246. “Entire left buttock blown off.”

Singleton, James W., S/Sgt 6999206 Age 24 A CO 165 Com. Eng.
Injured 1340 hrs 13 Dec 44 Shell frag.
Coll Co A 120th Med Bn 1510 hrs. Sulf dressing M.S. gr ½
Clr. Sta. 120th Med Bn 1530 hrs.   T.T. 1 cc
57th Field Hosp. 1545 hrs.    

Gen’l condition on admission poor. Shock severe. B.P. 86/60 P. 112. Dressings soaked with bright red blood as were the blankets. Two inches shortening in left leg. Abd. soft and no tenderness. Urine clear. Rectal exam shows no evidence of an intrarectal perforation however immediately at the anus there is a large wd which involves the external sphincter. Immediately lateral to this wound is a second wound. Each of these wds was 5 inches in length. Wd. over lateral left buttock was 7 to 8 inches in length.

Diagnosis: S.F.W. pen. and perf. left buttock, sv. F.C.C. femur, left; F.C. pelvis. Shock, secondary, severe. Paralysis partial leg left.

Preop Rx

1545 hrs. B.P. 86/60 P. 112 1000 cc plasma & 500 cc blood.
1630 hrs. B.P. 136/70 P. 92  
1630 hrs.     Urine clear. Catheter passed easily
25,000 units Penicillin.
1800 hrs. B.P. 116/74    
1920 hrs. B.P. 80/40   following Xray.
2000 hrs. B.P. 80/60 P. 160 500 cc blood 500 cc plasma 1000 NSG
2015 hrs. B.P. 80/60 P. 160 Endotracheal Ether & O2
2045 hrs.     Turned on side. Pulse good volume 134. B.P. before turning 100/60
2055 hrs.     Operation began.
2130 hrs.   P. 128 500 cc blood.
2210 hrs. B.P. 84/60 P. 134  
2230 hrs. B.P. 98/50   500 cc blood--500 cc blood.
2300 hrs. B.P. 90/50 P. 142 on Hawley table.
2335 hrs. B.P. 100/60 P. 120 Spica finished.

Pt. turned on right side. Perf. wds of buttock debrided. Isthmus of skin between two wds. incised and entire buttock laid wide open. There was extensive destruction of muscle. After thorough debridement to deep muscles (piriformis, gemelli, etc.) spine of Ischium were exposed. Left sciatic N. was exposed in wd. for a distance of 8 inches. Continuity of the nerve was not lost but it was severely contused and partially lacerated. Fractured femur was exposed in wd. There was considerable bony loss. Inf. and superior gluteal arteries were lacerated just as they pass thru inferior and superior pyriformic foramena. Pulsating but not bleeding. Ligated with silk. Penetrating wd. immediately at anus on left side divided the external sphincter. This wd. communicated with tract of perforating wds. Wds. irrigated with hot normal saline. 10 gms. sulfa dusted into wd. Dry gauze wicks and one penrose drain led to recesses of wound. Four silk retention sutures used to approximate incised portion of wound. Pt. turned on back. Loop colostomy made thru left McBurney incision. Dry gauze sponge on sponge stick introduced into pelvis--returned clean and dry. Loop colostomy opened. Spica cast applied. 25,000 cc total blood 1500 cc plasma total before and during operation. B.P. at end of op. 100/60 P. 120.

Dec. 14 S.G. blood 1040 S.G. plasma 1022. Hematocrit 24 Hb. 51%. Condition satisfactory. 500 cc blood 500 cc plasma.
Dec. 15 T. 102 is alert. 500 cc blood.
Dec. 17 500 cc blood. Ht. 36. T. still elevated.
Dec. 18 Cast split--pt. on belly--posterior half removed and wds dressed. All drains removed. Wd. looks excellent.
Dec. 20 Operation 1000 hrs. 2. gms. Pentothal. Cast removed. Wd. dressed. Necrotic skin flaps debrided. Zinc peroxide paste spread into recesses of wd. Transportation cast. 500 cc A.B. blood. 1 unit plasma.
Dec. 21 Evacuated this a.m.
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