Hemorrhagic shock from breast blunt trauma
© Madden et al. 2015
Received: 22 June 2015
Accepted: 19 August 2015
Published: 2 September 2015
Seat belt use has been associated with decreased life-threatening thoracic injuries. However, there has been an increase in soft-tissue injuries such as breast trauma.
We describe a case of a young healthy female who presented to a community hospital Emergency department without any trauma designation following a motor vehicle accident. The patient was found to have hemorrhagic shock from an intramammary hemorrhage and was treated with blood products and a temporizing external abdominal binder in preparation for a transfer to a level 1 center where she was successfully treated with angiographic embolization.
The objective of this study is to report on a case hemorrhagic shock from a breast hematoma as well as a review of the literature on previous seat belt associated breast trauma and its management in the emergency department.
Seat belt associated breast trauma is uncommon in the emergency medicine literature. However, it can be associated with life threatening intramammary bleeding. Emergency physicians should be aware of these injuries and their proper management.
The use of seat belts has reduced the incidence of life-threatening chest trauma but has increased the incidence of soft-tissue and internal organ injuries [1, 2]. One of the resulting injuries is a blunt injury to the female breast. Blunt breast trauma literature is scarce in emergency medicine . The aim of this paper is to report on a case of hemorrhagic shock resulting from a blunt breast trauma along with a review of the literature on the management of such an injury.
A 54-year-old female with a history of hypertension and abdominal laparoscopy presented to a small community hospital without any trauma designation after a motor vehicle accident. The restrained patient was driving at high speed on wet roads when she lost control of her car and hit the front end of her vehicle on an embankment causing the car to roll over. The airbags did deploy. Patient was able to self extricate and was ambulatory on scene. The patient denied any loss of consciousness.
On arrival to the emergency department, the patient was anxious and complaining of right breast pain and right ankle pain. Her initial vitals were as follows: temperature 36.7 °C, heart rate 94 bpm, blood pressure 201/139 mmHg, respiratory rate of 20, and SaO2 100 % on room air. There were no signs of trauma on her head and neck area. There was a large contusion overlying the right breast with mild swelling when compared to the opposite breast. There was exquisite bilateral rib tenderness at multiple levels, and her right ankle was swollen and tender with intact pulses and sensation. The bedside focused assessment with sonography in trauma (FAST) exam was negative. She was given Fentanyl 100 mcg IV twice for pain control, normal saline 1 l IV, and taken to CT. CT head and cervical spine were unremarkable. CT angiography of her thorax demonstrated a 11.8 × 11.4 × 7.6 cm right breast hematoma with active extravasation. Upon return from CT, the patient was more diaphoretic, anxious, and hypotensive at 82/56 mmHg. She was immediately given a 2 l normal saline IV bolus, and massive transfusion protocol was activated. Because the patient’s level of pain was unchanged after Fentanyl, she was given Ketamine 150 mg IV. While sedated, her right breast was wrapped using an abdominal binder and elastic bandage as a temporizing compression measure. The patient was accepted for transfer to a level 1 trauma facility. At the time of transfer, she received two units of PRBCs and her vitals improved to a heart rate of 108 bpm and a blood pressure of 156/113 mmHg. Platelets and FFP were not ready at time of transfer. She was taken via ambulance because of weather conditions. Her labs were significant for an initial hemoglobin of 12.8 g/dL, a lactate of 2 mMol/L, drug screen positive for opiates, and negative ethanol level.
Breast injury clasification
Mild crush injury consisting of bruising, ecchymosis, skin blistering, breast swelling, tenderness, friction burns over contact area.
Moderate crush injury consisting of intramammary hematoma, fat necrosis, skin avulsion or loss, skin laceration, skin ulcer
Severe crush injury consisting of subcutaneous partial or complete transection of the breast resulting in a permanent diagonal furrow across the breast corresponding to the line of the seat belt that cleaved the breast tissue into two parts
Avulsion breast injury consisting of subcutaneous avulsion of the breast from the chest wall with rupture of perforating branches of intercostal vessels, active bleeding into the breast and the space between the breast and chest wall caused by the traumatic shearing force
This is an interesting case of hemorrhagic shock following a seat belt injury to the breast. The patient presented to a small community emergency department with normal vital signs. However, concern of rapid deterioration soon occurred after discovery of arterial extravasation of the breast and resultant hypotension. This is the first case report that shows the application of an abdominal binder on an actively bleeding intramammary hematoma, and in so, should be of relevance to emergency physicians.
The patient has given her consent for the case report to be published.
The authors have no acknowledgement to disclose. The authors have no funding sources to disclose.
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