CASE STUDY, a paramedic gives rapid intravenous saline into a patient who has severe blood loss from a knife wound to the carotid artery, first aid with pressure over the wound, patient was initially breathing and had a weak pulse and responsive to painful stimuli before the administration of IV saline. Patients breathing then ceased, an oropharyngeal airway was inserted and ventilation was provided. The patient went into cardiac arrest, CPR was commenced , an endotracheal tube was placed and CPR was continued. Cardiac rhythm alternated between pulseless electrical activity and asystole. Adrenalin and a total of 3 litres of normal saline were administered intravenously. Time is now 30 minutes since arrival at the scene then a further 12 minutes to arrive at the hospital. At the hospital resuscitation was continued, intravenous fluids, blood and blood products were given. A total of 8 units of packed cells and two units of fresh frozen plasma was given. Attempts were made to control the bleeding from the neck using diathermy and clamping , there was a return of circulation that lasted 3-4 minutes CPR was recommenced for a further 25 minutes until a decision was made to terminate resuscitation efforts.... would love to know your thoughts on this scenario, it has been a hot topic of discussion at university. Many thanks.
Gemima, Thank you for your comment. This is a good example of severe refractory shock. When blood loss exceeds 25% the patient may not recover despite volume replacement. Lacerating the carotid artery can result in death within minutes. Replacing volume and resuscitation are not helpful when the total volume of blood loss is excessive. We will try, of course, because it is difficult to quantify blood loss. The administration of Normal Saline is appropriate, but Saline does not carry oxygen nor does it maintain vascular osmolality. The administration of blood products will help with oxygen carrying capacity and will improve perfusion. I fear that blood product administration was too late in this patient to be helpful. In my experience working with trauma patients, I have not seen anyone with a carotid artery laceration, like you describe, survive. I hope this helps, Dr. Woodruff
