High Acuity Response Unit Report
CASE
A patient in their 20s called the Queensland Police Service (QPS) threatening self harm. QAS Medical Director Dr Stephen Rashford Upon QPS arrival, the patient was found barricaded in a shower. As the QPS officers made their way in, the patient approached them with a knife. These officers used nonlethal force by way of a taser, followed by physical restraint. Upon QAS paramedic arrival, the patient was found to be highly agitated, with extensive blood loss on scene. A tourniquet was placed on the left proximal arm. Multiple incisional wounds to both arms and the chest were noted (twenty-five wounds to the left of sternum, three to the right of sternum, multiple arm wounds). The patient became progressively more lethargic, with no sedation needed by the attending crews. The patient was provided appropriate baseline cares, including supplemental oxygen, intravenous access and minimal crystalloid infusion. HARU met the crew enroute to the major trauma service hospital. At this time the patient’s condition was: • A–patent, self-maintained • B–RR 28/minute SpO2 100% on 15l/min oxygen • C–HR 110 bpm, weak peripheral pulses with delayed capillary return (peripheral circulatory failure) • Overall, the patient was pale and diaphoretic. • The tourniquet was loosened, and the wound dressed with a compressive bandage. • FAST (ultrasound): negative for intraperitoneal blood, no pericardial effusion, views of left thorax could not exclude haemothorax.
Overall Assessment and Plan: Haemorrhagic shock with multiple potential blood loss sites–external blood loss in shower and on the ground or a haemothorax. Prenotification call to the major trauma service prior to departure (short distance). One unit of packed red blood cells, 1g of TXA; patient responded well to the blood transfusion.
At the Emergency Department: Highly agitated with SBP 120 mmHg. Emergently ventilated, with significant hypotension post induction. Small left pneumothorax present. Haemodynamics normalised after three units of packed red blood cells and one unit of cryoprecipitate.
Discussion
Complex cases need careful thought at all phases of care to synthesise information and identify best clinical course. It can be difficult to estimate external blood loss. This patient had lost considerable blood on scene. The left hemithorax ultrasound view was difficult. Clinicians should balance the use of technology/investigations with value of clinical evaluation–both pre and in-hospital. Don’t forget your clinical examination–look, feel and then listen. This patient needed volume resuscitation prior to mechanical ventilation, due to the blood loss amplifying the reduction in preload experienced with positive pressure ventilation. Severe agitation and blood loss are a very difficult combination to address. All patients with severe agitation and disturbed vital signs should be treated as critically ill, with early monitoring instituted especially if sedation is considered. Ensure a dedicated clinician manages the airway and overall management.
Autumn 2021
39
