March 2016 Medical Case Study of the Month

Because we love you guys SO much, we decided to do a trauma and a medical case study this month. Let us know what you guys think!

HPI

You and your partner are working for a rural EMS service and are called to a residence for a mid-60s male complaining of leg pain. Upon your arrival to the scene, you are greeted at the door by family who direct you to the patient.  The patient is found lying on a bed in a rear bedroom feeling considerable amount of pain in the right groin and feels “numb” in his left leg. Per the patient, the pain started approximately thirty minutes ago, and has grown increasingly worse, rendering the patient unable to ambulate.

ASSESSMENT

  • Skin is pale, cool, and diaphoretic
  • Left leg is cyanotic in color and cool to the touch; Right leg is warm to the touch.
  • Pt has an absent Babinski response to left foot.
  • Rapid/regular/weak radial pulses on the right side; absent on the left
  • Respiration appears rapid, but non-labored
  • -L/S are clear/= in all fields w/= rise and fall of the chest
  • No obvious indicators of trauma noted

VITAL SIGNS

  • BP: 120/60 in the right arm; 50/24 in the left arm
  • HR: 120s/regular
  • RR: 20/regular
  • BGL: 157mg/dl
  • SpO2: 96% on R/A

HISTORY

  • Family advised that the patient has received recent treatment and surgical repairs for “PEs”; when the family gives you the discharge paperwork, you and your partner noted that the patient does NOT in fact have a history of pulmonary embolus, but was seen for surgical repairs two femoral aneurysms and a consult for another that needs to be repaired still.
  • HTN
  • Diabetes

MEDICATIONS AND ALLERGIES

  • Unknown medications
  • NKDA

TREATMENT

Crew continued to question patient about any pain; he stated that he felt a “pop” in his abdomen and then began to experience excruciating pain in his groin. Upon assessment of the abdomen, pulsating mass could be felt in lower quadrants. Due to extensive transport, the patient was transported emergently to a rendezvous point for intercept with air medical flight team.

While en route to the rendezvous point:

  • Two large bore IVs were established in the bilateral ACs
  • Crystalloid IV solutions administered (approximately 600ml 0.09% NS)
  • Patient placed in trendlenburg position and kept warm with blankets
  • High-flow O2 via NRB @15lpm
  • Maintained blood pressure of 50 systolic in left arm and 120 in right
  • Sinus tachycardia on the monitor with no ectopy of ST segment depression or elevation noted (No EKG provided from submitter)
  • Transferred to flight team and taken to surgery at local Level II Trauma center

FOLLOW UP

After arriving at the hospital, the patient’s aneurysm was fully repaired. The patient’s aneurysm tapenaded off prior to arrival at the hospital, but he had infarcted part of his spinal cord, causing him to lose sensation to the left leg. The patient was placed on dialysis due to infarct to renal artery as well, and remains at the hospital undergoing treatment and rehabilitation. He is expected to make a full recovery.

DISCUSSION

  • What would you have done differently?
  • Would your treatment have differed if you weren’t in a rural service?
  • If you couldn’t fly the patient, what would your next steps have been?
  • Studies are still being done on this, but do you believe that tranexamic acid should be considered for potential life-threatening hemorrhage regardless if from trauma?

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