I have a Resus dilemma for discussion – lets call it Darwinian Delayed Resuscitation.
We see quite a bit of trauma that presents late – hours (sometimes days) after the injury. I work in a place with basic surgical cover – but no subspecialists or ICU.
All of the common trauma protocols are really designed to deal with trauma that is fresh… still bleeding etc.
But I wonder about applying these same principles to patients who have survived their initial injuries, compensated for the derangement to their physiology and now arrived in ED to get a barrage of tests and “resus” measures. Are we causing more harm than good by following what works in the freshly injured patients?
For example, a patient I saw who was gored by a bull on a remote cattle station. It was a nasty injury – big chest wound, small pneumothorax over a large lung contusion and a splenic laceration. He was working on his own and was “down” for an hour before he could summon help on his radio, then the help took an hour to reach him.
HE was a fit young guy with great heart and lung function. It took a 1- hour helicopter flight, a 30-minute drive, then a fixed-wing flight to our ED – by the time we saw him he was nearly 8 hours post-injury and looked sore, but remarkably good.
He got a CT soon after arriving – that showed the chest injuries and spleen laceration with plenty of free fluid around the LUQ and paracolic gutter.
So the ATLS / EMST /ABC courses would all follow the alphabetic approach – but how much of this is actually going to harm this chap. Specifically…
1) IV fluids of any kind – blood, crystalloids etc – any benefit?
2) Surgery – sure it depends on the haemodynamic state – but if he has survived the first half day, is not shocked would it be best to keep out of his belly and watch him, rather than add another insult to his physiology?
3) How would you go about managing his potential acute coagulopathy in this setting -
Is there any evidence or wisdom out there eon the late- arriving, survivalist trauma patients?