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.
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 unstable haemodynamically
- Move to Resus
2. What initial blood investigations should be taken for this patient?
- Group & Cross Match 4 units
3. As a Junior doctor in Resus, how would you assess this patient?
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 potentional 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.
- 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.
Look for Long bone fractures or. Obvious deformity. Perform log roll and examine the back also.No other obvious external source was identified.
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 below. What do you see?
- Large hematoma and blood surrounding the kidney. Rt 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 morrison’s pouch which is abdomen’s most dependent area. Blood being retroperitoneal did not accumulate here hence was not visualized 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/Anesthetist 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.