Scenario posed to me by ICU nurse

tom.watkins

tom.watkins

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So I was in the ICU today doing some rounds for class and an RN hit me up for my opinion on a call she heard about....
"A 50 y/o male patient was driving along the highway between Toppenish and Goldendale, (pretty desolate stretch of HWY 97 in Washington state) when he lost control of his vehicle for unknown reasons and drove off the road, rolling at least one time. Time to dispatch was apprx. 10 mins, and first medic unit on scene arrived about 20 mins later. Pt was upside down, secured by seatbelt and was unable to free himself. Reporting party was unsure about moving him so he left him in place untill medics arrived. EMT and medic "cleared" c-spine and noted that pt was A&O to person, place, time and event; also denies loss of conciousness, denies chest pain, denies SOB, CMS normal in upper extremeties. Apprx. 1 minute after cutting the pt loose and safely removing him from the vehicle he becomes apneic and pulseless. Fast patches placed on pt, monitor shows assystole in 3 leads; CPR and ACLS on scene and continued for 40 mins to the nearest hospital. Pt pronounced DOA by ER physician." So that's a brief synopsis of the call, and the RN wanted to know my ideas behind the pt's sudden downturn. She brought up the idea of a massive lactic acid release, which I guess is feesible, but I don't know what the pt's labs showed in regards to LA. I do know that he was negative for troponin, negative for thrombi and had a clean echo except for some minor mitral valve regurg. (although I'm not sure how the echo was done correctly since the pt never had a ROSC). I'm leaning towards a massive increase in preload following removal from the vehicle, possibly causing trauma to baroreceptors and subsequent drop in BP, although I don't know all the particulars about the pt, i.e. numbness in legs, pedal pulses, etc. Or maybe a transient thrombus? I'd appreciate any ideas you have.
 
Lactic acid release? Was there a trapped extremity or something to cause her suspicion of such? I honestly do not have a clue as to how this might have happened. You say sudden cardiac arrest, with monitor applied immediately showing asystole?

I will defer conjecture, would like to hear what others think.
 
I asked her if there was compression to an extremity and she said no, and as for the immediate asystole, I would assume that the pt was in either v-fib/tach prior to the patches being applied and that it might have been a "documentation error" but I would not begin to imply that the medic did anything unlawful/illegal. The crews that respond out there do a wonderful job, but as we are all well aware, things happen that are completely inexplicable.
 
Unless a lactic acid level was drawn when alive or a shock index established, you may never know outside of an autopsy.

I'm curious as to how the spine was "cleared" (I hate that term, you aren't clearing anything, selective immobilization is a better term) with a dangerous mechanism present? A rollover per established criteria is an automatic for a collar and board.

Perhaps a transverse fracture or complete cord transection in the superior cervical spine when he was moved??
 
Autopsy was conducted, however I have no idea the outcome. I asked about trauma and she said that there was absolutely none present anywhere.
 
The most common fxs we see from rollovers, either in Trauma or SCI Rehab, are C1 -C2. The deficit may not be immediately apparent due to the ligaments holding the bones stable...until moved. Then, it may be death or the remainder of their life on a ventilator. However, if treated carefully, these two fxs can be the most stable and with a few months in a halo or C-collar, they may be just fine with minimal complications.

These fxs may also be hard to detect due to location which is why a CT Scan is used to clear rollover MVCs.

Neuro deficits are also not always obvious until the cord is damaged by bones fragments or swelling. I also don't always trust the patient to say "No, I don't remember losing consciousness". When you are dealing with C1-C2 damage, one would also have to consider the brainstem.
 
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VentMedic said:
The most common fxs we see from rollovers, either in Trauma or SCI Rehab, are C1 -C2. The deficit may not be immediately apparent due to the ligaments holding the bones stable...until moved. Then, it may be death or the remainder of their life on a ventilator. However, if treated carefully, these two fxs can be the most stable and with a few months in a halo or C-collar, they may be just fine with minimal complications.

These fxs may also be hard to detect due to location which is why a CT Scan is used to clear rollover MVCs.

Neuro deficits are also not always obvious until the cord is damaged by bones fragments or swelling. I also don't always trust the patient to say "No, I don't remember losing consciousness". When you are dealing with C1-C2 damage, one would also have to consider the brainstem.
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So basically, his neck was broke, they or patient moved his neck, "pushing the injury over the hill" resulting in his death right?
 
Hockey9019 said:
So basically, his neck was broke, they or patient moved his neck, "pushing the injury over the hill" resulting in his death right?
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I made this statement:
Originally Posted by VentMedic
The most common fxs we see from rollovers, either in Trauma or SCI Rehab, are C1 -C2.
Click to expand...

I did not say the paramedics killed the patient.
 
No, however the poor decision of the crew to not restrict spinal motion in this "hypothetical" scenerio probably did not help.
 
Sounds interesting. I have been working on a Class for Fall Arrest Systems Trauma (Anotherwards suspension trauma) and how to deal with it. This sounds almost like that, becasue like suspension trauma where a person is stuck in a harness hanging. In this case the person was "hanging" upside down while being trapped.

What I have found is that they begin to have venous pooling, and orthostatic intolerance. With the pooling, this causes shock to the heart because of the sudden rush of blood back to the heart.

All OSHA training on Suspension Trauma states that they should not be laid down immediatley, like we are taught with other trauma patients.

Just my 2 cents.
 
Actually, I work under the protocols for the county in question, and I've posted our C-spine procedures on here before. We are not to use MOI as an indicator to initiate C-spine precautions...there's a list of criteria to be met first.

I'm wondering if the seat belt cause some Compartmentalization Syndrome.
 
That's the road I was going down. It seemed sorta unlikely that the pt would succumb to it in only 30 mins, but then again this was a watered-down version of the story from an ICU nurse so who knows. Oh ya, and I forgot to say earlier that Yakima county doesn't go on mechanism alone....
 
MOI alone, no, however not taking into consideration the kinematics is neglegent. I realize the NEXUS criteria does not take into account MOI, but this in particular is why the Canadian C-Spine Rule has been documented superior to the NEXUS criteria. Personally, knowing the physics involved, I would have restricted them. To each their own based off their medical director's beliefs.

https://content.nejm.org/cgi/reprint/349/26/2510.pdf
 
This is where more emphasis is placed on a "recipe" rather than commonsense.

Yes, it is good to follow the checklist for charting but sometimes there must also be some logic used. If a small car with limited head room and flimpsy roof rolls many times, I may be a little more cautious than with a sturdy sport SUV that gently rolled to its side. But, some will just read the recipe and not understand there are exceptions to every rule. Unfortunately critical thinking takes a back seat for some.

I also would like to know how these EMT(P)s cleared a spine with a patient hanging upside down still in the seat belt. There is this little thing of stretching the spine in a different position. If anyone has even don't inverter exercises they can feel a different spinal alignment.
 
I thought C Spine protection didn't work...
 
Here in Australia petrol (gas) sniffing is a big problem amongst certain elements of the poor, indigenous population. I've read that that hey are often seen to die from sudden cardiac arrest a short while after the inhalation. Could you're pt have copped a load of fuel fumes from his smashed up ride? :ph34r:

There are probably a million more likely things, these are definitely zebra hoof beats, but thought I'd mention it.
 
I know I'm behind on this one. but I would of C-collard him and used a KED to safely and slowly move him out since A&Ox4. to me if you know he rolled at least once on a decolet streach of hiway he was probly speeding 65-70mph (I would be thinking about all this on the way to the sceen). but this is just me I'm sure I'm wrong, so correct me on anything.
 
That's an interesting case to say the least. My thoughts are what other's have already said which is a spinal cord injury possibly and the manipulation from removing from the seatbelt was the final insult. With being suspended upside down in a vehicle by a seatbelt.... it is impossible to not have any manipulation of the c-spine no matter what technique you use.... KED board or not. Im not saying dont immobilize in that situation but thats an extremely hard position to immobilize someone... especially if its a heavier person.

Also, a first thought I had was an internal abd rupture or hemorrhage of some sorts that perhaps the lap belt was tamponading and upon release the pt. bled out. I know that's getting pretty creative but ne thing's possible, right? Or just from the blunt force the pt. had an aneurysm.

And the lactic acid possibility... I would have to say highly doubt it.... there would have to be a complete occlusion of blood flow to a particular region for an extended period of time (2-3hrs) before the anaerobic metabolism creates a level of lactic acid and potassium to cause death.

I would love to hear what the autopsy showed.
 
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I would love to hear what the autopsy showed.
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Good luck trying to get a Washington coroner to release the results. I am still trying to get them to release redacted records for my research. Stupid privacy laws....
 
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