CODE BROWN: CRASHING TRAUMA PATIENT

We all know the rules for damage control resuscitation. Often the lines are clear. But sometimes it’s hard to make that call. We received a MVA trauma: a young man trapped in a wrecked vehicle for hours in the Norwegian Winter. Multi trauma with pelvic injury. He deteriorated during transport. Being wheeled into our trauma bay he was cold, pale, tachycardic and hypotensive, but with a GCS of 13. No recordable blood pressure or pulse oximetry. No palpable radial or femoral pulse, only carotid pulse.

Resus
We had O neg blood ready when he arrived for the primary survey, and was resuscitated aggressively while keeping him on the hypotensive side while taking him to the OR, where we continued resuscitation with 1:1:1 trauma packs of warmed blood products. He had received 1g TXA bolus prehospitally, and we continued with a 1g TXA infusion. He improved somewhat, but never got a SBP over 90 and was intubated in the OR on low dose ketamine and sux.

The general surgeon did his damage control surgery and packed the pelvis, while we did our damage control resuscitation. The patient responded well and seemed stabilised. During initial resus and surgery we managed to give enough blood products to get an acceptable circulation and after the pelvis was packed, we continued resus and normalised circulatory parameters. We also managed to rewarm the patient from 34 to 36 degrees Celcius and Lactate went from 8 to 2.4. It was all looking good. We were pretty pleased with ourselves.

The only thing that held back our high fives was the patient’s white and cold right leg. No palpable femoral pulse, no tibial or dorsal foot pulse, no doppler signal, no capillary refill.

Dilemma
The vascular surgeon and invasive radiologist were called, and agreed the patient needed to go to angio to have a chance of saving the leg. It had already been hours since the accident, so he needed to go now. Our dilemma: ICU or angio? ICU was protocol and would give us a ‘safe’ environment for further stabilisation, but the leg would be lost. Angio would put us into a more difficult environment, away from our resources, but had the potential to save the young man’s leg.

In life vs limb, life wins. But I’d prefer to have both.

Decision
We decided to wait for 15 mins in OR while continuing obs and ongoing resus and making ready to move with all important resus gear. The patient was fairly stable, but was still needed a bit of fluid during this time. So, were we in a stable resus phase, or was the patient still bleeding?

The surgeon was convinced he had packed the pelvis well. He had also placed two drains – there was no blood through any of them. Patient was left with an open abdomen with a clear plastic cover. No sign of bleeding through that. The patient might have a small, internal bleed from his broken left leg, but nothing that would give us serious trouble. There were no other suspected sites of bleeding.

In the end, the trauma team’s shared decision was to go to angio. I still had that little, uncertain feeling tingling in my stomach. My anaesthetic nurse and I packed blood and plasma as well as any resus meds we would need, including 10 mcg/ml of adrenaline. Most importantly, we had a plan for resus and return to OR.

Crashing patient
So we went to angio. The patient kept stable. But when we were getting ready to transfer the patient to the angio table, blood swelled up from the abdomen and made a bulge in the clear plastic cover. The patient’s blood pressure plummeted, his pulse rate skyrocketed. The clot had popped. The patient had a problem. We had a challenge.

Luckily, we had planned for disaster and had everything we needed. The crashing patient received small doses of adrenaline while blood and plasma were poured into him, and kept him afloat. We got his hemodynamics back up from the floor, and rushing back to theatre, heamodynamics were kept under control by ongoing infusions under pressure, but constantly fighting his bleeding. The patient was reopened, and blood poured out. The surgeon ‘clamped’ the aorta with his fist. Anyone who’s experienced clamping of the aorta in a crashing patient with a lower body arterial bleed knows how it immediately improves the circulation. This gave us time to fill up the patient. The surgeon and assistant repacked the pelvis, and slowly released the manual pressure on the aorta. The torrential bleeding had once again stopped, the patient was once again stabilising. We’d been very close to losing him. Far away from our resus and ICU environment.

Decisions, decisions
So, armed with the beauty of hindsight, what should we have done? Accept to lose the leg and play it safe? Or was it fair to try and save a young man’s limb when he seemed stablilised? Go too safe, and you might lose a lot of limbs. Go too cowboy, and you might lose a life.

Three lessons (re)learned:

1) Never trust a surgeon.
2) Always trust your gut.
3) Always plan for disaster.

Also, never underestimate your own feelings, projections and involvement. This was a man about the same age as all the involved staff, including myself. I know I really wouldn’t want to lose my leg. I suspect none of the others would, either. Sympathy instead of empathy can be a dangerous thing.

In the end, the patient lost his leg – but survived.

References
R. Dutton’s excellent and free article:
Resuscitative strategies to maintain homeostasis during damage control surgery, British Journal of Surgery, 2012.

A look at damage control resuscitation vs. old-standard care:
Damage control resuscitation: from emergency department to the operating room, Am Surg, 2011.

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17 Responses to CODE BROWN: CRASHING TRAUMA PATIENT

  1. Ari says:

    In some ways the decision to proceed to angio might have saved this patient depending on your hospital set up… Getting from IR to OR much easier than ICU to OR. Patient would have just exsanguinated…

    • Thomas D says:

      Agree. It depends on your set-up. In our hospital, the ICU is closer to OR and the ICU staff vigilant and quick to move patient if needed. IR is further away.

      I agree with your sentiment. ICU in itself is not necessarily what a patient like this needs. He just needs continued resus, a close watch and proximity to OR.

  2. Scott says:

    Fantastic case and exemplary management. The long-term solution is that major trauma should go to a combined OR/Angio suite, like the RAPTOR set-ups. Operation, perc. intervention, and ICU level resuscitation in one room.

    • Thomas D says:

      Hi Scott, thanks for the input! It was a pretty intense case. I agree with your solution, and we actually have a hybrid OR/angio suite on the way, ready for use next year. It’s mainly being planned for vascular and cardiac procedures, but it would also be optimal for trauma. Hopefully, we’ll start using it for trauma once we’ve gained experience with it.

    • Thomas D says:

      Also, how are things at your center for dealing with pelvic trauma? Are you set up with hybrid suites? If not, do you usually go with interventional radiology or traditional OR?

      In our center, as mentioned to Remi below, fairly stable patients with suspected pelvic bleed will go to angio suite, really unstable ones to the OR. If we’re suspecting any other abdominal bleed than pelvic vessels, the patient will always go to the OR.

      • Scott says:

        At my current center, we do the same. With the advent of extra-peritoneal packing (EPP), the OR can be a destination for pts with or without intra-peritoneal bleeding when unstable. Even better would be bedside EPP and then angio in the FAST negative patient. My center doesn’t have a RAPTOR suite. My place of trauma training, the Shock Trauma Center, does and that is where they would go I believe.

        • Thomas D says:

          Thanks again, Scott! It’s interesting to hear how others are doing this. And bedside EPP sounds like a great idea – stepping up the game once again.

          The Shock Trauma Center sounds like a fantastic place to experience.

  3. nfkb says:

    Hi !

    Breathless reading of this note !

    In the trauma center i work we have pretty quick embolization for pelvic fractures bleeding. I know it’s an ongoing debate but opening the abdomen for pelving packing might facilitate a new bleeding loosing the “autocompressive” phenomenon of blunt trauma. It’s very uncommon that we ask the surgeon to pack the abdomen (except major hepatic trauma with dilasceration)

    By the way… Nothing to deal with this case but i’m always concerned by femur fractures with others life threatening damages. Do you believe in albumin or corticosteroids to prevent fat embolism ?

    Thank you for sharing this case and sorry for my poor english

    • Thomas D says:

      Hi Remi, Thanks for your comments! Always appreciated!

      We also do embolisation, especially for pelvic bleeds. The problem at my current center is that the interventional radiologist is on call from home. So night time = no super-emergent embolisation. It was just a coincident he was in and popped by our OR that night.

      The other thing is that we don’t usually take very unstable patients to radiology. They would be taken to the OR. It’s just the way we’re set up. Do you guys take even very unstable patients like this one to radiology? What if the patient ends up needing a laparotomy anyway, if the bleeding can’t be stopped be radiologic intervention? I would be interested to hear how you do things. Would you have a hybrid set-up as Scott Weingart mentions above, or do you just take them to radiology?

      On the albumin/corticosteroids to prevent fat embolisms in trauma, I wouldn’t know. I haven’t looked into it. I would love to see any references/article links you might have on the issue.

      Thanks again for commenting. Your English is not poor at all. It’s very good, so keep it coming!

  4. nfkb says:

    Hi there !

    In our ED we’ve got a lot of doctors on call. Anesthesiologists manages the surgical emergencies. At night, we are two seniors anesthesiologists, two residents and one anesthesiology nurse.

    Our interventional radiologist is also at home (must be less than 20 minutes driving)

    I do not have the whole pictures and datas about your patient but it’s not in our habits to pack pelvis (nearly never). When a severe patients enters our “trauma room” we take all the blood samples we need, put the lines if needed, and the we rush for the whole body CT (except made for near-to-die-from-bleeding patients)

    The CT is the next door to our trauma room, easy.

    If the patients is bleeding from his pelvic fractures, even if he is shocked, we first try embolization. We call the interventional radiologist, put the central lines and blood in the while and a doctor and the anesthetist nurse go to the interventional radiology room where there’s a good ventilator and everything needed for practicing anesthesia. This room is something like 5-8 minutes walking from the “trauma-room and the OR”
    We are lucky to have good interventional radiologists. They do a lot of procedures so they are really good at managing such patients. But i need to say that i’m only doing on calls in the ED, everyday i’m working in the digestive surgery department so i might be not experienced enough to answer correctly to your questions. (i’ve just sent an email to my colleagues to ask them about pelvic packing in our hospital)

    What is a mixed setup ? Radiology in the OR ?

    About fat embolism, you can find some references from my zotero account :
    http://www.zotero.org/nfkb0/items/collectionKey/XJA93E9C

    • Thomas D says:

      Thanks for your comprehensive reply! Really interesting to get an insight into how other hospitals work, and how they deal with trauma. I’ve been reading up on this afterwards, and it seems interventional radiology is coming more and more in trauma care. Even in shocked/unstable patients. That’s quite a shift in trauma management! Who would’ve thought radiology would ever be an exciting ‘action’ specialty?!

      It’s interesting that you take unstable patients to CT. For me, that would be contra-indicated. We would go straight to OR. Any special things you do when taking a shocked patient to CT?

      We do have an anaesthetic set-up in the radiology intervention lab, but we only have the most necessary things, not everything, and not all the stuff you would like for trauma (like fluid warmers and pressure infusion systems). And it just doesn’t feel like ‘home’. You know that safe feeling you get if you get a patient to the OR? Because you feel at home and you know you got everything, and you know where everything is. That feeling is lacking over at radiology.

      Yes, a mixed set-up, a hybrid OR, is the best from both worlds: A big OR with radiology/angio capability. So you get a big C arm that can be moved in and out of the way, as well as lots of screens etc. See my recent Raptor Suite post.

      Thanks for the fat embolism link. Zotero seems like a good way to collect references!?

      • nfkb says:

        Hi Thomas,

        i’ve asked my anesthesiology colleagues from the intensive care unit of the ED. They do something like 5000+ anesthesia per year. From broken wrist to severe shocked patients. And they cannot remember a case who benefit from a surgical approach of a pelvic bleeding, they really do a lot of angios. But they are also fond of the Raptor concept. A new ED setup is in progress and there’s a RAPTOR room in the future OR.

        About CT in unstable patients. The first thing is that the CT is the next door to our trauma room, that’s really a good point. Of course the prehospital emergency teams have already done a lot to stabilize the patient : ventilation, fluids and catecholamines if needed. When the patient arrives, we quickly check ventilation, hemodynamics (and hemoglobin) and look for an obvious massive bleeding from scalp to toes ;) (you know that facial/scalp can bleed a lot, and of course we check (X-ray +/- fast echo) the thorax & abdomen).
        During this quick clinical approach the radiologist is warned and the nurse draws the blood with special focus on coagulation (we use thromboelastography in the ED)

        I do not want to make my snooty french doctor, but yes the trauma room is something we’re proud of because it works pretty well. And my colleagues in the ED can be proud of what they built in the last decade. (but for sure there are a lot of things that can be a way optimized…)

        And yes Zotero is a super free tool ! I guess my french directories might be a fuzzy way to sort papers but the keywords are still in english so feel free to explore my small database of medecine papers :) Now, i also use a cool wordpress plugin called Zotpress to insert paper references in my text as you can see in my recent anesthesia notes.

        A bientôt !

        • Scott says:

          You need to ask your anesthesiology colelagues if they are talking about an intra-peritoneal approach to the pelvic hematoma, which is generally a flail (except for the data published by Demetriade’s group on hypogastric ligation) compared to extra-peritoneal packing. If they are not using the latter, then they are probably correct. However in centers that are packing, it offers control of venous bleeding, which angio doesn’t offer. The 2 are complementary and not mutually exclusive.

          • nfkb says:

            Hi,

            actually sharing cases through blogging is a good way of learning other approaches to the patient :)

            Maybe we are wrong but neither anesthesiologist nor surgeons go for retroperitoneal packing of pelvic bleeding patients. The strategy is angio, shock treatment and being aggressive with the coagulation disorders. Trauma patients receive (sometimes in the prehospital setting) tranexamic acid, red cells, fresh frozen plasma, calcium, fibrinogen, platelets and sometimes PCC (under investigation)

            The retroperitoneal hematomas are know to achieve a self compressive phenomenom that lessen the venous bleeding.

            This is how i was taught :)

            On which findings do you ask a packing to the surgeon after the angio ?

            Remi/nfkb

          • Scott says:

            Generally packing occurs while waiting for the angiographer; it takes about 10 minutes. If the patient remained unstable after angio, that would also be an indication.

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