Case 1 Eva is a 28 y/o female restrained passenger of a single vehicle MVC. Paramedics note multiple long bone fractures and bruising across her abdomen. She is transported Code 4 to the local community hospital emergency department (ED). You and your CCP partner were called to the scene but will now rendezvous with Eva in the local ED. On your arrival, you find that Eva’s fractures have been splinted, an IV has been established, and initial labs have been drawn. The ED doc tells you that she is concerned that Eva might have intra-abdominal bleeding complicating the multiple long bone fractures. You and your partner agree that Eva needs to go to a trauma center ASAP. Vital signs: GCS 15, RR 24, HR 120, BP 94/60, Pupils 4+, Temp 35.6 Your CCP partner tells you that the HR and RR are very suspicious for significant hemorrhage. Explain how hemorrhage can cause tachycardia (fast HR) and tachypnea (fast RR). - Dropping blood volume = compensation with increased heart rate because of decreased blood pressure/poor perfusion - Tachypnea lack of oxygen reaching the tissues = increased oxygen intake Initial labs are drawn and the CBC is the following: WBC 18, Hgb 132, Hct 0.48, Plt 280 Explain how the Hgb and Hct can be normal in the setting of hemorrhage. - Testing the blood they drew, not an issue of bad blood, just not enough of it Why is the WBC count elevated? - Inflammatory response increases concentration of WBCs, lost at the same rate as everything else What component(s) of the WBC would you expect to be elevated? - Neutrophils (general immune response), Monocytes respond immediately. Eosinophils and basophils would also increase. Lymphocytes would be present in the case of infection. The ED doc gives Eva a little morphine for her pain and the next BP comes back 78/40. You start a bolus of normal saline and request blood for the transport. What outcome are you trying to achieve with the fluid bolus? - Increased blood volume to raise blood pressure. - Morphine reduces pain – reduces blood pressure. - Morphine releases histamine, reduces BP further through vasodilation. - Vasodilation increases the volume – diluting the formed elements, too much pipe not enough fluid. What are the limitations of crystalloid fluids in hemorrhage? - Diluting the blood, only replacing fluids, not formed elements - Diluting coagulation factors would also reduce ability to clot What blood product would you like for the trip (include ABO and Rh)? Why? - O- the universal donor blood would be ideal if you do not know her blood type - Could give O+ if she didn’t already have antibodies for it (pregnancy) and if she was a he, risk is acceptable for men, not for women. - RBCs, platelets, (formed elements minus WBCs) X - Give her whole blood ideally, don’t keep that around, in her case, give her all the pieces, especially RBCs, platelets, and plasma (contains clotting factors), usually need platelets the least 1:1:1 transfusion – one unit of each, essentially whole blood - Usually more like 3:1:1 to reduce reactions, because multi donor transfusions are necessary for plasma and platelets and more likely to cause a reaction. You have administered a couple of litres of saline and a unit of blood and you notice that Eva has goose bumps and is shivering. You also notice that the bleeding from her fracture sites has increased and seems slow to clot. Explain the causes of Eva’s hypothermia. - The saline was too cold and it is causing her body temperature to drop. - Blood isn’t circulating to all organs so temperature in those areas would drop. - All clothes were cut off, crappy thing they’re lying on, overall low temp in the hospital - Body works less well in terms of enzymes etc when too cold, including clotting reactions, need her to be warm enough to clot Explain why Eva now appears to have difficulty clotting. - The added saline has diluted her blood, not enough formed elements to clot effectively What blood product will improve her clotting ability? - Platelets – can be as low at 10 000 from 200 000 and still clot effectively - Plasma is more important, need the clotting factors to activate the platelets Under your excellent care, Eva’s HR is coming down and her clotting appears to be improving. Your partner reminds you to keep a close eye on the BP and not let it get too high. Your goal is to maintain a systolic BP of 85. Why target a low BP? (Hint, it relates to clotting) - High BP would push clots out as they form, lower BP allows clots to form more easily - Clots are super unstable when they first form In what situations would you consider targeting a higher BP? Why? - When bleeding is controllable (external/tourniquet) so they won’t just bleed out into themselves. - Elderly people would already be less able to perfuse effectively - Supply-demand ischemia – insufficient supply – tissues become ischemic, heart especially need lots of oxygen. Severe disease, heart starts to fail, the reserve the heart - has for hard tasks is used for everyday, no noticeable symptoms. No reserve left, no extra oxygen, demand is higher than supply. Type 2 MI = supply demand imbalance. Lower blood pressure in this population is too low, heart muscle starts to die. Other group would be brain injury patients, requires tons of oxygen, low BP = less oxygen to brain = secondary injury (caused by us). If there is a bleed, more pressure required to perfuse the brain. With your understanding of blood, bleeding, blood products, and clotting, you have anticipated all of Eva’s medical pitfalls and transport her safely to the trauma center where she can begin her long road to recovery. Great job!
