From the Guidelines
The major concern in this scenario is B. Hemorrhage, as significant blood loss can occur into the thigh compartments due to bilateral femur fractures, leading to hypovolemic shock. According to the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1, the initial treatment of trauma-induced hypotension uses the concept of a restricted volume replacement and permissive hypotension. This strategy is supported by several meta-analyses of retrospective studies alone, as well as combined prospective and retrospective studies showing reduced mortality in comparison to traditional aggressive volume replacement targeting normotension.
Key points to consider in management include:
- Controlling bleeding and stabilizing the fractures
- Maintaining adequate circulation with a target systolic blood pressure of 80-90 mmHg until major bleeding has been stopped, as recommended by the guideline 1
- Preventing complications like fat embolism syndrome which can occur with long bone fractures
- Considering the use of damage control surgery, fluid therapy, and vasopressors and inotropic agents as needed, based on the guidelines provided 1
While hypotension is present, it's a symptom of the underlying hemorrhage rather than the primary concern itself. Myoglobinuria is also a potential complication due to muscle damage (rhabdomyolysis) from the crush injury, which can lead to acute kidney injury, but the immediate life-threatening issue is hemorrhage. The guideline 1 emphasizes the importance of rapid bleeding control, particularly in patients without TBI and/or spinal injury, and highlights the need for further confirmation in adequately powered prospective RCTs.
From the FDA Drug Label
Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. Vasopressin injection is contraindicated in patients with known allergy or hypersensitivity to 8-L-arginine vasopressin or chlorobutanol.
The major concern is B. Hemorrhage, as the patient is hypotensive with bilateral femur fracture, which can lead to significant blood loss. Although the provided drug labels discuss vasopressors for increasing blood pressure, they do not directly address the patient's situation. However, given the clinical context, hemorrhage is a likely cause of hypotension in this scenario 2, 2.
From the Research
Major Concern for a Pedestrian Hit by a Car
- The major concern for a pedestrian hit by a car, crushed lower limb (L.L), with an x-ray showing bilateral femur fracture, and who is hypotensive, is B. Hemorrhage.
- This is because the patient's hypotension could be a sign of significant blood loss due to the fractures and other potential internal injuries 3, 4, 5.
- Hypotensive fluid resuscitation strategies are used to avoid worsening of uncontrolled bleeding, emphasizing the early use of blood products and restriction of other fluids to support coagulation and tissue oxygenation 3, 4.
- The use of crystalloids and colloids in prehospital fluid resuscitation is controversial, with some studies suggesting that large volumes of fluids can increase bleeding by elevating blood pressure, dislodging blood clots, and diluting coagulation factors and platelets 3, 4, 6.
- In the setting of hemorrhagic shock, isotonic crystalloid solution is the first-line agent of choice, with blood products introduced after initial crystalloid administration if there is ongoing need for volume replacement 7.
- Early administration of tranexamic acid is also recommended for patients at risk of massive hemorrhage 7.
- Overall management of major bleeding should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding 5.