A 26-year-old man is brought to the hospital after a motor vehicle collision. The patient was found unconscious at the scene and was intubated on the way to the hospital. Initial imaging showed left-sided epidural hematoma, multiple rib fractures, and a pelvic fracture. He was immediately taken to the operating room for epidural hematoma evacuation. During resuscitation and in the postoperative period, the patient received 4 L of intravenous fluids and 3 units of packed red blood cells. Although he was hemodynamically stable on day 1 of hospitalization, the nursing report on day 2 notes reduced urine output. In addition, there is persistent oozing from the patient's venipuncture sites and around the surgical wound. Which of the following is the most likely cause of this patient's bleeding?

Question

A 26-year-old man is brought to the hospital after a motor vehicle collision.  The patient was found unconscious at the scene and was intubated on the way to the hospital.  Initial imaging showed left-sided epidural hematoma, multiple rib fractures, and a pelvic fracture.  He was immediately taken to the operating room for epidural hematoma evacuation.  During resuscitation and in the postoperative period, the patient received 4 L of intravenous fluids and 3 units of packed red blood cells.  Although he was hemodynamically stable on day 1 of hospitalization, the nursing report on day 2 notes reduced urine output.  In addition, there is persistent oozing from the patient's venipuncture sites and around the surgical wound.  Which of the following is the most likely cause of this patient's bleeding?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d843_ee43_bc81_db89c5e8108d_MD0003_00 This patient's oozing from venipuncture and surgical sites and reduced urine output after a serious traumatic injury raises strong suspicion for disseminated intravascular coagulation (DIC), a consumptive coagulopathy. Traumatic injury increases the risk of DIC due to endothelial (exposes tissue factor) and tissue damage (releases procoagulant proteins and phospholipids); other common causes of DIC include sepsis, malignancy, and obstetrical complications. DIC is marked by: Overactivation of the coagulation cascade, leading to the formation of fibrin- and platelet-rich thrombi and the consumption of coagulation factors (prolonged PT/PTT), platelets (thrombocytopenia), and fibrinogen. Subsequent fibrinolysis (to break up the clots), which increases fibrin degradation products (eg, D-dimer). Anticoagulation proteins (eg, protein C/S) are also consumed. Patients with acute DIC usually develop bleeding from venipuncture/surgical sites, ecchymosis, and petechiae. Organ damage (eg, renal insufficiency [reduced urine output in the setting of intravascular fluids]) is also commonly seen. (Choice A) ABO incompatibility can cause DIC, but severe symptoms (eg, fever, chills, respiratory difficulty) typically develop within seconds or a few minutes of transfusion initiation; manifestations a day later would be atypical. (Choice B) Acute liver failure can cause prolonged PT/PTT and mild thrombocytopenia. Although patients are sometimes mildly hypocoaguable (eg, easy bruising), clinically significant bleeding and oozing from venipuncture sites is atypical. Most cases of acute liver failure are caused by viral hepatitis or drugs (eg, acetaminophen), not motor vehicle collisions. (Choice C) Complement-mediated microangiopathy (also called nondiarrheal hemolytic-uremic syndrome) is a hereditary disorder marked by unregulated complement activation and the formation of platelet-rich thrombi. Although renal insufficiency is common, it does not typically cause oozing from venipuncture sites. In addition, it is not typically associated with trauma (unlike DIC). (Choice E) Drug-induced thrombocytopenia is usually due to the formation of antibodies against platelets or the suppression of platelet production in the bone marrow. Most cases manifest several days (~1 week) after drug exposure (not within a day). (Choice F) Vitamin K is necessary for the formation of several clotting factors (eg, factors II, VII, IX, and X). Deficiency is rare in healthy individuals and takes several weeks or months (not a day) to develop. Most cases arise in patients with disorders of the pancreas/biliary system (because vitamin K is fat-soluble) or in those who take prolonged courses of antibiotics. Educational objective: Severe trauma increases the risk of disseminated intravascular coagulation, a consumptive coagulopathy, due to the exposure of tissue factor and the release of procoagulant proteins and phospholipids. Laboratory evaluation will reveal prolonged PT/PTT and thrombocytopenia. Patients usually develop signs of bleeding (eg, oozing from venipuncture/surgical sites) and organ damage (eg, renal insufficiency).

A 26-Year-Old Man Is Brought to the Hospital After a Motor