Hemorrhagic Shock With a Possible Head Injury
38-year-old unrestrained driver of a car struck broadside at highway speed. He is found on the pavement 15 feet from the vehicle. GCS 13 (E3 V4 M6); pupils equal and reactive. RR 28, HR 138, BP 82/58, SpO2 91% on room air. The abdomen is distended and rigid, the pelvis is unstable to gentle compression, the right femur is deformed with a palpable distal pulse, and a 6-cm scalp laceration is bleeding briskly. Breath sounds are equal. You are 12 minutes from a Level I trauma center and 4 minutes from a community ED with no surgeon on site. Two 18-gauge IVs are in place; you carry a pelvic binder, TXA, and 1 L of crystalloid but no blood products.
1. List your interventions in priority order and state a scene time target.
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Priority order:
- Control external hemorrhage - direct pressure and a pressure dressing on the scalp laceration. It is brisk, visible, and cheap to fix.
- Pelvic binder at the level of the greater trochanters, then splint the femur (traction splint) to reduce bleeding and pain.
- Spinal motion restriction proportionate to the mechanism; do not let collar and board placement consume the scene.
- Oxygen to keep SpO2 at or above 94% - hypoxia worsens brain injury more than hypotension does over the first hour.
- Judicious crystalloid: 250 mL aliquots titrated to a systolic target (see next question). Do not pour in a liter reflexively.
- TXA 1 g IV over 10 minutes if within 3 hours of injury.
- Prevent hypothermia - remove wet clothing, heat the cab, warm fluids.
Scene time: 10 minutes or less. Everything on this list can be done in the ambulance. A rigid, distended abdomen is a surgical problem and the only definitive treatment is an operating room.
Hemorrhage control and packaging should happen in parallel, not in sequence. If you are deciding between doing the 8th intervention and leaving, leave.
2. He has both hemorrhagic shock and a possible traumatic brain injury. What blood pressure are you targeting, and why does that conflict with your usual trauma practice?
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Target a systolic of roughly 110 mmHg, not the 80-90 you would otherwise accept.
Why this is a genuine conflict:
- In pure hemorrhagic shock, permissive hypotension (SBP around 80-90, or a palpable radial pulse) limits dilutional coagulopathy, clot disruption, and hypothermia until surgical control is available. That is the standard for a bleeding trauma patient.
- But this patient has a GCS of 13 with a mechanism that fits a head injury. After TBI, cerebral perfusion pressure depends on mean arterial pressure. A single episode of hypotension roughly doubles mortality. Current guidance is to keep SBP at 110 mmHg or above in adults with suspected TBI.
- The resolution: give the pressure without giving the fluid. Small crystalloid aliquots (250 mL) to reach the higher target, blood products if you had them, and then stop. One liter of crystalloid in this patient worsens coagulopathy and cerebral edema while raising his pressure only briefly.
Monitor and document serial GCS and pupils. If you cannot maintain the target, that is a radio report and an expedited destination decision, not a reason to give more saline.
3. Justify your destination choice between the Level I center 12 minutes away and the community ED 4 minutes away.
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Transport to the Level I trauma center.
The community ED is not a shorter trip to definitive care - it is a 4-minute stop plus triage, imaging, and another 12+ minutes of ground transport, which adds 15-20 minutes to the time to an operating room. With a rigid distended abdomen, an unstable pelvis, and a falling blood pressure, this patient almost certainly needs laparotomy and massive transfusion, neither of which exists at that facility.
The only defensible reasons to go to the closer ED:
- You cannot secure the airway and need immediate help.
- The patient arrests in front of you.
- The trauma center has declared diversion.
En route, give a radio report with mechanism, vital signs, GCS trend, and your estimated time. Consider air medical only if it reduces total time to the OR - with a 12-minute ground transport, a helicopter is usually slower door-to-door, so do not delay the wheels for it.
Common failure mode on this call: spending 15 minutes on scene because the patient 'looks too sick to move.' Sick patients are exactly the ones to move.