Where do you start!?!?! Bloody Case Scenario

[Doc Dutch]

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]

I would suggest securing the airway ASAP.

[Doc Dutch]

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]

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]

Agree with FMF Doc.

[swatsurgeon]

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)

ss