A 21-year-old man is brought to the emergency department after being stepped on by a bull approximately 30 minutes ago. The patient was bucked off of the bull, whose hind feet landed on his chest. On arrival, blood pressure is 75/50 mm Hg, pulse is 140/min, and respirations are 24/min. On examination, the patient moans in pain but does not answer questions. Two hoof prints are seen in the middle of the chest. He has decreased bilateral breath sounds, and crepitus is present over the anterior chest walls bilaterally. The abdomen is soft and nondistended. There is no obvious injury to the extremities, but they are cool, and capillary refill is decreased. Bilateral chest tubes are immediately placed, and 1.5 L of blood is returned from each side. Vital signs do not improve after placement of chest tubes. Four units of packed red blood cells are prepared for transfusion. What other blood products, if any, should also be administered at this time?

Question

A 21-year-old man is brought to the emergency department after being stepped on by a bull approximately 30 minutes ago.  The patient was bucked off of the bull, whose hind feet landed on his chest.  On arrival, blood pressure is 75/50 mm Hg, pulse is 140/min, and respirations are 24/min.  On examination, the patient moans in pain but does not answer questions.  Two hoof prints are seen in the middle of the chest.  He has decreased bilateral breath sounds, and crepitus is present over the anterior chest walls bilaterally.  The abdomen is soft and nondistended.  There is no obvious injury to the extremities, but they are cool, and capillary refill is decreased.  Bilateral chest tubes are immediately placed, and 1.5 L of blood is returned from each side.  Vital signs do not improve after placement of chest tubes.  Four units of packed red blood cells are prepared for transfusion.  What other blood products, if any, should also be administered at this time?

Quizplus · Accepted Answer

Explanation: This patient with a severe crush injury to the chest has signs of hemorrhagic shock (eg, hypotension, tachycardia, narrow pulse pressure, altered mental status, decreased capillary refill) from a noncompressible (intrathoracic) site (ie, bleeding source cannot be controlled by compression or tourniquet). Hemorrhagic shock is the leading cause of death in acute traumatic injuries, and this patient likely needs massive transfusions (eg, >3 units in 30 min) until definitive hemorrhage control can be obtained in the operating room. Massive transfusion protocols, developed to standardize resuscitation, are likely required in patients with ≥2 of the following: Penetrating mechanism of injury Positive focused assessment with sonography in trauma examination (ie, evidence of hemorrhage) Systolic blood pressure ≤90 mm Hg Pulse ≥120/min The appropriate proportions and types of blood products should be carefully considered to optimize volume status and tissue oxygenation and to reduce acid-base abnormalities and coagulopathy. Administering blood products in a 1:1:1 ratio of fresh frozen plasma [FFP]/packed red blood cells/platelets mitigates coagulopathy. Trauma itself can lead to coagulopathy due to dysregulation and inflammation. Coagulopathy can occur due to acidosis (hypoperfusion), hypothermia (transfusion of cold intravenous solutions), hemodilution (eg, clotting factor dilution), and factor consumption. If available, whole blood (packed red blood cells + plasma) is an alternative to the 1:1:1 ratio. Adjunct therapies for hemorrhagic shock include tranexamic acid (antifibrinolytic agent), which is effective in a subset of patients with acute life-threatening hemorrhage if administered within the first 3 hours of injury, and topical hemostatic agents (eg, kaolin-impregnated sponge, fibrin sealant dressing), which are applied to control external hemorrhage. (Choices A, C, D, and E) Administering more of one type of blood product dilutes the circulating amount of the others and increases coagulopathy risk. FFP (containing all clotting factors and plasma proteins) alone is usually considered for severe coagulopathy (eg, liver disease, disseminated intravascular coagulation) with active bleeding, some cases of warfarin-induced bleeding, or some inherited coagulopathies. Platelets are typically transfused for a platelet count <10,000/mm³ (risk of spontaneous hemorrhage) or a platelet count <50,000/mm³ with active bleeding. Cryoprecipitate is considered with low fibrinogen (eg, <100 mg/dL). ³ ³ Educational objective: Blood products should be administered early in patients with signs of hemorrhagic shock. They should be administered in a ratio of 1:1:1 (fresh frozen plasma/packed red blood cells/platelets) to reduce coagulopathy, a leading contributor to mortality in trauma patients. References: Massive transfusion and massive transfusion protocols. (http://www.ncbi.nlm.nih.gov/pubmed/25535421)

A 21-Year-Old Man Is Brought to the Emergency Department After