What’s Your Diagnosis? An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the ED
October 20, 2020
Posted by Andy Jagoda MD in: What's Your Diagnosis , trackback
Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Management of Deep Vein Thrombosis in the Emergency Department right.
Case Presentation: An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department
Your first patient of the night is a 45-year-old man who was involved in a highway motorcycle crash. He is complaining of abdominal and pelvic pain and had a 30-minute helicopter transport time. On arrival, his vital signs are: heart rate, 130 beats/min; blood pressure, 100/60 mm Hg; respiratory rate, 26 breaths/min; temperature, 37°C; oxygen saturation, 96% on room air; and GCS, 14. You know this patient will need fluid resuscitation, but you are unsure whether you should start with crys- talloid or blood…
After an EMS time-out, the primary survey for this previously healthy 45-year-old man in the motorcycle crash found him maintaining his airway but having intense pain with breathing, intact pulses, and clammy skin. He was quickly exposed, revealing a diffusely ecchymotic torso. The secondary survey revealed crepitus along his lower ribs and an unstable pelvis. Because your first priority was hemorrhage control, you applied a pelvic binder.
Your eFAST exam revealed free fluid in the Morison pouch, the splenorenal space, and behind the bladder, but no pneumothorax or tamponade. His shock index of 1.3 and his ABC score ≥ 2 indicated a high likelihood for needing ≥ 10 units of pRBCs, so you called for the first cooler of your hospital’s MTP, which followed 1:1:1 ratios of plasma, platelets, and pRBCs, supplemented with calcium and cryoprecipitate. Because your patient was now maintaining his SBP > 80 mm Hg and you did not suspect TBI, you did not bolus any crystalloid while the MTP was mobilized.
Tranexamic acid 1 g was administered by EMS, and his tranexamic acid infusion was initiated in the ED. Initial labs drawn included type and cross, VCT, CBC, PT/INR, fibrinogen, VBG with lactate, and ionized calcium, but the patient was taken swiftly to the OR by your activated trauma team for exploratory laparotomy. A splenectomy was performed and external fixator applied, in addition to pelvic packing. He recovered in the trauma ICU, with ongoing resuscitation.