unstable pt with low GCS

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> 47M post-MVA, comes in with GCS=8-9 which drops to 5, SBP in the low 80's,
> HR=129-135. Intubated, primary survey reveals, reduced L breath sounds,
> distended abdo and unstable pelvis. FAST pos, CXR shows widened
> mediastinum w NG in the L thorax, pelvic XR-open book fracture. Sheet
> around the pelvis, L CT inserted, fluids given, pts BP slowly comes back
> up to 100-110 but still labile with fast HR. Everything is done within
> minutes. What would be your FIRST step:
> 1.Do CT head since pt is responding to ivf (albeit partially) which means
> there is still time to r/o intracranial bleed/SAH etc pre-op
> 2. Angio given pt's open book fracture, which is likely the source of
> intraabdo/pelvic bleed and hypotension
> 3. Direct to OR; deal with CT head and angio afterwards.
>  
> Thanks. K
Khumar

This is the classic dilemma - but - A before B, before C, before D.

Positive FAST, distended abdo, partial responder - get to the OR. Open the
abdomen, fix the diaphragm (pressure on stomach and cardiac / mediastinal
compression may explain the poor response) and pack the bleeding. If the
pelvis is the COMPELLING source of the bleeding, maybe extra-peritoneal
packing. Transfuse 1:1:1 agrressively.

Usually the wide-mediastinum will NOT be the source of hypotension and the
treatment of the brain is with restoration of oxygen and blood-perfusion.
CT can follow during the DC-ICU phase. Maybe an ICP monitor while in the
OR if it won't delay and can be done while doing the lap.

My 2c
Tim
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer UKZN Dept Surgery
Deputy Director - IALCH Trauma Service

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