1. The Harmony Factor

2. Prehospital Saturday 12th February 17:48 Glamorgan Vale
M: Motorcycle v car at 80km/h
I: LOC, severe groin, L thigh & R leg pain
300mL blood loss PV
S: HR 110, SBP 98/74, Sats 98% RA, GCS 15
T: methoxyflurane, morphine 15mg, ketamine 80mg
Donway splint application
1200mL crystalloid

3. Arrival 19:20 AIRWAY & BREATHING CIRCULATION DISABILITY
Airway patent & protected
RR 20, Sats 100% NRB
CIRCULATION
HR 99, BP 85/43, cool peripherally
FAST negative
Active bleeding from vagina
DISABILITY
GCS 15, Temp 36.8

4. CXR

5. Pelvis Xray

6. First venous gas

7. Initial ED management CIRCULATION 3 units packed cells vagina packed
Medical notes
Medication chart
Fluid chart
INCOMPLETE DOCUMENTATION
CIRCULATION
3 units packed cells
vagina packed
Pelvic binder removed
ABs???
ADT???
Ketamine sedation???
Analgesia???

8. 2ndary Survey Urogenital injury Long bone injuries
Anterior labial laceration through clitoris
no bleeding in vaginal vault
Unable to identify urethra
For EUA
Long bone injuries

9. R leg XR

10. L wrist XR

11. CT scan 20:00 Open book pelvic # 12 rib # 4.5cm diastasis of pubis
R SIJ diastasis
Suggestion of blush R pudenal artery
12 rib #

12. Problem List/Injuries
Compound pelvis #
Vaginal laceration
Urethral injury
Active haemorrhage
Blush on CTA
R tib/fib #
L radius #

13. Further ED management Gynaecology r/v → EUA Urology r/v → EUA &
catheter placement
Orthopaedic r/v → EUA & washout
Surgical r/v → EUA (sigmoidoscopy)

14. Further ED management
Interventional Radiology review given CT findings and ongoing instability
IR suite – 00:00
no pelvic bleeding to account for PV loss
Placed SPC

15. Disposition
Stayed in ED awaiting EUA
To OT 07:58
ED stay 12 hr 38 min

16. Pre-op ABG

17. Transferred to OT with a single pink cannula
Thoughts?
Transferred to OT with a single pink cannula

18. Progress Intra-operatively Post operatively
Pre-op resuscitation & insertion of lines
Maintained C-spine precautions
Continued to bleed
→ Massive Transfusion
7 units PRBC, 9 FFP, platelets
Haemostasis with 3 stitches in anterior labial wound
Post operatively PE
ORIF pelvis

19. Issues raised…. ED
Documentation – need to have more senior doctors documenting
Should the binder have come off?? Awaiting IR for open book
C-spine clearance prior to OT
Under-resuscitated prior to OT, Single cannula, ‘forgotten patient’

20. Issues raised…. System Junior doctors galore – no decision makers
Multiple doctors identified bleeding from vulva (O & G, ortho, gen surg) yet no –one sutured it