1. Management of severe polytraumatism in A&E Case report Dr Dien, Dr Tuan, Dr David 9/09/2010

2. Patient 28 years old victim of a motorbike accident arrived 20 min. later in A&E with a taxi (initial assessment) 9h00 arrival in A&E: unconscious (G3), no breath (gasping) and no pulse and bilateral mydriasis 5mm He presents a head + face trauma with severe bleeding at the mouth + & right ear +++. He has also a contusion/deformation of the left arm Abdomen supple, no evident trauma No evident trauma at the legs

3. H0: Initial management 9h00: Suction of the blood in the mouth, ventilation with bag-valve mask O2 100% 9h05: IV line with serum NaCl 0.9% > Adrenaline CPR with cardiac massage and ventilation > recovered with pulse & spontaneous breathing. Neck collar placement

4. Secondary management 9h10: Rapid sequence induction (Etomidate 0.3mg/Kg + Suxa. 1mg/Kg) Oro-tracheal Intubation ETT 7mm and mechanical ventilation Sedation with Hypnovel & Fentanyl protocol (50mg Hypnovel + 500  Fentanyl) NorAdrenaline = Levonor 2mg/h IVES

5. Scanner full-body (9h35-9h45) Fracture skull base, fracture of the “ rocher ”, fracture of the skull, multiple fractures of the face bones. Pneumencephalie + diffuse cerebral edema Bilateral lung contusions and left rib fractures with mild pneumothorax Abdomen and rachis without evident lesion

11. Fluid resuscitation NaCl 0.9% x 5 (2.5 liters) Gelofusine 500ml x 2 (1 liter) 9h50: Order 2 “ Culots Globulaires ” O negative (delivered at 10h15 but too late … )

12. Evolution during 1h30 9h009h159h259h359h409h459h5010h 10h30 Pulse 0128 1241291281247020 BP 0 73/ 52 100/ 80 100/ 40 100/ 20 59/ 28 50/ 24 42/ 20 40/ 15 SpO2 09596 97 9570- Glasg. Score 333333333 Outcome: finally the patient died at 10h40 …

13. Discussion about management of polytrauma in A&E FVH Medical aspect: what are we able to do to save a severe patient Ethical aspect: Could we stop resuscitation before ? (desperate case?) Financial aspect: does FVH policy about indigent patient allows us to do everything to save life of all the patient? (including those who have no money)

14. Medical aspect Management of vital functions Cardiac arrest > CPR and ACLS … Coma Glasgow score </=8 and respiratory failure : intubation (rapid sequence induction followed by sedation ) Fluid resuscitation with IV catheter (x2) and infusion NaCl 0.9% & Gelofusine Vaso-active drugs: NorAdrenaline (Levonor) Transfusions? ( “ Culots Globulaires ”, platelets, fresh plasma?)

15. Medical aspect: Exams Head CT scanner + cervical rachis in case of severe head trauma (Glasgow </=8) full body CT: For severe patient with unstable hemodynamic (Head/Neck/Thorax/Abdomen) Blood tests ? (NFS, TP/TCA, blood group x 2, RAI)

16. Ethical aspect (medico-legal) Can we consider this case as a desperate case, so was it reasonable to perform full body CT and transfusion? What about the option to transfert the patient to Cho Ray before CT? What about the option to send the patient in OT for rescue surgery? (not in this case … ) Risks for the patient (and for care givers) to “ refuse ” to do what we are supposed to …

17. Economical aspect FVHospital is not a charity hospital … Private hospital = earn money Can we (care givers) avoid to consider this aspect of the problem? Must economical status of the victim interfere in the medical decision in this case?

18. FVH policy about this problem “FVH is not on non-for profit organization, its financial resources are limited, we don’t have grants from the authorities or any other financial sources than ours. In other words we just cannot be an open door for all patients whatever their financial status is and provide complete care for people who cannot pay. However the mission of the hospital is to take care of patients, therefore we cannot turn somebody away because he/she does not have enough money to pay for care. A balance must be found between medical ethics and financial realities”

19. FVH policy about this problem “The patient is in an acute condition but not life-threatening, then we must take care of the acute problem, stabilize and then transfer. For example: broken leg. The patient is in pain, we must provide first-aid and manage the pain and then organize as fast as possible the adequate transfer of the patient to the relevant organization, for example the Centre for Orthopaedics and Traumatisms (“CTO”) “

20. FVH Policy about this problem “The patient is in acute life-threatening condition, we must save the patient’s life and this could require hospitalization in ICU, surgery, etc if the patient cannot be transferred. Obviously this is a medical decision but the decision must be discussed with management, first and foremost with the medical director.”

21. ConditionFirst aid care Absolute investigations Cardiac arrest CPR, Intubation, EES, Adrenaline ECG Severe Head trauma (G</=8) Neck collar, IV line, Intubation Head & Neck CT scanner Polytrauma IV line, fluid infusion including transfusion if needed, airway management CT scan (full body if needed) X-ray focused on suspected lesions CBC, Blood Group, RAI, Coag. Tests Severe cardiac failure IV line, Oxygen, Medication, CPAP if needed Chest X Ray, ECG Supporting laboratory Tests