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Ref:trauma-list Digest, Vol 78, Issue 8

Ante Ćorić ante.coric85 at gmail.com
Mon Dec 14 01:21:48 GMT 2009


Up to 1500 mL of blood can be lost and patient would show any sings on
cardiac monitor, BP and puls would be normal. Only urinary output and to
some extend neurologic status would show sings of hypovolemia. Proper fluid
resuscitation isn't waiting till more obvious sings of shock emerge.
A

2009/12/11 Doc Holiday <drydok at hotmail.com>

>
> From: josemaya01 at prodigy.net.mx
> > ...fell from a two story building, hit her head and abdomen...
>
>
>
> --> For this sort of mechanism, we aim to get patient into the CT for our
> "Polytrauma CT" protocol (head, spine, chest, abdo, pelvis) as soon as is
> safe and possible, preferably as an adjunct at the end of the primary
> survey.
>
>
>
> > GCS of 7 at arrival to the ED, was intubated
>
>
>
> --> We'd do likewise
>
>
>
> > at her arrival to the ED had a BP of 113/65 and pulse of 90
>
>
>
> --> Nice. Sounds fit for our CT protocol if patient has these haemodynamics
> by the time she arrives in the ED.
>
>
>
> We'd complete ABCDE, with intubation, IV access, spare IV access, bloods to
> lab, venous BG and all that jazz and then scoop onto our CT table, with a
> quick visual-only glance at the back as we lift, aiming to have her on the
> scanner within 15 minutes of arrival (this is our AIM - meeting this target
> with her would depend on how easy to intubate)
>
>
>
> > FAST was done
>
>
>
> --> We wouldn't, as we're doing a CT anyway, which has fewer false
> negatives
>
>
>
> > reported as negative
>
>
>
> --> As Tom Jones used to say, "it's not unusual".
> Nor will we ever know whether it actually WAS "negative", or simply
> mis-read.
>
>
>
> (Still, in this case, what is "negative"? If some fluid was seen and the
> patient so stable at that stage, you'd not have gone to the OR anyway -
> you'd have done a CT to decide whether to manage conservatively! So the FAST
> may be fast, but not really good)
>
>
>
> > resuscitation was initiated with crystalloids
>
>
>
> --> I have no idea how long it took for the patient to get from impact to
> this point, but you have described no tachycardia and no hypotension, nor
> any evidence of blood loss.
>
>
>
> I see no reason for crystalloid, unless there is some evidence you have not
> mentioned here for a lesion you knew about then which required
> "resuscitation". Was there significant bleeding somewhere that you knew of?
> Some other indicator?
>
>
>
> > 2 hours after arrival her BP dropped to 80/40, a new FAST was done
>
>
>
> --> I guess that, at this stage, a FAST seems sensible
>
>
>
> > OR approximately 3 hours after arrival, laparotomy was done and damage
> control had to be done as the patient developed cogulopathy
>
>
>
> --> Which brings on the question of how much crystalloid had been given by
> now...
>
>
>
> I am no surgeon, so cannot comment usefully about the surgical bits which
> followed...
>
>
>
> Of course, as I sit here and make suggestions about a case with the
> hindsight you have provided, it is not as much of a challenge as being there
> at the time. Still, this is an ideal case to add to our list of example
> cases to demonstrate the utility of a polytrauma CT protocol for certain
> mechanisms of injury.
>
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