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Sudden deterioration in an elderly trauma patient
The Journal of Emergency Medicine, Vol 15. No 3, pp 367..370, 1997 Copyright
0
1997 tlsevier
S&me
Inu.
Printed in the USA, All rights reserved 1173h-4h7’l/Y7
ELSEVIER
$17 00 +
I)0
PII SO736-4679(97)00026-7
Case
SUDDEN
DETERIORATION
IN AN ELDERLY
Eric S. Nadel, MD,‘7 David F. M. Brown, Departments
PATIENT
and Ron M. Walls, hnD*t
of Emergency Medicine, *Brigham and Women’s Hospital and *Massachusetts General Hospital and tHarvard Affiliated Emergency Medicine Residency Program, Boston, Massachusetts Reprint Address: Eric S. Nadei, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
Dr. Adler: There does not appear to be evidence that a MAST suit controls hemorrhage, but it may stabilize an unstable pelvic fracture by limiting soft tissue and vascular damage and by reducing the degree of hemorrhage.
Dr. Ron Walls: Today’s case is that of a 75-yr-old woman who presented to the emergency department (ED) by helicopter after a rollover motor vehicle crash. She was an unrestrained front seat passenger and was ejected, landing approximately 20 feet from the vehicle. Upon arrival at the scene, the patient was found awake and alert, following commands. It was unclear whether the patient had suffered loss of consciousness. The initial vital signs in the field were: blood pressure (BP) 90 by palpation, pulse 110 beats/min, and respirations 20 breaths/min. The patient’s neck was immobilized in a cervical collar and a peripheral intravenous (IV) line was inserted. As she was being loaded onto the helicopter, her level of responsiveness deteriorated, and her systolic BP decreased to 80 mmHg. She was intubated by using rapid sequence intubation with lidocaine, fentanyl, and succinylcholine. A second intravenous line was placed, and she was transported to our hospital. Her husband, the unrestrained driver, had remained in the car and was taken to a local hospital with minor injuries. Are there any questions about prehospital management? Dr. Jonathan Adler: patient?
uo,t*
TRAUMA
Dr. Walls: That is a good point. The original theory regarding inflatable trousers, called MAST, or Military Anti-Shock Trousers, was that they would decrease venous pooling in the extremities, increase venous return, and decrease blood flow to the extremities by arterial compression, thus improving central circulation. Respite these theories, a mortality reduction with the use of MAST could not be demonstrated (1). Currently, the antishock garment is used in the prehospital setting to stabilize suspected pelvic fractures, especially if there is a long transport time. However, the use of the MAST suit has significant risks (2). Compartment syndrome has been reported, and there is a risk of systemic acidosis on removal of the garment. There also have been reports of the garment concealing serious injuries. In any case, the flight crew did not feel that the patient’s pelvis was unstable and the MAST suit was not used on this patient. Are there any other questions about the prehospital course?
Was a MAST suit applied to the
Dr. Walls: lt was not. Is there evidence that a MAST suit is beneficial in traumatic hemorrhage?
Dr. David Brown: Who managed her airway and were there any issues with airway management‘?
.____
Case Presentations is coordinated by Eric S. Nadel, MD, of Brigham and Women’s Hospital, Harvard Me&Cal School and by David F. M. Brown, MD of MassachusettsGeneral Hospital, Harvard Medical School, Boston, Massachusetts
RECEIVED:
18 March 1997;
ACCEPTED: 18 March 1997 367
368
Dr. Walls: The patient’s airway was managed by the flight nurses without difficulty. The flight crew went through a very significant thought process about the intubation. They wanted to use lidocaine for central nervous systemprotection becausethey felt sheprobably had significant head injury (3). They wanted to use an induction agent that would be cerebroprotective but not cause any problems with her blood pressure. That is a difficult thing in somebody who is hypotensive because there really is no such agent. They chose fentanyl, which is not an induction agent in the dose used, but a reasonable choice in this circumstance. I think this airway was managedvery well. There is great variability in prehospita1 airway managementdepending on the prehospital system and protocols. The flight crews in this area are very experienced with airway managementand with the use of paralytics and rapid sequenceintubation. Helicopter transportation was uncomplicated. She arrived at our resuscitation room 23 min after intubation, receiving 2000 cc of crystalloid on route. On presentation to the ED, the vital signs were: blood pressure82 by palpation, pulse 110 beats/mm, and respirations 14 breaths/mm by bag valve mask. She was intubated with a 7.5 oral endotracheal tube. Pulse oximetry was 91%. She was unconscious and paralyzed, with a Glasgow Coma Score (GCS) of 3. We verified tube placement with an end tidal CO, detector, showing good color change.Physical examination showed multiple abrasions and ecchymosesaround her head. The tympanic membranes were normal. The cervical collar was opened briefly, maintaining inline stabilization, to evaluate the neck. The trachea was midline; there was no hematoma or swelling. Chest expansion was symmetric. There was no crepitus, and the lungs were clear bilaterally. Cardiovascular examination was normal. The abdomenwas soft and nondistended; tenderness could not be assessed. Bowel sounds were present. The pelvis was stable to compression in all planes. Extremities were without obvious deformity. There were multiple ecchymoses,abrasions, and contusions over her entire body. The patient was completely unresponsive. Rectal tone was absent. A physician: You mentioned that the patient had been paralyzed with succinylcholine during intubation. Was extremity movement noted before intubation? Had she received another paralytic agent during transport? These facts would be important in assessingthe neurological statusin the ED and the possibility of intracranial injury. Dr. Walls: Prior to intubation, the patient was moving all four extremities. After intubation, the flight crew gave her 3 mg of pancuronium, which most likely is a subparalytic dose. When making the transition from succinylcholine, which is a depolarizing agent, to pancuro-
E. S. Nadel et al.
nium, which is a nondepolarizing competitive neuromuscular blocking agent, a full dose of pancuronium is required. The paralytic dose of pancuronium is 0.08-0.10 mg/kg. Once paralysis is initiated, 2-mg or 3-mg doses will continue the neuromuscular blockade (NMB). Even though the patient received a subparalytic dose, she was completely unresponsive on arrival in the ED, and we were unsure as to whether this unresponsivenesswas related to the pancuronium or intracranial pathology. A medical student: Are pupillary reflexes preserved in the presenceof neuromuscular blockade? Dr. Walls: Pupillary responses are preserved. NMB only affects skeletal muscle. Fixed and dilated pupils cannot be ascribed to NMB. Rectal tone, however, will be absent in the presenceof NMB. So the question that faced us now after the initial evaluation was, What do we needto do? Who would like to help prioritize this case? Dr. Richard Wolfe: The airway is controlled, and there does not appearto be a tension pneumothorax. The next priority is to evaluate the cause of hypotension, which likely is due to hemorrhage. Portable chest and pelvic films should be obtained. A cross-table lateral cervical spine film will not add a lot of information regarding hypotension in the acute phase but may be helpful in suggesting spinal shock if a fracture is present. It is imperative to quickly assessfor the presence of intraperitoneal blood, either by diagnostic peritoneal lavage (DPL), ultrasound, or computed tomography (CT). I would also begin transfusing this hypotensive patient with uncross-matchedblood. Dr. Kathleen Raftery: If you transfuse this patient, O+ blood should be used becauseO- blood is reserved for women of childbearing age. Dr. Erik Barton: Was an arterial blood gas (ABG) drawn to evaluate the base deficit and the degree of metabolic acidosis, which may be indicative of poor tissue perfusion and under-resuscitation, and may represent the degree of hypovolemia? Dr. Walls: I think an ABG is often useful in this setting. I haven’t seen any good literature that it is predictive or that it makes an outcome difference, but I like it as a clinical tool for exactly the purpose that Dr. Barton identified. A blood gas had been drawn, but the results were not available at this time. To pursue Dr. Wolfe’s point, the radiographs were now available. The cervical spine film was normal. The
369
Case Presentatton
chest radiograph revealed no pneumothorax or hemothorax, and the mediastinum was normal. The pelvic film revealed a right iliac wing fracture that extended through the right acetabulum. Our first priority was to determine the source of the hypotension. We would never attribute this degree of hypotension to a head injury. There was no radiographic evidence of hemothorax. Dr. Wolfe raised the possibility of intraperitoneal bleeding. Where else could there be blood loss?
Dr. Walls: In fact, one study demonstrated that a head CT scan before laparotomy in the presence of a GCS of more than 8 was so low yield as to not be helpful, and the authors advocated prompt laparotomy without CT in such patients (4). At this time, we performed a DPL. The initial aspiration was negative for gross blood. The lavage fluid was very lightly red tinged, essentially negative. The fluid was sent to the laboratory for cell count. At this time, her blood pressure was I lOi70.
A resident: In this patient with a pelvic fracture, hemorrhage into the retroperitoneum likely is due to the fracture itself or an associated renal injury. Although not apparent in this case, long bone fractures can cause hemodynamically significant blood loss into the extremi ties.
Dr. Wolfe: The next step is to evaluate the retroperitoneum. First, there may be a large retroperitoneal hematoma secondary to the pelvic fracture. Second, the genitourinary tract needs to be assessed for renal injury.
Dr. Eric Nadel: We have focused on hemorrhagic shock in this patient, but other causes of hypotension need to be considered. A tension pneumothorax has been ruled out, but the remote possibility of pericardial tamponade still exists. Although this is rare in blunt trauma, a bedside ultrasound, if available, would be helpful to rule it out Dr. Wolfe: Tamponade from blunt trauma is unlikely here because patients with tamponade most often have profound hypotension that rapidly evolves into traumatic arrest. In this setting, I think it is more important initially to look for hemorrhage and evaluate for cardiac tamponade only in refractory hypotension once hemorrhagic shock has been excluded. At this point, I would assess for intraperitoneal hemorrhage. Although the blood pressure is 120170, the baseline blood pressure is unknown, and in an elderly patient, this blood pressure may represent significant hypotension and hypovolemia. I would proceed with a bedside ultrasound, if available, to look for blood in Morison’s pouch or with a DPL if ultrasound was unavailable. If either test was positive, I would send this patient straight to the operating room (OR) for a laparotomy. Dr. Walls: How would you deal with the conflicting priorities presented by the possible head injury? Dr. Wolfe: A patient with hemorrhagic shock from a known intraperitoneal injury should go straight to the OR, regardless of head injury. The intraabdominal hemorrhage needs to be controlled immediately. A delay while waiting for a CT scan of the head to evaluate intracranial injury may be fatal. In the OR, the neurosurgeons could place an intracranial pressure (ICP) monitor or perform a craniotomy.
Dr. Carlo Rosen: turia?
Did the urinalysis (lJA) reveal hema-
Dr. Walls: The UA revealed 520 red blood cells (RBCs) and 17 white blood cells. but the diagnostic meaning of microscopic hematuria in this setting is vague. In the evolution of renal injury evaluation, we used to become excited about 50-100 RBCs/HPF. We now recognize that significant renal injury can occur with or without microscopic hematuria. Really, it is the mechanism of injury and the presence of shock that require evaluation of the kidneys by CT or intravenous pyelogram, and the urinalysis alone isn’t terribly helpful. although it may help focus the workup. We felt that the patient was hemodynamically stable and decided to send her for a CT scan of the head, abdomen, and pelvis. We were intent on determining the source of the hemorrhage. Ten minutes later. as the scanning was completed, she became pulseless. Cardiopulmonary resuscitation was initiated, and the patient was moved back into the trauma room. What action would you recommend now? A physician:
Perform a left thoracotomy.
Dr. Wolfe: Many would argue that patients with cardiac arrest after blunt trauma are not salvageable. If there were abdominal or retroperitoneal injury, the aorta could be cross clamped on the way to the OR. I recognize that chances of survival with thoracotomy are poor in this situation. Our 15yr series from Denver, yet to be published, suggests that 2% of patients with cardiac arrest after blunt trauma have good outcome and are neurologically intact if signs of life are present in the ED. However, before performing a thoracotomy. the circulatory status must be assessed. Was she in full arrest? Dr. Walls: Although pulseless, the patient had a sinus tachycardia at ! 10 beats/min, and we transfused
370
E. S. Nadel et al.
the patient through the rapid infuser. As the thoracotomy tray was being opened, bilateral needle decompression was performed that revealed no rush of air. A pericardiocentesis was performed; the aspiration was negative. At this point, pulses returned, and she had a blood pressure of 80 by palpation. We continued the resuscitation. The radiologist reported the CT scan results. The head CT revealed bilateral subdural hematomas, right greater than left, but without significant mass effect or midline shift. The abdominal CT scan revealed a large right retroperitoneal hematoma. Her pelvic fracture, which looked reasonably innocuous on plain radiography and was stable to palpation, was multifragmented with opening of the sacroiliac joint. Dr. Rosen: The pelvis may need to be stabilized, and one should consider whether the pelvic bleeding might be controlled through embolization. Dr. Walls: Orthopedics was consulted regarding placement of an external fixator. They felt that an external fixator would not help because the pelvic ring was intact. A decision was made not to proceed with angiography because the blood pressure had stabilized at 105/75. The patient was admitted to the surgical intensive care unit (ICU), where fluid resuscitation could be monitored closely. Embolization would be reconsidered if hemodynamic instability returned. The neurosurgeons felt that operative intervention was not indicated, and they placed an ICP monitor in the ICU. Her ICU course was complicated by a transient coagulopathy, but she remained hemodynamically stable, Neurologic improvement was minimal. The pa-
tient was eventually discharged to a nursing facility in a semivegetative state. It is always worth considering what we might have done to improve her outcome. The ABG, which was drawn as the patient went to CT, did not return until after the arrest. The pH was 7.31, with a pC0, of 19. In retrospect, she was probably under-resuscitated when she left for CT. Had we known the ABG results earlier, we could have begun more aggressive fluid resuscitation in the trauma room, improved her volume status, and then sent her over to CT. Although adequate volume resuscitation does not immediately correct the metabolic acidosis, the degree of acidosis should be taken as an indicator of incomplete resuscitation. Until the controversy regarding volume resuscitation in the context of ongoing hemorrhage is resolved, the appropriate course in this circumstance would be to restore intravascular blood volume as completely as possible. Of course, rapid intravenous fluids were continued while the patient was in CT, but more aggressive volume restitution is available in the trauma room. However, we had to move quickly to localize her blood loss, thus the dilemma. Are there any final questions or comments? Dr. Wolfe: This case is illustrative of how much work we still have to do with polysystem trauma. The patient’s course was typical of severe head injury in this age group where the patient develops severe, irreversible neurologic deficit extremely rapidly after the injury, and the prognosis is very poor. The patient was basically doomed by her injuries at the time of the accident, yet our emergency care kept her alive. The next challenge is to be able to return this kind of patient to a functional life.
REFERENCES 1. Mattox KL, Bickell W, Pepe PE, Butch J, Feliciano D. Prospective MAST study in 911 patients. J Trauma. 1989;29: 110412. 2. Chang AK, Dunford J, Hoyt DB, Rosen P. MAST 96. J Emerg Med. 1996;14:419-24.
3. Walls RM. Rapid-sequence intubation in head trauma. Ann Emerg Med. 1993;22(6):1008-13. 4. Fulton RL, Everman D, Mancino M. Ritual head computed tomography may unnecessarily delay lifesaving trauma care. Surg Gynecol Obstet. 1993;174(4):327-32.
0
1997 tlsevier
S&me
Inu.
Printed in the USA, All rights reserved 1173h-4h7’l/Y7
ELSEVIER
$17 00 +
I)0
PII SO736-4679(97)00026-7
Case
SUDDEN
DETERIORATION
IN AN ELDERLY
Eric S. Nadel, MD,‘7 David F. M. Brown, Departments
PATIENT
and Ron M. Walls, hnD*t
of Emergency Medicine, *Brigham and Women’s Hospital and *Massachusetts General Hospital and tHarvard Affiliated Emergency Medicine Residency Program, Boston, Massachusetts Reprint Address: Eric S. Nadei, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
Dr. Adler: There does not appear to be evidence that a MAST suit controls hemorrhage, but it may stabilize an unstable pelvic fracture by limiting soft tissue and vascular damage and by reducing the degree of hemorrhage.
Dr. Ron Walls: Today’s case is that of a 75-yr-old woman who presented to the emergency department (ED) by helicopter after a rollover motor vehicle crash. She was an unrestrained front seat passenger and was ejected, landing approximately 20 feet from the vehicle. Upon arrival at the scene, the patient was found awake and alert, following commands. It was unclear whether the patient had suffered loss of consciousness. The initial vital signs in the field were: blood pressure (BP) 90 by palpation, pulse 110 beats/min, and respirations 20 breaths/min. The patient’s neck was immobilized in a cervical collar and a peripheral intravenous (IV) line was inserted. As she was being loaded onto the helicopter, her level of responsiveness deteriorated, and her systolic BP decreased to 80 mmHg. She was intubated by using rapid sequence intubation with lidocaine, fentanyl, and succinylcholine. A second intravenous line was placed, and she was transported to our hospital. Her husband, the unrestrained driver, had remained in the car and was taken to a local hospital with minor injuries. Are there any questions about prehospital management? Dr. Jonathan Adler: patient?
uo,t*
TRAUMA
Dr. Walls: That is a good point. The original theory regarding inflatable trousers, called MAST, or Military Anti-Shock Trousers, was that they would decrease venous pooling in the extremities, increase venous return, and decrease blood flow to the extremities by arterial compression, thus improving central circulation. Respite these theories, a mortality reduction with the use of MAST could not be demonstrated (1). Currently, the antishock garment is used in the prehospital setting to stabilize suspected pelvic fractures, especially if there is a long transport time. However, the use of the MAST suit has significant risks (2). Compartment syndrome has been reported, and there is a risk of systemic acidosis on removal of the garment. There also have been reports of the garment concealing serious injuries. In any case, the flight crew did not feel that the patient’s pelvis was unstable and the MAST suit was not used on this patient. Are there any other questions about the prehospital course?
Was a MAST suit applied to the
Dr. Walls: lt was not. Is there evidence that a MAST suit is beneficial in traumatic hemorrhage?
Dr. David Brown: Who managed her airway and were there any issues with airway management‘?
.____
Case Presentations is coordinated by Eric S. Nadel, MD, of Brigham and Women’s Hospital, Harvard Me&Cal School and by David F. M. Brown, MD of MassachusettsGeneral Hospital, Harvard Medical School, Boston, Massachusetts
RECEIVED:
18 March 1997;
ACCEPTED: 18 March 1997 367
368
Dr. Walls: The patient’s airway was managed by the flight nurses without difficulty. The flight crew went through a very significant thought process about the intubation. They wanted to use lidocaine for central nervous systemprotection becausethey felt sheprobably had significant head injury (3). They wanted to use an induction agent that would be cerebroprotective but not cause any problems with her blood pressure. That is a difficult thing in somebody who is hypotensive because there really is no such agent. They chose fentanyl, which is not an induction agent in the dose used, but a reasonable choice in this circumstance. I think this airway was managedvery well. There is great variability in prehospita1 airway managementdepending on the prehospital system and protocols. The flight crews in this area are very experienced with airway managementand with the use of paralytics and rapid sequenceintubation. Helicopter transportation was uncomplicated. She arrived at our resuscitation room 23 min after intubation, receiving 2000 cc of crystalloid on route. On presentation to the ED, the vital signs were: blood pressure82 by palpation, pulse 110 beats/mm, and respirations 14 breaths/mm by bag valve mask. She was intubated with a 7.5 oral endotracheal tube. Pulse oximetry was 91%. She was unconscious and paralyzed, with a Glasgow Coma Score (GCS) of 3. We verified tube placement with an end tidal CO, detector, showing good color change.Physical examination showed multiple abrasions and ecchymosesaround her head. The tympanic membranes were normal. The cervical collar was opened briefly, maintaining inline stabilization, to evaluate the neck. The trachea was midline; there was no hematoma or swelling. Chest expansion was symmetric. There was no crepitus, and the lungs were clear bilaterally. Cardiovascular examination was normal. The abdomenwas soft and nondistended; tenderness could not be assessed. Bowel sounds were present. The pelvis was stable to compression in all planes. Extremities were without obvious deformity. There were multiple ecchymoses,abrasions, and contusions over her entire body. The patient was completely unresponsive. Rectal tone was absent. A physician: You mentioned that the patient had been paralyzed with succinylcholine during intubation. Was extremity movement noted before intubation? Had she received another paralytic agent during transport? These facts would be important in assessingthe neurological statusin the ED and the possibility of intracranial injury. Dr. Walls: Prior to intubation, the patient was moving all four extremities. After intubation, the flight crew gave her 3 mg of pancuronium, which most likely is a subparalytic dose. When making the transition from succinylcholine, which is a depolarizing agent, to pancuro-
E. S. Nadel et al.
nium, which is a nondepolarizing competitive neuromuscular blocking agent, a full dose of pancuronium is required. The paralytic dose of pancuronium is 0.08-0.10 mg/kg. Once paralysis is initiated, 2-mg or 3-mg doses will continue the neuromuscular blockade (NMB). Even though the patient received a subparalytic dose, she was completely unresponsive on arrival in the ED, and we were unsure as to whether this unresponsivenesswas related to the pancuronium or intracranial pathology. A medical student: Are pupillary reflexes preserved in the presenceof neuromuscular blockade? Dr. Walls: Pupillary responses are preserved. NMB only affects skeletal muscle. Fixed and dilated pupils cannot be ascribed to NMB. Rectal tone, however, will be absent in the presenceof NMB. So the question that faced us now after the initial evaluation was, What do we needto do? Who would like to help prioritize this case? Dr. Richard Wolfe: The airway is controlled, and there does not appearto be a tension pneumothorax. The next priority is to evaluate the cause of hypotension, which likely is due to hemorrhage. Portable chest and pelvic films should be obtained. A cross-table lateral cervical spine film will not add a lot of information regarding hypotension in the acute phase but may be helpful in suggesting spinal shock if a fracture is present. It is imperative to quickly assessfor the presence of intraperitoneal blood, either by diagnostic peritoneal lavage (DPL), ultrasound, or computed tomography (CT). I would also begin transfusing this hypotensive patient with uncross-matchedblood. Dr. Kathleen Raftery: If you transfuse this patient, O+ blood should be used becauseO- blood is reserved for women of childbearing age. Dr. Erik Barton: Was an arterial blood gas (ABG) drawn to evaluate the base deficit and the degree of metabolic acidosis, which may be indicative of poor tissue perfusion and under-resuscitation, and may represent the degree of hypovolemia? Dr. Walls: I think an ABG is often useful in this setting. I haven’t seen any good literature that it is predictive or that it makes an outcome difference, but I like it as a clinical tool for exactly the purpose that Dr. Barton identified. A blood gas had been drawn, but the results were not available at this time. To pursue Dr. Wolfe’s point, the radiographs were now available. The cervical spine film was normal. The
369
Case Presentatton
chest radiograph revealed no pneumothorax or hemothorax, and the mediastinum was normal. The pelvic film revealed a right iliac wing fracture that extended through the right acetabulum. Our first priority was to determine the source of the hypotension. We would never attribute this degree of hypotension to a head injury. There was no radiographic evidence of hemothorax. Dr. Wolfe raised the possibility of intraperitoneal bleeding. Where else could there be blood loss?
Dr. Walls: In fact, one study demonstrated that a head CT scan before laparotomy in the presence of a GCS of more than 8 was so low yield as to not be helpful, and the authors advocated prompt laparotomy without CT in such patients (4). At this time, we performed a DPL. The initial aspiration was negative for gross blood. The lavage fluid was very lightly red tinged, essentially negative. The fluid was sent to the laboratory for cell count. At this time, her blood pressure was I lOi70.
A resident: In this patient with a pelvic fracture, hemorrhage into the retroperitoneum likely is due to the fracture itself or an associated renal injury. Although not apparent in this case, long bone fractures can cause hemodynamically significant blood loss into the extremi ties.
Dr. Wolfe: The next step is to evaluate the retroperitoneum. First, there may be a large retroperitoneal hematoma secondary to the pelvic fracture. Second, the genitourinary tract needs to be assessed for renal injury.
Dr. Eric Nadel: We have focused on hemorrhagic shock in this patient, but other causes of hypotension need to be considered. A tension pneumothorax has been ruled out, but the remote possibility of pericardial tamponade still exists. Although this is rare in blunt trauma, a bedside ultrasound, if available, would be helpful to rule it out Dr. Wolfe: Tamponade from blunt trauma is unlikely here because patients with tamponade most often have profound hypotension that rapidly evolves into traumatic arrest. In this setting, I think it is more important initially to look for hemorrhage and evaluate for cardiac tamponade only in refractory hypotension once hemorrhagic shock has been excluded. At this point, I would assess for intraperitoneal hemorrhage. Although the blood pressure is 120170, the baseline blood pressure is unknown, and in an elderly patient, this blood pressure may represent significant hypotension and hypovolemia. I would proceed with a bedside ultrasound, if available, to look for blood in Morison’s pouch or with a DPL if ultrasound was unavailable. If either test was positive, I would send this patient straight to the operating room (OR) for a laparotomy. Dr. Walls: How would you deal with the conflicting priorities presented by the possible head injury? Dr. Wolfe: A patient with hemorrhagic shock from a known intraperitoneal injury should go straight to the OR, regardless of head injury. The intraabdominal hemorrhage needs to be controlled immediately. A delay while waiting for a CT scan of the head to evaluate intracranial injury may be fatal. In the OR, the neurosurgeons could place an intracranial pressure (ICP) monitor or perform a craniotomy.
Dr. Carlo Rosen: turia?
Did the urinalysis (lJA) reveal hema-
Dr. Walls: The UA revealed 520 red blood cells (RBCs) and 17 white blood cells. but the diagnostic meaning of microscopic hematuria in this setting is vague. In the evolution of renal injury evaluation, we used to become excited about 50-100 RBCs/HPF. We now recognize that significant renal injury can occur with or without microscopic hematuria. Really, it is the mechanism of injury and the presence of shock that require evaluation of the kidneys by CT or intravenous pyelogram, and the urinalysis alone isn’t terribly helpful. although it may help focus the workup. We felt that the patient was hemodynamically stable and decided to send her for a CT scan of the head, abdomen, and pelvis. We were intent on determining the source of the hemorrhage. Ten minutes later. as the scanning was completed, she became pulseless. Cardiopulmonary resuscitation was initiated, and the patient was moved back into the trauma room. What action would you recommend now? A physician:
Perform a left thoracotomy.
Dr. Wolfe: Many would argue that patients with cardiac arrest after blunt trauma are not salvageable. If there were abdominal or retroperitoneal injury, the aorta could be cross clamped on the way to the OR. I recognize that chances of survival with thoracotomy are poor in this situation. Our 15yr series from Denver, yet to be published, suggests that 2% of patients with cardiac arrest after blunt trauma have good outcome and are neurologically intact if signs of life are present in the ED. However, before performing a thoracotomy. the circulatory status must be assessed. Was she in full arrest? Dr. Walls: Although pulseless, the patient had a sinus tachycardia at ! 10 beats/min, and we transfused
370
E. S. Nadel et al.
the patient through the rapid infuser. As the thoracotomy tray was being opened, bilateral needle decompression was performed that revealed no rush of air. A pericardiocentesis was performed; the aspiration was negative. At this point, pulses returned, and she had a blood pressure of 80 by palpation. We continued the resuscitation. The radiologist reported the CT scan results. The head CT revealed bilateral subdural hematomas, right greater than left, but without significant mass effect or midline shift. The abdominal CT scan revealed a large right retroperitoneal hematoma. Her pelvic fracture, which looked reasonably innocuous on plain radiography and was stable to palpation, was multifragmented with opening of the sacroiliac joint. Dr. Rosen: The pelvis may need to be stabilized, and one should consider whether the pelvic bleeding might be controlled through embolization. Dr. Walls: Orthopedics was consulted regarding placement of an external fixator. They felt that an external fixator would not help because the pelvic ring was intact. A decision was made not to proceed with angiography because the blood pressure had stabilized at 105/75. The patient was admitted to the surgical intensive care unit (ICU), where fluid resuscitation could be monitored closely. Embolization would be reconsidered if hemodynamic instability returned. The neurosurgeons felt that operative intervention was not indicated, and they placed an ICP monitor in the ICU. Her ICU course was complicated by a transient coagulopathy, but she remained hemodynamically stable, Neurologic improvement was minimal. The pa-
tient was eventually discharged to a nursing facility in a semivegetative state. It is always worth considering what we might have done to improve her outcome. The ABG, which was drawn as the patient went to CT, did not return until after the arrest. The pH was 7.31, with a pC0, of 19. In retrospect, she was probably under-resuscitated when she left for CT. Had we known the ABG results earlier, we could have begun more aggressive fluid resuscitation in the trauma room, improved her volume status, and then sent her over to CT. Although adequate volume resuscitation does not immediately correct the metabolic acidosis, the degree of acidosis should be taken as an indicator of incomplete resuscitation. Until the controversy regarding volume resuscitation in the context of ongoing hemorrhage is resolved, the appropriate course in this circumstance would be to restore intravascular blood volume as completely as possible. Of course, rapid intravenous fluids were continued while the patient was in CT, but more aggressive volume restitution is available in the trauma room. However, we had to move quickly to localize her blood loss, thus the dilemma. Are there any final questions or comments? Dr. Wolfe: This case is illustrative of how much work we still have to do with polysystem trauma. The patient’s course was typical of severe head injury in this age group where the patient develops severe, irreversible neurologic deficit extremely rapidly after the injury, and the prognosis is very poor. The patient was basically doomed by her injuries at the time of the accident, yet our emergency care kept her alive. The next challenge is to be able to return this kind of patient to a functional life.
REFERENCES 1. Mattox KL, Bickell W, Pepe PE, Butch J, Feliciano D. Prospective MAST study in 911 patients. J Trauma. 1989;29: 110412. 2. Chang AK, Dunford J, Hoyt DB, Rosen P. MAST 96. J Emerg Med. 1996;14:419-24.
3. Walls RM. Rapid-sequence intubation in head trauma. Ann Emerg Med. 1993;22(6):1008-13. 4. Fulton RL, Everman D, Mancino M. Ritual head computed tomography may unnecessarily delay lifesaving trauma care. Surg Gynecol Obstet. 1993;174(4):327-32.