This is a very sad case of an 18-year old male who was brought in by EMS as a trauma alert after being hit by a car while riding his motorcycle, and died four days later. It was reported at the scene that was knocked off his motorcycle, slid across the road, and his friend on the motorcycle behind him had run over his chest. EMS found him covered with red ants. EMS records show that he was initially alert and oriented x2 with a GCS of 12, wearing a helmet, with "road rash from nipple line to pelvis, diminished lung sounds on the right side and absent lung sounds on the left with obvious deformity to the left side, crepitus noted on left side of rib cage, abdomen painful n all four quadrants with road rash, pelvis stable, priapism noted, both shoulders dislocated, obvious deformities to both wrists, right radius and ulna obvious deformity, right humerus deformity, obvious left radius and ulna deformity, road rash over entire back from shoulders to buttocks." He was able to report to EMS that he was allergic to iodine and ibuprofen. He was intubated by EMS because he had 60% O2 sats, and he was unresponsive throughout the ER and trauma initial evaluations.
He was initially diagnosed with thoracic and lumbar spine fractures, concussion, hypotension, hemorrhagic and hypovolemic shock associated with trauma, respiratory failure, multiple deep abrasions, hemorrhage, closed nondisplaced fracture of the surgical neck of the right humerus, chest injury, and bilateral pneumothorax with right hemopneumothorax. The trauma surgeon ordered CT with contrast of the chest, abdomen, and pelvis, which was done, and a massive transfusion protocol, along with other treatment. It appears that the patient was given several units of O positive blood, even though he was O negative.
Over the next several days in the ICU, the patient suffered from refractory shock, which the consulting cardiologist deemed vasodilatory in nature as opposed to cardiogenic. On day 2, the trauma service noted, "His picture appears to be that of distributive shock. Unknown reason for this at this time. We have ostensibly ruled out neurogenic, cardiogenic, hemorrhagic shock. As such we will work on aggressive fluid resuscitation...." The patient continued to deteriorate, with hypotension and multisystem organ failure. He eventually became unresponsive, and later arrested and was unable to be resuscitated.
The patient's sister, who had been at his bedside, reported later that his face and neck had been swollen in a manner she had seen in the past when the patient had suffered an anaphylactic reaction to ibuprofen.
My questions are: Could either the CT contrast medium (in a patient with iodine allergy), or the O positive blood, have caused or contributed to his refractory shock and death? And if that is plausible, was it negligent to order the CTs with contrast and/or to give the O positive blood, given the nature of the emergency?
Many thanks.
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Do you believe there might have been medical error?
The patient sustained multiple injuries and arrived at the trauma bay intubated and in hemorrhagic shock. Based on the brief summary, the patient received massive blood product transfusion. Without reading further I cannot be sure, but if the patient was in hemorrhagic shock, he required rapid administration of multiple blood products. There was not time for blood typing and screening. O negative blood is the standard for emergent blood products. If he had a reaction to the transfusion, I would expect that to happen at the time of the transfusion, not to be reflected as distributive shock several days later. It would be helpful to review the record for signs of transfusion reaction such as fever. There are later complications of massive transfusion, particularly transfusion related lung injury (TRALI) which can manifest similarly to ARDS with aggressive respiratory failure, but I would have to further evaluate the record to make a comment about that. There is always a limited risk associated with blood product transfusion, but based on the summary, the patient was at higher risk of immediate death from hemorrhagic shock, and the team treating him in the trauma bay treated him appropriately with regard to blood product transfusion. Regarding the use of intravenous contrast for the CT scans, it is a similar risk-benefit analysis. A non-contrast CT scan runs the risk of missing severe injuries (eg, pelvic hematoma with active extravasation). Any reaction to the iodinated contrast would be unlikely to manifest itself 4 days after the event, but rather would be more immediate. Such a reaction could be managed by protecting the airway -- he was already intubated -- and supporting his blood pressure with fluid administration and pressers, which I infer was likely done.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is unclear to me that either blood transfusion or iodinated contrast resulted in distributive shock that lasted 4 days. I would be concerned about other etiologies, such as a missed intra-abdominal injury, but I would have to review more of the record to render a clear opinion
What makes you a good expert for this case?
I am an acute care surgeon at an academic Level I trauma center, and I treat patients with poly trauma and mixed shock on a regular basis both in the trauma bay, the operating room, and the surgical ICU. Part of the job is dealing with patients who come in from the field with uncertain histories and making decisions based on the best available information at the time -- similar to what the team did in this case. As an educator, I focus on the decision making process and cultivating good clinical judgment.
How often do you encounter cases similar to this one in your practice?
I deal with poly trauma patients and patients in shock on a daily basis.
Do you believe there might have been medical error?
We often order IV contrast in patients who have iodine allergy, and it can be managed if they have anaphylaxis, with steroids and benadryl, IV fluid administration and additional resuscitation. If the trauma surgeon has high suspicion for ongoing bleeding, it can be appropriate to give IV contrast in this setting, in which the benefits of identification of the bleeding source outweigh the risks of anaphylaxis. If the anaphylaxis is recognized in a timely fashion and airway is already secured, this is a safe course of action. However, failure to recognize the ensuing anaphylaxis is an error. It's also possible that the EMS staff did not communicate the patient's known allergies in real time to the ordering trauma surgeon or ED staff. It's unlikely that this was an ABO reaction - tho Rh portion of blood typing is not of importance except in women of childbearing age. In trauma, it is safe to give Rh+ blood to RH- patients who cannot wait for type specific blood. This is supported by multiple recommendations and literature. However, the patient may have a delayed hemolytic or allergic reaction, which should be recognized and treated. Citation: https://www.hematology.org/education/patients/blood-basics/blood-safety-and-matching It's possible that there was neglect and failure to recognize anaphylaxis as a cause of shock and treat it appropriately. Nothing done to the patient was purposefully negligent - the care was appropriate, but there may have been a delay or error in recognizing the known complications of these treatments.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It seems tat the patients workup and decision making tree was appropriate. This patient had blunt trauma and received appropriate workup and treatment. No error resulted in an injury, but there was possible negligence in understanding the complications. It was not wrong to give the IV contrast or the O positive blood. What is potentially an error is the failure to recognize and manage the known complications of those treatments.
What makes you a good expert for this case?
I am a trauma surgeon with 12 years experience and am the chief of trauma and emergency surgery at a large urban, academic level 1 trauma center. I sit on the blood bank committee. We treat over 4,000 blunt trauma patients per year, and I manage the quality council for trauma for the hospital.
How often do you encounter cases similar to this one in your practice?
I am a trauma surgeon managing a level 1 trauma center - we have such cases daily.
Do you believe there might have been medical error?
THis is a complex critical polytrauma case. Contrast can have iodine, but it is more likely than not that the shock is resultant of the very high severity of injury that can cause distributive shock despite the absence or cessation of hemorrhage. Having said that, the only way to know with certainty would be with a more detailed review of the records, the timeline of the shock and the timing of the contrast and other care interventions.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There are enough reasons to explain the shock. Swelling of the face is not uncommon after major fluid resuscitation. The question rather should be whether the contrast might have contributed rather than caused to the deterioration, worsening of shock and death.
What makes you a good expert for this case?
I am a trauma surgeon and surgical intensivist in one of the busiest and largest level 1 trauma centers in New England, an Associate Professor of Surgery at Harvard Medical School and a well known authority in trauma care across the US and internationally, with more than 400 peer reviewed scietific publications in the field. I take care of similar patient/cases on a daily/weekly basis.
How often do you encounter cases similar to this one in your practice?
I take care of trauma patients on a daily basis in a busy level 1 trauma center. Blunt trauma like a motorcycle crash is the predominant mechanism of injury I see.
Do you believe there might have been medical error?
This is an extremely complex case from a trauma standpoint. However, focusing on the specific question posed - was this anaphylactic shock- it is highly unlikely that this is the etiology of the patient's decompensation. The patient had received contrast on presentation and the notes above describe decompensation and concern for vasodilatory shock over the next several days. It is most common for patients to develop anaphylaxis within minutes and very rarely within hours. It is not plausible that it would present days after the exposure. In regard to giving O+ blood to an O- male, there is minimal risk of causing a hemolytic reaction which would warrant consideration of Rhogam but it is not associated with anaphylactic shock, again especially days after the event and after receiving massive transfusion protocol in the trauma bay.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient had a significantly high severe injury score based on the description above and thus a high risk of mortality from presentation. It is common for patients in this state to present initially with hemorrhagic shock and then develop vasodilatory shock secondarily as their injuries manifest further and they deplete their intrinsic pressor stores. This is the likely explanation for the patient's initial improvement and then decompensation a few days into his stay.
What makes you a good expert for this case?
I am a board certified trauma/critical care surgeon with extensive experience in a level 1 trauma center with over 2000 blunt and penetrating trauma cases treated during my time as an attending. I would be happy to investigate this case further if required for opportunity for improvement or further causality of the patient's decompensation, but related to anaphylaxis would be very low on the differential if at all.
How often do you encounter cases similar to this one in your practice?
This is a common encounter in my practice, seeing several significant motor vehicle/motorcycle crashes multiple times in a week.
Do you believe there might have been medical error?
The fact that the patient received an incompatible blood transfusion is itself a medical error. Upon arrival to the emergency department, blood samples are obtained from trauma patients for type and cross match to determine the patient's blood type in order to be given the correct blood transfusion. If however, an emergency blood transfusion is required, as in this case, then standard practice is to administer O negative blood until the patient's blood type is determined. The fact that this did not occur and the patient received incompatible blood can be definitively stated to be a medical error. The fact that the patient received IV contrast in the setting of a known iodine allergy can be considered a medical error as well. However, IV contrast can be administered in the setting of a known allergy if steroids and antihistamines are administered prior to IV contrast administration. In this case, it can be justified to give the contrast, as the risk of an adverse outcome due to allergic reaction can be less than the risk of morbidity/mortality secondary to missed injuries due to lack of IV contrast administration. Having said that, the patient must be monitored and promptly treated in the event of an allergic reaction to the IV contrast.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It seems from the information provided that the patient died from untreated anaphylactic shock. Also, it is stated that the patient has distributive shock with unknown etiology and other forms of shock were "ostensibly ruled out" with no mention of anaphylactic shock. The fact that the patient had distributive shock, other types of shock have been ruled out, and the patient received products that he is allergic to, points to anaphylactic shock. The patient had additional findings consistent with anaphylactic shock, including face and neck swelling. In addition, the patient has a history of a similar allergic reaction in the past. The CT contrast medium (in a patient with iodine allergy), and/or the O positive blood, to a reasonable degree of medical certainty, contributed to his refractory shock and death. It is not negligent to order the CTs with contrast, given the extent of the injuries, provided the potential for adverse reactions to the contrast was being monitored and prompt treatment initiated. It is negligent to give the incompatible blood transfusion if protocols were not followed and it was not recognized until after administration of the blood products.
What makes you a good expert for this case?
I am an academic trauma surgeon working at an ACS certified trauma center. I am double board-certified in general surgery and surgical critical care. Active clinical practice with nearly a decade of experience. Fellowship-trained trauma surgeon. Active clinical practice includes elective general surgery, emergency general surgery, trauma surgery, and critical care. Active nonclinical work includes medical expert for medical records review and review of medical education curricula. As an actively practicing academic trauma surgeon and instructor for Advanced Trauma Life Support (ATLS), it is part of my regular practice to evaluate, manage, and treat patients sustaining multiple injuries requiring prolonged stay in the intensive care unit (ICU). In addition, I provide coverage for the medical and neuro ICU and have extensive background in delivery of critical care. As Clerkship Director for medical students and Assistant Professor of Trauma and Surgical Critical Care, I routinely deliver lectures and teachings on the most up-to-date guidelines on the care of critically injured patients.
How often do you encounter cases similar to this one in your practice?
I encounter critically injured trauma patients on a daily basis. My practice involves acutely injured patients from motorcycle and motor vehicle accidents and all forms of blunt and penetrating trauma. I am involved in the acute trauma resuscitation and operative intervention, as well as delivering critical care throughout the duration of their hospital stay.
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