Clinical Case 082: Traumatic fluid resus OR Midnight at McDonald’s?
Traumatic fluid resuscitation. This is one area of Emergency medicine where the dogma is pretty entrenched and the evidence has moved on quite a bit in the last 10 years. It is a poorly understood area of practice – probably because it has gone thorugh several permutations of name and ideology in recent history – “permissive hypotension”, “minimal volume resus”, “damage-control resus”….
There has also been a quick increase in the range of fluids and blood products, factors and other agents that we use in big, traumatic bleeding patients in the last few years. So I thought I would throw a case out there and let you know what I do, based on my reading, the guidelines and practical possibilities in a smallish hospital.
So here is the case:
23 yo builder was working on a roof when he tripped and fell over the scaffolding and landed awkwardly on an upturned wheelbarrow. His left flank took the brunt of the fall.
After a quick scoop the Ambo crew have inserted 2 x 14 Ga IVCs and he has received 1.5 L of normal saline over 15 minutes en route.
On arrival to the ED his vitals are as follows: pulse = 120 (though weak at the radials), BP is 90/60, RR 18/min, Spo2 97% on 6L/min, he is alert but looks scared / in a lot of pain.
A quick look at his chest shows some deformity of the left lower rib cage with lots of contusion over the LUQ. He is in C-spine precautions, no obvious trauma to the head or neck.
OK – as per ATLS / EMST etc. You start with your primary survey:
A: He is talking, asking for pain relief, seems oriented to the situation and can give an AMPLE history
Don’t forget the C-spine. OK he has lots of reasons that we cannot clear him clinically – mechanism, distracting injury – so he is going to need some imaging – but for now we need to move onto B and C – keep him still.
B: Hmmm. He is not breathing well at all. He is splinting his left chest wall and you think there might even be some paradoxical movement – Hey? Is this a flail? His Sats seem OK, but he does appear to be labouring to move air.
C: Just as you arrive at C he goes all grey and ashen and vomits (not pretty in a collar). Now – DO NOT reach for the anti-emetic meds! Vomiting in this context (trauma & bleeding) is due to hypovolemia until proven otherwise!
I think we can all agree that his numbers and the mechanism suggest he is bleeding somewhere – could be into his chest or maybe a spleen… or both.
Here is the part of “C” that is often missed – you need to look and see if there are any obvious bleeding sources that you can control easily – pack, sew, tamponade or compress. Sounds obvious, but a lot of the manuals will insist that you ignore “dramatic distracting injuries” on your mission to complete the primary survey. This is just bonkers – if you see something you can fix – then do it. Pull that femur straight, bind the pelvis, whack on a tourniquet. Sure – if you are all alone, then you need to be quick, but in even the smallest hospital you can ask the orderly, trainee nurse or even a Medical Student to lean on a pulsing arterial spurter for a few minutes.
Now back to our case – he clearly has some bad bleeding in his torso somewhere and is unstable. If you have the crew you might do a super fast FAST scan to confirm this. In this case it looks a bit like this:
OK, we are worried. Lets pause the clock here and outline the dilemma.
You are in a small hospital, the surgeon and theatre team are 30 – 45 minutes away from knife time [ this is reality in my shop ]. Lets assume his Obs are as they are stated above
Here are my questions for you to ponder this week and I will give you my answers in a day or two:
(1) What are you going to hang next on this guy’s IV?
(2) Given he is going to need an operation – will you go ahead and tube him in the ED, or wait for the tea to be ready to go in theatre then do it at the last minute?
(3) Are there any other medications / devices etc that might be worthwhile in the meantime – and how will you get ahold of them?
(4) Just for fun – what is your intubation plan for a chap with an uncleared C-spine injury who really needs a blue cigar soon?
OK – let me know your answers to these questions.
I will post my thoughts in a day or two for your dissection.
Here is the answer from my special SMACC 2013 guest – Dr Scott Weingart. Scott was generous enough to spend a few minutes outlining his plan for this patient.
And what does this have to do with “midnight at MacDonalds” – well you will just have to wait and see…..
Casey
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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
You’ll give him the O negative we’ve got in the blood fridge. Will you give him some tranexamic acid (finger in dam stuff, but maybe all the same…)? Can’t answer intubation questions.
Hello Casey-
my approach would be as follows: If we assume the guy needs a laparotomy ( I don´t find the US that conclusive regarding intraperitoneal FF) I would call the surgeon myself and have him/her rendezvous us directly in the OR. Meanwhile I would clear the c-spine (and the pelvis, while we´re at it) by x-ray. If clear, intubate conventionally – if unstable, by awake fibreoptics. Maintain anesthesia with fentanyl/midazolam or ketamine/midazolam and paralytic. Put in a chest drain. If possible, save drained blood for retransfusion. If still convinced that laparatomy is needed, proceed to OR and start preparing equipment, meanwhile giving TXA and ABX (because science says so) and what PRCs i have to maintain systolic BP of 80-90. Switch to cristalloids if I run out of blood. Prep and drape the patient. By now, 30-45 minutes have comfortably passed. If the surgeon does not arrive in time and the patient crashes, cut by myself and pack or compress aorta.
Patrick
I’d start with 1:1:1 starting with platelets and FFP then RBC. 1gm TXA for sure. Prime rapid infusion pump ready to go once I put in the subclavian. *bleeding may be from splenic lac, rib lacs causing intercostal or internal mammary bleeding.
Intubate in the ED for work of breathing and potential thoracotomy. He may also have a diaphragmatic rupture. Can insert NG tube and check CXR once intubated.
Preoxygenate with 100%, insert NG and aspirate stomach before intubation, and depending on hemodynamics:
– if tachy/hTN, use midaz 5mg and sux 120mg. Collar off, manual inline stabilization.
– if hypertensive, use midaz 5mg, fentanyl 50-100mcg, and sux.
I’d suction down ETT before ventilating to remove any possibly aspirated material so I don’t push it further into his lungs.
After intubation, reapply collar, complete primary and secondary survey, and insert subclavian cordis on side of injury and attach to rapid infuser. Actively warm patient. CXR, then pan-CT while waiting for surgeons/OR to be ready.
1) Need to replace blood with blood, no time for Xmatch so will prob be O+. Would you consider Gelofusine if no blood available (only 2 units in some country hospitals), lastly crystalloid…still need to prevent shock somehow.
2) Not sure on indication for tubing, but might drop BP further. Conversely need to keep O2 sats up if he decides to keep the haemothorax going plus the ?rib fracture/fail
3) Tranexamic acid, ?chest tube for thorax – means will have be tubed/sedated though?
4) will watch what the masters have to say!!
Correction O-, damn keys too close!
This is a bloke – if we have O+ I’d be pretty willing to give it to him, on the presumption that he’s not had any previous Rh+ blood to sensitise him and produce lots of antibodies.
Is there obvious free peritoneal fluid in the FAST scan? I think I see some above the spleen which I would presume was intrathoracic until proven otherwise.