Case #59 "Trauma - Sweet and Salty Issues"
by Charlene Babcock Irvin, MD

62 y/o male presents after a car accident. EMS notes his GCS is 7, and his blood pressure is 85 by palpation. It was a single vehicle accident (patient went off the road and hit a tree), and he smells of alcohol. No seat belts were used. EMS did a scoop and run and attempted IV en route (unsuccessful). According to EMS, the only bleeding noted is from a scalp laceration (still bleeding), and a contusion to the upper abdomen is noted from the steering wheel. EMS has no medical history available for this patient.

Primary survey: (as you ask for IV, oxygen, monitor, fully undress the patient, repeat vital signs, and draw blood) reveals:

Airway open, gag is present, = breath sounds, no subcutaneous air, equal chest excursion, abdomen soft, no AAA palpated, appears to be non-tender, small contusion noted in the epigastric area. Pelvis is stable, no clear bleeding or deformities to extremities. Scalp is bleeding and a closer inspection reveals an arterial pumper in the laceration.

Neurologically, opens his eyes to pain (2), moans incomprehensibly to pain (2), and he withdraws to pain (4).

1. In addition to ‘trauma’ labs, CT head/c-spine/abdomen and pelvis, CXR, pelvis x-ray, and bedside FAST (although you don’t really order FAST..you just do it), what other tests should you order?

2. Should you give fluids to this patient? Are you concerned about permissive hypotension?

3. What is the role of hypertonic saline in this situation?
 

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