Perspectives – Aortic Laceration in a Rural Mississippi ED: A resident’s response

Author: Taylor Webb, MD (EM Resident Physician, University of Mississippi Medical Center) // Reviewed by: Brit Long, MD (@long_brit)

I am a third year Emergency Medicine chief resident at the University of Mississippi Medical Center (UMMC) and want to share one of my experiences to all medical residents and providers. Remember that while mistakes in resuscitation are often dissected and analyzed, it is equally crucial to acknowledge and celebrate the moments of impeccable execution, where lives are saved and hope is restored.

In the Spring of my senior year, I was moonlighting at one of the University’s satellite locations. As usual, I was the only physician staffing this rural critical access hospital with limited resources which sits 61 miles away from our state’s only Level 1 trauma center.

It was an ordinary night, and I was asleep in the on-call room. But soon enough, I was startled awake by the physician’s phone ringing. “We have a knife stab wound to the chest or abdomen coming. The patient is not responsive and the paramedics cannot get a blood pressure. Should be here in 5 minutes.” reported one of the seasoned nurses. She was calm. My response: “Call everyone. Prepare everything. I’m coming.” I have been a part of many traumatic codes and resuscitations during my training, but I knew this one would probably be my most difficult one. I was the sole provider. So I did what we as ED physicians are all so good at – I prepared.

Let’s get suction and all airway supplies ready and at the head of the bed.

Lay out peripheral IV supplies on both sides of the stretcher.

Get the manual and automated blood pressure cuffs ready.

Find the chest tube tray and thoracotomy kit.

I need a scalpel in my hand.

Put the central line and IO kits nearby.

Get all the blood we have. “Doc, we only have one unit of emergent release blood.”

I keep reciting A-B-C in my head. We are gowned up and ready. I meet the paramedics at the door. They look frantic while bagging the patient. I notice that the patient is not moving. He is thin and pale – the kind of pale that you have seen far too many times that tells you the patient is exsanguinating. My eyes are redirected to a large wound on his chest at the costal margin just to the left of the midline. “Tell me what you know.” The medic recited the sign-out that I got earlier from my nurse. Fortunately, they had placed an IV en route. Before transferring the patient to our stretcher, I give a hard sternal rub while placing my stethoscope to his chest. He does not move. I hear good breath sounds on the right but diminished breath sounds on the left while the parametric is still bagging. A quick feel of the femoral pulse tells me that he had some inkling of a blood pressure.

We quickly move him to our stretcher. Nurses are throwing on monitor leads, and we completely expose him and do a fast roll to look at his back. No other injuries. The automated blood pressure cuff is going, and my nurse cannot get a manual. The radiology tech has his hand on a weak femoral pulse. It’s still present. The respiratory therapist is bagging. The patient needs an ET tube, but I’m worried he has a tension pneumothorax based on his injury. We cannot get a sat because he is so cold. A quick finger thoracostomy to the left chest only expels a small amount of air. Chest tube is in place. “Please hold this chest tube and don’t let it move. I need to intubate.” Still no BP or sat. Here we go. Vasopressin 4 units IV push. “The blood will be here in one minute.” Femoral pulse feels stronger. ET tube placed quickly without RSI medications. Half of the blood is in the patient. We have blood pressure! Systolic is 60. Great! XR of the chest shows the ETT and chest tube are in good position. No hemothorax or free air under the diaphragm. XR abdomen does not show any retained foreign body.

“Doc, he’s waking up.” Patient moving all extremities and shaking his head. “We don’t have any restraints here.” The cuff just ran and the BP is 100 systolic. A mild sedative did just the trick. BP still is holding.

Just prior to the patient’s arrival, we contacted Medcom, which is Mississippi’s centralized medical communication system, to let them know the critical nature of our situation. Early contact with Medcom ensured that they would be able to activate one of the most effective and competent air EMS teams in the state – AirCare. The nearest team would be available to us in about one hour once they finished providing care in Meridian, MS about 105 miles away.

Back to the patient. Did I mention that we only had one unit of blood in the hospital for emergent release? We had sent off a Type and Screen as soon as the patient arrived at the ED. We do not have the technology for invasive hemodynamic monitoring at this facility so we are constantly cycling our BP cuff. His pressure is dropping now. The first unit of blood is complete. He is on a vasopressin infusion now after the four unit bolus from the initial resuscitation. His systolic plunges down to 30. “Give another push-dose vasopressin and get an ETA on the helicopter. We are going to have to start running IVFs.” We get a moderate response after push-dose and 200 mL of IVFs. His blood was typed now, and we had our second and final unit of blood to give this critically ill patient. Help is about 30 minutes away. Systolics holding in the upper 60s and low 70s. I kept hearing a whisper in my head – permissive hypotension. Let it ride.

OK, now what else can we do? He’s intubated, has a chest tube, getting blood, and on the best vasopressor for trauma that I know. We avoided IVFs as best we could. Whew! Next, we do all the little things. We stacked 6 blankets on him and got the Bair hugger on to warm the patient. I ordered calcium gluconate, tranexamic acid and updated the patient’s tetanus. He’s holding steady and AirCare is about 15 minutes away.

It’s shift change now and my friend and co-resident walks in concerned about all of the police outside. I give him a brief update. “Have you done an ultrasound yet?” This guy is an ultrasound guru. We take a look. No pericardial effusion. “Call Medcom back, we’re putting in an arterial line for them to hook up when they get here.”

I hear the helicopter and AirCare arrives. BP on the arterial line is in the low 60s. Our AirCare crew carries whole blood so he gets two units. Remains permissively hypotensive. A little ketamine for the flight since he was waking up again, and they were off to the Trauma Center.

I call Medcom for an update. The patient began to deteriorate in flight and required 6 units of whole blood during transit. Massive transfusion protocol (MTP) was activated prior to the patient’s arrival to the Trauma Center thanks to effective interhospital coordination between Medcom and the ED staff at UMMC. The flight crew was met at the helipad with a box of blood, and the patient was rushed to the OR immediately.

The trauma team performed an exploratory laparotomy and were faced with an abdomen full of bright red blood. The chest was opened and the aorta clamped. The surgeons quickly identified a 30% partial transection to the aorta just distal to the SMA take off point. He also sustained gastric, liver and splenic injuries. He was repaired and left partially open. The patient had required four total massive transfusion protocols.

He was taken back to the OR the next day for closure. The patient was extubated within 48 hours and discharged to home on day 17 with normal neurologic function..

After this experience, I realized some crucial factors that contributed to this patient’s outcome:

(1) Know your resources. I have fortunately worked at this facility to know that if a patient is very sick and needs blood, then it is imperative to arrange transport quickly and pray the weather is favorable. Emergent release blood is always limited so get a type and screen as soon as possible.

(2) The critical life saving procedures in the ED are quick and easy. In a penetrating trauma, you will find yourself standing in front of the patient after all of your interventions thinking what can I do next. We are not surgeons so our ability to care is somewhat limited. Remember the supportive care options and adjuncts like warming patients, TXA if indicated and replete calcium if you are giving or anticipate giving large amounts of blood.

(3) A robust pre-hospital and interhospital system can save lives when implemented effectively. 

(4) Trust your training. You’ve learned from some of the best and are capable. The chair of our program calls us experts in resuscitation. Resuscitationist if you will. It is true.

*A special thanks to my great team, Medcom, AirCare flight crew, ED staff, trauma surgeons and intensivists. Everyone involved with this case did everything right, and I am humbled and proud to have been a part of this patient’s care.