I’ve had combative patients in my ER lots of times. Combative enough to warrant sedation or anaesthesia. And bleeding patients. Serious bleeding. Lots of times. But not the extremes of both at the same time.
The trauma call alerted us to a fall trauma from about 6 meters. Patient is reported to be awake. No other details. At arrival, the patient is awake, but very pale and with a respiratory rate of 40. The ‘severe bleeding’ bells go off in my head. But we have a problem. The patient is awake, but non-co-operative.
He is confused and moving violently about on the bed all the time. So, i.v. access is difficult and made worse by the patient accidently removing them at the same rate we put them in. We can’t get him to wear an oxygen mask, we can’t get sats or BP. There is no radial pulse, but a strong femoral pulse. He must be bleeding. Blood is being prepared. But the patient is combative.
In a severly bleeding trauma patient like this, I usually want to keep him awake and breathing on his own until we get to the OR. Anaesthetising this patient will take away most of his sympathetic drive that he’s relying upon to keep the circulation going in this bled out state. Also, the shift from spontaneus, negative pressure ventilation to positive pressure ventilation will decrease venous return, especially in a near bled out patient, and thus lower an already low cardiac output. Anaesthetising and ventilating a severely bleeding patient is usually not a good choice. It could easily be lethal.
For the combative ones, sedation will usually do. As bled out patients can be very sensitive to meds, I start with small doeses. I try midazolam. No response. Ketamine. No response. Still combative after supra-anaesthetic doses. His skin color’s getting greyer and paler. Usually this is the point were they get lethargic, but this patient is just getting more confused, aggressive and combative.
I really want to talk myself out of this intubation, but I no longer have a choice. I would have to call a code brown and sleep this patient. Without prior fluid resus. Without preoxygentation. And not having reacted normally to my meds, I’m not even sure he will be sleeping.
All I’m sure about, is that he’s going to get medically paralysed in half a minute – and I am going to save him or kill him over the next few minutes. If this bled out patient crashes on me and goes into cardiac arrest, there wouldn’t be much more to do. CPR wouldn’t really help. If I don’t get the tube down quickly and he arrests on a partly hypoxic background, I also seriously doubt he will ever get started again. He’s too close to being bled out. This is the scariest intubation scenario I’d ever done.
Four points I want to emphasise from this case:
1) Capnography – shows that the patient’s being ventilated, and that he’s circulating
2) Have a plan. Know what you want to do after a critical procedure.
3) In bleeding: Blood, not pressors.
4) Ultrasound for the win
1) Capnography – the most important monitor
The intubation goes quickly and smoothly. Tube with stilette. Capnography is the monitoring on top of my list in this situation. We immediately got an EtCO2 curve that tells me I’ve placed the tube in the trachea, and that the patient is still circulating. My own pulse normalises slightly.
Then we get pulse ox, first reading 87%. Then an art line is put in, and invasive BP showing 57/39. Still with good femoral pulse – and good capnography curves. More blood had already been started as soon as the patient was intubated and we had gotten more iv lines, but these readings scaled up the blood component giving to a much more aggressive level.
With the patient lying still, the rest of the trauma assessment goes smoothly, in traditional trauma style. The anaesthesia saved the situation – but could’ve killed the patient.
2) Won the battle, now win the war
When a critical procedure that goes well, and after the first high fives are done, it’s easy to stand there and not really know what to do next. I’ve been there after my first cardiac arrest save, thinking “Now what!?!”. So have a plan. Here, under ongoing massive transfusions on blood warmers, the trauma assessment was quickly finished and recapped before the patient was taken straight to OR, where they found massive bleeding in the pelvic region.
We had problems giving enough products to keep up with the bleeding, as well as TXA. But after the pelvis was packed, the bleeding stopped and the patient stabilised. Through 1:1:1 transfusions and active warming, the labs started to normalise. The first lactate was 19, now we were down to 6. Due to the massive transfusions and old SAG’s, K went up and calcium down. We had spiked T-waves at one point, but gradually got the potassium levels back to more normal levels through insulin/glucose, tribonate and calcium. The patient was in need of repeated calcium boluses.
Surprisingly, his TEG stayed normal, and the bleeding seemed to be controlled, so apart from tranexamic acid given early, and ongoing transfusions, we didn’t give any other coaguloactive drugs.
3) Blood, not pressors
Massive transfusion given effectively helped us steer clear of any cardiovasoactive drugs, and minimised clear fluids. This is key in getting good resuscitation in a massive hemorrhage. After we got the bleeding under control, we followed Dutton’s Damage Control Resuscitation strategy with Fentanyl 0,1mg, then wait to see BP slightly down, give more fluids, then repeat until well filled with fentanyl and warm and well perfused extremities.
4) Ultrasound FTW
This case was also another win for ultrasound. During the whole resuscitation, ultrasounds was a great diagnostic tool as well as helping with procedures.
X-rays were blurred and useless due to the patient thrashing around, but UL was used to confirm sliding pleura and to do a RUSH/FAST showing fluid in the pelvic region, and an assessment of the heart with no pericardial fluid, pumping well, but looking underfilled with kissing ventricles.
Also, after the patient was put to sleep, US was used for iv access, arterial cannula, and for putting in a high flow catheter in the internal jugular vein. Management would have been a lot more difficult and dodgy if we hadn’t had ultrasound readily available in the trauma bay.
A good save
Due to multiple and complicated pelvic fractures, the patient needed several operations and a rather long stay in the ICU before he was ready to move on, but made it through with no serious sequelae.