MANAGEMENT OF CRITICALLY ILL PATIENT FOLLOWING MULTIPLE ABDOMINAL TRAUMA WITH MASSIVE HEMORRHAGE : CASE REPORT
DOI:
https://doi.org/10.53555/ab2jq958Keywords:
Abdominal trauma, massive bleeding, massive transfusion protocolAbstract
Background: Most patients with severe abdominal trauma with massive bleeding require intensive care. On most occasions patients will be admitted to Intensive Care after surgery and require close monitoring of vital signs. Care in the ICU will focus on monitoring and supportive measures. The management of bleeding in critically ill patients is a dynamic and complex process. In addition, transfusion strategies during bleeding may involve several concurrent strategies to monitor coagulopathy, transfusion of blood products, and administration of drugs to correct coagulation disorders.
Case report : A 48-year-old male was admitted to the ICU after a traffic accident. The patient came to the emergency room with bleeding shock and fluid resuscitation was performed to restore MAP 60 mmHg. Damage control surgery and massive transfusion were performed to save the patient. After the first operation, the patient returned to shock, producing 1500 cc hepatal and subphrenic drain in 3 hours. Re-laparotomy abdominal re-breaking surgery was performed again with additional packed red blood cells (PRBCs), Fresh Frozen Plasma (FFP) and platelet transfusion during surgery. Post-second surgery, the patient's hemodynamics were stable and vasopressor drugs could be weaned. The patient was admitted to the ICU with invasive monitoring and mechanical ventilator. After the 4th day, the patient experienced volume overload and pulmonary edema. Furosemide was given to eliminate fluid accumulation. The patient was extubated on day 6 and moved to the ward on day 7.
Discussion : In cases of intra-abdominal trauma, Focused Assessment With Sonography For Trauma (FAST) examination can be performed quickly so that the decision to perform surgical resuscitation can be made immediately. Damage control surgery is performed in conditions where bleeding cannot be controlled through definitive procedures. Abdominal packing can be performed to prevent further bleeding while waiting for hemodynamic stabilization and coagulopathy in the ICU. Giving massive transfusions such as PRBCs, FFP and platelets according to protocol prevents the occurrence of lethal triad in massive bleeding patients. On the other hand, massive transfusion also brings side effects and complications such as volume overload, electrolyte disturbances, acidosis, transfusion reactions and infection in patients. The administration of blood and fluid transfusion in post-traumatic patients in the ICU must be done carefully to prevent these complications.
Conclusion : In cases of intra-abdominal trauma patients with massive bleeding, early diagnosis, damage control surgery and proper management of massive transfusion are the management that must be done to save the patient.
References
. de Bruin S, Eggermont D, van Bruggen R, de Korte D, Scheeren TWL, Bakker J, et al. Transfusion practice in the bleeding critically ill: An international online survey—The TRACE-2 survey. Transfusion (Paris). 2022;62(2).
. Kozar RA, McNutt MK. Management of adult blunt hepatic trauma. Vol. 16, Current Opinion in Critical Care. 2010.
. Kozar RA, Feliciano D V., Moore EE, Moore FA, Cocanour CS, West MA, et al. Western trauma association/critical decisions in trauma: Operative management of adult blunt hepatic trauma. Journal of Trauma - Injury, Infection and Critical Care. 2011;71(1).
. Van Der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, et al. Successful nonoperative management of the most severe blunt liver injuries: A multicenter study of the Research Consortium of New England Centers for Trauma. Archives of Surgery. 2012;147(5).
. Arvieux C, Thony F. Management of splenic trauma in hemodynamically stable patients: Lessons to be drawn from the French SPLASH trial (Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) Study Group). Vol. 159, Journal of Visceral Surgery. 2022.
. Morey AF, Brandes S, Dugi DD, Armstrong JH, Breyer BN, Broghammer JA, et al. Urotrauma: AUA guideline. Journal of Urology. 2014;192(2).
. Jang JY, Kang WS, Keum MA, Sul YH, Lee DS, Cho H, et al. Antibiotic use in patients with abdominal injuries: Guideline by the Korean Society of Acute Care Surgery. Ann Surg Treat Res. 2019;96(1).
. Miller RD, Eriksson L, Fleisher LA, Wiener-Kronish JP, Young WL. Miller’s Anesthesia . 7th ed. Philadelphia; Else; 2010.
. Levi M, De Jonge E. Clinical relevance of the effects of plasma expanders on coagulation. Vol. 33, Seminars in Thrombosis and Hemostasis. 2007.
. Rao S, Martin F. Guideline for management of massive blood loss in trauma. Update in Anaesthesia. 2012;28(1).
. O’Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R. A massive transfusion protocol to decrease blood component use and costs. Archives of Surgery. 2008;143(7).
. Nunez TC, Young PP, Holcomb JB, Cotton BA. Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient. Vol. 68, Journal of Trauma - Injury, Infection and Critical Care. 2010.
. McCormack PL. Tranexamic Acid: A review of its use in the treatment of hyperfibrinolysis. Vol. 72, Drugs. 2012.
. Neal MD, Marsh A, Marino R, Kautza B, Raval JS, Forsythe RM, et al. Massive transfusion: An evidence-based review of recent developments. Vol. 147, Archives of Surgery. 2012.
. Roberts I, Shakur H, Ker K, Coats T. Antifibrinolytic drugs for acute traumatic injury. In: Roberts I, editor. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2012.
. Hawkins WA, Smith SE, Newsome AS, Carr JR, Bland CM, Branan TN. Fluid Stewardship During Critical Illness: A Call to Action. Vol. 33, Journal of Pharmacy Practice. 2020.
. Jiang Z, Ren J, Hong Z, Ren H, Wang G, Gu G, et al. Deresuscitation in Patients with Abdominal Sepsis Carries a Lower Mortality Rate and Less Organ Dysfunction than Conservative Fluid Management. Surg Infect (Larchmt). 2021;22(3).
. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition. 2016;40(2).
. Genton L, Romand JA, Pichard C. Basics in Clinical Nutrition: Nutritional support in trauma. E Spen Eur E J Clin Nutr Metab. 2010 Apr;5(2):e107–9.
. Kondrup J, Ramussen HH, Hamberg O, Stanga Z, Camilo M, Richardson R, et al. Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials. Vol. 22, Clinical Nutrition. 2003.
. Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6).
. Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9).
. Skeik N, Westergard E. Recommendations for VTE Prophylaxis in Medically Ill Patients. Ann Vasc Dis. 2020;13(1).
. Saeed M, Bass S, Chaisson NF. Which ICU patients need stress ulcer prophylaxis? Cleve Clin J Med. 2022 Jul 1;89(7):363–7.
Downloads
Published
Issue
Section
License
Copyright (c) 2023 Journal of Advanced Research in Medical and Health Science (ISSN 2208-2425)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Licensing
Ninety Nine Publication publishes articles under the Creative Commons Attribution 4.0 International License (CC BY 4.0). This licensing allows for any use of the work, provided the original author(s) and source are credited, thereby facilitating the free exchange and use of research for the advancement of knowledge.
Detailed Licensing Terms
Attribution (BY): Users must give appropriate credit, provide a link to the license, and indicate if changes were made. Users may do so in any reasonable manner, but not in any way that suggests the licensor endorses them or their use.
No Additional Restrictions: Users may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
