Example Case Submission

Name: Zander Prewitt

Email Address: alexanderpr@pcom.edu


Diagnosis/Assessment: Example Case: hypovolemic shock, hemothorax, hemoperitoneum secondary to GSW to R chest in setting of hemophilia B


Chief Complaint: Altered Mental Status/GSW


HPI/Patient Presentation: e.g. John Doe is a 22yo male presenting with AMS after what appears to be a gunshot wound to the right chest at the 4th ICS. He was brought into the ED via police and has no IV access established. Police state they found him down in the street after receiving a report of gunfire in the area and rushed him to your ED. It took them about 10 minutes to transport him here. His family has been notified and is on their way to the hospital now. Patient is currently unresponsive [responds to pain only, GCS 8 (E1V3M4)]


PMH: Once the family arrives (5 minutes into the scenario) they state that Mr. Doe has hemophilia B but has never required a transfusion for it before. He has no other PMH.


Vital Signs: Monitor: Sinus Rhythm rate of 132, drops to rate of 110 4 mins after fluid resuscitation is initiated

Initial VS (hypovolemic shock):
98.6
132
70/50
32
85%

2L NSS improves BP to 96/62, and HR to 110 4 minutes after initiation all other VS unchanged

Note: If pt. is intubated before hypotension is addressed, pt's BP drops to 38/0 and loses pulses ---> PEA for 2 mins or until hypovolemia is addressed.

Placing 15L via NRB improves RR to 22 and O2Sat to 90%


Physical Findings: GCS= 8 (E1V3M4), GSW entry wound in R 4th ICS, no exit wound. e-FAST exam shows R hemothorax, and free fluid in hepatorenal space. R Lung sounds decreased. PERRLA, cardiac exam normal. All other exams are negative/wnl.


Management

Initial Stabilization (must all occur within 7 minutes or pressure drops and patient enters PEA):
- Assess pulses and mental status, expose patient, Obtain VS, establish 2 large bore IV's, perform rapid trauma assessment and E-FAST
- notify trauma surgery (trauma surg is not ready to take the pt. until the scenario is complete)
- notify respiratory therapy
- Administer 2L NSS bolus, call for 4U uncrossmatched O+ PRBC, 4U FFP, 4U Platelets
---- pressure comes up to 96/62 after 4 minutes; decision to RSI once SBP > 90 results in effective intubation
- place on NRB 15 lpm 100%O2
- place R chest tube
---- 2L blood drained from thorax

Initial Labs:
- Type and Cross
- CBC (to evaluate h+h)
- BMP
- Lactate

Once PMH is obtained from family:
- consult hematology, notify trauma surgery
- PT/INR
- PTT
- obtain factor IX levels (takes a while to come back)
- administer FFP


Diagnostics Results: reference ranges are put in parentheses

CBC: WBC= 8000 hgb= 5 hct= 27 Plt= 169

BMP: wnl

PTT= 80 (22-35)

Lactate= 3.8 (0.5-2)