Shock Syndromes II
Patient Case
Questions 3 and 4 pertain to the following case.
D.R. is a 37-year-old man with an unknown medical history who presents after a helmeted motorcycle collision
into a deer. On primary survey, his endotracheal tube is secured, respiratory rate is 37 breaths/minute, SBP is 72
mm Hg, heart rate is 141 beats/minute, and Glasgow Coma Scale score is 5T. His FAST examination is positive.
An MTP is initiated, and the patient is taken to the operating room for an emergency exploratory laparotomy.
Which is the best initial resuscitation strategy to manage his hypotension?
In the operating room, the patient is found to have grade 5 hepatic laceration and grade IV spleen injury
status after perihepatic packing and splenectomy. His abdomen is left open with a wound vacuum-assisted
closure, and he is taken to the ICU. On arrival to the ICU (5 hours after injury), an arterial blood gas reveals
a pH 7.18, partial pressure of carbon dioxide 22 mm Hg, lactate 12.7 g/dL, and Pao2 of 86% on 40% Fio2
with assist control ventilation. He has received 14 units of erythrocytes, 12 units of plasma, and 12 units of
platelets. His laboratory values include aPTT 37 seconds, INR 1.3, Hgb 7.5 g/dL, and Plt 154,000/mm3. His
temperature is 99°F (37.2°C) and ionized calcium is 0.7 mmol/L. Which is the best pharmacologic treatment
strategy to manage his ongoing hemorrhagic shock in a goal-directed fashion?
Patient selection
Assessment of bleed severity in patients treated with oral anticoagulants is critical to guide
decisions related to reversal.
The American College of Cardiology (ACC) 2020 expert consensus decision pathway suggests
consideration for anticoagulation reversal in a major bleed, generally defined as bleeding into a
critical site, hemodynamic instability, or clinically overt bleeding.
Critical bleed site:
| (a) | Bleeding in a critical site can compromise the organ function, may cause severe disability, |
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and can potentially require surgical intervention.
| (b) | These sites include: intracranial, other central nervous system (spinal, ocular), thoracic |
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(e.g., pericardial tamponade, hemothorax), intra-abdominal, retroperitoneal, airway
bleeding associated with respiratory distress, or extremity bleeding (e.g., intraarticular,
intramuscular) causing compartment syndrome
| (c) | Intraluminal GI bleeding is not considered a critical site; however, GI bleeding may be |
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considered a major bleed on the basis of hemodynamic or overt bleeding criteria.