Clinical Case 014: “That’s not a knife….”
So this is a typical Broome case. As always – I will not sugar-coat it for you , just a blow by blow description of how it rolled out. Oh, and this one has a happy ending
30 yo. woman presented via ambulance after being stabbed in the left chest (through the axillary tail of her breast). Seen at 3AM, primary survey all OK, a bit drunk though. Secondary survey – single stab wound only, explored under local – could not see any penetration through the intercostals, though difficult to say clinically. portable CXR = no pneumothorax, no effusion. No FAST scan done. Admitted to the ward for observation, IV fluids and surgical RV in AM. Obs were not normal, but steady overnight. Hb 134 g/l on gas.
The next AM, complaining of abdo pain, now some shoulder tip pain on the left. Repeat formal CXR – no PTX, small effusion left costophrenic angle. I was on for anaesthetics – so called for pre-op review to explore the wound further. P= 120/min, BP = 110/50, RR = 25/min, feeling sick / vomited. Hmmm…. not good
I decided to put in a big IV and send bloods for repeat Hb, VBG, cross match etc…the surgeons opted for a CT to look into the cause of the abdo pain – ? occult visceral injury. So off to the “doughnut of death”
So the VBG comes back: lactate is 4.2 So – something is up, not perfusing her organs as one might hope. Meanwhile in CT they have found a large amount of blood in the left upper quadrant, a small left chest effusion but no clear source for the bleeding ? spleen. Clearly she needs some volume resuscitation – the plan is “Haemostatic Resuscitation“, check out the link for an awesome lecture on this topic. Bottom line – lots of salty water is a bad thing for a bleeding patient, you gotta give some red stuff and products.
So without further ado we whiz her off to OT for a laparotomy, she does pretty well on induction / RSI, art line, central line, IDC and so on. We now get the formal Hb back – it is 59 g/l (Doh! not good) and we start the packed-cells. I called for some FFP to give and well – we don’t have platelets. Of course the lab want us to document ‘coagulaopathy’ before thawing the FFP. This is one of my pet peeves – in the 60 minutes they take to thaw the FFP, we will likely be in the deep end of ‘coagulopathy’. Can’t they just trust me, we need some FFP! (See Emcrit podcast on Massive transfusion for details) My guess was we were dealing with a concurrent blunt trauma to the spleen.
At this point I started to get a bit nervous – I had been ventilating the patient for an hour and was starting to think – there must be a lung injury here, is she gonna blow a pneumothorax? So what to do? I got out the USS and took some intercostal views to look for a PTX. None to be seen.
USS has been shown to be more sensitive and specific than supine CXR in trauma – see this review of the literature
So they got control of the bleeding and we got our PRBCs and FFP in and by the time we were closing she had a Hb of 100 and was peeing like a trooper. We decided to fly her out – the pancreas injury is not one we wanted to “observe” in our little hospital – if she got sick from this we would be in a lot of trouble. On follow-up all was well – no further surgery required.
The local con’stab’ulary popped in later to say they had found a very long, fishing knife at the scene – my estimate was that it had to be 40cm from the skin wound to the pancreas!
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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Good trauma case presentation, Casey. Great to hear you using USS in the OT for PTX assessment! I use it on the aircraft for same reason. As for the FFP, have you ever given Prothrombinex ( freeze dried factor concentrate licensed for warfarin overdose) instead?
Only other question I had was what target MAP were you shooting for when you were inducing her and during the early operative phase prior to haemorrhage control? Do you subscribe to the permissive hypotensive or haemostatic resuscitation theories?
Hi Minh. Unfortunately we don’t carry any PCC, we do have Novo7 but it is way too expensive.
As far as resus MAP goals go – the goal is 65mmHg – as per the evidence, however if the starting BP is better than that and you are going to be using volatile agents I am happy to leave it there until the dust has settled post-intubation. Giving sympatholytics then dumping in the volatiles / etc can crash the CO too far. So I tend to aim a little higher intially – knowing what I am about to do to the patients peripheral vasc. resistance. Having a good A-line give you a good idea of peripheral perfusion in real time.
For this case we used fentanyl up front, then some ketamine and volatile agents. She got some morphine to keep her comfy towards the end of the case.
Resus goals re: fluid staus – unfortunately you cannot do IVC US mid-laparotomy! The art line trace can give you a clue – you want it to have minimal pulse wave variation with the ventilator cycles. Urine output is good, and chasing the lactate down with serial ABGs.
I don’t think there is a single ideal, but if you have all this info + a CVP trend then you have a range of numbers which make up a “gestalt”, and if they are all improving then good, if not then you need to change the plan – more blood, more products, consider inotropes.
I like to ask myself. What would Weingart do? Any comments
All sounds reasonable. I think people can get confused about the controversy that permissive hypotensive theory or haemostatic resuscitation can bring. I had one colleague who deliberately restricted IV fluids post stabbing to back whilst awaiting retrieval team arrival..unfortunately the patient crashed and died whilst waiting!
I think if you are in the OT with a surgeon ready to go and it is more than likely the surgeon can control the bleeding. then I think permissive hypotensive theory or haemostatic resuscitation goes out the window.
It is really a theory that most applies to prehospital work when you are needing to get someone for definitive care and you do not want to make things worse by exarcebating bleeding. Its okay in my view for 1-2 hrs but beyond that I am uncertain of the evidence for it. I am really uncertain of its applicability to kids or the elderly.
I mean would you keep doing haemostatic resuscitation if the lactate was worsening and the urine output had dropped off??
what you do in your trauma anaesthetic makes sense. you just want a decent perfusing pressure and address any coagulopathy with all the tricks you have at hand.
Novoseven ..yes thats a hard one due to the lack fo convincing evidence. No bright answers on that one But I have seen it stop bleeding in a couple of patients who were clearly going south.