By Dr Emily Shardlow
On 17 May Shyamenda Purslow falls off his mountain bike on Kinder Scout Mountain, turning his life upside down. Fortuitously the Mountain Rescue team was on exercise in the next valley, and rapidly attended and mobilized the air ambulance. Shyamenda had sustained an isolated wound to his right groin caused by penetration of the handlebars of his mountain bike.
Shyamenda was a previously fit and well man. He initially compensated for his blood loss and was reported to be cardiovascularly stable during transfer. He arrived in the Emergency Department where he was received by the trauma team and was noted to have deteriorated rapidly. He is suffering a severe blood loss but reported to be cardiovascularly stable during transfer.
“If the Air Ambulance team and the Trauma team had not been there to control the bleeding, the outcome may have been different”.
The Trauma team notes a rapid deterioration and a GCS of 14. Shyamenda is verbalizing, but drowsy and confused. He has a respiratory rate of 34 per minute and his saturations are unrecordable. He has a heart rate of 125 per minute and an unrecordable blood pressure. He is profoundly shutdown, cold and noted to be hypoglycaemic. His BP transiently improved to 80/40mmHg after rapid infusion of 1L crystalloid and 250mls of 10% dextrose was infused to normalize blood glucose.
There was a large open wound in the right groin, which started to bleed profusely on inspection. Immediate pressure and CeloxTM (haemostatic agent) was applied but he continued to haemorrhage rapidly. Shyamenda deteriorated and became obtunded as he continued to bleed. A transfusion of O negative blood was commenced and the anaesthetic team intubated him in the emergency department in order to secure his airway.
A Vascular surgeon was bleeped and transferred to theatre. The major haemorrhage protocol was activated and transfusion of O negative blood was continued whilst en route to theatre.
The General, Vascular and Orthopaedic teams are scrubbed and waiting for Shyamenda in theatre. His right groin was explored and the haemorrhage was controlled quickly. His superficial femoral artery was then reconstructed and fasciotomies performed over the subsequent 5 hours.
Shyamenda required 8 units of O negative blood, 8 units of FFP, 2 doses of platelets, 2 pools of cryoprecipitate and tranexamic acid in theatre.
He also received 6L of crystalloid, mannitol, calcium gluconate and was alkalinized with 8.4% bicarbonate due to a profound acidosis and reperfusion injury. An intraoperative TOE was performed which excluded cardiac tamponade and confirmed good left and right ventricular function with normal heart valves.
Shyamenda is transferred to the ICU following a trauma CT scan. On admission to ICU, all vasopressor support had ceased and he was producing >1ml/kg of urine. He was sedated with propofol and alfentanil infusions and ventilated with an FiO2 <0.5.
“Shyamenda’s case is not extraordinary, but it displays the significant amount of professionals involved and how they are communicating at every step to save lives”.
He had an Hb was 10.7g/dl and a lactate of 1.6mmol/L. During the subsequent 6 hours on ICU he became pyrexial, tachycardic and hyperkalaemic.
48 hours after injury
Shyamenda returned to theatre for further exploration and extension of the fasciotomy wounds.
As anticipated, Shyamenda developed rhabdomyolysis and his Creatine Kinase peaked at 147950 IU/L. He was oliguric despite a large positive fluid balance, and his serum creatinine elevated to 346 mg/dL.
5 days after
Renal support (CVVH) was commenced on 20 May and Shyamenda was extubated on a dexmedetomidine infusion on the 21 May, five days after his initial injury. Shyamenda’s main issues on ICU over the subsequent days were delirium, pain, hypertension and an acute kidney injury (AKI), which required on going CVVHDF. His delirium and agitation peaked on the 2nd night following extubation, but started to subside after 72 hours. He was managed with reassurance, reorientation and haloperidol.
10 days after
On 27 May, the Plastic Surgery team performed closure of his fasciotomies. He started to mobilize with the physiotherapy team and began to make good progress.
Shyamenda was discharged to the ward after 15 days on ICU. His AKI gradually improved and he did not require any further dialysis. There was ongoing concern regarding a persistent tachycardia, pyrexia and positive growth of E-Coli in his blood cultures.
An MR scan of his right femur excluded significant bone pathology or collection. A wound infection was diagnosed which required 14 days of Meropenem.
Shyamenda continued to make excellent progress and was highly motivated to recover from his injury. Nursing staff commented in his extremely positive attitude and his determination to get better. He was well supported by many friends and family on the ICU during his recovery.
“Shyamenda’s motivation made a real difference to his recover. Shyamenda went to see the mountain doctors and the nurses after his recovery. These things help us as professionals to reflect positively on what we do”.
45 days after
30 June, forty-five days after his admission to the hospital, Shyamenda is discharged home. He is fondly remembered by staff as a very positive person who embraced each challenge and stage of his therapy.