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.
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.
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.
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.
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.
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.
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.