62 y/o male presents after a car accident. EMS notes his GCS is 7, and his blood pressure is 85 by palpation. It was a single vehicle accident (patient went off the road and hit a tree), and he smells of alcohol. No seat belts were used. EMS did a scoop and run and attempted IV en route (unsuccessful). According to EMS, the only bleeding noted is from a scalp laceration (still bleeding), and a contusion to the upper abdomen is noted from the steering wheel. EMS has no medical history available for this patient.
Primary survey: (as you ask for IV, oxygen, monitor, fully undress the patient, repeat vital signs, and draw blood) reveals:
Airway open, gag is present, = breath sounds, no subcutaneous air, equal chest excursion, abdomen soft, no AAA palpated, appears to be non-tender, small contusion noted in the epigastric area. Pelvis is stable, no clear bleeding or deformities to extremities. Scalp is bleeding and a closer inspection reveals an arterial pumper in the laceration.
Neurologically, opens his eyes to pain (2), moans incomprehensibly to pain (2), and he withdraws to pain (4).
1. In addition to ‘trauma’ labs, CT head/c-spine/abdomen and pelvis, CXR, Pelvis x-ray, and bedside FAST (although you don’t really order FAST..you just do it), what other tests should you order?
I also ordered an Acucheck (bedside glucose) and an EKG/cardiac enzymes (and PT if not part of the ‘trauma’ panel).
All patients with an altered mental status must have an acucheck, even when presumed cause of altered mental status is trauma related or toxin (ETOH) related.
In addition, I would do an EKG/send cardiac enzymes. The contusion is near the sternum, and as it was a single vehicle accident, it would be impossible to rule out an arrythmia as the precipitating case for the MVA (although alcohol is more likely). Additionally, just because of the age, I would be concerned about cardiac ischemia.
Finally, if not included in your routine trauma panel, I would do a PT as Coumadin is a common medication in older individuals.
2. Should you give fluids to this patient? Are you concerned about permissive hypotension?
Permissive hypotension refers to withholding fluids (and allowing modest hypotension) from traumatically (penetrating torso) injured patients so that an uncontrolled hemorrhage is not made worse from giving fluids (which dilutes the clotting factors and also dilutes the hemoglobin (oxygen carrying capacity of the blood), and additionally increases the intravascular pressure which may ‘pop the clot’ and restart massive bleeding). However, the key is the uncontrolled hemorrhage part.
Uncontrolled hemorrhage is most commonly seen in penetrating torso trauma (gunshot/stabbing). Blunt trauma is a different mechanism of injury, and it may be difficult to know if the patient has an uncontrolled hemorrhage. There is significant discussion about the potential to translate the research regarding permissive hypotension in penetrating torso trauma to blunt torso trauma. (An interesting blog to read is form the trauma.org site: “http://www.trauma.org/index.php/main/article/374/”
However, the real issue is that evidence is lacking that permissive hypotension is appropriate in blunt torso trauma. Having said that, I agree that the evidence that you SHOULD automatically give 2 liters of fluid to blunt trauma patients is also lacking. So, my opinion…(without evidence as there is no good evidence either way)…is to start the IV, but run it at TKO, control other bleeding (i.e. the lac on the scalp), as long as the patient is talking coherently and has no evidence of traumatic brain injury. Why we continue to give 2 liters of saline to young talking blunt trauma patients with blood pressures of 100 systolic is not clear to me. Following the ‘cookbook’ approach of knee jerk IV fluids may not always be in the patient’s best interest.
The reason why the presence of potential brain injury is key, is that cerebral perfusion pressure (CPP) will suffer at the expense of permissive hypotension. So, if I felt the patient had a brain injury, I would give fluids/blood to restore adequate cerebral perfusion pressure. (1). In a recent study looking to maintain CPP of 70 in patients with traumatic brain injury, investigators found that patients with the CPP goal started in the first hour did better (survival and neurologic outcome). (2). It is also known that patients with traumatic brain injury have twice the mortality rate when hypotensive, compared to normotensive patients (3).
For a great summary of numerous permissive hypotensive abstracts, see this link: “http://www.trauma.org/archive/resus/permissivehypotension.html”
In this patient because of the concern for a closed head injury, I would not withhold fluids/blood, and I would attempt to normalize blood pressure to maximize CPP.
3. What is the role of hypertonic saline in this situation?
Hypertonic saline can be used as an osmotic agent just like Mannitol. Hypertonic saline in the setting of traumatic brain injury has the potential to decrease ICP (intracranial pressure) and also increase blood pressure. This combination acts to increase cerebral perfusion pressure (CPP=MAP-ICP).
In some European countries, hypertonic saline is recommended for prehosptial fluid administration in patients with traumatic head injuries. (3). Because a smaller volume of hypertonic saline can restore blood pressure (and also decrease ICP), the military also has an interest in this area. (4).
As this area continues to be investigated, it may turn out that hypertonic saline could become the fluid of choice, especially for isolated head injuries (my opinion). But for now, its use in trauma is still under investigation. On a side note, hypertonic saline is also being investigated in sepsis patients. (5-6).
In the United States, there is currently no role (other than research) for hypertonic saline in trauma. However, there may be a role (isolated closed head trauma, long transport time…makes the most ideal patient….my opinion) in the future.
Two IV’s established, and fluid bolus (500 cc) given for hypotension.
Repeat blood pressure up to 105 systolic. Labs sent, Acucheck was 50, and amp of D-50 given with significant improvement in mental status (GCS increased to 13: 4 eyes + 4 verbal+ 5 motor). Scalp laceration bleeder tied off, and wound stapled. Pressure dressing applied.
EKG with ischemia (ST depression and flipped T-waves in lateral leads-no old EKG for comparison)
CXR no pneumothorax, rib fractures or effusion. Pelvis: No fracture.
CT head/neck/ abd/ pelvis all negative.
Blood work: Remarkable for hypoglycemia (lab Glucose = 45), elevated CPK/MB/ and troponins, elevated alcohol (280), and anemia (HBG=7 mg/dl).
Patient transfused because of ischemia on EKG and anemia.
Most likely story: ETOH—driving—hypoglycemia—MVA (?ETOH vs hypoglycemia vs both)—scalp laceration—anemia and hypotension from blood loss—cardiac ischemia (from hypotension).
They did end up doing a cardiac catheterization and stented a lesion, as he ended up ruling in for a NSTEMI.
Finally, as a side note: I have seen one patient bleed from a scalp laceration down to a hemoglobin of 5mg/dl (and that patient died—he was a transfer from an outside institution, long transport time (1 hour), and no one thought to stop the bleeding from his scalp lac. The paramedics kept giving saline for his intermittent hypotension..and he arrived essentially dripping ‘Kool-Aid’ (ie very diluted blood) from his scalp lac). So, although we often don’t consider it life threatening, attention to all bleeding sites is still important.
1. Pepe PE, Mosesso Jr JV, Falk JL. Prehospital Fluid Resuscitation of Tepateitn with Majory Trauma. Prehsopital EMerg Care 200-2 Jan-Mar;6:81-91. Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/11789657?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedreviews&logdbfrom=pubmed”
2. Pace MC, Ciciarella G, Barbato E, Maisto M, et al. Severe Traumatic Brain Injury: Management and Prognosis. Ninerva Anesthesiol 2006;72:235-42. Entire manuscript accessed at:
3. Cooper JD, Myles PS, McDermott Ft, et al Prehospital Hypertonic Saline Resuscitation of Patients with Hypotension and Severe Traumatic Brain Injury. JAMA 2004 March:291(11):1350-1357. Entire manuscript accessed at: “http://jama.ama-assn.org/cgi/content/full/291/11/1350”
4. Dublck MA, Bruttig SP, Wade CE. Issues of Concern Regarding the Use of Hypertonic/Hyperoncotic Fluid Resuscitation of Hemorrhagic Hypotension. Shock 2006 Apr;25(4):321-8. Abstract accessed at:
5. Wade CE. Hypertonic Saline Resuscitation in Sepsis. Critical Care 2002,6:397-398. Accessed at: “http://ccforum.com/content/6/5/397”
6. Oliveira RA, Velasco I, Soriano FG, and Firedman G. Clinical Review: Hypertonic Saline Resuscitation in Sepsis. Critical Care 2002, 6:418-423. Accessed at: http://ccforum.com/content/6/5/418