Any chances of survival?

[ericdamiansean]

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Hey guys, just want an opinion on an emergency case I saw recently.

This guy came in, was run over the chest by a van, came in with full Glasgow Coma scale, did not show any gross signs of trauma,was tachypneic, but on examination, multiple rib fractures, auscultation showed fluid in both lungs.

A few minutes after that, IV lines were put in, intravenous blood and NS. He was too tachypneic so was sedated slightly, and was next intubated. Chest tube was not put in until about 40 minutes after that.

Patient was practically still awake during the whole thing, he was not given any extra sedation because the team was afraid he might lapse.

His condition deteriorated over time, went into cardiac arrest, CPR started as well as cardioversion..but at the end, he died.

Just want an opinion on this, how could this have been managed better and can a patient who had a van run over his entire chest survive?

 

[docB]

...can a patient who had a van run over his entire chest survive?

Yes.

As for the question of this particular guy it's hard to say without knowing exactly why he died. Was an autopsy done?

As for what could have been done better it's also hard to say. These pts are tough because they look goo and go down rapidly. I'd say that two large bore IV's and NS bolus should have been started immediatley on presentation. CXR and pelvis should have been done immediately after. Was this in a trauma center?

 

[ISU_Steve]

Yes, the patient could have survived (I've seen a case exactly like the one described except the patient lived thanks to extremely aggressive care), but as was said by DocB, to be sure, you would need to know what killed him to know what you should watch out for the next time you see this.

 

[Seaglass]

Well, it's hard to say if THIS patient could have survived, but people certainly have survived worse.

 

[EMResident]

Hey guys, just want an opinion on an emergency case I saw recently.

This guy came in, was run over the chest by a van, came in with full Glasgow Coma scale, did not show any gross signs of trauma,was tachypneic, but on examination, multiple rib fractures, auscultation showed fluid in both lungs.

A few minutes after that, IV lines were put in, intravenous blood and NS. He was too tachypneic so was sedated slightly, and was next intubated. Chest tube was not put in until about 40 minutes after that.

Patient was practically still awake during the whole thing, he was not given any extra sedation because the team was afraid he might lapse.

His condition deteriorated over time, went into cardiac arrest, CPR started as well as cardioversion..but at the end, he died.

Just want an opinion on this, how could this have been managed better and can a patient who had a van run over his entire chest survive?

This is like an M&M. There's always something that could be done better. From what you describe, perhaps an earlier intubation, more vigorous resuscitation and aggressive chest tubes may have improved survival. Without being present, however, it's hard to know what interventions may have improved this person's chances.

I'm impressed if his bilateral hemothoraces were diagnosed on either primary or secondary survey (absent a CXR).

As far as the patient being awake, there may have been a plan behind that. Withholding pain medicine isn't a kind thing to do, though, and fear of hypotension is powerful.

 

[ericdamiansean]

Yes.

Was this in a trauma center?

Nope, this was at the A & E department

No X-rays were done..but I did hear recently from a senior surgeon that chest tubes should be done clinically rather than following a protocol ie. chest x-rays etc, this true?

 

[docB]

Nope, this was at the A & E department

No X-rays were done..but I did hear recently from a senior surgeon that chest tubes should be done clinically rather than following a protocol ie. chest x-rays etc, this true?

Yeah, if you've got a picture of your tension pneumo you've screwed up.

 

[Febrifuge]

Hey, I'm just the guy in the burgundy scrubs who keeps his gloves dry until someone tells me otherwise, but 40 minutes in the dept without a CXR is a little weird.

Then again, if physical exam gave them two hemothoraces, okay, maybe you don't get a picture at this hospital -- but then you need two chest tubes, right (...asked the EMT)? I would assume protecting the integrity of the lungs has got to be one of the first few things you do, once you know you have hemothoraces. Do you ever just observe and wait with bilateral lung compromise?

There's a buttload I don't know yet, but my Mattel "My First Retrospectoscope" is getting a reading here.

 

[Seaglass]

The A&E as in England?

 

[ericdamiansean]

The A&E as in England?

Accident and Emergency 🙂

 

[Apollyon]

Accident and Emergency 🙂

a/k/a "Casualty" - as in, "I work in Casualty at Stoke-Mandeville".

 

[a_ditchdoc]

Although it is difficult to judge third hand, it sounds to me as if the patient asphyxiated secondary to pulmonary contusions and the resultant edema. The time frame sounds about right as well If that is the case, there is little that could have been done to prevent the downward spiral.

 

[Seaglass]

Yes, I know what A&E stands for, what I was trying to get at was whether or not this was an American ED where the standard of care may be a bit different than in England.

 

[Apollyon]

Yes, I know what A&E stands for, what I was trying to get at was whether or not this was an American ED where the standard of care may be a bit different than in England.

I thought it was in the Asian South Pacific (Malaysia, Indonesia, or somewhere).

 

[ericdamiansean]

I thought it was in the Asian South Pacific (Malaysia, Indonesia, or somewhere).

Malaysia 😛

 

[Celiac Plexus]

it's hard to comment without having been there, or having spken to the op to fill in a lot more data....

that said, a chest xray is critical. in fact this patient should have had plain films of the c-spine, chest, and pelvis. if there was loss of consc. or if the pt was confused on arrival, a non-contrast head ct should have been done as well.

the airway management is first though, and intubating the patient is an appropriate move if there are airway issues. i don't think intubation for "tachycardia" is std. of care though. the patient should have been on continuous pulse ox, and cardiac monitoring.

back to the cxr, if the cxr showed ptx, or gross htx, a chest tube should have been placed. remember to get a cxr after placing the tube to confirm placement. a cxr is also important after intubation in this trauma patient to make sure that the et tube is aerating both lung fields.

one of the problems with a patient like this is the possibility of pulmonary contusions (as mentioned by another poster). this condition prevents gas exchange, and can be quite painful. if pulse ox had been done, we might have seen saturations in the 80s or 70s, and a steady decline until cardiac arrest.