darkhorse
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A 21-year-old man is brought by ambulance to the emergency department after being involved in a high-speed collision on his motorcycle. The patient struck a retaining wall at over 100 miles per hour. At the scene, he was non-responsive. He was intubated, a peripheral intravenous was placed, and he was transported to the hospital. On arrival, the patient is non-responsive to command. His temperature is 37.0 C (98.6 F), blood pressure is 60/30 mm Hg, pulse is 140/min, and respirations are 10/min via mechanical ventilator. He has multiple ecchymoses on his abdomen and chest, with an open femur fracture on the right and a depressed skull fracture. His abdomen is distended and tense and a radiograph suggests massive blood in the abdomen from a venous tear. A femoral vein cut-down is performed by the surgical team and a femoral vein central line is placed. After rapid infusion of 6 liters of crystalloid and 4 units of packed red cells via the femoral line, the patient is noted to be in pulseless electrical activity. The most appropriate next step in the management of this patient is to
A. bring the patient emergently to the operating room
B. continue rapid transfusion of blood products and crystalloid via the femoral line
C. give epinephrine, intravenously
D. place an upper extremity intravenous line and infuse volume and blood product
E. perform DC cardioversion at 200 Joules
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| Justice
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A. bring the patient emergently to the operating room
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| darkhorse
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| Kamsi
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E Cardioversion at 200 J
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| darkhorse
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| Doc750
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D
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| darkhorse
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can u explain ur answer plz
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| Doc750
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Sure, after giving six units of 6 liters of crystalloid and 4 units of packed red cells, you would expect a change in his BP. There is no change so the line must be comprimised due damage from the femoral fracture or abdominal trauma.
So the next step is to try a different location. I would go with two big bore IV lines, one in each arm, and run them at full drip, .9% saline.
Once the BP is stable, then you can look for surgical treatment options.
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| darkhorse
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hmmmm...sensible explanation...good thinking
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| darkhorse
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Explanation: The correct answer is D. The utility of central lines are related to the nature of the injury or clinical condition of the patient. For example, internal jugular lines are useful when the shoulders or chest is going to be operated on. For this patient who likely has an inferior vena cava rupture, a precaval line does nothing except deliver blood product to his vena cava that promptly discharges it through a defect into the abdominal space. This patient is now in PEA because he has continued to lose volume through his defect. An upper extremity line should be placed (utilizes SVC) and volume should be delivered in that manner. Attempting to bring the patient emergently to the operating room (choice A) could result in his death. Patients must be stabilized (the ABCs of resuscitation) before any additional interventions are taken. This patient is in an ACLS arrest and must be resuscitated prior to being discharged from the emergency department to the operating room. For the reasons discussed above, to continue rapid transfusion of blood products and crystalloid via the femoral line (choice B) would be ineffective at restoring this patient's pressure.Similarly, giving epinephrine intravenously (choice C) is not correct because this is only called for in pulseless VT or VF. DC cardioversion at 200 Joules (choice E) is incorrect because this patient is in PEA arrest. This ACLS algorithm calls for interventions that restore the circulatory tone. There is no evidence that this patient is in pulseless ventricular tachycardia or fibrillation, which does call for countershock.
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