Simple accidents can lead to serious injuries
The Case
90 year old male, driver.
turning slowly to the right side
Hit on driver side by another car at about 40km/hr
Airbags deployed and hit his chest
Able to get out of the car
C/O mild central chest pain from airbags impact BUT declined analgesia -asking me when can he go home as looks after his wife
PMhx
MVR replacement 15years ago - on warfarin
+ Hx of Hypothyroidism taking thyroxine
10 years ago had bilateral TKR
Assessment
Stable patient HR 65/min BP 130/80 Sats 99% but noticed on 2lits of O2 (which I had a micro second though why is he on O2)
Mild central sternal chest pain
Bedside eFAST scan shows small amount of fluid right chest ? blood ? Fluid
Reviewed by Trauma who requested - CT Pan scan -
Reviewed images - Sternal body fracture + Right 4-6rib fracture + large sided side HTx likely from Internal mamary artery
As I was reviewing images…
Progress
Dropped SBP 80 - HR 67/min no tachycardia response
Rpt bedside US increased fluid in the right lung + Rpt VBG Dropped Hb from 120 - 106 INR result 3.0
Management
Gave him 500mls IVF called lab for X match and FFP and Prothrombinex
Started warfarin reversal : Given vitamin K + FFP + Prothrombinex
Called the surgical team + IR + CTx and ICU put in right sided Chest drain under ketamine sedation (900mls of blood straight away)
Informed his son about condition deterioration
After 2 PRBC and 2 FFP and Prothrombinex Stablised
Moved to IR for angio embolisation and later taken to ICU in a stable condition
Learning points
Be very very careful about TRAUMA elderly patients especially on warfarin or apixaban or dibagatran
FALSE Sense of security with stable Haem-dynamics ( because no tachycardia due to catecholamines insensitivity / atheroscleorsis/ BB/ CCB)
ONE study demonstrates 8/15 geriatric patients wit BLUNT TRAUMA had cardiac output <3.5lits/min and remaining 7 with normal cardiac output had impaired inadequate O2 delivery - I now remember patient on nasal prongs O2
Haemodynamic stable especially if the bleeding is very slow and NO tachycardia and then suddenly drop SBP
Methodical approach for warfarin reversal - prosthetic valve - high risk of emobilsation and CVA so 2 FFP + 20units /kg of prothrombinex rpt INR and rpt same if INR still elevated + ongoing Haem-dynamic compromise due to ongoing bleeding (so MONITOR bleeding)
You can also check fibrinogen and given cryoprecipitate if patient is hypofibrinogenic
Other thing to consider is ROTEM guided MTP protocol or consult haematology ICU early for directed MTP
Geriatric patients can decompensated with over aggressive volume repletion as as quickly they can decompensate due to inadequate resuscitation SO EARLY BLOOD & Blood PRODUCTS which will enhance tissue O2 delivery and minimise tissue ischaemia and acidosis
Rest any deterioration call and keep family upgraded
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