blood transfusion, rehydration to correct shock, dehydration, and reduction of intracranial pressure, bleeding, hormones, and antibiotics were administered, stabilizing the patient's vital signs. In the afternoon, the patient's temperature increased up to 39°C, so physical cooling with an ice cap and intramuscular injection of antipyretic drugs were applied, resulting in a drop in temperature. The next day, the patient showed an increase in disturbance of consciousness. A follow-up CT scan revealed that the original contusion lesions in the bilateral frontal lobes had increased bleeding and edema, shifting the midline leftward by about 0.5 cm on the right frontal side. Hematoma evacuation along with internal and external decompression and tracheostomy were performed. Postoperatively, the patient’s disturbance of consciousness gradually decreased. Three days after surgery, a follow-up head CT showed good reduction of the right frontal lobe brain tissue, restoration of midline structures, and clear brain structure. On the fourth day, the patient opened their eyes for a long time spontaneously, with increased frequency of pain response upon stimulation. In the afternoon, the patient’s body temperature rose to 39.5°C, pulse and respiratory rate increased, wet sounds were heard in the lungs, heart rate was 160 beats per minute, and irregular breathing was noted. The abdomen was flat, with a reaction upon pressing the abdomen. After questioning the family members, it was confirmed that the patient had discharged and bowel movements post-injury. Antibiotics, nutritional support therapy, enteral feeding, physical cooling with ice caps, and increased hormone application were associated with improvement in her condition. Six days after surgery, the body temperature increased again, the abdomen slightly bulged, muscle tension was present, tenderness was noted, and a B-ultrasound review indicated ascites. Abdominal paracentesis yielded pale yellow viscous liquid, turbid without significant sediment or foreign matter. Analysis of the puncture fluid showed: yellow, cloudy, Li Fan test positive, microscopy: pus balls (+ + + +), red blood cells (+). Considered: delayed liver contusion secondary to diffuse peritonitis; bedside placement of a peritoneal drainage tube with normal saline and metronidazole rinse was conducted. Following previous nutritional support therapy and joint application of effective antibiotics, nearly 10 hours after the procedure, the drainage tube suddenly emitted large amounts of turbid yellow liquid containing mucus and brown particles, leading to septic shock with acute pulmonary edema. While actively correcting shock, laparotomy was performed. Intraoperatively, a large amount of pale yellow purulent exudate was seen in the abdominal cavity, with a duodenal perforation of 0.8 cm in diameter. Line perforation repair was done, followed by repeated flushing of the abdominal cavity with saline and metronidazole, intra-abdominal retention, and multi-placement of drainage tubes in the liver, spleen fossa, and pelvis. Preoperative, intraoperative, and postoperative vital signs were unstable, with low blood pressure, arterial oxygen saturation, oliguria, and emergence of multi-system organ failure (MSOF). The patient eventually died.
Discussion:
The patient had severe multiple injuries, including severe traumatic brain injury and serious multiple rib fractures with hemopneumothorax. After active closed thoracic drainage, vital signs stabilized; clinical observation of exacerbations in brain injury led to timely craniotomy for hematoma removal, internal and external decompression, improving the patient's condition. Secondary diffuse peritonitis due to burst ulcer perforation caused MSOF and death. Diagnosis and treatment points: (1) Multiple injuries and organ damage in patients are severe and complex, with more complications. (2) The patient remained in a light coma, not fully conscious, with no complaints. Abdominal examination post-injury and the next few days showed no abnormalities, and abdominal B-ultrasound examination on the day after injury was normal. The patient had discharge and bowel movement, with no careful examination revealing abdominal signs, thus masking the peritonitis from duodenal ulcer perforation. (3) Post-traumatic fasting lasted five days after injury, and the condition suddenly worsened, leading to abdominal puncture revealing food sediment and foreign matter. Combined with normal abdominal B-ultrasound on the day after injury, and review B findings seven days after injury did not consider duodenal rupture or perforation, hence conservative treatment was observed, failing to proceed with laparotomy. Duodenal ulcer perforation in patients may be due to: (1) history of previous ulcers without obvious symptoms but untreated; (2) stress after traumatic brain injury; (3) high-dose dexamethasone inducing ulcers or even acute perforation. There have been reports of severe trauma-induced stress ulcer bleeding, but fewer reports of ulcers. This patient warns us to carefully conduct comprehensive physical examinations on unconscious patients to identify causes and pay attention to complications. Mastering good indications for surgery, timely and decisive surgical treatment is necessary to save patients' lives. For patients with severe trauma, less hormone use should be considered, paying attention to preventing stress ulcer bleeding or even perforation occurrence.