# A lacerated artery



## SpecialK (Apr 14, 2016)

You are responded to a patient who has lacerated their brachial artery.

Upon locating, the patient is surrounded by a very large pool of blood, is GCS 3 with no palpable pulse (but has a HR of 150/min on he monitor), no recordable blood pressure and is taking intermittent agonal gasps..

The scene is fifteen minutes by road to the hospital.

Ask yourself: what do you think this patient needs for them to have the best chance of having their life saved? what do you do about it? what do you not do? 

I would be interested in hearing your thoughts.


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## cprted (Apr 14, 2016)

SpecialK said:


> Upon locating, the patient is surrounded by a very large pool of blood, is GCS 3 with no palpable pulse (but has a HR of 150/min on he monitor), no recordable blood pressure and is taking intermittent agonal gasps.


That's called "traumatic cardiac arrest" in my books ... 

The prognosis for this patient is very poor.

Start CPR, tourniquet the lac, load and go, fluid bolus and epi to try and regain a little perfusion. Call ahead to the hospital so they have blood ready.


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## STXmedic (Apr 14, 2016)

I agree to an extent. Definitely a tourniquet and load and go. There should be virtually no scene time.

While I'm not a fan of crystalloids in trauma, I would give this guy some warmed LR, hopefully to at least generate some recordable blood pressure. 

His ventilations certainly need to be assisted. Oxygen is unlikely to affect his hypoxia, but I'd still bag him with oxygen, just to make sure oxygenation is optimized. Maybe drop a king during transport if I had time and hands.

And yes, definitely have blood ready at the ED. Even better if I can drop a 14 or 16 in this guy during transport.

As for epi, or any pressors- no, wouldn't even cross my mind. I'm also fortunate enough to have US. If I saw wall movement, I wouldn't perform CPR either- just let the fluid hopefully increase preload enough to move blood more effectively. CPR isn't going to do anything considering there's little left to circulate.


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## Carlos Danger (Apr 14, 2016)

- direct pressure
- tourniquet
- airway management with fio2 1.0
- 4 units of PRBC's with NO crystalloids (if available)
- if no PRBC's available, 2 liters of crystalloid (or as little as necessary to regain a pulse)
- titrate boluses of ephedrine or dilute epi to maintain a pulse
- go to the closest facility that has O neg available, does NOT have to be  a trauma center initially


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## chaz90 (Apr 14, 2016)

Remi said:


> - direct pressure
> - go to the closest facility that has O neg available, does NOT have to be  a trauma center initially



I think this is key. Free standing EDs are suddenly extremely worthwhile if you're 15 minutes away from a real trauma center.


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## CANMAN (Apr 16, 2016)

chaz90 said:


> I think this is key. Free standing EDs are suddenly extremely worthwhile if you're 15 minutes away from a real trauma center.



IF they have quick access to blood products, which around my way they don't/wouldn't release it in a timely enough fashion. If we showed up to a free standing ED in my area and called ahead for blood they would laugh..... Even most of the hospitals around me take a word from Jesus himself to get emergency release O- rapidly brought to the ED for a non-type and crossed patient. Only places that have blood in the unit, or available quickly are the trauma centers unfortunately, and honestly I would be really suprised if a local ED worked this guy for more then 5 minutes and even attempted to give blood. 

I would treat the same as everyone else has already stated, apply a second tourniquet if needed, and if we are still bleeding after that then attempt to pack the lac with our QuickClot packing gauze. Would be concerned about body temp to prevent hypothermia induced coagulopathy.

Depending on where the guy is located I would also consider HEMS as a possibility, IF they have blood on board. In a rural part of PA where I fly frequently we often have less then a 15 minute time from dispatch to skids down, and have 2 units of O-, plasma, and TXA on board. Granted 2 units is gonna be just a start, but if that was a real timeframe, and the closest hospital is 15-20 minutes away, knowing what I know about their lack of QUICK access to blood might be something I consider calling for......


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## zzyzx (Apr 21, 2016)

Since he's peri-arrest, this would be a good indication for a rapid bolus as well as a vasopressor.
On the plus side, you have already stopped the source of their bleeding. If he survives to the ER, then he has a good chance of living. The ER should be waiting with blood products and a rapid infuser primed and ready to go.


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## nater (Apr 25, 2016)

This patient needs blood as quickly as possible. We carry 2 units of O- PRBCs on our rig as well as TXA. These will help, but they will also need more blood, FFP ready as well. 

Remember the lethal triad of hypothermia, coagulapathy and acidosis. NS is acidic, so you don't want to go overboard if you can help it. LR is a slightly better choice, but not perfect either. Keep this patient warm, use a fluid warmer and turn the heater on. Cut off and remove all wet or blood soaked clothes to reduce more heat loss.

You may get pulses back with increased volume, so try resuscitation. Unfortunately, this patient may be past the point of surviving this injury.


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## JIP00 (Jun 10, 2016)

Impending arrest.

TQ/Hemostatic agents
Airway
IV with fluid titrated to SBP 90ish (Permissive Hypotension)
KEEP PT WARM


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## Handsome Robb (Jun 10, 2016)

What is TXA going to do at all for this patient? Seen it mentioned a couple of times and I don't see it being indicated in this situation. You've controlled the bleeding, it's a high pressure vascular injury which is going to require surgery to fix. 

Not saying it's contraindicated but I don't see it being useful at all. 

Pretty much what people have already said, TQs, boogie to the hospital that has blood, big lines, push dose pressors, as little crystal loud as possible but enough to generate a BP and airway management. 

I'd be hesitant to intubate this patient until his hypotension has been fixed. Ideally you want to fix his hypoxia before intubating as well but that's not really possible unless you've got blood products.


Sent from my iPhone using Tapatalk


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## SpecialK (Jun 11, 2016)

Permissive hypotension is only for patients who have hypovolaemia from uncontrolled hemorrhage.  

This patient needs access to blood as fast as it can possibly be delivered.  There should be no time on-scene other than placing a tourniquet.  IV or IO access can be obtained enroute and given how sick this patient was it would be most effective to put an IO in while en route to hospital.  

This is a real case where hospital was approximately 15 minutes away, however the crew spent approximately 25 minutes on scene doing CPR and having multiple unsuccessful attempts at IV access.  

The fundamental questions to be asked of any patient are "what is wrong with them (diagnosis) and what do they need" and "what is the most efficient way of getting them what they need?"; in this case the answers are "resuscitation with blood" and "at the hospital".

I will also say something which many will find a bit controversial: I wouldn't have done CPR on this patient.  Why? The heart was still beating despite a palpable pluse however there was no blood to pump so what is the point?


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## nater (Jun 15, 2016)

SpecialK, could this crew have felt bound by protocols preventing them from transporting a pulseless patient? I know many services are preferring not to transport until we get ROSC or call them on scene. To me, this would be an easy exception since the patient needs blood products and surgery to have any chance at survival. Unfortunately it seems, many agencies would rather crews not think outside of protocol book and when they do, they might be looking for a new job.

As for the TXA, I would consider it. For our use, it is  normally indicated for internal hemorrhage but could have some clotting benefit for these patients as well. I am aware of controversy surrounding its use and unfortunately I missed a recent debate on its use between two surgeons at my facility. A tourniquet, rapid transport and blood would still be my first priority.


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## Jacob Horrell (Jun 22, 2016)

SpecialK said:


> You are responded to a patient who has lacerated their brachial artery.
> 
> Upon locating, the patient is surrounded by a very large pool of blood, is GCS 3 with no palpable pulse (but has a HR of 150/min on he monitor), no recordable blood pressure and is taking intermittent agonal gasps..
> 
> ...



I'm an explorer so please criticize my process. 

Upon arrival, I would tourniquet above the laceration, gauze and wrap the laceration itself. Start CPR, since GCS is under 8 I'd intubate. Deliver blood, rush to hospital, 

How'd I do?


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## STXmedic (Jun 22, 2016)

Hopefully you're not intubating anybody as an explorer... And GCS <8 intubate is an old mantra that needs to die.

Also, I don't know of anywhere except maybe a couple flight programs that actually carry blood.


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## Handsome Robb (Jun 23, 2016)

nater said:


> SpecialK, could this crew have felt bound by protocols preventing them from transporting a pulseless patient? I know many services are preferring not to transport until we get ROSC or call them on scene. To me, this would be an easy exception since the patient needs blood products and surgery to have any chance at survival. Unfortunately it seems, many agencies would rather crews not think outside of protocol book and when they do, they might be looking for a new job.
> 
> As for the TXA, I would consider it. For our use, it is  normally indicated for internal hemorrhage but could have some clotting benefit for these patients as well. I am aware of controversy surrounding its use and unfortunately I missed a recent debate on its use between two surgeons at my facility. A tourniquet, rapid transport and blood would still be my first priority.



If you're 15 minutes from the hospital and they are in cardiac arrest secondary to exsanguination that's an injury incompatible with life. They will not come back from an arrest like that with that much time with no circulatory volume. You can pump the chest all you like but if there's no blood to oxygenate and circulate mechanically it's futile.


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## SpecialK (Jun 24, 2016)

nater said:


> SpecialK, could this crew have felt bound by protocols preventing them from transporting a pulseless patient?



This is the norm in _primary _cardiac arrest yes, although not a written instruction per-se but it is normal not to transport a primcary cardiac arrest unless ROSC is achieved, or the circumstances are extraordinary however not in this case/  Generally the crew, indeed all ambulance crews, are free to apply their discretion and judgement as they see fit when treating a patient generally.  



Handsome Robb said:


> If you're 15 minutes from the hospital and they are in cardiac arrest secondary to exsanguination that's an injury incompatible with life. They will not come back from an arrest like that with that much time with no circulatory volume. You can pump the chest all you like but if there's no blood to oxygenate and circulate mechanically it's futile.



I don't think the patient was actually in cardiac arrest.  They might have had no blood pressure which was non-invasively recordable and no palpable pulse but if they have a heart rate of 140 bpm then their myocardium is still contracting; there is just nothing to pump around it.

The patient may still have died or had a bad outcome but the point is there could have been a very small chance this patient's life could have been saved, particularly if an early decision was made to transport to hospital and they were notified so as to have blood available and waiting when the patient came through the door.


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## Jacob Horrell (Jun 28, 2016)

STXmedic said:


> Hopefully you're not intubating anybody as an explorer... And GCS <8 intubate is an old mantra that needs to die.
> 
> Also, I don't know of anywhere except maybe a couple flight programs that actually carry blood.



THank you for the information, and no, I'm not intubating as an explorer.


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## sack jears (Aug 30, 2016)

Being bls I'd definitely start with tourniquet proximal to the wound, assist ventilations with o2 and wrap him in a blanket and crank the heater in the rig. About all I can do.


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## shelvpower (Aug 30, 2016)

Had a similar case here in South Africa a month or 2 ago. 

Pt was stabbed approximately 1cm above sternal notch. O/A pt was found on a couch with a massive amount of blood on the floor, couch and his clothes. The wound was still bleeding. 
Pt was 		+- GCS 12 O/A but quickly deteriorated to GCS 3 (within 2 minutes). 
Patient had an unrecordable BP and no pulses present with a HR of 40bpm on the ECG. 

Patient was quickly intubated on scene while performing CPR. A decision was made to load patient and proceed to hospital (local ED), about 7 minutes away, while performing CPR. 

O/A at hospital the doctors decided to see if they can clamp the artery and was successful after about 30 minutes (keep in mind this is normal GP doctors). 4 units of O- was given in hospital. The pt regained strong pulses and a good blood pressure but lost it again after 10 minutes. After about another 10 minutes of CPR pulses and a good BP was regained. This happened a couple of times, but eventually we managed to stabilise the patient (after about an hour and a 20 minutes of CPR). 

After stabilising the patient we transported him to the trauma facility which is 30 minutes away.  During transportation the patient's GCS improved to approximately 9/15. Pt had to be sedated with some midazolam. 
Unfortunately the patient died on the operating table about 2 hours later.


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## Specialized (Aug 30, 2016)

If I came upon this scene where I work...

1.) Call Dispatch and inform them of this situation, then pick up my phone and call 911 and get an ALS rig over asap.
2.) I would apply direct pressure over the wound. not ignoring the huge pool of blood of course, if that didn't work, then I'd apply a tourniquet and tighten until bleeding stops. Or maybe apply a hemostatic dressing, unless that's contraindicated when pt has a tourniquet on?
3.) I would bag the pt with a BVM hooked up to O2 at 15lpm. Elevate feet, wrap in a blanket. 
4.) This step would probably replace step 1 since BLS wouldn't carry a cardiac monitor, but I'd start CPR. 

Definitely not a BLS call that's for sure...


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## SpecialK (Sep 1, 2016)

And how long is all of that going to take? What is calling for backup going to achieve? How far away is your backup vs how far is the hospital? 

I think we sort of "call for backup" as a bit of an instant knee-jerk reaction without actually considering w_hy.  _The better question to ask is "what does the patient need and how can they get it most effectively" i.e. considering the larger context.  

In this case, the patient needs resuscitation with blood.  I wouldn't call for backup, even though HEMS could respond by road with blood, it is going to be faster to take him to hospital.


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## EpiEMS (Sep 1, 2016)

SpecialK said:


> And how long is all of that going to take? What is calling for backup going to achieve? How far away is your backup vs how far is the hospital?
> 
> I think we sort of "call for backup" as a bit of an instant knee-jerk reaction without actually considering w_hy.  _The better question to ask is "what does the patient need and how can they get it most effectively" i.e. considering the larger context.
> 
> In this case, the patient needs resuscitation with blood.  I wouldn't call for backup, even though HEMS could respond by road with blood, it is going to be faster to take him to hospital.



Calling for backup in the case of many systems is required...for some reason. In this case, unless they're a minute away and can meet you en route, a BLS ambulance could (should) transport emergently.

Then again, 15 minutes away, no palpable pulse (BLS -- so I don't have a monitor)...why would this not be a candidate for field termination?


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## SpecialK (Sep 1, 2016)

EpiEMS said:


> Then again, 15 minutes away, no palpable pulse (BLS -- so I don't have a monitor)...why would this not be a candidate for field termination?



Because the patient is not dead.  They have no palpable pulse but they still have mechanical output (on the monitor) just very little blood volume to pump mechanically!

If one recognises what the patient needs early and rapidly ensures they are delivered somewhere they can get it, then it is entirely possible their life can be saved.

As I have said previously, the most important thing we can do is formulate a diagnosis, decide what the patient needs and how best to ensure they get it as efficiently as possible.  Calling for backup and waiting on scene will achieve nothing.  This patient is truly time critical and needs to be transported to hospital.


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## EpiEMS (Sep 1, 2016)

SpecialK said:


> Because the patient is not dead.  They have no palpable pulse but they still have mechanical output (on the monitor) just very little blood volume to pump mechanically!
> 
> If one recognises what the patient needs early and rapidly ensures they are delivered somewhere they can get it, then it is entirely possible their life can be saved.
> 
> As I have said previously, the most important thing we can do is formulate a diagnosis, decide what the patient needs and how best to ensure they get it as efficiently as possible.  Calling for backup and waiting on scene will achieve nothing.  This patient is truly time critical and needs to be transported to hospital.



Right, I follow given that you have monitoring capability -- I'm curious as to whether BLS can say "Alrighty, this is incompatible with life" or not. I certainly agree that rapid transport makes sense here, if you can ascertain that there is cardiac output.


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## Specialized (Sep 1, 2016)

EpiEMS said:


> Right, I follow given that you have monitoring capability -- I'm curious as to whether BLS can say "Alrighty, this is incompatible with life" or not. I certainly agree that rapid transport makes sense here, if you can ascertain that there is cardiac output.



For BLS, that would be hard to determine. I certainly wouldn't make that call myself. Unless I see decapitation or rigor mortis present. They aren't dead until they're warm and dead with zero cardiac output.


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