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Chief Complaint: 31-year-old African American male injured while rock-climbing.

History of Present Illness: This 31-year-old male was rock-climbing with two friends at a national park 14 miles away from the nearest hospital when he suddenly lost his footing and slid 18 feet to the ground. Both friends who witnessed the fall said that he slid against sharp rock all of the way down, landing almost in a standing-up position, finally slumping to the ground. They also said that his head was not jarred during the slide. The man was alert and oriented when his friends reached him, and could move all four extremities quite easily. He had multiple scrapes over his anterior torso and a large gash over his right anterior upper thigh (near the groin) which was bleeding profusely. A makeshift tourniquet slowed the bleeding. The party was able to radio to the park ranger's station for help. The ranger, in turn, contacted the "med-evac" unit at the city hospital. The helicopter located and evacuated the man. A large-bore IV was placed in each arm in-flight, and normal saline fluid was administered intravenously. The patient became increasingly disoriented during the flight, reaching the emergency room about 40 minutes after the fall.

Past Medical History: According to the man's friends, the patient was in good health prior to the accident, with no history of allergies, anemia, bleeding disorders, or diabetes mellitus.

Family History: Family history was not attainable. The patient's family lived in another state and could not be contacted.

Physical Examination: The patient was lethargic but responsive to shouting and sternal pinch. He had multiple abrasions over his chin, neck, anterior thorax, and abdomen. A six-inch-long, half-inch deep laceration was noted in the right inguinal region, extending into the right, upper thigh. The tourniquet placed in this area was soaked with blood. Height 6' 2", weight 205 lbs. Vital signs were as follows: HR = 112 (supine) and 128 (sitting), BP = 108 / 60 (supine) and 92 / 52 (sitting), RR = 32, rectal temp = 99.4^oF. Skin was cold and clammy, and nail beds, palms, and mucous membranes were pale. Carotid, radial, left femoral, and dorsalis pedis pulses were all weak and thready. Cranial nerves, to the extent that they could be tested, were intact bilaterally. Pupils were equal, regular, and reactive to light. External jugular venous collapse point was not visible in either the sitting or recumbent position. Heart sounds were regular, tachycardic, with no murmur, S₃ or S₄ sounds. Lungs were clear to percussion and auscultation. Abdominal guarding was noted, attributable to multiple lacerations; no masses were felt. Blood was drawn, typed, and crossed. A urethral catheter was placed to monitor urinary output, and another catheter was placed into the right subclavian vein and threaded into the superior vena cava to monitor central venous pressure. A cardiovascular surgeon was consulted for repair of the lacerated right femoral artery.

Laboratory Studies: Laboratory studies of the venous blood revealed the following:

Laboratory studies of the arterial blood revealed the following: