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