iPhoneIcon_Big-31I’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.

Bad combination
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.

Critical minutes
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.

Hemorrhagic Shock Resuscitation – EMCRIT podcast 30 interview with Richard Dutton

Hemostatic Resuscitation – lecture by Richard Dutton, from EMCRIT

Rapid Ultrasound for Shock and Hypotension – the RUSH Exam, from EMCRIT

This entry was posted in Code Brown, Emergency Medicine, Trauma, Ultrasound. Bookmark the permalink.


  1. Vikig One_per says:

    Great great case.
    Again and again this prooves that ART LINES SAVE LIFES!!!
    especially when positive pressure ventilating hypovol patients.
    I carefully remind that the skilled prehospital provider should DO the same in prehospital setting when faced w patients like this.
    And do it BEFORE RSI in extereme cases like this.
    It is the one and only way to balance ventilation. And work carefully with level of PEEP, I:E ratio and mean airway pressure.
    Well done to the author of this case and thanks for sharing.

    • Thomas D says:

      Yes, art lines can be of great help in critical patients. In this case, it was impossible to place an art line before anaesthesia due to the patient being so combative. In that setting, the capnography will be my monitoring equipment of choice, and provide the first reading and a good clue to the pt’s circulation status. The art line was high on my list of monitoring equipment, and helped gear the blood transfusions to a new level, also supported by the lactate drawn from the art line.

  2. Vikig One_per says:

    sharing experiences
    Good stuff

  3. Øyvind S H says:

    You said you used Midazolam and Ketamine in supra-anaesthetic doses. What made the PT sleep finally?

    • Thomas D says:

      Rocuronium 🙂

      Seriously, I gave him a rather large dose of ketamine (for someone in bled-out shock, but I don’t remember the dose). I didn’t know if he’d be asleep, I just knew my rocuronium would work. And in this setting, I’d rather gamble on the risk of awareness than circulatory collapse.

      In the OR, I could add gas and more fentanyl for his anaesthesia. Titrating together with blood transfusions.

  4. HEMS_Doc says:

    Great case, thanks for sharing!
    Agree on focused monitoring for patients “in extremis”. Personally in the prehospital setting I prefer monitoring with pads or 3-leads for electrical activity together with capnography for airway confirmation /cardiac output monitor. On the off chance youre getting a reading on your pulseox – youre ventilating (carefully!) with 100% O2 and any Peep will probably do more harm than good – initially youll just have to accept your SaO2.. With deterioration postinduction and any sort of indication of thxtrauma you will also probably proceed w thxstomies?
    Agree with your priority on paralysing the patient, with anywhere near adequate analgesia, awareness is not likely to be a problem on these patients?
    Duttons talks on the subject are truly fantastic!
    Arterial lines in the prehospital setting on these patients? Sure, but when timecritical not before the patient stops moving and your vehicle starts moving (ie enroute)
    And a prehospital patient like this is of course a good case argument for prehospital transfusion..

  5. Tom Halliday says:

    It pains me as an anaesthetist to say this but arterial lines do not save lives. Especially not in trauma patients. After control of the situation, in this case via ketamine/rocuronium, massive transfusion and surgical control must be the priority. An art-line is always nice but life saving? Not really.

  6. HEMS_Doc says:

    Tom, I agree in part.
    However, as a prehospital critical care physician I see a few situations where an arterial line is of benefit:
    TBI with little suspicion of concomitant bleeding: As a part of delivering hospitalquality neuroprotective anaesthesia I would even consider doing this preinduction at scene
    Post ROSC patients: Neuroprotective reasons as above, but especially if timecritical (STEMI) I would do it enroute
    Traumatic bleeders: As a means of delivering aggressive hypotensive resuscitation to young patients and at the same time avoiding hypovolemic cardiac arrest (of course you can partly suspect an oncoming event like that from your ECG tracing with increasing “irregularities” (eg ventricular extra beats etc), however this is a rather late and unsure phenomenon and I believe invasive blood pressure monitoring is of benefit. These patients are of course extremely timecritical and therefore when done I choose to place the line enroute.
    my 2 cents..

  7. Vikig One_per says:

    I indeed agree with HEMS_doc!!
    And, for the case with massive bleeding…
    If a patient is so sick that they need massive transfusion, then there is certainly a NEED for invasive BP recording.
    It is well proven to be much more accurate than non invasive BP when BP is in the extremes in either direction.
    And for patients needing massive transfusion there will always be hands around to put in an art line without delaying any other treatment.

  8. Tom Halliday says:

    Agree with your comments HEMS-doc and viking one… but. In this case it was an in-hospital patient, and when it comes to out of hospital I’m very unqualified to comment but the gist was that an arterial line in itself is not something that in acutely bleeding trauma patient should cause any delay to the definitive treatment and all procedures take time – usually longer than we think they do. That art lines are useful is hopefully not up for debate but please don’t start putting them in while the surgeon is waiting to fix the bleeding!

    • Vikig One_per says:

      Thanks f good debate.
      I m never talking about delaying treatment.
      These patients usqually get art lines before the surgeon has even started thinking or recognized they need for surgery. And should never delay it.
      And by the way. I cannot see how art lines in radial artery delays start of surgery??

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