A 56-year-old male was trapped for a prolonged period from the waist down between his slow rolling 4- wheel drive car and a brick wall. On presentation, he has a heart rate of 150 beats/minute and a systolic blood pressure of 80 mmHg. He has obvious bruising extending from his lower abdomen to just above his knees. There is blood at his penile meatus.
a) List the likely injuries (3 marks)
b) Outline your blood product and fluid administration over the first 24 hours (4 marks)
c) List the complications you would anticipate in this patient during the first 72 hours (3 marks)
Syllabus topic/section: 2.1.13 Trauma Intensive Care
Discussion:
Candidates who scored well in part a) provided a structured list of injuries relevant to the case. Conversely answers that lacked structure tended to miss relevant injuries and this then correlated with missing complications in part c). The above standard answer concentrated on injuries relevant to the stem, including pelvic, complex lower limb (including vascular) injuries and crush injuries including rhabdomyolysis.
Blood transfusion management in part b) was generally well answered. Many candidates did not put equal emphasis on fluid administration, which was equally important, given the significant risk of crush injury and associated rhabdomyolysis. Both Blood AND fluid management was asked for in the stem. Easy marks were lost due to not following the question directions.
Given the history provided, complications secondary to crush injury with rhabdomyolysis and vascular injury were required for an at standard answer. A broad range of complications in part c) was required and better answers included those of therapy (eg MTP) as well as complications from the different injuries sustained. Examples of complications likely for this patient within the first 72 hours include AKI from both traumatic mechanisms and therapy, complications secondary to potential haemorrhagic shock and subsequent massive transfusion, complications of long bone fractures including fat embolism, compartment syndrome and ischemia from threatened vascular supply to the lower limbs.
a) List the likely injuries (3 marks)
The stem presents us with a clearly crushed person. The clues in the stem include:
This "list" question is weighed three marks, which suggests that something more than just "crush injuiry, rhabdo, pelvic fractures" was expected. A general rule is that a "list" like this scores more marks if it is ordered and categorised. For example:
This is 97 words, i.e. something representative of a 5-mark answer. Systemic consequences were not asked for and would probably not have scored many marks, but then the college commentary lists rhabdomyolysis as an injury, which one might argue it is not (one could characterise it as a post-injury systemic syndrome resulting from muscle necrosis)
b) Outline your blood product and fluid administration over the first 24 hours (4 marks)
Blood and fluid were asked for. The abundant mark allocation suggests that the examiners expected a considerable amount of detail, and that the management steps could afford to be very specific. Thus:
Mutschler et al, 2013, observed that patients at this end of the spectrum required about 10 u PRBCs on average.
c) List the complications you would anticipate in this patient during the first 72 hours (3 marks)
Again, a list with lots of marks attached suggests a need for more than just a basic unordered pile. Ordering this by systems may have value.
Mutschler, Manuel, et al. "The Shock Index revisited–a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU®." Critical care 17.4 (2013): R172.
Kodadek, Lisa, et al. "Rhabdomyolysis: an American association for the surgery of trauma critical care committee clinical consensus document." Trauma Surgery & Acute Care Open 7.1 (2022).