(P57) An Usual Cause of Shock in a Trauma Patient with Hemodynamic Instability and Large Volume Intra-abdominal Free Fluid

Chief Complaint : Abdominal pain after fall on ice from standing height, transferred for hypotension and positive EFAST.

History of Present Illness : 18-year-old female without significant past medical history presented as a transfer from an outside hospital with hypotension and a positive EFAST exam after a fall. The patient was walking outside when she slipped on ice and fell. She had immediate abdominal and lower back pain after her fall. At the outside hospital, the patient was found to be tachycardic with a systolic blood pressure in the 60s. A bedside ultrasound was reportedly grossly positive for intraabdominal fluid. Two units of packed red blood cells were initiated and transferred for trauma surgery evaluation. The patient denied recent illnesses or influenza-like symptoms. She reported that she may have felt dizzy or lightheaded preceding the fall, but does not recall any preceding symptoms. She denied chest pain or shortness of breath. She denied having abdominal or back pain preceding her fall. Currently complaining of severe mid abdominal and low back pain.

Pertinent Physical Exam: Initial vitals showed a heart rate of 139, blood pressure (BP) of 113/65, respiratory rate of 25, and oxygen saturation of 100% on four liters by nasal canula. While undergoing evaluation she had systolic BPs consistently in the 60s-70s. She was alert, oriented and following commands. She was obviously in pain and appeared pale. Head atraumatic. Lungs were clear with equal bilateral breath sounds. She was tachycardic with a regular heart rhythm. On abdominal exam, she was obese, soft and diffusely tender to palpation with voluntary guarding. She had no midline spinal or paraspinal tenderness and ranged extremities without pain.

Pertinent Laboratory Data: Initial labs showed hyperemia (hemoglobin 18.6 (11.2-15.7) and hematocrit 61.7 (34-45)), normocytosis (WBC 8.0 (4.0-10.0)), and thrombocytopenia (platelets 50 (150-400)). Her coagulation panel showed a prolonged PT (21.4 (9.4-12.5)) and PTT (39.6 (25.0-36.5)) with an INR of 1.9 (0.9-1.1). Her basic metabolic panel was within normal limits. Her lactate was 5.0 (0.5-2.0). She had a metabolic acidosis with a pH of 7.19 (7.35-7.45), pO2 of 71 (85-105), and pCO2 of 38 (35-45). Her troponin and proBNP returned after initial management but were elevated at 0.22 (0-0.01) and 197 (0-178).

Case Discussion: 18-year-old female without significant medical history transferred for trauma surgery for intra-abdominal free fluid and hypotension after a ground level slip and fall. A trauma alert was called with emergency medicine and trauma surgery teams at bedside. On arrival, the patient had normal mentation but was hemodynamically unstable with tachycardia and hypotension. Ultrasound showed a grossly positive FAST exam with free fluid in the right upper quadrant and suprapubic views. Massive transfusion initiated in setting of large intraabdominal free fluid with trauma and hemodynamic instability. In discussion with trauma surgery, planned to attempt to stabilize the patient, establish additional IV access and perform cross-sectional imaging. Able to stabilize vitals, so patient not brought directly to the OR for exploratory laparotomy, which would have been the usual practice. Initial labs showed a metabolic acidosis and elevated lactate concerning for hypoperfusion. On CT imaging, the abdominal fluid was surprisingly thought to be large volume simple fluid from a ruptured ovarian cyst. Unexpectedly, CT imaging showed bilateral pulmonary emboli with a large thrombus in the right main pulmonary artery with right heart strain. Given uncertainty about the origin of the abdominal fluid, deferred administering tPA (tissue plasminogen activator). A heparin drip was started, and the patient was admitted to the ICU in stable condition.
After admission, the patient went to the catheterization lab for emergent aspiration thrombectomy with interventional radiology, which was unsuccessful, and a tPA catheter was placed. Her inpatient course was complicated by a groin hematoma and acute blood loss anemia requiring transfusion as well as post-PE pulmonary hypertension. She was discharged after an 18-day hospital stay on apixaban and sildenafil and had no thromboembolic provocation factors. She will undergo extended outpatient hypercoagulability workup and is back to her normal activities, unfortunately with persistent tachycardia and mild hypoxia with exertion.

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