Case 0001 – Multitrauma

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?

Check out this EMCrit podcast for the latest from the US gurus at Shock Trauma (cool name for a hospital!)

Casey

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