43 yo. woman who wandered onto road when drunk. Struck by 4WD @ 70kph to right side. GCS 15 @ scene, clinically deformed right femur and “mangled” R forearm.
On arrival to ED 20/60 later – pulse 120, thready, BP 100/40, agitated, GCS now 12, normal response rate / work.
Over next 5 mins 2L of N/saline in pulse 110, BP 130/60. Patient increasingly combative but not making consistent respiratory effort. Pupils 2 mm, symmetric.
Quick secondary survey – fractured right femur with massively distended thigh, fracture through right ilium, de-gloving injury to right forearm. No obvious chest injury / flail etc, E-FAST scan = scant fluid in hepato-renal angle, no pneumothorax. No obvious head injury.
Over the next 5 minutes the patient becomes increasingly combative and her obs = P – 120, BP – 120/50, RR – 8, Spo2 on non-RB mask – 98%. Unable to maintain good C-spine immobilisation due to patient’s dyscoordinated attempts to sit up.
So two questions:
1) would you elect to sedate / intubate this woman? If so when? What agents would you use? Any traps to watch for??
2) She is clearly hypovolemic – history / exam and obs all agree – so what fluids would you use to resuscitate her? What end points will you use to decide when she is adequately resuscitated?
I don’t think this is an uncommon scenario for the average rural Doc, we often do what we have been doing since our training days. What does the evidence suggest?
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