Blood on the floor and 5 places more

18 Apr

Hello everybody, today we have a very interesting case for you (that was send to me by one of my great collegeaus and friends working in the Netherlands!) Sadly the forensic pathologist had to give the diagnosis, which is always a bad sign.

An 80-year old man came to the ED during a nightshift, after falling a few steps from the stairs. He was complaining of neck and back pain, pain in his left elbow and in his  right wrist. It was uncertain if he had fallen on his head, but he had no loss of consciousness. Because he used marcoumar a CT-scan of brain was ordered which showed no traumatic brain injury. The CT-scan of neck, thorax and abdomen showed 2 vertebral fracture from C4 and T2 and 3 ribfractures (#1, 2, 7) on the right side with no pneumo-/hematothorax or vascular injury. In the thorax or abdomen no free fluid was found.  In the extremities there was also a fracture of the left elbow.

Patient got admitted and vitamin K was given for an INR of 4.1. His Hb on admission was 7, but dropped during admission to 3,6. Despite adequate treatment (with blood products and cofact) the patient died later that night and no source of  bleeding was found.

So in conclusion we have a 80-y old man who fell from the stairs, with multiple fracture, but no (active) bleeding source on CT. Still his Hb dropped very fast during admission and he developed hemorrhagic shock and died! So what was missed??? This is were the forensic pathologist came into the picture.

During autopsy a large hematoma was found in the subcutaneous tissue from the back, dorsal from the vertebrae, around the ribfractures, between the scapulae, in the subpleural space, and in the dorsal thoracal region. This was explained by the force of the trauma on the back. No other major bleeding source was found and this was concidered the cause of dead.

So this patient died of a large hemorrhage in het subcutaneous tissue of the back, in which he lost liters of blood. No doctor knew about this, but the forensic pathologist had seen it before in patients using anticoagulation. Sadly there is not much you can do about it, except starting your protocol for blood loss / hemorrhagic shock (giving blood products etc…)

Greetings Egon

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7 Responses to “Blood on the floor and 5 places more”

  1. cariannedeelstra April 18, 2013 at 12:52 #

    Interesting but sad case!
    Did you do a CT angio of the thorax and abdomen at the initial work up in the ED? Nothing to coil?
    I’m missing the Cofact in your story, but I’m convinced you must have given him a lot.
    But what do you think about tranexaminic acid in this case?

    • EMDutch April 18, 2013 at 13:36 #

      Hi Carianne,

      It was not a CT-angio and I am not sure if coiling is a possibility..I will ask my radiologists and get back to you. I know that cofact wasn’t initially given, but when the Hb dropped I am sure it is given, since the protocol for blood loss was started (in the ward). I also think that transexamenic acid was given when the protocol was started, but I am not sure. It was not given in the ED. Personally I am a believer of transexaminic acid. There is data supporting it and it’s cheap. Interesting for a post in the future!!!
      Gr. Egon

    • Egon Zwets April 19, 2013 at 14:56 #

      Carianne, the radiologist I spoke said coiling is (probably) since it’s probably multiple small vessels that cause the bleeding.

      • Egon Zwets April 19, 2013 at 14:57 #

        I meant probably not an option 🙂

  2. geertje de rijck van der gracht April 20, 2013 at 00:14 #

    interestingly enough we’ve had a comparable case quite recently. a 60 something year old patient with chronic liver failure due to alchol abuse who fell down the stairs. initial trauma screening showed no abnormalities besides a known trombocytopenia. when the patient became hemodynamically unstable we redid our physical exam (but did not turn her again and therefore did not see her back!) and ordered a CT scan of the thorax and abdomen, which showed severe subcutaneous bleeding in the back, which could also not be coiled. patient was admitted to the ICU, transfused, given cyclokapron and pressure on the bruises on her back. as far as we know, she has made a good recovery. and as far as i know, i will from now on always check the patients back again!

  3. notfor222 April 21, 2013 at 09:09 #

    Hi,

    Thanks for posting the case. The part that concerns me is the sole use of vitamin K for reversal of the anticoagulantion. In the UK we now always use PTC in addition to vitamin K, as vitamin K alone takes over 24h to have an effect (http://onlinelibrary.wiley.com/store/10.1111/bjh.12107/asset/bjh12107.pdf;jsessionid=4F6A8B3507A1EA3110543127709CF1BE.d02t04?v=1&t=hfrxhzjc&s=e9fd102e5b27feddf8b4b6bdcd8b6e69ceeb9fcb) This may be something to consider in the future.

    • EMDutch April 21, 2013 at 12:57 #

      Hi notfor222,

      I stronlgy agree! I did not see this patient myself, since this was a case that was send to me, but my philosophy is that any patient with a very serious trauma (which this clearly was looking at the fractures) who is on anticoagulation should get cofact. As you mentioned vit K doesn’t work for 24h, so it’s like giving nothing in your ED! Thank you for the feedback and I will take a look at your article!

      Grtz. Egon

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