#MiniTeach: I'm Drunk, And That's All I Can Tell You
"A 57-year-old intoxicated male is brought in by paramedics when his roommates called an ambulance after noticing a lot of blood on his trousers."
The patient had been drinking all day and had later returned home stating that he had stumbled on the street. He apparently had a head injury with a small laceration on his forehead, which is not actively bleeding on arrival.
He is alert and oriented but couldn’t provide any details of the fall. On arrival to ED, the patient is seen in the Assessment Bay by the nurse.
Observations:
P: 75/min, BP: 65/35, SpO2: 99% (on room air), RR: 15/min, Temp: 35.9°C
1. As an Assessment Bay nurse, what priority would you assign to this patient and where should he be managed?
Priority 2 as this patient is haemodynamically unstable.
Move patient to the Emergency Room.
2. What initial blood investigations should be taken for this patient?
FBC, U+E, LFT, VBG, Coagulation, Group & Cross Match 4 units
3. As a Junior doctor in Resus, how would you assess this patient?
ACBCDE approach:
Don’t forget to assess the cervical spine as the patient has had a head injury and has alcohol on board.
Check for areas of potential haemorrhage.
External: Since this patient has blood marks on his pants with no obvious source, it is important to expose the patient to look for the source of external bleed. It turns out this patient’s underwear was soaked in blood and there was fresh blood around the meatus.
Look for long bone fractures or obvious deformity. Perform a log roll and examine the back also. No other obvious external source was identified.
Intra-abdominal: Perform Abdominal exam and bedside Ultrasound. Bruising, guarding or rebound tenderness on examination can suggest intra-abdominal bleed. PR exam is part of abdominal exam. Free Fluid on FAST scan in the event of trauma always suggest internal bleeding but negative fast scan does not rule it out.
Pelvis: Any tenderness around pelvis. Be cautious not to spring pelvis in such patients as it can worsen the pelvic bleed. Pelvic binder should be applied in such patients.
Intra-thoracic: Hemothorax.Chest x-ray will be diagnostic.
4. List important steps in management of this patient that you as a Resus Reg will take within initial minutes?
Inform ED consultant
2 large bore IV
Group & Cross Match 4-6 units
IV fluids 10mls/kg
Tranexemic acid 1gm IV
Call Surgical Registrar
Perform US FAST
Arrange Abdominal CT but patient needs to be stabilized to go for CT abdomen
5. After infusing 1L of Hartman fluid, the patient’s blood pressure improves to 95/60. A CT abdomen is performed. Look at the CT scan images. What do you see?
Large haematoma and blood surrounding the kidney. Right kidney has multiple lacerations and was reported by the radiologist as shattered kidney.
6. Why was the US FAST negative for free fluid in this patient?
Intra-peritoneal fluid accumulates in Morison’s pouch which is the abdomen's most dependent area. Blood being retroperitoneal did not accumulate here hence was not visualised during the FAST scan.
7. After returning from the CT scan, the BP drops to 58/40. List the immediate actions required at this stage.
Call ED consultant & Surgeons (if not already there)
Involve ITU/Anaesthetist as patient is likely to be transferred to theatre.
Put the patient in a head down position.
Start Blood products. (O negative if group cross match not ready)
Consider using Rapid infuser.
Activate massive transfusion protocol.
8. You contact the surgical registrar by phone who tells you that he has seen the scan. He says that this is a problem for the urologists, not the general surgeons. He suggests that the patient should be transferred to the General Hospital. How would you deal with situation?
This patient is unstable and cannot be transferred to the General Hospital.
You should involve the ED consultant immediately at this stage and contact the surgical consultant on call. The urologists should be involved. In a critical situation like this, the urology registrar or consultant will transfer across site to the Royal Infirmary. You should involve Urology Registrar and make sure that Surgical Registrar is on the shop floor with this patient to be ready to take him to theatre for urgent laparotomy if condition worsens. Make sure ED consultant is on board if there are any specialty issues.
Conclusion
This patient was diagnosed to have a grade 5 laceration of the right kidney with large retroperitoneal bleed. It was the case of blunt abdominal trauma. Surgeons and Urologist made a decision to keep theatre on stand by and attempt embolisation of bleeding artery 1st as patient’s condition had stabilised with ongoing blood transfusion. Embolisation was successful and Perfusion scan performed next day showed that large amount of right kidney had been salvaged and was functioning normally.
