August 2017 Trauma Case Study

HPI

You are working for a rural service and are dispatched to a stretch of interstate highway for a motor vehicle accident. While en route to the call, dispatch advises that multiple callers are reporting possibly 2-3 victims trapped inside a car that is completely engulfed in flames. You are dispatched as the secondKing LT size 3-6538_0 unit to the accident to assist the initial crew. You find one vehicle off the roadway approximately ten feet down an embankment. The car is burned beyond recognition and unable to tell extent of body damage to the vehicle. One victim was found ambulatory on the scene and was taken to the first arriving ambulance for care.

  • A 30ish year old male is found lying supine on the stretcher. Pt is alert and oriented and yelling that he is going to die.
  • Has charred face and hair; soot noted in the patient’s nares and oral cavity.
  • Has blanched white skin around his ears, eyes, nose, and mouth.
  • Second degree burns noted to chest and lower extremities bilaterally; has what appears to be “blast injury” to both hands and is missing digits on both hands. Skin has sloughed off and bone ends exposed. Bleeding is controlled and clotted off.
  • Airway is mostly clear upon initial assessment, however, wheezing is noted at this time

INTERVENTIONS

  • Pt has 18g IV’s  established in bilateral AC’s.
  • 100mg of Succinylcholine and 20mg Amidate administered for RSI
    • No ET intubation attempts were made and KING-LTD placed and secured.

VITALS

  • B/P: 130/82
  • HR: 118.
  • ETCO2 shows good wave form at 35.
  • Clear and equal lung sounds in all fields

TRANSPORT/HANDOFF

  • Transported emergently to local community hospital approximately ten  minutes away to wait for air-medical transport.
  • **Note: Air medical transport had 35 minute ETA; closest trauma center was 25 minutes by ground.**
  • Transferred inside for evaluation by ER physician at the community hospital.
  • X-ray imaging was performed which showed air in the abdomen; KING-LTD was removed and intubation was performed.
  • Patient placed on propofol drip; OG attempted x2 by ER physician and were unsuccessful.
  • Transferred by air-medical transport team for transport to regional level II trauma center for clearance and then to a local burn center.

DISCUSSION

  • What are some downfalls for SGA placement for this patient? ETI?
  • Transport decision is key. What are your standing orders for air transport?
    • Rule out trauma before burn unit
  • Other considerations/concerns for this patient to improve outcome?
  • What are your standing orders for fluid resuscitation for patients with burns and hemodynamically stable vital signs?

 

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