Case summary:

An ALS crew along with an EMS physician was called to a suicidal male who had a firearm with him.  While crew was in the staging area, law enforcement reported the sustained a gunshot wound to the face and they were called to the patient to assess him.  The found the patient with two penetrating wounds, one to the bottom of the jaw and the other to the forehead.  Due to a large amount of bleeding to the face that was going into the airway, the aggressively suctioned blood while preparing equipment to intubate.  Crew administered ketamine and rocuronium to perform rapid sequence intubation (RSI) to control the airway.  Despite massive airway contamination with blood, the crew was able to place an ETT in the trachea and successfully intubate.  Tube placement was confirmed with end-tidal waveform capnography.  This entire time, the patient was still bleeding from the mouth and face, and the crew was unable to find a compressible source.  The patient’s blood pressure down trended while they were controlling the airway.  The crew also administered tranexamic acid (TXA) given massive amount of non-compressible bleeding and hypotension.  Right after the ETT was placed and the TXA was given, the patient developed a bradycardic heart rate, and the patient lost his pulse.  There was an estimated more than 2.5-3.0L of blood loss pointing towards exsanguination as the cause of the arrest.  Given they were still a long distance from the nearest trauma center and the patient was in traumatic circulatory arrest from exsanguination, the crew did not feel transport and further care would lead to a meaningful recovery, so further resuscitative efforts were stopped and the EMS physician on scene pronounced the patient.

Highlights of the case:

In trauma, stopping compressible bleeding and airway are the only things more important than transport.

Trauma patients are load and go patients with the only exceptions being airway interventions and stopping bleeding (tourniquet, pelvic binder, ect).  This is something we have emphasized in previous cases, but it is worth highlighting again due to how important this concept is.  For the patient in this case, he had airway compromise from massive bleeding in the mouth.  The crew was correct to delay transport to manage the airway since he had a high risk of quickly drowning on his own blood.  Given the amount of bleeding, this was likely an incredibly difficult airway, and the crew deserves a ton of credit for getting an airway placed within 10 minutes of patient contact.  If the crew could not get the patient intubated, then the crew would have needed to proceed with a cricothyrotomy.

Field termination of resuscitation is reasonable when meaningful recovery is unlikely.

Despite this crew providing a heroic attempt to save this patient, he unfortunately exsanguinated due to his severe penetrating facial trauma.  If a patient can arrive at a trauma center within a few minutes of arrest in the setting of trauma, it is reasonable to quickly transport the patient since giving blood products and performing procedures to control bleeding and resolve obstructive shock pathology can potentially save the patient’s life.  In the case of this patient, at the time he bled enough to go into arrest, the crew was still >10 minutes from a trauma center meaning that irreversible severe brain injury would likely occur even before he made it to the hospital making meaningful recovery unlikely even if we could achieve hemostasis and transfuse blood.  Given this, it was very reasonable of the on-scene team to terminate resuscitation when they did.  Even though the patient expired, this crew provided amazing and heroic care and gave this patient his best chance at survival.