29 year old woman who is injured in a motor vehicle accident

[Voxel]

29 year old woman is injured in a head on two car collision. She is transported to your ER department. You are the only doctor on duty in a small rural hospital. The nearest trauma center is 190 miles away. She arrives.

On examination, the patient is in acute respiratory distress. Her respiration rate is 34 bpm. Her blood pressures is 88/58, pulse is 106 bpm. Her heart sounds are somewhat distant and slightly muffled. Breath sounds are absent from asculatation of her right lung field. Her jugular venous pressure appears to be elevated. There is a large scalp laceration. There appears to be blood and pink-tinged fluid leaking from her nose.

Physical examination of her abdomen produces pain and she pulls back, with maximal tenderness in the left upper quadrent. Her right hip is externally rotated. There is blood at the uretheral meatus and her pelvis appears to be oddly positioned. Her cervical spine appears adaquately immoblized.

Her neurologic examination reveals a right dilated pupil. She is responsive to pressure and deep pain and deep palpation of her abdomen.

1) What is your first priority?

2) What is your second priority?

3) What is the likely cause of this patients respiratory distress?

4) What other things are you concerned about?

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[Brewster]

The first, second, and third priorities in any trauma situation are airway, breathing, and circulation. I suspect she has a patent airway. For breathing, she is tachypneic, in respiratory distress. The abscence of breath sounds on the right suggest a pneumo- and/or hemothorax to which I would attribute her respiratory distress. With the increased JVP and hypotension (circulation, the third priority), I would also be worried about a tension PTX and would look carefully for tracheal deviation. The JVP and hypotension could also be due to tamponade (in light of the distant heart sounds).

She needs oxygen. Then, if there is indeed a tension pneumo, she needs a needle thoracostomy the relieve the pressure. Alternatively, tamponade would require fluid resuscitation and pericardiocentesis.

So, to answer your fourth question, my problem list would look like:
1) pneumothorax, possibly tension PTX
2) tamponade
3) intracranial hemorrhage with herniation - right third nerve palsy in head trauma is concerning for transtentorial herniation, I would attribute this to intracranial hemorrhage with the history of trauma
4) basilar skull fracure - blood tinged fluid from nose, I suspect CSF mized with blood
5) possible C-spine injury
6) spleen injury/rupture - acute abdomen with tenderness in the LUQ s/p trauma, concerning for splenic laceration/rupture
7) right femur/pelvic fracture
8) GU trauma (I suspect urethral or bladder)

 

[lizzied2003]

Agree with Brewster.

Would start making arrangements to air transport patient. Needs skelatal survey and CT. Pelvis needs to be stablized. Routine labs (cbc, t&C, lyts, coags). Notify blood bank for type O blood. Also call in available surgeon, right away and OR team (in case transport not possible--in which case you might want to start praying too). However, transport should not be delayed for testing.

 

[womansurg]

Eeek. This patient would be dead on arrival if you transferred her, lizzie. Anyone with a respiratory rate in the 30's, no lung sounds on one side, hypotensive with jugular venous distension is going to crump on you in a very brief interval. This is classic 'golden hour' stuff: interventions you can undertake in the immediate post trauma period which can alter the course of patient decompensation.

She's suffering tension pneumothorax of the right lung. Current ATLS guidelines would be needle thoracostomy followed by chest tube placement. These are under review, as needle thoracostomy is seldom indicated, is overused, and causes iatrogenic trauma more often than it helps.

I would obtain an immediate airway with endotracheal intubation, followed by immediate right thorocostomy tube placement. A truly crashing/coding patient with tension pneumo might warrent a needle - but short of that I'd stick with tube placement, which can be done in less than 30 seconds by an experienced individual.

 

[lizzied2003]

oops, womansurg, I didn't mean to make it sound like we should all go stand on the helipad and wait. What I meant was i agree with Brewsters' comments and yes as you appropriately mentioned I too would promptly do a needle thoracotomy and secure an airway. What I should have posted is:


"once the need for transfer is recognized, arrangements should be expedited and not delayed for diagnositc procedures (ie. peritoneal lavage, CT) that do not change the immediate plan of care" ATLS guidelines pg. 327.

Also of note is that 'the doctor asses their own capabilites and limitations as well as those of their institution'

Prior to transfer an airway/breathing/circulation and immobilization are established.

I should have been clearer with my post. As well I mentioned all of the above because of setting being in a 'small rural hospital...only doc on'.
thanks.

 

[iamubiquitous]

except maybe

formal R chest tube
portable CXR
suprapubic

and

large bores + 2 liters wide open tamponade or no tamponade

ready self for patients from the other car.

 

[Voxel]

Her airway looks patent. You realize that the cause of her respiratory distress is the most important thing to take care of at this point (ABCs). It is likely secondary to tension pneumothorax on the right side. You procede with needle thoracostomy with resultant whoosh of air that comes out. You procede to place a chest tube on the right and order a portable cxr. Breath sounds are now heard on the right side. The patients BP perks up to 106/66. Her breathing improves to 22 breathes per minute. You place her on 2 liters O2 by nasal canula with a pulse ox of 99%.

At the same time nurses place a large bore 14G IVs in each arm (2 large bore ivs) and procede to send off a multitude of tubes with blood for stat cbcc/sma-7/pt, ptt, inr/type and cross.

You have the nurses page anesthesiologist on call to intubate/or be ready to intubate the person given a patient with possible complex facial trauma and in a cervical collar ( as you have little experience with this, but if the patient's airway starts to crump you will be prepared to do it yourself).
You also have the nurses page the general surgeon, urologist, and orthopaedic surgeon on call (probably the only one of each in this town) to evaluate the patient. The nurses relay a message from them, hang in there... we'll be there in 15-30 minutes.

1)What are the next 2 things you will turn your attention to?

2)What will you do?

3)Why these problems over others?

4) Please explain the physics of a chest tube and the pleurovac(sp?). How would you connect the chest tube to it?

 

[droliver]

You would need to go on and address her airway while she's relatively stable. I would be worried with her midface trauma that she will not wait 15-30 mins before she turns into an emeregent airway. I would cancel the GU consult, its just a waste of everyone's under these circumstances (rural ER with trauama patient awaiting transport) & a potential bladder or urethral injury is not life-threatening. With no blood in your chest tube, other potential sources of life-threatening bleeding need to be assessed with a pelvic xray, if she has a fracture there & drops her pressure again she needs her pelvis wrapped with a sheet to close her pelvis volume down & tamponade until she could possibly get an external fixeter by your orthopedist prior to transport. As a non-surgeon there is little you could do about intraabdominal bleeding so I'm not sure there's anything you could do for that other then to document it with a FAST scan on ultrasound if that modality is available to you (unlikely in this rural ER). If your surgeon gets there & she still is having hypotension, a supraumbilical DPL would help differentiate intaabdominal from pelvic bleeding - if its her pelvis still she's likely SOL & going to die by the time the orthopedist gets there (I'm assuming there is no vascular IR service available to embolize her pelvis). Pericardial tamponade is an extremely rare but possible life-threatening after this blunt chest injury , but if she has that she's going to die nearly 100% before you can adequately treat that given your described resources. A very important thing to assess with this patient is correction of her base-deficit on her ABG's which gives you better feel for the adequacy of her fluid resucitation. With her constellation of possible injuries I would be very low threshhold to go on order O- blood

Your most valuable service to this patient after her airway & IV access + chest tube is to be urgently arranging transport by helicopter or ambulance to a more appropriate facility

 

[iamubiquitous]

I say get some kind of airway control now -- laryngeal mask?
Empty her stomach -- OG tube here right?
Exposure--->Secondary survey: w/ eardrum, pulses, rectal etc.
GCS
Read CXR -- tube good? lung up?mediastinum?etc.
XR Pelvis -- pelvic fx vs femoral fx
Palpate, reaproximate/reduce and stabilize skeleton
Initial blood volume from CT?
Tox screen (are we getting any urine?),EtOH,b-hcg
Her circ volume is probably getting pretty thinned out -- give PRBCs

Question: Can a skull fx w/ resultant loss of CSF and drop in CSF pressure give you a 3rd nerve palsy?

 

[lizzied2003]

I wouldn't wait for anesthesia to intubate. You are an ED doctor for goodness sakes !
If anesthesia is in house that's a different story. At the very least her airway needs to be assessed by you.
Put her in hi flow oxegen. Even if her sats are 99% she has a pneumo and you are not sure of her perfusion/ventilation. Get an ABG if you feel strongly about leaving her in only 2 liters.

Get a better neuro exam. What is going on with the ipsilateral pupil. With the moaning and response we are sure her GCS in not greater than 8. I would safely assume she has a head injury and i think this is most concerning. (another reason why we shouldn't wait to intubate)

what about her spinal cord? We say that it appears to be immobilized well. Is there a chance of an injury? While we are getting her CXR for pneumothorax it would be a good idea to get pelvic / spinal films. If there is any indication of spinal injury she should get some methylprednisolone

Give her crystalloids. I am not sure if there is any worry about hypothermia but if she's going to get large volume replacement it is not a bad idea to warm them.

Reassess her abdomen. Is there any evidence that she is loosing blood into her perineum? Is there a chance of a rupture?
As previously stated FAST is not a bad idea.

I agree with IAU. Calling in more people (such as GU) may only deter her transfer. A general / trauma surgeon is definitely in order. If for nothing else than assessing the situation, determining what else should be done and clearing for transfer.

 

[ERMudPhud]

I would have yelled at the ER clerk to get the helicopter on its way. Then I would address the following issues

1. Airway, it might be "patent" for now but not for long. She has multisystem trauma, severely compromised mental status and a long flight in front of her if she is going to live. Intubate her now. Anyone working in an ER anywhere should have at least two airway options (intubate, Cric, LMA, something)

2. Breathing. I agree with womensurg. Needles are for prehospital providers and people who don't know how to do chest tubes. I have seen patients come in with multiple 14G angiocaths in their chest and still with tension or even worse no PTX at all, not even the one the angiocaths should have induced. If my physical exam revealed multiple rib fx's, SubQ air, OR, a deviated trachea I would put the tube in now, otherwise I would take the a few seconds to shoot a CXR as breath sounds alone are notoriously unreliable in diagnosising a PTX.

3.Circulation. The nurses can put in large bore IV's but I would put in a subclavian cordis. This allows me to dump large amounts of blood into her and measure her CVP. If her CVP is still high after the chest tube then she likely has tamponade. Finally, go ahead and start dumping in blood products (O-, FFP, etc) she is going to need it.

4. Undress her and shoot the big three: portable lateral C-spine, CXR, pelvis xray. You can actually shoot a bed side urethrogram while doing the pelvis xray in about 10 seconds and know if it is ok to place a foley. I assume we will see a normal c-spine, a CXR with a chestube and an endotracheal tube, and a pelvic fx. If the ER physician is ER trained and has an U/S a quick check of her heart can rule out tamponade and a FAST scan of her abdomen can confirm what we already know, she has significant intra abdominal/pelvic bleeding

5. Now that her she is intubated, her PTX is taken care of, and she is receiving fluid and blood products we can turn our attention to her other injuries. Immobilize her pelvis with a sheet to decrease intrapelvic bleeding. This plus adequate resuscitation with PRBC's, FFP, and platelets is all you can do for her internal bleeding.

6. Intracranial injury. Go ahead and give her mannitol. It might buy some time. While waiting for the helicopter, scan her head. If the CT shows an epidural with incipient herniation you have a tough decision to make. Her brain will likely be cottage cheese before she gets to a trauma center. I know rural ER's where the general surgeon of even the ER doc do burr holes so you might have to consider it. Anything other than incipient herniation from an epidural will likely have to be deferred.

7. Is her femur fractured or hip dislocated? fractured= traction splint dislocated=reduce

8. Finally, if the helicopter isn't there yet CT her abd/pelvis. A single source of bleeding like an avulsed spleen(unlikely) might benefit from being fixed prior to transport if your surgeon is quick. More likely she is bleeding from multiple internal injuries and pelvic fractures and needs to be on her way to a trauma center.

Hopefully this answers most of Voxel's questions except the one on the pathophysiology of chest tubes. javascript:smilie('')

 

[Voxel]

NS IV fluid is going in.
Type-O blood is ready.

You decide to intubate the patient given her poor GCS. Although it takes you two attempts, you manage to succesfully intubate the patient.

You place a right sided subclavian triple lumen central venous catheter.

No blood in the chest tube, just fluid and air. You send off an abg on ice.

Also you had the nurses call the nearest trauma center to send the medi-copter (helicopter) to transport the patient to a trauma facility. It will be here in about 1 hour.

2ndary physical exam: rectal exam, guaiac neg, brown stool, good spinchter tone. Pt continues to have a dilated pupil. Other cranial nerves appear to be intact, but is hard to assess as the patient does not respond to verbal command. The patient continues to respond to painful stimuli.

The patient's bp continues to go up now, it's 180/100, and the patient's heart rate slows down to 70.

Along with the portable chest xray, you order films of the pelvis, c-spine, abdomen, and femur.

The anesthesiologist arrives. The general surgeon arrives and does a supraumbilical DPL and finds bloody fluid on lavage.

You have the availability of getting a CT if you so choose. No portable ultrasounds are available, except the big machines down in the radiology department in the basement.

1) What do you do next?
2) What is/are the most important thing(s) to do at this time?

 

[ERMudPhud]

Originally posted by iamubiquitous

Question: Can a skull fx w/ resultant loss of CSF and drop in CSF pressure give you a 3rd nerve palsy?

There are case reports of low ICP causing cranial nerve palsies (usuall #6) but this is not likely the case here.

 

[womansurg]

Originally posted by Voxel
. Pt continues to have a dilated pupil. Other cranial nerves appear to be intact, but is hard to assess as the patient does not respond to verbal command. The patient continues to respond to painful stimuli.

The patient's bp continues to go up now, it's 180/100, and the patient's heart rate slows down to 70.

Cushing's reflex: bradycardia, hypertension, respiratory irregularity. Shoo the general surgeon away for now. The patient's going to herniate from increased intracranial pressure.

Admininster paralytic (vecuronium, etc), mannitol 25 grams IV, hypervenitilate to PCO2 around 25-30, and elevate the head of bed to 30 degrees. Stat neurosurg page. If she is enroute, ask if she wants you to attempt head CT, versus proceed straight to OR to prep for craniotomy. In OR also prep abdomen/chest for exploration.

If neurosurg unavailable and transfer is still an hour away, you're probably out of luck. Try to keep stabilized. If the patient is actively decompensating, you can attempt burr hole or craniotomy with your general surgeon, if she's willing.

 

[lizzied2003]

I think that the best you can do is try to keep stabilized with agressive pharmacologic agents and paralyze her and prevent further herniation. Is there some type of ventilatory support that will help reduce the ICP??
However, given what has been presented you may be out of luck.
Perhaps a helicopter should have landed at the scene--(this is what i always see on late nite Discovery Channel.)

On a side note--I also think the ED doc should not have ahd to 'tell the nurses' to call the nearest trauma center. Hopefully a skilled triage nurse would have known that the doc was up to his bum in alligators. Waiting to be told to do something you should already know results in a potential organ donor.

As stated control of this head injury probably supercedes everything.

Good job getting her intubated. In the event she herniates and progresses to brain death would keep her intubated and continue agressive supportive measures until familiy and organ bank can meet.

 

[iamubiquitous]

Forget CT
To OR
Drill head now or harvest organs later

but in reality contact family b/c

mortality has now reached essentially 100%

 

[droliver]

Womansurg,

wouldn't a cushing response have hypotension (not hyper) + bradycardia? Also I think a (+) DPL would neccessitate immeadiate ELAP regardless of her ICP, as ongoing bleeding would be the most immeadiate and treatable threat to her cerebral perfusion pressure. You would be treating her as best you could medically (transient hyperventilation,postural drainage, & manitol) simultaneously.

As far as an emergent craniotomy, I know some rural surgeons know how to do them, but it is fewer & fewer who recieve training. I've been told by a few Neurosurgeons that Burr holes are ineffective unless you see the pupil blow in front of you. An emergent EVD drain might be something to consider, but it's unlikely that they would have them @ a hospital that does no neurosurgical procedures. In practical terms, you are probably DOA if you have a severe CHI this far removed from an area without Neurosurgical coverage. Same thing goes for heavily bleeding posterior element pelvic fractures when angiography is not available.

 

[womansurg]

Doc Ollie! If you haven't stood helplessly at the bedside while a young person with head injury undergoes uncal herniation under your very eyes, then you haven't done enough trauma, son!

This is a pretty classic description of impending herniation. The person goes on to have extreme autonomic instability - widely variable blood pressures, profound swings from brady to tachycardia...then suddenly, all is calm. They herniate and everything stabilizes, but pupils are fixed and blown. Then you keep 'em stable for organ harvest.

You would have to address the impending herniation in some fashion immediately, or else brain death is imminent. I've done ex laps while the neurosurg was doing their cranie - and that would be the probable chain of events here, if neurosurg capability existed.