Call-out on Monday at 10:00am on a warm sunny morning with little wind. Female on Coffin Route route, tripped and fell, bleeding from head and abdominal pain. Walking towards her on the route, what is going through your mind?
On arrival (10:45am), the casualty, a 50 yr old female, is lying on the ground by a gate on the path on gently sloping ground (Danger – none). There are three or four passers-by, who raised the alarm and who have covered her with jackets, around her. She is responding to questions but in quiet distress (Response – conscious, coherent). There are no pools of blood on her or the ground (Catastrophic haemorrhage – none), but she has a laceration above the right eye.
Initial conversation establishes that she has no COVID symptoms. A fell-runner, she remembers tripping up whilst running, fell flat on her face and has developed very bad abdominal pain. She didn’t lose consciousness.
PRIMARY SURVEY
Airway Normal speech, so no need to further assess
Breathing Not breathless, but rate checked by hand on bottom of the sternum: 14/min – normal. No tenderness or pain over the ribs, but upper abdominal pain with deep breathing.
Circulation Good colour, cool skin, cap refill 2secs, pulse good strength, 62/min regular. No chest injuries; definite tenderness on examining the upper abdomen, with guarding (tensing the abdominal muscles in response to the pressure of the examining hand)
Disability moving all limbs, speech - responding to questions (V), face symmetrical, pupils 2-3mm
Environment/ Warm day but cool in the shade of the casualty site
Exposure
What do you think might have happened?
Because of the mechanism of injury, the laceration above her right orbit, and her V on AVPU, manual inline stabilisation (MILS) was started in case of a cervical spine injury.
We used the Propac: BP, 124/87, SpO2 100% on air, ECG normal.
Cannula to the back of the right hand and IV morphine 4mg given.
Temp 36.8oC, glucose BM 6.8
Meantime we continued with SAMPLE.
Symptoms She was complaining of quite bad abdominal pain. This had developed after the fall.
She had not suffered from any such pains previously, and had no medical history of abdominal problems. She had no other symptoms.
Allergies No allergies
Medication HRT
Past History None
Last ate Breakfast
Events As above
Secondary Survey
Bruising both knees and elbows
DIAGNOSES?
There are some concerning features to consider with the above picture. What are you worried about?
On the positive side, she is coherent responding to questions, and her vital signs (pulse, BP, O2, cap refill, disability [neurology]) are all normal. Her potential C-spine injury is being protected. So what’s the problem? Let’s just put her on a stretcher and get her to a land ambulance and a check-up, x-rays etc at an A&E dept.
The big concern here is that the abdominal exam is very abnormal, and strongly suspicious of serious trauma to the internal organs. Normal abdominal exam reveals a soft, non-tender abdo (practice on your family). If the internal organs are significantly damaged, they bleed or leak fluid, and the body responds by “protecting” the organs, tensing up the abdominal muscles and becoming very sensitive to touch.
A lot of blood can be lost this way, and casualties can quickly deteriorate. So in this situation of hidden blood loss, normal pulse and BP can be falsely reassuring.
MANAGEMENT
Given the history with the serious examination finding, a decision was taken to request helicopter assistance.
She was given more pain relief with another 4mg and then a further 2mg of morphine IV, along with ondansetron 4mg IV (could also be given by buccal film) to reduce nausea.
Her vital signs / observations remained stable.
A really strong example of clinical practice occurred at this point: one team member, newly arrived, assessed the situation and went through a step-by-step verbal review of ABCDE with the main attendants. Great practice to ensure that all the key issues were covered thoroughly - a “Time-out” during the process.
Cervical spine could not be cleared via NEXUS* - she was V on AVPU, so was not truly Alert.
She was lift/slided onto a vacuum mattress, then stretchered down to the Helimed helicopter. Part-way down, we stopped and reassessed her. Vital signs: P60, Resps 16, BP 114/76, SpO2 100%. Abdomen: more tender, tense and rigid, with “guarding” - worse pain on lifting the examining hand quickly.
HELIMED
The Helimed team arrived and assessed her. They agreed with our findings, and used a portable scanner on her abdomen - this showed free abdominal fluid (likely to be blood), confirming our concerns about significant intra-abdominal injury. She was airlifted to Preston Major Trauma Centre.
OUTCOME
She spent 12 days on the Major Trauma Unit, where they found her to have sustained:
Significant internal bleeding from Grade III lacerations to liver and Grade I lacerations to spleen (graded out of 5). She had a fractured right orbit, and a couple of small rib fractures. She required medication to assist with blood clotting (tranexamic acid), and narrowly escaped open surgical intervention - a really difficult / last ditch treatment.
Should we have given tranexamic acid? No - there was no indication: we had no proof of bleeding and her pulse and BP were normal.
FOLLOW-UP
Three weeks later, she is just starting to turn the corner.
…I remember everything very clearly. I’m a fell-runner, rock-climber, mountain biker and the Coffin Route is one of the lowest risk places I go! I simply caught my toe and fell hard onto rocks. …..I think I was going in and out of consciousness before you got there - I moved myself to the place on the path but felt I was going into shock. I felt so relieved when you all arrived. You were so co-ordinated, working at many things at the same time, and at the same time I felt really cared for, respected, and very safe. You were all utterly amazing. I work in health and social care, and my specialty is co-ordinating teams, so I am speaking from an informed position. I can’t thank you all enough.
MORE INFORMATION
Blunt abdominal trauma (BAT) is most commonly seen in vehicle accidents, after assaults and only 7.5% occur in falls. The most commonly injured organs are the liver and the spleen, followed by the pancreas and gut. The findings on examination of tenderness and firmness/rigidity are strongly suspicious of bleeding. The liver and spleen are very vascular organs, crammed full of blood vessels and relatively vulnerable. They can be injured directly, or from their “protecting” overlying ribs when fractured.
in alert patients free of distracting injuries, the most reliable symptoms and signs of BAT are abdominal pain, abdominal tenderness, and peritoneal findings**, particularly when risk factors for abdominal injury are present. Patients with visceral injury present with local or general abdominal tenderness in up to 90 percent of cases. (UpToDate)
LEARNING POINTS
Significant / life-threatening intra-abdominal trauma can be present in casualties with normal vital signs
Getting to know the feel of a normal abdomen is key to knowing when its not normal
The mechanism of injury is a valuable clue to the casualty’s problems
Time-outs are an effective way to ensure comprehensive good practice
Grade III Liver injury
Reference and key:
Management of blunt abdominal trauma in adults. UpToDate.com.
*NEXUS criteria = National Emergency X-Ray Utilisation Study; NEXUS criteria remembered by the abbreviation NSAID
NSAID = Neurological impairment [e.g. loss of sensation or movement] Spinal Tenderness; Alert; Intoxicated; Distracting injuries)
**peritoneal findings: abdominal exam findings suggesting irritation / inflammation of the peritoneum e.g. guarding