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View Full Version : Where do you start!?!?! Bloody Case Scenario


Doc Dutch
06-29-2008, 17:58
Ok, you have a 27 year old male coming in to your ED with multiple stab wounds and 4 minutes out by report. Per pre-hospital personnel report over the patch phone you have a BP 80/palp, HR of 140, and patient having difficulty controlling the airway secondary to secretion. Initially, the secretions were bloody but now it is just mucus being spit up. They are worried about intubating him and losing his airway without a physician ready to cric him. (Sorry, that is all we had prior to his arrival).

When the patient arrives. He is pale and diaphoretic. His heart rate is now 130 bpm with initial BP of 85/40 after the pre-hospital personnel's one liter of RL. RR is 35 and SaO2 is in the low 90's. He is on high flow O2 by facemask. There is one IV (18 gauge in the right upper extremity. There is blood everywhere on his clothes (his shirt, pants and on his shoes are soaked).

On PE there appears to be a 5 cm laceration to his right neck in the anterior triangle from just lateral to the midline and above or at the level of cricoid cartilage. There are several tears on the right and left side of his shirt which is cut away by your staff. You see a 5 cm laceration to his left shoulder, a 6 cm laceration beginning over his right anterior chest wall above and extending lateral to the right nipple (bubbling with sucking sounds), a 4 cm laceration to the right of the sternum at the 3rd intercostal space (not bubbling) but clear next to the sternum, and a 12 cm laceration to the patient's left axialla which is bleeding. He has good pulses in each wrist but we have only taken a BP on the right upper extremity.

Again, blood everywhere and the young man starts crying for his mother (very commonly seen and described as his mental status slips to a GCS of 13 - not following commands and localizes but becoming incoherent). Suddenly, your next BP is read as 60/palp!

Now what are you going to do?

(After a little discussion, I will tell you what we did).

Thank you,

Dutch Matthews, MD

Red Flag 1
06-29-2008, 19:16
Dutch,

I would suggest securing the airway ASAP. Confusion could well be from hypoxia. Sucking chest wound and SaO2 low 90s supports decision. Patient may become combative and hamper eval. Neuromuscular blockade!! Likely headed to the OR before long.

Needs at least another large bore IV or two. Labs including T&C x4. Breath sounds after intubation very crutial here IMHO. Chest and neck films/CT would be nice if time allows. Is an OR available?

Any other bleeding? Any Abd stab wounds? Any blood in the esophagus? Any idea of knife blade length? Any noted motor loss to LUE?

My $.02 from the head of the table. Like to hear what was found!

Thanks!

RF 1

Doc Dutch
06-29-2008, 20:06
Exactly correct. Airway before breathing and then circulation as this is not a military type of injury requiring "C" first.

Now, as we went to intubate, the clot in the pharynx that was on the inside of the neck broke lose and the patient started hemorrhaging from the neck's mucosa internally and externally as had been reported by the ground crews before the neck wound stopped hemorrhaging by itself. The EM physicians were surprised and started yelling for a surgical cric as they repeated an ETT airway attempt while suctioning blood quickly. That is when I went to head of the bed and applied pressure to the wound with a stack of 4 x 4's. They had paraylzed the patient with Etomidate and SUX (short acting) IV. As the bleeding slowed to a stop, they were able to intubate (sigh of relief). The nurses got two more IV's in peripherally (another in the right upper extremity and one in the left upper extremity) with all of the comotion at the head of the bed. I cautioned the nurses and the physicians about not using the one on the left (any guess as to why?). So, we have three functioning IV's. We did draw a trauma panel (everything under the sun) but the key draw was the T and C.

Now we are intubated . . . bleeding from the neck without pressure and now with a large air leak from the right chest after the ETT is in. Last BP was 60/palp in the right arm.

Now what???

Dutch

FMF DOC
06-30-2008, 01:09
With airway somewhat secured, Then Chest tube and seal for sucking chest wound, if possible locate the bleeder in the neck and clamp it. Remove all other clothing and sweep from head to toe looking for anyother wounds.
Stat X-rays/CT scan and off to OR.

Red Flag 1
06-30-2008, 08:35
Fluids in LUE may wind up on the sheets! IV's on right more reliable IMHO.

Something worth considering is that there may have been lacerations to trach, and/ or mainstem bronchi. Really need CXR at least, ABG's for sure post intubation.

Agree with FMF Doc.

RF 1

swatsurgeon
06-30-2008, 12:29
Something was missing.........I KNOW!! Someone forgot to apply the tourniquet to his neck! Isn't that what's supposed to happen?

So was the cardiac tamonade seen on FAST/echo?

Stop giving IVF....give blood and get to the OR for resus; thank the medics for getting there with out hemodiluting him so that his dilutional coagulapthy doesn't kill him and needle in each chest that has an injury, although with the right side "open/sucking" the intubation takes care of that, the left needs a decompression. ....... FUN, FUN, time to play (sick trauma surgeon humor:munchin)

ss

Doc Dutch
06-30-2008, 14:23
It was a lot of fun indeed.

Next we quickly prepped the right chest and slid in a chest tube while in the ED. It put out about 300 cc of blood and had a persistent airleak (no surprise) but the blood output stopped there and throught the remainder of his hospital ICU course. We pulled it three to four days later once on H20 seal and the airleak had stopped. Covering the chest wound with bandages slowed the airleak but not completely.

CXR showed a partially collapsed lung before the chest tube and an ETT in place. No blood in the left chest on X-ray. No widened mediastinum. After the right chest tube was placed, the right lung had come up nearly to normal, but again the right chest tube had a small airleak.

Yes, started blood right out of the refrigerator in the trauma bay - two units with an increase in the SBP into the low 90's and a heart rate finally dipped into the 120's to 110's.

FAST was negative by report by the EM physicians(resident) but poor PI and quality control (the images were not perfect). So, I had another plan . . .

Left arm BP was checked and was eqaul to the right arm BP. The bleeding in the left axilla looked non-pusatile (a persistent ooze), just a dark and constant bloody oozing. When we looked into the left axilla wound temporarily in the trauma bay, we did not see an arterial or large venous injury, i.e. no huge gush or torrent of blood.

So, off to the OR we went . . . (my favorite place in the world!)

Any thoughts on how to attack these lacerations/explorations? Which order would you go after these lacerations? Explore the neck vessels on the right? Pericardial window? Explore the left axilla? Right chest wall next to the mediastinum?

Looking back, this was a great case and wonderful mental exercise. I hope my residents appreciated it as much as I loved doing it with them.

Thanks,

Dutch Matthews

Doczilla
06-30-2008, 15:34
From the ER doc's perspective....
Screen for domestic violence
Screen for immunization status
Screen for HIV
Screen for flu
Screen for TB
Screen for hepatitis
Start Medicaid application
Apologize for the long wait
Refer to clinic for primary care
:D

I think for the airway I'd prefer a Glidescope or fiberoptic bronch in any event. Quick question, say the intubation attempt failed, and with the laceration/hematoma at or about the cricothyroid membrane, were you thinking that you might go more inferior and do a bedside trach? Or was the anatomy clear enough to allow you to do the cric?

Since he's going to the OR anyway, would an intraop transesophageal echo provide some help in decision making since you couldn't get much info from the FAST? At least you would know where the pericardium sits on your "to do" list. Or would this take too long to setup and perform while everyone is scrubbing in?

Looking forward to reading more. Great case! :lifter

'zilla

Red Flag 1
06-30-2008, 17:33
Fiberoptic is great for tube placement, there should be fiberoptic training and practice for all who are responsible for securing an airway. Fiberoptic intubation by a practitioner with experience can provide a diagnostic information as well. Given the injuries, I would have been looking for subglottic bleeding, and the integrity of the airway to the carina and below, as well as ET placement.. IMHO, fiberoptic intubation can be faster that Cricothyrotomy. Fiberoptic intubation is less traumatic, and " muddys" the water less that cricothyrotomy. We already have enough neck trauma to deal with!

The choice of Etomidate was a good one. This agent does support hemodynamic stability, in the face of hypotension, better than Diprivan or Sodium Pentothal. Ketamine would be a choice, and probably my chioce, because it lasts longer and has better sympathomimetic ability. Ketamine also provides analgesia which the hypnotics do not. I would have opted for Ketamine as an induction/sedation agent!

Sux( Anectine ) is also a great relaxant because of its' speed of onset and short duration. Sux needs to be followed up with a Nondepolarizer after a few minutes. Something not many know is that a metabolite of Succinlycholine ( Sux/ Anectine ) is succinnylmonocholine, which, in its self, is a non-depolarizing relaxant. It is known as a phase II block, and is time and dose related. A phase II block is usually seen after multiple injections, or "dip infusion" after bolus administration for intubation, usually seen during C-section under general anesthesia. Phase II block is resistant to reversal, and just requires a " tincture of time " to resolve. I suspect that if Anectine were presented to the FDA today for patient use, it would not make it!

Great case Dutch!!

SS,, sometimes it is hard to resist putting the NIBP cuff around the neck! I have always been a proponent fo replacing cells with cells in cases like this.

RF 1

Doc Dutch
06-30-2008, 19:06
All great suggestions. I especially love the recommendations to start filling out the Medicaid application and also the referral to the primary care clinic. Ha! What a hoot! So, true. So, true.

Yes, fiberoptic intubations are neat and give you added detail to be able to look around and I would have pushed it if they had not been able to do it with the conventional laryngoscope and an ETT. Also, a cric would have been simple to just extend the incision down and over to the left. We could have converted the cric over to a trach subsequently.

Sadly, we do not have an esophageal scope in the OR for Anesthesia to look for a pericardial effusion. One is coming as we are starting a CT program, but right now it was out of our reach (another great idea).

Etomidate is a good med as is SUX but the truth is that the Anesthesiologist pushed the Norcuron IV on arrival to the OR.

So, as for the case . . .

We prepped chin to the knees and table to table (and with a foley placed by the intern). My chief resident and I went for the neck first as it was bleeding the most. We quickly cut down on the right carotid sheath (luckily, no injury to the carotid or the jugular). We explored the gapping hole in his right neck that got close to the right carotid sheath. The laceration went into the throat above the thyroid cartilage and you could see and feel the ETT passing through the vocal chords. It was the mucosa and the muscles that were bleeding into the pharynx/larnyx and had temporarily clotted until distrurbed by our first attempted intubation in the trauma bay. We closed the mucosa and muscles and left a drain, did a quick tracheostomy and then closed the skin after a few washouts with a bulb syringe.

At this point still a little hypotensive with SBP in the mid to upper 90's despite two units of blood and more on the way with FFP thawing. Had about two liters of crystalloid IV so far. So, at this point we did a subxiphoid pericardial window secondary to the hypotension and the right sternal stab wound. Lucky for us and the patient, the window was negative for blood.

At this point we went after the chest wounds and explored each as well as the right shoulder, concerned about an intercostal bleeder. Now, the chest tube on the right did not have any more blood coming out of it since placement, but in the back of my mind I was thinking about it being clotted off with blood. So, explored each wound on the right chest including the one next to the sternum. No bleeding from any of them but saw a laceration to the lung anteriorly which we sprayed with Tissel. Irrigation from each chest wound washout was coming out of the chest tube so I realized we were not clotted off.

Finally, went after the left axillary wound. Washed it out with saline bulb syringe and explored it. Could feel the axillary artery pulse through some fat but no injury or expanding hematoma or staining in the area. So, washed it out and stopped any miscellaneous bleeding and closed it with sutures deep and staples on the skin.

He was transfused a total of 5 units of packed RBC's and 4 of FFP, close to a 1 to 1 resuscitation of pRBC's to FFP. We got a post-op chest CT scan which did not show a vascular blush anywhere and an expanded right lung. Also, did a soft tissue CTA of the neck and vessels and it showed nothing that we did not already know. Figured we find out right away if we needed to go back and reoperate on an inominate artery or vein injury or if I had missed an injury somewhere else, so had the nurses hold the room until we called back from the CT scanner. As it was negative we released the room and went up to the Surgical ICU.

Next thing I know they were calling the trauma team to the trauma bay stat. We had a GSW to the abdomen that "walked in". Luckily they came in one after the other and not at the same time.

Dutch Matthews

The Reaper
06-30-2008, 19:38
We lost a good soldier in Honduras back in 1986 with stab wounds including a major one to the neck.

He expired on the way to the nearest hospital by ground evac, despite the best efforts of several good 18Ds. When we got to the hospital, the Docs said that the only thing more we could have done for him was transfusions and a cut down on the neck to close off the bleeders. We did not bring the IV kit due to the nature of our mission, and the medics were not qualified to be doing vascular surgery on the head and neck. I was very proud of what they accomplished with what we had.

I counted 13 empty 500ml and 1000ml IV bags on the ground the next morning. Next deployment, we brought the transfusion kit, and learned not to count on air MEDEVAC.

This thread brings back memories, and is a good lesson learned. RIP, Tim.

TR

Doc Dutch
06-30-2008, 20:16
Sir,

If I can be frank with you, we all have cases in our closet that we shy from. On a very personel note, my father who is a cardiologist, once told me something when I was in medical school and saddened by the hopelessness I felt regarding a dying patient. He said that as a physician when you close your eyes at night you walk through a cemetery where you will see patients's faces, some that you knew well and some that you only knew for minutes as they had too quickly passed on before you could help them. He told me that over time their faces become less sorrowful and may even become your friends. It was his way of comforting his son and a very junior doctor. I have found that over time this to be true as I accrue more knowledge and realize that there are some injuries that we just cannot fix. Many times we as trauma surgeons, emergency medicine physicians and nurses have been put in positions where even if we had everthing at our disposal, the damage is too severe and too much blood and time were lost.

I am saddened by your loss and promise I will do everything I can while on service to remember your story.

D-

Red Flag 1
07-01-2008, 09:22
If memory serves me correctly, left axillary stab wounds were common in Zulu wars. The left arm carried the shield. Foes would try to sweep the shield away exposing the axilla which was then penetrated with a spear as deep as possible. Injury resulted in motor loss to the left arm, leaving the combatant defenseless, and bleeding. The axilla wound was almost always fatal either directly or indirectly.

Re: Sux. Phase two block is not something to strive for, more of a complication. I would likely have pushed Vit "N" ( Norcuron) as soon as he recovered from the sux.

Great case.

RF 1

Doczilla
07-01-2008, 11:04
Outstanding case. Great learning points all around.

It's a great thing to see a trauma surgeon get down to business. This patient was an impending disaster, and there is no question that you saved his life. :lifter

'zilla