usalsfyre's Train Wreck #2

[usalsfyre]

I appologize, it's two days late but I got my gluteus handed to me Monday at work and was on Dad duty yesterday. So here goes....

You are working overnights as part of a double medic truck in a city of 100k. At appx 2200 you get dispatched just outside of the city limits to a MVC, report of one patient ejected. On arrival you see an undamaged Volkswagen convertible and a crowd of people standing around what appears to be a male teen 120+ feet away.

What now?

 

[abckidsmom]

I appologize, it's two days late but I got my gluteus handed to me Monday at work and was on Dad duty yesterday. So here goes....

You are working overnights as part of a double medic truck in a city of 100k. At appx 2200 you get dispatched just outside of the city limits to a MVC, report of one patient ejected. On arrival you see an undamaged Volkswagen convertible and a crowd of people standing around what appears to be a male teen 120+ feet away.

What now?

Look for the cops. This smells like a shooting with the assailant on scene. Otherwise, I am suspecting a bout of stupid that brought on a car surfing or some idiocy.

 

[systemet]

Scene safe?

Make sure no one's under the car / no little kid under the seats, etc. Anything exciting in there? Odour of alcohol / pot / crack?

Are we in the right place? Are there any other vehicles around?

Environmental factors? Weather? Road conditions?

Skid marks on the road? Vehicle on the tarmac or in the ditch?

Available resources?

 

[fast65]

How far out is law enforcement? There's something quite odd going on here, and we just can't rule out some sort of shooting or other violent act.

Is the top down on the convertible? Skid marks? Blood on the vehicle? Any alcohol or illicit substances in the vehicle?

I'm thinking it could possibly be car surfing as well.

 

[usalsfyre]

Wow, sharp folks, y'all hit an angle I hadn't even considered yet.

Sheriff's deputies are on scene. Vehicle has the top down, two skidmarks of changing direction are behind it. A bystander that was in the following vehicle saw the patient attempt a "powerslide" at a high (90+mph) rate of speed in the middle of a straight section of road, be ejected from the drivers seat and strike a large oak tree with the anterior side of his body aproximately 100 feet away and then fall/slide to his current location. Initial assesment reveals an unconscious male in his late teens with the following:

A:Airway is obtunded, foamy, pink sputum is mixed with frank blood in the airway. He is missing most of the visible dentation. His face appears to be distorted.

B:Agonal gurgling respirations are noted. The patient's chest rise is paradoxical and diminished on the right side. Breath sounds on the right are absent

C: A weak, rapid radial pulse is present. The patient has venous bleeding from an open fracture of the patient's left forearm and left tib/fib

D:Patient is unconscious and shows decorticate posturing. Skin is mottled. The patient was wearing a t-shirt and shorts, there's abrasions over most of the exposed skin.

What now?

 

[fast65]

Wow, sharp folks, y'all hit an angle I hadn't even considered yet.

Sheriff's deputies are on scene. Vehicle has the top down, two skidmarks of changing direction are behind it. A bystander that was in the following vehicle saw the patient attempt a "powerslide" at a high (90+mph) rate of speed in the middle of a straight section of road, be ejected from the drivers seat and strike a large oak tree with the anterior side of his body aproximately 100 feet away and then fall/slide to his current location. Initial assesment reveals an unconscious male in his late teens with the following:

A:Airway is obtunded, foamy, pink sputum is mixed with frank blood in the airway. He is missing most of the visible dentation. His face appears to be distorted.

B:Agonal gurgling respirations are noted. The patient's chest rise is paradoxical and diminished on the right side. Breath sounds on the right are absent

C: A weak, rapid radial pulse is present. The patient has venous bleeding from an open fracture of the patient's left forearm and left tib/fib

D:Patient is unconscious and shows decorticate posturing. Skin is mottled. The patient was wearing a t-shirt and shorts, there's abrasions over most of the exposed skin.

What now?

Hmmm, this is quite odd. But, I'll do my best considering I'm relatively new at this

At this point we're calling the chopper, is it available? We'll clear his airway of any debris (i.e. teeth) or secretions, I'm wanting to intubate ASAP, so, if he has no gag reflex I'll just intubate him, if gag reflex is present I'll RSI. Confirm placement, secure tube, and bag at a rate dependent upon our ETCO2 readings.

Now I'm guessing breath sounds are still unequal so we'll decompress the right side of his chest. Breath sounds present?

How much blood has he lost from the open fractures? If it's a substantial amount then we'll try to control that.

I'm gonna cut all his clothes off now, do a rapid trauma assessment, any other injuries? After that, we're gonna C-spine him and get him packaged for transport.

We'll keep monitoring his airway, get him on a cardiac monitor and my partner is getting a set of vitals. ETCO2 readings? He's getting two large bore IV's and probably a good amount of fluids. We'll splint his open fractures if time permits.

 

[abckidsmom]

Hmmm, this is quite odd. But, I'll do my best considering I'm relatively new at this

At this point we're calling the chopper, is it available? We'll clear his airway of any debris (i.e. teeth) or secretions, I'm wanting to intubate ASAP, so, if he has no gag reflex I'll just intubate him, if gag reflex is present I'll RSI. Confirm placement, secure tube, and bag at a rate dependent upon our ETCO2 readings.

Now I'm guessing breath sounds are still unequal so we'll decompress the right side of his chest. Breath sounds present?

How much blood has he lost from the open fractures? If it's a substantial amount then we'll try to control that.

I'm gonna cut all his clothes off now, do a rapid trauma assessment, any other injuries? After that, we're gonna C-spine him and get him packaged for transport.

We'll keep monitoring his airway, get him on a cardiac monitor and my partner is getting a set of vitals. ETCO2 readings? He's getting two large bore IV's and probably a good amount of fluids. We'll splint his open fractures if time permits.

Manual c spine
Decompress the chest
Cric him
Board him
Begin transport
Control bleeding
IVs

Reassess.

Not wasting time with the helicoptor unless transport is >45 minutes. It just doesn't save time around here.

 

[fast65]

Manual c spine
Decompress the chest
Cric him
Board him
Begin transport
Control bleeding
IVs

Reassess.

Not wasting time with the helicoptor unless transport is >45 minutes. It just doesn't save time around here.

Are you doing a cric because of the facial deformity?

I went with helicopter out here, because the closest level II trauma center is about an hour away and the closest level I is 1.5 hours away on a good day. Although, thinking about it, I would have just had the chopper meet us at the local hospital.

 

[abckidsmom]

Are you doing a cric because of the facial deformity?

I went with helicopter out here, because the closest level II trauma center is about an hour away and the closest level I is 1.5 hours away on a good day. Although, thinking about it, I would have just had the chopper meet us at the local hospital.

Yeah, digging into this airway will be a total mess. I might possibly waste ONE attempt and one attempt only on an oral intubation, but he needs an airway, and pronto, and with the smushed up face and teeth, blood and tree bark obstructing his airway, he'll be fine with a cric.

Well, fine in the way that completely decimated, dead-but-young-enough-that-the-heart-hasn't-caught-up people are.

ETA: And what better case to use as a skills training lab than a train wreck, huh?

 

[fast65]

Yeah, digging into this airway will be a total mess. I might possibly waste ONE attempt and one attempt only on an oral intubation, but he needs an airway, and pronto, and with the smushed up face and teeth, blood and tree bark obstructing his airway, he'll be fine with a cric.

Well, fine in the way that completely decimated, dead-but-young-enough-that-the-heart-hasn't-caught-up people are.

ETA: And what better case to use as a skills training lab than a train wreck, huh?

Alright, that makes sense. Thanks!

 

[Handsome Robb]

Bah! I missed the beginning of this one but I'll still play.

How far is the Trauma Center? What's the ETA on the chopper, can they fly considering you wouldn't let them in the last one ? if the TC is to far to drive I want them to meet me en route.

A) Suction secretions, clear debris and take control of the airway. Depending on how distorted his face is ETI could be relatively contraindicated but airway>jaw. They can fix the jaw later, his airway can't wait. This guy just bought himself a surgical cric.

B) Ventilate him and splint his chest. Paradoxical chest rise along with mechanism makes me think flail chest. Decompress the right side of the chest if splinting my suspected flail segment didn't help his breath sounds. This guy needs to be oxygenated.

C) If he is bleeding profusely even with it being venous I'll go direct pressure for a bit but would probably switch to tourniquets pretty quickly.

Make him trauma naked like Fast said and do a rapid. Any fluid from ears/nose? The posturing makes me think increased ICP. Any crepitus in the neck? JVD? Tracheal deviation? How's his abdomen? Pelvis? Anything in the LEs besides the compound tib/fib? UEs besides the forearm?

I want a quick set of vitals, c-spine and lets go. I'll take a FF/EMT if they are on scene with me in the back in case this guy goes south. We can get the IVs en route and get some fluids going and get him on the monitor. If I had time I might consider dropping an OG/NG tube considering he may have swallowed a lot of blood and knowing my luck its gonna come right back out at me. This guy sounds like a trauma team activation.

Bah ABCkidsmom beat me too it! I guess thats what you get for trying to do hw and respond to this on and off.

 

[usalsfyre]

A cric it is. BTW, you chose wisely. If you had attempted to use a laryengoscope his whole face would have moved (Lefort II&III fractures) and you would have visualized blood. Generally mucking around with a patient who is already hypoxic and has frank facial injuries is a bad idea. There's not a lot of cases that call for cutting early. This is one. A cric is established and you needle his chest. Inital rush of air...now there's also blood coming out. What can you do about this? The patient improves slightly, but there's still COPIOUS amounts of pink, frothy sputum coming out of the tube. ETCO2 confirms placement but you can't get a number above 20mmHG. The patient is stripped and placed on a long board. You have two transport choices. A well equiped community Level II 25 minutes away by ground, and an academic Level One 45 minutes away by aircraft, it's clear blue and 22 tonight so you can defintely get an aircraft. Which one?

Secondary assesment reveals....

HEENT: Crepitus and abrasions throughout the facial region. Exopthalmos. Blood coming from the ears and nose. Missing dentation. Pupils are a 6 and minimally reactive. JVD was noted on inital exam but now the jugular veins are not visible at all.

Chest:Crepitus in multiple sections per rib, bruising and lack of stability from the third to the seventh intercostal space on the right (basicly the right side of his chest is mush), Flail segment is "splinted" by PPV. Breath sounds are present, but still very diminished on the right, relatively clear on the left. Blood is still coming from the 14ga you used to decompress the patient.

Abdomen:Closed, and the beginings of some minor rigidity noted in the right upper quadrant. Bowel sounds are present. When the pelvis is palpated you note crepitus and it doesn't feel stable. You note a small amount of blood at the meatus

Extremities:Left tib/fib and radius and ulna are open. Deformity is noted in the kids left femur as well. Abraded all over. Bleeding of the open fractures is controled with direct pressure. Looks like moderate blood loss.

Neuro:Decorticate posturing to painful stimulus. Moaning slightly occasionally, GCS is E1, V2, M3

Vitals are as follows: BP:82/70; HR:142;RR:(he's got a tube, you tell me);SpO2:84% by BVM on O2; ETCO2:24

Two lines will be established. What fluid and what are we running them at? While we're taking him to the truck, he goes into a grandmal seizure. What now?

 

[abckidsmom]

A cric it is. BTW, you chose wisely. If you had attempted to use a laryengoscope his whole face would have moved (Lefort II&III fractures) and you would have visualized blood. Generally mucking around with a patient who is already hypoxic and has frank facial injuries is a bad idea. There's not a lot of cases that call for cutting early. This is one. A cric is established and you needle his chest. Inital rush of air...now there's also blood coming out. What can you do about this? The patient improves slightly, but there's still COPIOUS amounts of pink, frothy sputum coming out of the tube. ETCO2 confirms placement but you can't get a number above 20mmHG. The patient is stripped and placed on a long board. You have two transport choices. A well equiped community Level II 25 minutes away by ground, and an academic Level One 45 minutes away by aircraft, it's clear blue and 22 tonight so you can defintely get an aircraft. Which one?

Secondary assesment reveals....

HEENT: Crepitus and abrasions throughout the facial region. Exopthalmos. Blood coming from the ears and nose. Missing dentation. Pupils are a 6 and minimally reactive. JVD was noted on inital exam but now the jugular veins are not visible at all.

Chest:Crepitus in multiple sections per rib, bruising and lack of stability from the third to the seventh intercostal space on the right (basicly the right side of his chest is mush), Flail segment is "splinted" by PPV. Breath sounds are present, but still very diminished on the right, relatively clear on the left. Blood is still coming from the 14ga you used to decompress the patient.

Abdomen:Closed, and the beginings of some minor rigidity noted in the right upper quadrant. Bowel sounds are present. When the pelvis is palpated you note crepitus and it doesn't feel stable. You note a small amount of blood at the meatus

Extremities:Left tib/fib and radius and ulna are open. Deformity is noted in the kids left femur as well. Abraded all over. Bleeding of the open fractures is controled with direct pressure. Looks like moderate blood loss.

Neuro:Decorticate posturing to painful stimulus. Moaning slightly occasionally, GCS is E1, V2, M3

Vitals are as follows: BP:82/70; HR:142;RR:(he's got a tube, you tell me);SpO2:84% by BVM on O2; ETCO2:24

Two lines will be established. What fluid and what are we running them at? While we're taking him to the truck, he goes into a grandmal seizure. What now?

When you say train wreck, you really mean it, right?

I don't think the guy is stable for the longer transport to the LI trauma center. I would take him to the LII where he can get more stable or reach terminal stability.

Let's summarize his injuries:

LaForte II and III fx, open head injuries (shearing or bleeding, his brain is in trouble) now with seizures and posturing

Right tension pneumo/hemo, flail segment, pulmonary contusions, etc.

Liver lac? Diaphragmatic abruption?

Bladder rupture?

Ortho: L tib/fib, radius, ulna, femur and pelvis. Somebody's going to be getting a new boat out of this repair.

SO. This guy will be one for the record books if he survives tonight. For now, we'll head to the 25 min away LII facility and let them know that he's coming in enough time for them to call in the troops. LII have on-call neuro and ortho, not necessarily in-house. If he makes it to the OR, they'll need all the friends.

The fluid, ideally would be skillful and complicated combination of FFP, PRBCs, and isotonic crystalloids. Alas, we're in an ambulance, not an ICU, so I'm going to run the NS or LR at a fast KVO, or maybe give him a couple of gentle 500 ml boluses. This is one who will suffer badly from over-fluid-resuscitating initially, though he does need some fluid in his system, he still needs all the oxygen carrying capacity he can get.

He's seizing, I will give him benzos to stop that forthwith, and paralyze and sedate him for the ride because he absolutely, positively must not be moving around and hurting anything else.

Without another complicating event, I will be shocked if he arrives alive in the ER 25 minutes away.

 

[Handsome Robb]

Hmm. The pinky frothy stuff is no good. Could you try a PEEP valve to try and force the fluid out of the aveoli and back into the vascular space? Although I was under the impression that you had to be spontaneously breathing to use PEEP. As for the rate I'd be aiming for an EtCO2 of somewhere around 30 mmHg if we can ever get it there. Hypercapnia will dilate cerebral blood vessels and increase blood volume in the cranial vault therefore increasing ICP which is exactly what we DON'T want.

What is the ETA of the chopper to me? If its any longer than 10-15 minutes I'm not even going to bother but if they are close my thoughts are that I can't do a whole lot about the Hemopneumothorax but a flight nurse might be able to place a chest tube and relieve that pressure and improve his SpO2?

As of now I want to go to the Level II. Shorter ETA and Level IIs are essentially the same as a Level I minus the academic portion and having everyone on-site. Let them know now that you are inbound with a trauma team activation so they can get all the boys and girls out of bed and to the facility to be waiting for you.

As for your fluids you have either Lactated Ringers or NS. I was always told LR is incompatible with blood products, which this guy is going to need, so I'd go for NS. I'd shoot to maintain his systolic above 80, it doesn't need to be WFO.

For the femur you cant do much for it with the open tib/fib below it. If he displays signs of bleeding into his thigh, even though a tourniquet would be contraindicated with the femur fracture I'd call med control and talk to them, if you don't stop that bleeding somehow this guy is going to die.

 

[abckidsmom]

Hmm. The pinky frothy stuff is no good. Could you try a PEEP valve to try and force the fluid out of the aveoli and back into the vascular space? Although I was under the impression that you had to be spontaneously breathing to use PEEP. As for the rate I'd be aiming for an EtCO2 of somewhere around 30 mmHg if we can ever get it there. Hypercapnia will dilate cerebral blood vessels and increase blood volume in the cranial vault therefore increasing ICP which is exactly what we DON'T want.

He likely has a big hole in his lung as well, or even a leaky airway...subcu air, usals? How's his neck feel around that tube?

You can always put some PEEP on the tube, but I would not expect it to make a big difference, and I might even see that it would drop his blood pressure a little. Increasing intrathoracic pressure in this guy, even with a little bit of PEEP that will come from the device on the tube, might just be enough to stop whatever blood return is happening and kill his preload.

What is the ETA of the chopper to me? If its any longer than 10-15 minutes I'm not even going to bother but if they are close my thoughts are that I can't do a whole lot about the Hemopneumothorax but a flight nurse might be able to place a chest tube and relieve that pressure and improve his SpO2?

Evacuating this hemo/pneumo right now, on the side of the road, regardless of who you are is a risky endeavor, unless you're prepared to autotransfuse that blood back into the IV. Sad to say, as long as there are *some* breath sounds on that right side, I would just let it be until he's in the presence of a lot of blood products, because that will just bleed and bleed once it's opened up.

As of now I want to go to the Level II. Shorter ETA and Level IIs are essentially the same as a Level I minus the academic portion and having everyone on-site. Let them know now that you are inbound with a trauma team activation so they can get all the boys and girls out of bed and to the facility to be waiting for you.

As for your fluids you have either Lactated Ringers or NS. I was always told LR is incompatible with blood products, which this guy is going to need, so I'd go for NS. I'd shoot to maintain his systolic above 80, it doesn't need to be WFO.

For the femur you cant do much for it with the open tib/fib below it. If he displays signs of bleeding into his thigh, even though a tourniquet would be contraindicated with the femur fracture I'd call med control and talk to them, if you don't stop that bleeding somehow this guy is going to die.

Tourniquet on the bad leg is a good idea. Probably won't be much difference in the perfusion than he's getting right now. Double check that there are pulses in there at all before placing it, and know that you are almost certainly making the decision about amputating that leg. It will be a long time before he can re-establish perfusion to that foot.

I didn't mention it before, but it's really cold out, and he's really going to be cold. This is a patient that you really, really want to take a second and put a blanket under him on the board, and keep as much of him covered as possible, with hot packs in his axillae and groin, and scattered about. Letting him get too cold will also help him die.

 

[fast65]

Geez usalsfyre, you really know how to pick him Are these actual calls you've had?

Well, I of course am regretting my initial decision to attempt ETI, but that being in the past, and my pt. being cric'd right now, I can move on. Obviously we don't have good gas exchange, so I'm gonna try to suction the tube real quick, and if I still can't get the ETCO2 up to 32 like I would prefer, then to the best of my knowledge there's not a whole lot I can do for this guy. A PEEP valve wouldn't be indicated in this case because it can cause in an increase in ICP, no use adding fuel to the fire. Honestly, I'm not real sure what to do about the blood coming out of the decompression.

This guy is going to the level II center, and they're getting a notification really early so they can get all of their toys ready. I'd like to add more detail, but unfortunately I have to run.

 

[Handsome Robb]

Geez usalsfyre, you really know how to pick him Are these actual calls you've had?

Seconded

A PEEP valve wouldn't be indicated in this case because it can cause in an increase in ICP, no use adding fuel to the fire.

I'm interested in the physio behind this? Does slowing of the off gassing of CO2 play a roll in this? Still a baby student with too much to learn.

Honestly, I'm not real sure what to do about the blood coming out of the decompression.

I'm right there with ya! haha Possibly seal it to minimize blood loss? But then your going to compress the lung by not allowing the blood to escape which could move over to the other side of the chest as well and just make things worse, so never mind, bad idea

 

[abckidsmom]

Seconded



I'm interested in the physio behind this? Does slowing of the off gassing of CO2 play a roll in this? Still a baby student with too much to learn.



I'm right there with ya! haha Possibly seal it to minimize blood loss? But then your going to compress the lung by not allowing the blood to escape which could move over to the other side of the chest as well and just make things worse, so never mind, bad idea

Throw a 3-way stopcock on that catheter and wait for another tension pneumo/hemo to develop, then let it bleed off again.

It's not going to be pretty, either way.

 

[MrBrown]

You sure can pick em, candyman my ***, candyman would have Brown back at station watching telly

This bloke is super, mega crook.

Provided we have decompressed his massive haemopneumothorax (uber want a chest tube into this bloke) Brown is going to RSI him, chuck a splint onto his nunngered tib/fib/arm and get transporting to the hospital.

Brown would give him up to one litre of fluid in 250ml cc boluses ... again, this bloke is mega, super crook and Brown doubts he will live >24 hours.

In hospital Brown would order a chest tube, blood replacement, plain film of c-spine, head, pelvis and chest, a CT scan, belly ultrasound and lets get him to the operating room for an ex-lap and repair/fixation of his buggered tummy, leg and arm then off to ICU.

 

[Pelagic]

Concur with all the above - surgical airway, decompress chest etc - but would make sure he gets a Pelvic Binder when boarded - instability mentioned - probably the biggest cause of the hypovolemia?

My view is that this guy needs minimal interventions on scene (IV etc) and maximum diesel and right foot to the nearest Trauma centre?