Management of severe polytraumatism in A&E

Case report

Dr Dien, Dr Tuan, Dr David9/09/2010

Patient 28 years old victim of a motorbike accident arrived 20 min. later in A&E with a taxi (initial assessment)

9h00 arrival in A&E: unconscious (G3), no breath

(gasping) and no pulse and bilateral mydriasis

5mm

He presents a head + face trauma with severe

bleeding at the mouth + & right ear +++.

He has also a contusion/deformation of the left

arm

Abdomen supple, no evident trauma

No evident trauma at the legs

H0: Initial management

9h00: Suction of the blood in the mouth,

ventilation with bag-valve mask O2 100%

9h05: IV line with serum NaCl 0.9% >

Adrenaline CPR with cardiac massage and

ventilation > recovered with pulse &

spontaneous breathing.

Neck collar placement

Secondary management

9h10: Rapid sequence induction (Etomidate

0.3mg/Kg + Suxa. 1mg/Kg)

Oro-tracheal Intubation ETT 7mm and

mechanical ventilation

Sedation with Hypnovel & Fentanyl protocol (50mg Hypnovel + 500 Fentanyl)

NorAdrenaline = Levonor 2mg/h IVES

Scanner full-body (9h35-

9h45)

Fracture skull base, fracture of the “rocher”, fracture of the skull, multiple fractures of the face bones.

Pneumencephalie + diffuse cerebral edema Bilateral lung contusions and left rib

fractures with mild pneumothorax Abdomen and rachis without evident lesion

Fluid resuscitation

NaCl 0.9% x 5 (2.5 liters)

Gelofusine 500ml x 2 (1 liter)

9h50: Order 2 “Culots Globulaires” O

negative (delivered at 10h15 but too

late…)

Evolution during 1h30

9h00

9h15

9h25

9h35

9h40

9h45

9h50

10h 10h30

Pulse 0 128 128 124 129 128 124 70 20

BP 073/52

100/80

100/40

100/20

59/28

50/24

42/20

40/15

SpO2 0 95 96 96 97 97 95 70 -Glasg. Score

3 3 3 3 3 3 3 3 3

Outcome: finally the patient died at 10h40…

Discussion about management of polytrauma in A&E FVH

Medical aspect: what are we able to do to save a severe patient

Ethical aspect: Could we stop resuscitation before ? (desperate case?)

Financial aspect: does FVH policy about indigent patient allows us to do everything to save life of all the patient? (including those who have no money)

Medical aspect Management of vital functions Cardiac arrest > CPR and ACLS… Coma Glasgow score </=8 and respiratory

failure : intubation (rapid sequence induction followed by

sedation )

Fluid resuscitation with IV catheter (x2) and infusion NaCl 0.9% & Gelofusine

Vaso-active drugs: NorAdrenaline (Levonor) Transfusions? (“Culots Globulaires”, platelets, fresh plasma?)

Medical aspect: Exams

Head CT scanner + cervical rachis in case of

severe head trauma (Glasgow </=8)

full body CT: For severe patient with unstable

hemodynamic (Head/Neck/Thorax/Abdomen)

Blood tests ? (NFS, TP/TCA, blood group x 2, RAI)

Ethical aspect (medico-legal)

Can we consider this case as a desperate case, so was it reasonable to perform full body CT and transfusion?

What about the option to transfert the patient to Cho Ray before CT?

What about the option to send the patient in OT for rescue surgery? (not in this case…)

Risks for the patient (and for care givers) to “refuse” to do what we are supposed to…

Economical aspect

FVHospital is not a charity hospital… Private hospital = earn money Can we (care givers) avoid to consider

this aspect of the problem? Must economical status of the victim

interfere in the medical decision in this case?

FVH policy about this problem

“FVH is not on non-for profit organization, its financial resources are limited, we don’t have grants from the authorities or any other financial sources than ours. In other words we just cannot be an open door for all patients whatever their financial status is and provide complete care for people who cannot pay. However the mission of the hospital is to take care of patients, therefore we cannot turn somebody away because he/she does not have enough money to pay for care.

A balance must be found between medical ethics and financial realities”

FVH policy about this problem

“The patient is in an acute condition but not life-threatening, then we must take care of the acute problem, stabilize and then transfer. For example: broken leg. The patient is in pain, we must provide first-aid and manage the pain and then organize as fast as possible the adequate transfer of the patient to the relevant organization, for example the Centre for Orthopaedics and Traumatisms (“CTO”) “

FVH Policy about this problem

“The patient is in acute life-threatening condition, we must save the patient’s life and this could require hospitalization in ICU, surgery, etc if the patient cannot be transferred. Obviously this is a medical decision but the decision must be discussed with management, first and foremost with the medical director.”

Condition First aid careAbsolute

investigations

Cardiac arrest CPR, Intubation, EES, Adrenaline

ECG

Severe Head trauma (G</=8)

Neck collar, IV line, Intubation

Head & Neck CT scanner

Polytrauma

IV line, fluid infusion including

transfusion if needed, airway management

CT scan (full body if needed)

X-ray focused on suspected lesions

CBC, Blood Group,

RAI, Coag. Tests

Severe cardiac failure

IV line, Oxygen, Medication,

CPAP if needed

Chest X Ray, ECG

Supporting laboratory Tests