Fig. 4

Clinical course and treatment. Elapsed course of intervention and examination were shown with a value of lactate and partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio. On day 1, preperitoneal pelvic packing was performed introducing resuscitative endovascular balloon occlusion of the aorta as hemostatic treatment strategy. Emergency thoracotomy after computed tomography examination was performed, and transcatheter arterial embolization was sequentially performed to stop the bleeds from multiple injuries. Veno-venous extracorporeal membrane oxygenation was performed because of a deterioration of the patient’s pulmonary function with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio of below 50 just after admission to the intensive care unit. The partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio was remarkably improved by veno-venous extracorporeal membrane oxygenation, and the patient was successfully weaned off from the veno-venous extracorporeal membrane oxygenation on day 7. There was an obvious inverse correlation between lactate level and partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio. The lactate value was affected by hypoxia as well as hemorrhagic shock. On day 2, the planned reoperations for the chest and pelvis were performed and the hemorrhages in the thoracic injuries were successfully stopped. Since bleeding from the pelvic fracture could not be fully controlled, preperitoneal pelvic repacking was performed, and packing gauze was removed on day 5. A bronchial block balloon was inserted into the right lower bronchus to protect the stump of lung resection site from collapse due to excess intrabronchial pressure. We performed tracheostomy on day 5 as the patient was required to be on mechanical ventilation for a long period of time. CT computed tomography, DCS damage control surgery, ICU intensive care unit, IVR interventional radiology, P/F partial pressure of oxygen in arterial blood/fraction of inspired oxygen, PPDP preperitoneal pelvic depacking, PPP preperitoneal pelvic packing, PPRP preperitoneal pelvic repacking, REBOA resuscitative endovascular balloon occlusion of the aorta, VV-ECMO veno-venous extracorporeal membrane oxygenation