Case of the Week

Wide Open



A 9-year-old boy was skateboarding with his friends over a hill when he entered a
major intersection and was hit by a car going approximately 40 mph down the
cross street. On arrival to the ED, HR 160 BP 110/70 RR 26, SpO2 96% RA. 
His primary survey was significant for thoraco-abdominal ecchymosis; secondary survey showed a GCS of 11 with agitation.  He was endotracheally intubated for declining clinical course and behavior control.

CT of his abdomen shows grade III liver laceration; initial hemoglobin is 9 g/dL.  On return from radiology, HR 170 BP 88/60.  He is started on a massive transfusion protocol in a 1:1:1 ratio (PRBCs:Plasma:Platelets); after 40 mL/kg of PRBCs, his repeat vital signs show HR 110 BP 100/80 with normal urine output and skin signs.  
While awaiting a bed in the intensive care unit, he develops a wide-complex
tachycardia with a palpable peripheral pulse:
What action should be taken immediately?

     A. Perform thoracotomy, cross-clamp aorta, open cardiac massage
     B. Membrane-stabilization therapy
     C. Re-initiate massive blood transfusion to optimize oxygenation
     D. Emergent hemodialysis

In the meantime, a quote – 

Every man prefers belief to the exercise of judgment.

– Lucius Annaeus Seneca, Roman Stoic philosopher (4 BC – AD 65)


Experts often possess more data than judgment.

– Colin Powell, retired US Army general (1937 - ) 


C Cresswell link
05/29/2013 10:20pm

Gr8 case. How do I subscribe to case of the week?

TH link
05/31/2013 11:05am

Chris -- thanks for your note! I post the case every Sunday night here and its link on Twitter @EMtogether, then the 'answer' on Tuesday morning -- thanks for following!

Everyone -- follow Dr Cresswell at @EMTutor on Twitter or for some very well thought out and produced tutorials/lectures/hot topics. Thanks, Chris!


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