A 24-year-old woman is brought to the emergency department (ED) after a motor vehicle collision. She was the passenger in a vehicle that collided with an 18-wheeler. Paramedics state that the patient was ejected from the vehicle and found on the side of the road. They placed 2 large-bore intravenous lines, infused 1 L of crystalloid, and transported her to the ED. Blood pressure is 80/50 mm Hg, pulse is 138/min, and respirations are 24/min. On examination, the eyes are closed, and the patient is moaning. Auscultation of the lungs reveals decreased breath sounds on the right. The abdomen is tender in the right and left upper quadrants. The patient has an obvious deformity of the left thigh. The extremities are cold and clammy. Chest x-ray reveals a right hemothorax. Focused assessment with sonography for trauma examination shows evidence of free fluid in the right and left upper quadrants. A right chest tube is placed, and 1.5 L of blood is returned. Which of the following is the best next step in management?

Question

A 24-year-old woman is brought to the emergency department (ED) after a motor vehicle collision.  She was the passenger in a vehicle that collided with an 18-wheeler.  Paramedics state that the patient was ejected from the vehicle and found on the side of the road.  They placed 2 large-bore intravenous lines, infused 1 L of crystalloid, and transported her to the ED.  Blood pressure is 80/50 mm Hg, pulse is 138/min, and respirations are 24/min.  On examination, the eyes are closed, and the patient is moaning.  Auscultation of the lungs reveals decreased breath sounds on the right.  The abdomen is tender in the right and left upper quadrants.  The patient has an obvious deformity of the left thigh.  The extremities are cold and clammy.  Chest x-ray reveals a right hemothorax.  Focused assessment with sonography for trauma examination shows evidence of free fluid in the right and left upper quadrants.  A right chest tube is placed, and 1.5 L of blood is returned.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d844_d8a4_bc81_37ea70d4aff6_MD0003_00 This patient has multiple sites for blood loss: hemothorax (decreased breath sounds, 1.5 L of blood from chest tube), hemoperitoneum (tender abdomen, positive focused assessment with sonography for trauma [FAST] examination), and femur fracture (left thigh deformity). In the setting of blood loss, a systolic blood pressure (SBP) <90 mm Hg, along with tachycardia >120/min, altered mental status (eyes closed, moaning), and delayed capillary refill (cold, clammy extremities), suggests at least 30% loss of circulating blood volume, generally classified as class III hemorrhage. This presentation is consistent with hemorrhagic shock from bleeding at noncompressible sites (chest and abdomen). Type-specific blood is the optimal choice for transfusion; however, depending on several factors (eg, trauma vs nontrauma center, presence of antibodies), it can take significant (eg, >20 min) time to prepare (eg, after type and cross-matching). Patients in hemorrhagic shock, such as this one, can exsanguinate in that time (Choice E). Therefore, in such situations, group O, Rh D-negative blood should be administered unless type-specific blood is immediately available. Most hospitals keep O Rh D-negative blood (universal donor) ready for use in emergencies. To prevent hemolytic disease of the newborn in future pregnancies, it is particularly important that this type of blood be given to women of childbearing age, as in this patient, and to young girls. In men and in women past childbearing age, O Rh D-positive blood can be given (Choice D). hemolytic disease of the newborn When there is concern for massive transfusion requirements (eg, SBP ≤90/mm Hg, pulse ≥120/min, positive FAST, penetrating mechanism of injury), blood products should be given in a 1:1:1 fresh frozen plasma/packed red blood cells/platelets ratio to minimize risk of coagulopathy (eg, widespread tissue damage, lactic acidosis). (Choice A) In acutely injured trauma patients, excess crystalloid use exacerbates the lethal, trauma-induced triad of hypothermia, acidosis, and coagulopathy, increasing mortality. Research supports limited crystalloid administration (eg, 1 L) in patients with hemorrhagic shock when blood is not immediately available. (Choice B) Vasopressors are appropriate for patients with severe peripheral vasodilation due to distributive (eg, septic, neurogenic) shock. Patients with hemorrhagic shock should receive volume resuscitation with blood transfusion while awaiting definitive management of the hemorrhage (eg, surgical intervention). Vasopressor administration without appropriate resuscitation can worsen tissue perfusion. Educational objective: Blood transfusion should be initiated early in patients with hemorrhagic shock. Group O, Rh D-negative blood (universal donor) should be transfused while waiting for type-specific blood to be available. References: Massive transfusion and massive transfusion protocol. (http://www.ncbi.nlm.nih.gov/pubmed/25535421)

A 24-Year-Old Woman Is Brought to the Emergency Department (ED)