A High Level of Fibrinogen Degradation Product on Arrival as the Only Clue Suggesting Deterioration in a Blunt Trauma Patient

Abstract

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.