A 31 year old male was brought to the local trauma center by EMS after being found in full arrest with stab wounds to the bilateral lower extremities and a significant amount of blood at the scene but no other obvious injuries. In the field he was pulseless and apneic, initial rhythm was an agonal PEA with a rate of 35 with no associated pulse. CPR and BVM ventilation were initiated. IO access was established in the right tibia with a crystalloid bolus infusion. The lower extremity wounds were noted to bleed in pulsatile fashion in sequence with chest compressions and proximal tourniquets were applied bilaterally. The patient received a single dose of epinephrine 1 mg IO just prior to arrival to the hospital without effect.
On arrival to the trauma bay the patient was intubated without medications via direct laryngoscopy. Waveform capnography was initiated and showed an initial end tidal CO2 of 9. The patient was placed on the ventilator as resuscitation was continued. Cardiovascular assessment at this time demonstrated weak upper extremity pulses during chest compressions but no palpable pulse when CPR was paused. Crystalloid infusion was stopped at approximately 500mL of normal saline and replaced with 2 units unmatched PRBCs via rapid infuser. Femoral central venous access was established proximal to the right lower extremity injury. Bedside echo showed no pericardial effusion and near-total cardiac standstill with slight mitral valve flutter as the only perceptible motion. Telemetry showed asystole.
Disability exam showed dilated unreactive pupils with GCS 3T. The patient was fully exposed and turned in search of other injuries. The only wounds were two deep lacerations to the lower extremities: a 4cm laceration to the medial aspect of the right leg just distal to the knee and a 5cm laceration to the lateral anterolateral aspect of the distal left thigh. EFAST examination showed no free fluid in the abdomen, no pneumothorax or hemothorax, no pericardial effusion, and confirmed cardiac standstill.
At this point the patient had received approximately 50 minutes of CPR, 30 minutes in the field and 20 minutes in the resuscitation bay. Two units of PRBCs had been transfused. The patient had shown no signs of life at any point during the resuscitation. The senior physicians on the trauma team began to discuss resource utilization and the utility of further resuscitative measures. Pulse check was repeated and no pulses were palpable, telemetry showed asystole with rare narrow complex agonal beats, and repeat echo showed only minimal mitral valve flutter.
The entire team was addressed regarding the intention to terminate resuscitative efforts, a recap of the resuscitation was made by the trauma team leader, and suggestions were solicited from the entire team prior to termination of efforts. One of the emergency nurses suggested a round of epinephrine and atropine, which was deemed within the realm of reasonable intervention, and the patient was given 1 mg of each via central line.
Within 30 seconds of administration of the medications the end tidal CO2 monitor jumped from 8 to 62. This prompted a pulse check which revealed weak bilateral upper extremity pulses, confirmed by strong cardiac contractility on bedside echo, telemetry shoed sinus tachycardia at 122 bpm. Manual blood pressure at this time was 69/40. Another 2 units of PRBCs were initiated, TXA was given, and the blood bank was alerted to initiate massive transfusion protocol.
The patient was prepared to go to the OR for wound exploration. He continued to have GCS 3T despite no sedation. Cooling protocol was discussed but deferred to SICU post-operatively. He was transferred to the operating room with the expectation that he would have poor neurologic outcome given prolonged downtime. BP at the time of transfer to the OR was 125/70.
In the OR, the surgeons identified complete transection of the R posterior tibial artery, which was ligated. The LLE wound was explored with no significant vascular injury identified and it was closed primarily. In the SICU 12 hours later, the patient was awake and alert, following commands, and gesturing to be extubated. He currently has significant coagulopathy and marginal urine output likely related to his prolonged resuscitation but is grossly neurologically intact and hemodynamically stable.
Although I have reflected extensively on this case, I’m not sure what the lessons learned should be. Analytically, this patient had an abysmal prognosis from first EMS contact onward and each time I retell this story there are multiple points in the resuscitation where I think it would have been reasonable to terminate efforts. There were multiple protective factors: young age, lack of comorbidities, ambient temperature of 25 degrees Fahrenheit, and the inexplicable protective effects of a serum ethanol level of 285. However, a strict evidence based approach to this patient would have said there is no utility in giving ACLS medications to a traumatic arrest patient in asystole with cardiac standstill (or probably anyone for that matter). Despite the lack of evidence, this patient survived. We don’t want to practice based on anecdotal medicine or the outcome of our last case, but the difference in a few more minutes of resuscitation to this patient who appeared to be headed to the morgue but now appears to be headed home are profound and immeasurable. I’m sure I will run my next few codes a few minutes longer because of this case, and I’m sure there will be no more inexplicable saves than if I’d stopped them a few minutes earlier. However, in our specialty where it is so easy to become jaded and cynical maybe the occasional miracle to rejuvenate our optimism is a good thing.
Happy Festivus everyone, may your feats of strength be especially strong this year!