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CASE #6 : FIND THE BLEEDING, STOP THE BLEEDING

Critical illness is part of the remit of rural doctors, albeit encountered relatively infrequently – which of course makes it all the more challenging! Moreover rural doctors have to deal with such cases with limited staff, no backup and paucity of lab tests and definitive care.

Perhaps one of the most commonly encountered true emergencies in the bush is dealing with major haemorrhage. Our patients work on farms, in heavy industry, or are involved in road crashes.

Let’s consider a hypothetical case and see how FOAMed could help.

THE SCENARIO

It’s Tuesday morning and you are busy working through a routine Primary Care Clinic in anticipation of the afternoon off. The local Rotary are hosting a BBQ at the nearby football oval and you’ve been invited as a guest speaker on the pros & cons of prostate cancer testing.

Clinic is rudely interrupted by a loud “BANG” from the direction of the footy pitch – looking out the window you see a pyre of smoke and decide to abandon Clinic to investigate.

On arrival you see the local bank manager, a proud Rotarian, lying on his back. Community members tell you that the gas BBQ exploded, igniting other gas cylinders. He was thrown some 8m backwards through a window, impacting a goalpost in his rotund abdomen & is now flailing around on the footy pitch with an obvious source of bleeding…

TRAUMA

find the bleeding, stop the bleeding

PRIMARY SURVEY

A – Crying in pain, hoarse voice, obvious facial burns

B – RR 26 bilateral BS, PN symmetrical, trachea central

C – obvious traumatic amputation. P 120 BP 80. Cap refill 3 secs. Tender in LUQ.

D – localises pain, groaning only, eyes open spontaneously

E – clothing tattered. Numerous glass shards embedded in zone 2 of neck and across the shoulder girdle.

Q1 : What are your priorities in managing this patient?

Yes, we’ve all done EMST/ATLS courses. But does this approach really work?

Q2 : What equipment is available in YOUR hospital (or prehospital pack) to help manage his bleeding?

Circumstances will differ – I’m interested in your answers!

Q3 : The patient has a history of non-valvular atrial fibrillation. Some bright spark (not you) decided to start him on dabigatran 3 months ago. What next?

Like it or not, there’s a whole gamut of new blood thinners out there – which affect trauma management.

Q4 : Retrieval services are flat out elsewhere in the State and will take at least 2 hours to arrive. Is there anything else that can be done locally?

Again circumstances will differ – some rural hospitals will have theatre capability and access to blood – some not. Interested in your responses


9 Comments

  1. […] re-record that when he gets back. But just to whet your appetite, try the trauma case of ‘find the bleeding, stop the bleeding‘ – feel free to post your thoughts on this case. I expect answers that go […]

  2. James Doube says:

    1) “DRCABC”, with the first C being for catastrophic haemorrhage – he is still talking, but will not be for much longer if we don’t stop the tide.
    – Option 1 local pressure
    – Option 2 tourniquet (CAT if you have one in your back pocket, otherwise any sort of belt/strap can be used in the short term). Could use a heamostatic dressing but unlikley to need on a periphery, and far less likely to have available than something to tourniquet with….. (Unless we want to go back to using cobweb – yes, it does work!)
    – Option 3 try to secure the bleeders with something (but unlikely to have a clip in our pocket)

    And we clearly need to sort out a definitive airway soon (facial burns and horse voice). And be rather careful with the glass in the neck…

    2) We need to stop the bleeding well before hospital, but once there I would give him tranexamic acid ASAP given risk of other/internal bleeding (and CRASH-2).

    3) Bugger…. I gather Prothrombinex still helps, which I suppose makes sense as dabigatran is a factor 2 inhibitor, and prothrombinex contains lots more factor 2. So I’d start the normal 1 vial per 10kg, and phone a clever doctor ASAP….

    4) Do not excessively fill him with fluid – we do not need any more pressure than to keep his brain perfused (once intubated aim for SBP of around 90, and hopefully some urine output), and we do not want to dilute the clotting factors with liquid which neither clots nor carries oxygen. And he will be getting lots of oedema anyway, so lets not make it worse than we need to.
    If we do need fluid, blood would be a good option (the fresher the better).

    Keep him warm.

    Give him a dose of antibiotic (clearly a compound fracture) – given the potential environmental contamination it may be better to go a bit broader than just a gram of cephazolin… maybe a decent doze of ceftriaxone and metronidazole or fluclox/gent/flagyl (the latter would hit the gram positives better, but maybe also the kidneys/ears).
    And an ADT.

    Once he is properly surveyed and stable, we should be able to remove the dressing (or release the tourniquet) and tie off the main bleeders, before giving the wound a decent clean (but leaving as much tissue there as possible for use later).

  3. James Doube says:

    Correction – Dabigatran is a direct inhibitor of thrombin (the enzyme which turns fibrinogen into fibrin), not its precursor prothrombin (which is factor 2, and in Prothrombinex)…..

    But prothrombin concentrates are still indicated – I just found a far more eloquent summary by Scott Weingart http://emcrit.org/misc/bleeding-patients-on-dabigatran/
    – I am not sure how many rural hospitals have Novo7 (not sure why this works if the thrombin is still inhibited) or dialyisis….

    [Tim, this high speed internet is great when you have it!]

  4. Hi Tim – rough day “at the office”. I will have a crack at a non-alphabetical approach to this one!

    1) Get control of environment – ensure safety of spectators, self and patient. IS there going to be another explosion. Delegate a Rotarian (e.g.. a plumber) to check out the gas bottles.

    2) Get your kit in place – send somebody to your rooms to get your pre-organised trauma kit and your practice team including the drugs from the fridge / S8 cupboard (will be needing some ketaminh)

    3) OK now to the patient – forget ABC. First priority is a torniquet on the bleeding stump. No point in having an intact airway on a dead guy. And then put pressure on anything that looks like it is bleeding. The airway can wait until the kit arrives

    4) Now – mobilise your blood bank – whatever that happens to be, we are going to need some good stuff – PRBCs, FFP, TXA, Cryo – or even whole blood if you have a walking supply. But please resist the urge to give 2 L of cold saline! A BP of 80 is OK! Lay him down and feel for peripheral perfusion. ( You might give 500 ml of warmed crystalloid if no palpable radial )

    5) Lets assume our kit has arrived. He is going to get a tube – this is inevitable. You have time to do it as controlled as possible. Ketamine 30 – 40 mg, will make the scene much more relaxed and give the pt great analgesia as you set up the airway team / kit

    6) Assume this is going to be a tough tube. Possible trauma to trachea / lungs, facial & pharynx oedema.
    For me this is a ketamine / rocuronium scenario. PLan A = Video guided ETT. Plan B – arguably go straight to surgical airway if you have no view with a decent VL. (Controversial – I know)
    * Remember to keep the tube a bit longer – allow for swelling. And carefully secure on burnt skin – a tie – nothing adhesive

    7) Cervical spine – yadahyadahyadah . Just keep it neutral, no collar, no weird devices. Just have a coordinated team to move him onto a board to get into ambulance to ED / OT

    8) Ventilator up and rolling. Lets do a SUSSIT exam to really detect what is going on with all that glass, the LUQ and ensure no creeping PTX on the ventilator, look at the eyes for FB etc

    OK guys that is my first reaction. I will leave it to the rest to correct and carry on the good work!
    Casey

  5. Great case! I’ll take a stab.

    Q1) My immediate priorities of this patient are (in order): Get a tourniquet on that leg, obvious airway compromise – intubate as soon as able , obvious internal bleeding (pelvis too? probable.) TXA right this second (sooner the better), PELVIC BINDER, dabigatran cascading the bleeding (probable head bleed), glass in the neck (subq emphysema? pneumothorax?). Really, he’s got a lot of factors here that aren’t in his favor.

    Q2) My current pack has combat tourniquets, gauze, and saline.

    Q3) FVIIa, FFP, PCC (and prayers)

    Q4) If we had time get out the ultrasound probe and perform an eFAST. Give this man blood products if we got it 1:1:1 (the less dilutional coagulopathy the better). Stable enough for a CT? Grab a pan scan if we can – definitely one of the head. ROTEM guided coagulation factor replacement if we want to get real fancy. Damage control surgery once he gets to where he’s going.

  6. Tim – I reckon the dabigatran is a red-herring!
    Sure – he might bleed a bit more. But if you are on KI and there is limited blood / factors around then the best thing to do is provide surgical haemostasis. Get him into theatre quick smart so you have the right gear, exposure and access to do Damage Control surgery

    Actually – even if he is on nothing – the best thing to do is surgical fix of anything bleeding. The whole massive transfusion / PCC /TXA etc (Novo seven has a poor evidence base) is all window dressing around the main intervention – clamp / tie-off / pack and sew up anything that is bleeding!
    The mantra should be – don’t give him anything that makes his coagulopathy worse, keep him warm and manage his acidosis. Spending time and effort on searching the cupboards for exotic factors is not a good idea!

    No CT on KI – good! He will die in the doughnut! Serial US exams looking at his major bleeding areas – if his belly is filling with black-red stuff then he needs a laparotomy if he remains unstable

    Casey

  7. Hildy says:

    How many hands are available?

    (I’ve never worked in a resource limited environment like this, so some of my answers may be off-base.)

    1. Gloved hands on the bleeder. Too easy for a tourniquet to become venous, especially if applied when patient is flat and then patient is resuscitated.
    2. Access and monitoring.
    3. Secure airway.
    4. Transport.
    (I’m not totally convinced about pelvic binders but I guess they can’t hurt.)
    ——————————

    In hospital:
    – massive transfusion pack – 1:1:1 or whole blood.
    – antibiotics – piptaz is the antibiotic of choice in this situation
    – DTPa!
    – release pressure, see if it’s clotted (unlikely with dabigatran onboard), maybe a quick stitch-tie (can be redone in theatre) or even just a haemostat.
    – two-shot panscan (or one-shot even)
    – depending on whether the intraabdominal haemorrhage is controlled or free, decision about OT here or in the ivory tower

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About

Http://about.me/timleeuwenburg

Http://about.me/timleeuwenburg

I am a Rural Doctor on Kangaroo Island, South Australia with interests in EM, Anaes & Trauma. Avid user & creator of #FOAMed; EMST & ATLS Director, Instruct & Direct on ETMcourse.com; faculty for Critically Ill Airway course and smaccAIRWAY workshops. My sites include KIdocs.org & RuralDoctors.Net, affiliated with smacc Opinions expressed on these sites must not be used to make decisions about individual health related matters or clinical care as medical details vary from one case to another. Reader is responsible for checking information inc drug doses etc.

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