Case Study: Life-Threatening Traumatic Bleeds and Anticoagulation Reversal in the ED

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Dr. Möckel:
So, I would like to add a small case study. So, this is a life-threatening trauma bleed. So, a patient with a motor vehicle accident, a 65-year-old male brought in by the EMS. The driver was unrestrained for the high-speed collision on a rural highway, prolonged extrication, so risk of hypothermia and transported by local ground EMS. Initial vital signs is a little bit lower, blood pressure 84 over 48, increased heart rate, respiratory rate of 30, and temperature is 35.5 degrees Celsius, which equals to 96 Fahrenheit.

So past medical history. So, it's a patient with hypertension, with poorly controlled diabetes, obesity, COPD, Afib as the indication for anticoagulation and coronary artery disease. He had also a CABG five years ago, and knee replacement two years ago, no allergies, and his social history is that he is occasionally drinking alcohol, but not regularly. He has 50-pack years and is on no recreational drugs. He has a complex medication, including Lisinopril for his heart, and Metformin for his diabetes. Atorvastatin as secondary prophylaxis in coronary artery disease. Aspirin, Apixaban, Abuterol and Budesonide.

And so, the primary survey is that he was rescued using a spine board and stiff neck, he was ill appearing and diaphoretic, he had no blood or obstruction in the airways, so every protection was done. Breathing was tachypneic but not labored, circulation was weak but positive distal pulses, he had a delayed capillary refill, and he has an open, displaced fracture of the right distal lower extremity, but he moves all four extremities, and the exposure you see was that he was extracted over a couple of minutes from the car, and has, therefore, a low body temperature.

So, he's awake and alert, answers questions, is a little bit confused, but oriented to do person and place. He had no spinal tenderness, lungs were clear, tachypneic, but the abdominal was tender to palpation. He was voluntary guarding and bruising on abdomen, and his pelvis was stable to rock, but he has this already mentioned, open, displaced right lower extremity fracture. And good distal pulses and moved, as said before. And then you got the trauma CT approach, and you can see here that he had a concussion, a traumatic brain hemorrhage.

That he has a grade four liver laceration, and so this guides then the further treatment. So, he was transfused, one to one packed red blood cells, and fresh frozen plasma due to hemorrhagic shock. And he was administered Andexanet alfa for the brain hemorrhage, using a full dose, because it was assumed that the last dose was taken that morning, and he was on two times daily, five milligram. He was then taken directly for exploratory laparotomy, and the liver restoration has been managed, and he got a transfixation of the right open tibia, fibula fracture, and was repeat, had CT scans, he was stable so no hemorrhage expansion. He could leave the trauma ICU after five days, and transfer to rehabilitation on day seven. And yeah, the anticoagulation for afib was held for two weeks and it was deferred to primary care for restart, which was considered after hemorrhage, after approximately four weeks. So, for that, thank you very much for your attention, and we are now open for your questions and discussion.

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