My wife is dying ...

[Alan L Serve]

She's a-bleedin'.

She may die.

Get in the lines, fill her up, and see if you can't find a few bags of blood. PRBC and FFP. Medicines to help with getting her BP up and the heart to beat a bit nicer.

She's probably a gonner. Search her purse for her credit cards. It'll be fun until you go to jail.

 

[SpecialK]

She's a-bleedin'.
She may die.
Get in the lines, fill her up, and see if you can't find a few bags of blood. PRBC and FFP. Medicines to help with getting her BP up and the heart to beat a bit nicer.

Where do you think she is bleeding from?
Do you think 200-300 ml of blood loss is compatible with her near moribund state? Doesn't the pattern of deterioration look a bit odd?
Why would you give packed cells and plasma but no platelets? Why not just give her whole blood?

 

[Alan L Serve]

Where do you think she is bleeding from?
Do you think 200-300 ml of blood loss is compatible with her near moribund state? Doesn't the pattern of deterioration look a bit odd?
Why would you give packed cells and plasma but no platelets? Why not just give her whole blood?

Years ago a rookie EMT asked me a question.

"Where is the blood from this very hypovolemic patient? I see a tiny amount!"

To which I told the rookie, "The patients bleeds both on the outside and the inside."

Blood is so important, more than simple crystalloids. FFP, PRBC, and platelets. There is even a magic ratio to help with bleeding. Did you know this magic thing? 3:1 FFP to PRBC.

The coagulation factors are in the plasma. The secrets are in the stars.

 

[Akulahawk]

I'm a few days late in responding to this but I read the initial story when it first posted and I thought AFE as well. Given the transport destination variables, I would call for HEMS while I'm still on scene, do what I can, and head toward the closer facility. Their capabilities are likely going to be quite a bit more extensive than I'd be able to offer in my ambulance. If anything, HEMS can rendezvous on the closer facility's pad and take the patient from there to the tertiary facility and if the patient is still trying to die before I can get her going, HEMS is still en-route to their pad and I can go to that closer facility, have them begin stabilizing the patient while waiting for HEMS to arrive, take over stabilization and begin rapid air transport to the tertiary facility. If she's doing OK and is at least somewhat stable, I might consider a run directly toward the tertiary facility and have HEMS rendezvous with me somewhere on the way.

 

[SpecialK]

Years ago a rookie EMT asked me a question.
"Where is the blood from this very hypovolemic patient? I see a tiny amount!"
To which I told the rookie, "The patients bleeds both on the outside and the inside."

Blood is so important, more than simple crystalloids. FFP, PRBC, and platelets. There is even a magic ratio to help with bleeding. Did you know this magic thing? 3:1 FFP to PRBC. The coagulation factors are in the plasma. The secrets are in the stars.

Let's look at the "big picture".

This happened 20 minutes ago. In that relatively short time, she developed profound and severe shock which the husband says came on very quickly. She also has severe difficulty breathing and upon listening to her chest, we hear something like wheezes with crackles. Given this information and her presentation, the pattern of her shock is really a bit odd don't you think? Does hypovolaemic shock usually present like this; i.e. with such a fast onset including severe difficulty breathing and a wheezy chest? No. What does? Anaphylaxis (or in this case, an anaphylaxis-like reaction).

We cannot say for sure she is not bleeding somewhere (unless of course you can do USS) but given the above I'd be leaning towards hypovolaemia not being the cause of her problem. It might be, but what is going to be more important, i.e. what is going to likely be fatal if we do not treat it, is the anaphylaxis-like reaction she is having. There have now been a number of cases of AFE where despite profoundly rapid and continued deterioration the patient has made a normal recovery once receiving IV adrenaline.

And yes, I am aware of 3:1 ratio for FFP to PRBC. My question is why you are going to give her plasma (which contains fibrinogen) but no platelets? And do you honestly want to piss-arse around carrying frozen plasma and red cells? Wouldn't it just be so much easier and more sensible to carry whole blood like a number of services are now doing?

 

[MonkeyArrow]

Blood is so important, more than simple crystalloids. FFP, PRBC, and platelets. There is even a magic ratio to help with bleeding. Did you know this magic thing? 3:1 FFP to PRBC.

The most recent literature states that a 1:1:1 ratio of PRBCs to Platelets to FFP is best in trauma patients. While not a trauma patient, the reason you transfuse those patients is due to hypovolemia, the same mechanism you are proposing to transfuse for in this patient.

 

[Alan L Serve]

The most recent literature states that a 1:1:1 ratio of PRBCs to Platelets to FFP is best in trauma patients. While not a trauma patient, the reason you transfuse those patients is due to hypovolemia, the same mechanism you are proposing to transfuse for in this patient.

Trauma is not medically sick.

Very different mechanisms.

Like black magic vs dark magic. Similar, yet different.

 

[VFlutter]

This lady sounds very early in her presentation and likely in the first phase which predominantly is obstructive shock. I doubt she has progeessed to DIC and hemorrhagic shock at this point in time. The hypoxia and cardiac collapse kill most AFE before they even get to the second phase.

 

[Akulahawk]

This lady sounds very early in her presentation and likely in the first phase which predominantly is obstructive shock. I doubt she has progeessed to DIC and hemorrhagic shock at this point in time. The hypoxia and cardiac collapse kill most AFE before they even get to the second phase.

I agree that she seems to be in this phase. My suspicion is that the closer hospital probably doesn't have the ability to crash patients on to ECMO and probably has the ability to transfuse large amounts of blood (whole or 1:1:1 components) to get her through the DIC/Hemorrhagic phase.

 

[Alan L Serve]

I agree that she seems to be in this phase. My suspicion is that the closer hospital probably doesn't have the ability to crash patients on to ECMO and probably has the ability to transfuse large amounts of blood (whole or 1:1:1 components) to get her through the DIC/Hemorrhagic phase.

The chances of her dying,
using 1:1:1,
Grow like a fetus in womb.

 

[VFlutter]

The chances of her drying,
using 1:1:1,
Grow like a fetus in womb.

I'm not sure I follow your rationale. This is not a coagulopathic issue.

 

[Alan L Serve]

I'm not sure I follow your rationale. This is not a coagulopathic issue.

DIC or bleeding=coagulopathy

 

[VFlutter]

DIC or bleeding=coagulopathy

My argument is that she is not currently in DIC. Although DIC is a part of AFE it is usually later in the presentation, to which ~60% never survive to.

 

[ERDoc]

She's a-bleedin'.

She may die.

Get in the lines, fill her up, and see if you can't find a few bags of blood. PRBC and FFP. Medicines to help with getting her BP up and the heart to beat a bit nicer.

She's probably a gonner. Search her purse for her credit cards. It'll be fun until you go to jail.

Except for the fact that clinically she looks nothing like hypovolemia.

 

[Carlos Danger]

The pathophysiology of AFE is interesting. I just read a CEU thing on it recently. For one thing, amniotic debris is found in something like 30% of tested parturients, even though only 1 in 10,000 or fewer develop the AFE syndrome. No idea what actually causes the syndrome. The initial phase can appear primarily obstructive (d/t what is essentially pulmonary artery spasm), vasoplegic, or coagulopathic and can happen at any point from late pregnancy to several days postpartum. Presenting symptoms can be anything from a headache or mild SOB to nearly instant vascular collapse. The "A-OK" cocktail apparently really works, and reduced mortality significantly in the retrospective analyses. Aside from the A-OK cocktail, treatment is simply supportive.

Probably no role for blood replacement, at least not until the later coagulopathic stages.

 

[Alan L Serve]

Except for the fact that clinically she looks nothing like hypovolemia.

Roses are red,
Violets are blue,
She looks like,
Someone who has hypovolemia

 

[ERDoc]

Roses are red,
Violets are blue,
She looks like,
Someone who has hypovolemia

Sure, except for the fact she is not losing any volume. All of her H&P points to a cardiac/resp cause.

 

[Alan L Serve]

Sure, except for the fact she is not losing any volume. All of her H&P points to a cardiac/resp cause.

My friend,

We will agree to disagree.

 

[ERDoc]

And you, my friend, will kill the pt

 

[Alan L Serve]

And you, my friend, will kill the pt

And you,

my friend,

are my dearest friend.