5. The ER physician diagnosed myocardial contusion. A first year Medical student

Question

5. The ER physician diagnosed myocardial contusion. A first year Medical student knew that this could cause A-fib, and could lead to blood clotting and stroke. He suggested that they give her anti-coagulants. In unison, the ER trauma team yelled “NO!”. Why would you not give anti-coagulants to Bobby Sue? Bobby Sue was ready for her second date. She was a little nervous because the first date went really well, and she was hoping that this might work out. After all, she was a junior at State University, and her mother kept reminding her that it was time to get that Mrs. degree. She was meeting Sam at the local cafe for dinner and then a movie. As Bobby Sue got into her car, she thought about how perfect her outfit was, and that she didn't want to wrinkle her dress with a seatbelt. It would only be about a mile away-no harm, right? Well The sound of crunching was overwhelming as the pick-up truck swerved into her lane-head-on collision. Then there was the smell of burning, and she felt like her legs were bent backwards as her knees were both broken. But the pain on her chest was crushing. She couldn't breathe. Sam saw the whole thing, and was able to keep calm enough to call 9-1-1. Bobby Sue's blood made the road slippery when Sam ran over. He wiped out, but got up in time to talk to her and keep her calm while they waited for the ambulance. Luckily the ambulance came quickly, and Bobby Sue was brought to the ER where she was assessed for trauma. (More on this later.) Physicians were worried about a myocardial contusion or other myocardial damage, and ran an EKG. Below is an image of a 6 second strip. They checked her blood pH (7.11 ; low), blood oxygenation (86%, low), and body temperature (95.8 ). The broken knees were wrapped, but surgery was put off until her metabolic condition was stabilized. After all, bones can be fixed later-cells are more difficult to replace. This is termed Damage Control" in trauma: stabilize the patient, schedule major surgeries to repair massive injuries once the patient is stable. In exsanguinating hemorrhage, patients die from coagulopathy, hypothermia, and metabolic acidosis. The metabolic failure is often the terminal condition, and therefore must be dealt with immediately. (More on all of this later in the semester.)

Explanation / Answer

It was an unlucky day for Bobby Sue as she suffered from exsanguinating hemorrhage. Thanks to Sam who hurried her to ER where she could be given first aid and let the doctors diagnose her completely.

Exsanguination generally leads to death as the subject has lost more than half of the circulating blood from the body, In such a condition, excessive blood loss causes loss of blood platelets from the body which impairs blood clotting. This makes coagulopathy obvious along with hypothermia, low oxygen levels and acidosis and ECG shows cardiac arrhythmia.

Coming back to Bobby's case, she is showing all the classical symptoms of exsanguination. But wait! The ER doctor has given a statement that Booby has myocardial contusion due to chest injury which has damaged some of her heart walls. This would lead to local blood clotting in the cardiac region and the first year medical student is impatient to treat her with an anti-coagulant. The ER team ruthlessly said no because Bobby needs to stabilize her condition, especially the huge amount of blood lost by her in that accident. If treated with anti-coagulant, she can dangerously bleed from small wounds and that can ultimately kill her. So, the first year medical student needs to take back his instant suggestion of administering an anticoagulant. A big negation from ER team saves Bobby Sue.

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