Page 108 - 2022 Spring JSOM

shock index of 1.52. Central venous access was achieved with of arrest, specific order of interventions, medications given,
a large-bore catheter in the right internal jugular vein. RSI and timing of ROSC if achieved, is limited by the charting per-
was performed 5 minutes after arrival. There was no recorded formed by the deployed provider. Despite these limitations this
induction agent and 200mg of succinylcholine was used. PA case series highlights the risks of performing RSI on a patient
occurred after intubation. The patient underwent damage with hemorrhagic shock.
control surgery in which he had bilateral common iliac ar-
tery and vein injuries requiring surgical intervention, followed Historically, the mantra “airway, breathing, and circulation,”
by a right common femoral artery and vein ligation, and left has dictated that airway management takes precedence over
pneumatic tourniquet. Throughout resuscitation the patient circulatory resuscitation. More recent Advanced Trauma Life
received vasopressin, 1L normal saline, and cefazolin. No Support (ATLS) and Tactical Combat Casualty Care (TCCC)
blood products were given prior to intubation. A total of 69 U guidelines, however, have placed greater emphasis on priori-
7,8
PRBC, 47 U FFP, 2 U of PLT, and 5 U of CRYO were provided tizing treatment of hemorrhage. This paradigm shift is con-
within 24 hours of the injury. The patient did not survive to sistent with the knowledge that positive pressure ventilation
30 days after the injury. reduces the suboptimal venous return in a shock state and de-
presses cardiac output. 9,10 Recent studies have also described
Case 7 preintubation hypotension to be associated with an increased
A 22-year-old US Airman presented to a role 2 facility in Af- risk of post-intubation hypotension, PA, and death. 11–14 This
ghanistan via air ambulance following a blast injury from a body of literature, taken with recent shifts from classic teach-
rocket-propelled grenade. The Airman had a left lower extrem- ing, should encourage clinicians to prioritize blood resuscita-
ity tourniquet placed and received an unrecorded amount of tion before airway management in patients presenting with
fentanyl prior to arrival. Physical exam revealed weak pulses hemorrhagic shock.
in all extremities, a left hand with four digits amputated, and a
massive left lower extremity soft tissue injury with tourniquet Of particular interest in this case series is that zero of the seven
in place. Initial vitals include a SBP of 87, DBP of 40, HR of patients had a single unit of blood transfused before RSI, and
102, RR of 22, SaO of 100%, and GCS score of 15. The all suffered PA within 10 minutes of intubation. Indications
2
patient had an initial shock index of 1.17. RSI was performed for endotracheal intubation are described in the Eastern As-
31 minutes after arrival using an unrecorded dose of propofol, sociation for the Surgery of Trauma Practice Management
3mg of midazolam, and an unrecorded dose of succinylcho- Guidelines and include: airway obstruction, hypoventilation,
line. PA followed intubation. No blood products were given persistent hypoxemia, GCS < 9, severe hemorrhagic shock,
15
prior to intubation. A total of 8 U PRBC, 6 U FFP, 1 U of or cardiac arrest. Though the cause of each patient’s arrest
FWB, and 3 U CRYO were given within 24 hours. The Airman was multifactorial, and the specific indication for intubation
underwent damage control surgery and survived past 30 days was not documented, this case series highlights the potential
(Table 1). danger of adhering to trauma management guidelines without
consideration of the entire clinical picture. Moreover, a recent
retrospective analysis of battle-injured personnel demonstrated
Discussion
that pre-intubation blood product use conferred a statistically
PA immediately following RSI of combat trauma victims suf- significant benefit in reducing post-intubation hypotension
fering traumatic hemorrhagic shock has been anecdotally de- and PA. While the patients in this case series may have been
6
scribed by forward deployed military healthcare providers. intubated per trauma guidelines, the clinical outcome of these
This case series describes the clinical features of several such patients should draw attention to the complexity of this clini-
cases. Of note, the descriptions of each case, to include timing cal management decision.

TABLE 1 Patient Clinical Results
Preintubation Arrival to
Patient # Initial SBP Initial DBP Initial HR Shock Index GCS Score Blood Products Given IntubationTime
1 88 unknown 160 1.82 6 No 3 minutes
2 90 60 140 1.55 unknown No 16 minutes
3 108 56 156 1.44 15 No 45 minutes
4 unknown unknown unknown unknown 10 No 2 minutes
5 69 47 140 2.02 15 No 19 minutes
6 61 41 93 1.52 13 No 5 minutes
7 87 40 102 1.17 15 No 31 minutes
Summary of Injuries and Blood Products Used Prior to Intubation
1 29-year-old US Marine sustained a single extremity amputation and head injury. No blood products prior to intubation.
2 29-year-old US Marine sustained multiple extremity amputations and head injury. No blood products prior to intubation.
3 20-year-old US Marine sustained multiple traumatic injuries not including head trauma or extremity amputations. No blood
products prior to intubation.
4 22-year-old US Marine sustained multiple extremity: amputations and a head injury. No blood products prior to intubation.
5 26-year-old US Soldier sustained multiple extremity: amputations and a head injury. 1 Unit pRBC was started, but not complete
prior to intubation.
6 29-year-old US Marine sustained multiple extremity: amputations and a head injury. No blood products prior to intubation.
7 22-year-old US Airman sustained multiple traumatic injuries an extremity: amputation and head injury. No blood products
prior to intubation.

106 | JSOM Volume 22, Edition 1 / Sping 2022