Yanagawa Youichi, Nagasawa Hiroki, Ishikawa Kouhei
Acute Critical Care Medicine, Juntendo University Shizuoka Hospital, Izunokuni, JPN.
Cureus. 2022 Oct 31;14(10):e30914. doi: 10.7759/cureus.30914. eCollection 2022 Oct.
We report the case of an 89-year-old woman who was struck by a car while walking and fell to the ground. She had hypertension, dyslipidemia, and cerebral infarction requiring medication. She was transported to a nearby acute critical care center. Upon arrival, her vital signs were stable. A physical examination showed right facial and hip contusion, right shoulder tenderness, a right elbow contusional lacerated wound, and bilateral knee abrasion wounds. She vomited when her face moved. Radiological studies showed a right proximal humerus fracture and a right minor ischial fracture. Her injury severity score (ISS) was 5 points, and her probability of surviving was 97.8%. However, a blood test revealed an extremely high fibrinogen degradation product (FDP) level (573.3 μg/mL). Because of this elevated FDP value and her inability to walk due to vomiting on motion, she remained in the emergency room (ER) for monitoring. At five hours from arrival, she became comatose, and hypotension and bradycardia (30 beats per minute) were noted followed by cardiac arrest. She underwent advanced cardiac life support and obtained spontaneous circulation. Repeated blood tests showed hyperkalemia, anemia, and hypoglycemia. She immediately underwent infusion of glucose and insulin and continuous infusion of catecholamine. Repeated whole-body CT scans revealed only increased hematomas where the fractures and contusions existed. She was admitted to the ICU. Her post-admission course was quite eventful. She required transfusion until the fourth hospital day to control circulation and anemia and underwent transfusion of 28 units of red blood cells, 30 units of platelets, and four units of fresh-frozen plasma in total. After her circulation and respiratory function had stabilized, she was extubated. However, her condition became complicated with the deterioration of her knee wounds and gall bladder inflammation in the ward. All complications were treated by non-operative management. She was transferred to another hospital for rehabilitation on day 70. This report discusses our experience with a blunt trauma patient in whom a high FDP level on arrival was the only clue indicating the deterioration of her condition. Such patients need close observation with hospitalization.
我们报告了一名89岁女性的病例，她在行走时被汽车撞倒在地。她患有高血压、血脂异常和需要药物治疗的脑梗死。她被送往附近的急性重症监护中心。到达时，她的生命体征稳定。体格检查发现右侧面部和髋部挫伤、右肩部压痛、右肘部挫伤裂伤以及双侧膝部擦伤。当她的面部移动时会呕吐。影像学检查显示右肱骨近端骨折和右坐骨小骨折。她的损伤严重程度评分（ISS）为5分，存活概率为97.8%。然而，血液检查显示纤维蛋白原降解产物（FDP）水平极高（573.3μg/mL）。由于FDP值升高以及她因运动时呕吐而无法行走，她留在急诊室进行监测。到达后五小时，她陷入昏迷，出现低血压和心动过缓（每分钟30次心跳），随后心脏骤停。她接受了高级心脏生命支持并恢复了自主循环。重复血液检查显示高钾血症、贫血和低血糖。她立即接受了葡萄糖和胰岛素输注以及儿茶酚胺持续输注。重复的全身CT扫描仅显示骨折和挫伤部位的血肿增加。她被收入重症监护病房。入院后的病程相当波折。她在住院第四天之前需要输血以控制循环和贫血，总共输注了28单位红细胞、30单位血小板和4单位新鲜冰冻血浆。在她的循环和呼吸功能稳定后，拔除了气管插管。然而，她的病情在病房中因膝部伤口恶化和胆囊炎而变得复杂。所有并发症均通过非手术治疗。她在第70天被转至另一家医院进行康复治疗。本报告讨论了我们对一名钝性创伤患者的经验，该患者到达时FDP水平升高是其病情恶化的唯一线索。此类患者需要住院密切观察。
