This weekend we had yet another 40 something male with a big motorcycle who could not stay on the road. As seems to be the local habit he came off without any head or neck injury and came in talking in severe chest pain.
Quick positive findings:
Head and neck apparently clear but protected
Chest painful with some lower left rib fractures and a high splinted diaphragm. saturations OK initially on suplimental oxygen
In grade 3-4 shock and only a transient responder.
Probabley the pelvis has opened then closed from the pictures (confirmed split sacrum on day2 CT)and definite mid femur fractures
No external bleeding
Belly expanding.
after 30 mins became severely unstable (now 60 mins post pick up)
RSI with transient severe desaturation and agonal ECG with central palpable pulse. Responded to hyperventilation and large volume input and transferred to theatre for further resuscitation;
In theatre needing inotropes and mass volume.
Spleen removed, pelvis clamped, femur fixed, large retroperitoneal haematomas packed. Chest drains as diaphragm seen to blow down on ventilation on left, small bloody effusion and small amount of air comes out, right drain as prophylaxis, minimal drainage.
Develops DIC on table after 2 hours: Chest leaks 6 litres and all wounds leak and uses all hospital supplies of platelets, FFP and pre-prepared clotting factors.
belly left open and sealed with plastic sheeting.
Stabilises on ITU, producing urine with the help of inotropes and diuretics and stops bleeding.
At 48 hours develops ARDS and Acute Renal failure.
This pattern is happening 2-3 times a year for us.
The patient develops severe metabolic acidosis during the initial hour or two despite fluid and respiratory support. The acidosis continues despite major fluid replacement with good CVP and apparently adequate peripheral circulation for the first few hours. The acidosis persists and we can't find any source of ischaemia. I tend to worry about the abdomen but in this guy you can see the bowel through the plastic sheet.
The lungs are 1/3 contused on both sides on CT.
There is retroperitoneal haematoma but the kidneys are perfused at day 2 on CT and the pancreas appears intact physically. The limb pressures are apparently normal.
The questions I do not know the answer to:
Can you develop metabolic acidosis from lung contusion?
Is it the inotropes in a bleeding patient?
Where else can you generate severe metabolic acidosis?
Are we doing something wrong? or Not enough of something?
Are these patients doomed but because they are young are going to take their time in dying?
Anyone any views?
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