Clinical Case 031: Big transfusion, Little Hospital = big trouble

I have been working on a post dealing with massive transfusion – Broome style – for a while now.  So last week we landed in a tricky situation.  My colleague had taken a chap with a splenic rupture to theatre and used a good volume or red cells – depleting our small blood bank, when we received another incoming trauma case!  So I thought this case was a good one to illustrate the “Stripped back” approach to massive transfusion / trauma resuscitation as I see it in smaller hospitals with limited agents.

Here is the Case:

40 yo man with major crush injury. The chap’s abdomen was trapped for about ten minutes until the load could be moved.  Remained conscious throughout this period.  Ambos bundled him into ED within 10 minutes and he arrived… then had a PEA (likely combo of hypovolemia and severe acidosis) arrest.  CPR and IV adrenaline en route to OT.  Regained consciousness as the ETT went down (doh).  Anaesthetised and prepped for laparotomy.  Initial ABG came back showing a lactate of 15! pH = 6.8.

Laparotomy showed a bunch of sub-segmental mesenteric vein ruptures, a big rectus haematoma with a few litres of red in the peritoneum.  The lab called to say – only 4 bags of FFP left, more PRBCs coming in by plane from elsewhere…

So – how to proceed?  Lets keep this big picture – what strategies do we want to use for:

(1)  Anaesthesia / analgesia

(2)  Fluid resuscitation – what type, how much?  targets?

(3) How do we monitor / measure if we are winning?  What is useful?

(4)  Surgeon – what should they do? When?

(5)  This chap developed quite good going “ACoTS” – what agents / strategy should we use to treat this?

I hope to do a post soon looking at the new guidelines released in 2010 and strip them down to make them usable in the smaller hospitals where blood doesn’t grow on trees and budgets are non-existent.  Watch this space….

So all you experts – what gives us bang for our buck, what can we store for a while and what is just hard / expensive for a small hospital.  Better still – what is cheap and easy, available and going to make a difference to patients like this?

Casey

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