Trauma Patient… October 19, 2011
Posted by ebmedicine in Cardiovascular Emergencies, Hematologic/Allergic/Endocrine Emergencies, Traumatic Emergencies.trackback
EMS arrives with a 24-year-old male who was the victim of a hit-and-run accident in which the driver apparently backed over him after first clipping him with the car and knocking him to the ground. When you walk into the patient’s room, you find him awake and angry, complaining of pain in his right upper quadrant. He is on a backboard, wearing a cervical collar, and has obvious bruising to the right chest and abdomen. His airway is patent and his breath sounds are equal bilaterally. The patient’s initial vital signs are: heart rate of 125 beats per minute, blood pressure of 120/80 mm Hg, respiratory rate of 20 breaths per minute, temperature of 98°F (36.6°C), and SpO2 of 94% on room air. Per EMS, the patient was hypotensive on their arrival, with initial blood pressure of 80/40 mm Hg, but it rapidly improved with 2 L of crystalloid given in the field. A second large-bore IV is placed and labs are drawn. The FAST examination reveals significant hemoperitoneum. He then becomes diaphoretic, and repeat blood pressure is now 75/40 mm Hg. The nurse asks if you want 2 more liters of crystalloid.
What is your next step?
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“Trauma + hypotension = haemorrhage”, in this case demonstrated by free fluid in the peritoneum (and may be the patients “angryness”). This patient is haemodinamically unstable, we must really run and fight for his life. “ABCDE” from ATLS O.K.? Continue maximum Oxigen.The next steps are: alarming the operating room and team and the anesthesists (to prepare the patient in the E.R. for surgery: R.S.I.?) for emergency damage contro surgery (NO further radiology at this time; I’m sure the alvays done eco FAST exluded PNX, pleural fluid and pericardial tamponade, and that the inf. vena cava is collapsed. This patient don’t goes to the CT scan, he goes directly in the operating room), at the same labs emergency panel to the laboratory and to the blood bank, ready for emergent blood transfusion four packs urgent + four FFP (liver damage + transfusions + polytrauma = imminent coagulopathy, the surgeons don’t like that) and two packs 0 NEG immediately in the second large-bore IV in the E.R.. At the same time I answer yes to the nurse: yes, put 2 grams tranexamic acid in 250 ml saline and start infusion at the maximum rapidity, then rapidly plasma expanders “ad libitum” for the moment (a little byrd in my ear urged me: and vasopressin?). And now hurry with the intubated patient in the Operating Room, then two words to the anguished parents. Everything else comes afterwards.
But that’s a dream. Greetings from Sardinia
Surgical team should be contacted and patient taken to the operating room.
O neg blood should be ordered. Pelvic & chest films orderedTrauma and orthopaedic surgeons on board and pt should be taken to the OR…poss pelvis GC and liver lac.
Trauma 2 Hospital:repeat IV Fluids, portable chest while OR team is assembled to go to OR. In a Trauma1: To the OR/ Chest eval can be done in OR while pt is being prepped for abdominal exploration.Get O- blood and t/x match x 6 u prbc’s ready NOW!!
Watch out the “spinal” shock probability and early treatment with vasopressor drugs (e.g. norepinephrine)
Arrange urgent blood transfusion and leprotomy
1. Place surgery team on standby
2. Order O neg blood
3. Pelvic, Abdominal and Chest x-ray
4. Transfer to surgery
This a case of blunt abdominal trauma with shock, we have to start blood transfusion with informing the surgical team at the time of preparation for lapratomy we ‘d do secondary survey for the other parts of the body to exclude the other part injury.
Practical solution !!
Telephone two places 1 .blood bank ( blood :ffp:platelet )
Place no 2 . OT
All the surveys next in OT !!
Target BP 80/40 till you clamp that bleeder !!
Higher dose opioids once airway secure ( block sympa with that pain) ……adjust a pelvic film prior to shifting to OT !!!
With the history of MVA clip, pain and bruising, hypotensive responding to fluids by EMS prior to arrival I would have suspected abdominal bleeding and called the surgeons. Upon his arrival I would have type and cross for 6 units of packed RBC.
He does not need more RL or .9 NaCl fluid. He needs surgery for most likely a liver injury. Fluid resuscitation include packed RBC, platelets, fresh frozen plasma and cryoprecipitate.
laparotomy stat meanwhile coloids and blood transfusion if not available give crystalloids
Call surgical team for emergent abdominal exploration
Emergent blood transfusion
I will get the trauma surgeon down to the ER asap. Alert the OR and anaesthetist. Get O neg blood, do a quick secondary survey and get him to the OR. He need a laparatomy to save his life
Immediate and simultaneous actions of:
1. Order type specific uncross matched packed red cells (2 units to give stat + 4 units ready). Untill ready (usually in 10 miutes) give crystallod fluids maintaing systolic blood pressure between 80-90 (not more!).
2. Call the surgical team and according to hospital policy alert/book the operating room.
3. Order 4 units of cross matched blood
Pt is class III-IV shock and has only transiently responded to IV fluid resuscitation. Ongoing blood loss is the most likely cause of his deterioration. Management would include: continue IV fluid resuscitation, call for blood for transfusion and gain immediate surgical consult whilst notifying the OR and preparing patient for emergency laparotomy. Vasopressors are contraindicated as they will worsen tissue perfusion. Patient requires immediate surgery and any delays can be lethal.
Colloids can be given while awaiting O neg blood for transfusion.
surgical consult
First thing emergent call surgeon and notifying Operation room (i thing nurses should sent blood for cross maching and grouping when they saw him on admissin,so we will request that blood (4units)until the blood comining we should start with Fluids 2L in 2 I.V Line and nasal airway 100%O2 15L/min and send him to the operation room.
Good morning Dr Jagoda, I m glad for answer your clinical case challenge:
The patient has a abdominal, and thoracic closed trauma, and he is a “transient responder” to crystaloid therapy, and has a significant hemoperitoneum, this patient is angry as a response to the hypovolemia, so, I would
secure the airway, then, add suplementary Oxygen, since the nurse team establish another periferic (or preferably central by the surgeon) venous access, I would start another warm 2000 cc Iv bollus while prepare 2 units of red packed cells “O negative” (and start the hemotherapy when become possible), and ask for crossmatch tests and hemogram (as a reference for next tests), blood gases, BUN, creatinine; simultaneously, I order a vesical catheter, and start fluids balance and urinary output quantification; call to the surgeon, prepare the patient and a operating room for a possible “damage control” surgery, once the patient is on surgery, I call the intensivist for to book a bed on that service; if is posible, ask for a portable pelvic, thoracic and spinal column plain films, as the surgery allow them; I think the patien has a closed abdominal trauma, initially transient responser, but with a possible liver / spleen injury (assuming for the closed trauma and the most frecuently wounded organs), so I hope he is well…
by the way, sorry because I cant answer the last clinical challenge, and forgive my bad english…