October 2017 Trauma Case Study

tree standIt’s a calm and cool morning on a fall weekend. You and your partner are working for a rural ambulance service. Your truck checks are done, a fresh pot of coffee is brewing. You and your partner are looking for a relaxing weekend shift. Shortly after day-break, you get called to a local farm residence for a hunting accident. Dispatch has no further information for you at the time of dispatch. Your town has a local community hospital with no trauma service capabilities. The closest trauma center is a level II which is approximately 50 minutes or more by ground.  Since your coverage area is vast farmland and  has limited access to interstate, your ground transport time will be well over an hour. Due to the distance and time, you request air-medical transport to come up on standby. Generally it takes 15 minutes to have a helicopter leave the level II hospital to your scene.  Your response time is approximately 20 minutes to the scene. While en route to the call, dispatch updates you that the patient fell from a 16ft deer stand and landed on his back. The caller advises that they are deep in a woods and will try to have someone meet you at a nearby clearing to escort you back to the patient.  Upon your arrival you are greeted by another hunter who advises that the patient is several hundred yards into a deep woods.  A local volunteer fire department is on scene with you able to assist. You instruct the fire department to prep a LZ and request the helicopter to the scene. You and your partner and a few firefighters trek into the woods with a stokes basket and backboard. You make contact with the patient. He is alert and oriented to all questions. He states that he was sitting in the deer stand and fell landing on his back. He states that he was not wearing a harness, and does not remember falling. The patient advises that he remembers waking up on the ground and having excruciating back pain and shortness of breath. A fellow hunter with the patient is holding manual C-spine. Patient denies neck pain and is able to move upper and lower extremities. Patient complains of right sided back pain. The patient landed on his right side on  a medium sized log after falling from the stand. He has several layers of thermal clothing and hunting camouflage on that was removed for assessment.  Several abrasions to right flank and chest area are noted. He has slight crepitus to the back and posterior ribs upon palpation. The patient complains of pain radiating to his sternum and shoulder area. You place the patient in a c-collar and secure to long spine board. Patient is placed in stokes basket and carried to clearing to your ambulance to wait for air-medical transport. Further assessment is done within your ambulance. Your partner establishes large bore IV’s while you conduct another assessment. There is crepitus noted to chest, but no paradoxical motion is noted. The patient has a midline trachea, and no JVD is noted. You note that the patient has diminished lung sounds. Patient has no other significant signs of trauma noted in your assessment. Vitals are obtained. Vitals are significant for the patient being hypertensive with a pressure of 178/110, heart rate of 112, and an initial SpO2 reading of 78% on room air. You check to make sure that the probe is attached properly. Probe is fastened correctly to the patients finger. The pleth wave on the monitor is consistent with respirations.  You apply 15lpm of supplemental O2 via NRB mask. SpO2 levels rise to 83% and maintain at this level. You ask your partner to decompress the chest while you update the incoming flight crew via radio. Your partner declines stating that he does not feel it appropriate, and wants to wait until after flight team arrives.  Several minutes later flight team arrives on scene and care is transferred to the flight team. The patient is then flown to Level II trauma center and undergoes evaluation.

Tension PneumoThe hospital calls a few hours later with an update on the patients status. The flight crew performed needle decompression; it was noted by the team that  the decompression was unsuccessful and neither the SpO2 levels or lung sounds improved. Inside ED, the patients status changed and started to go into respiratory arrest. After performing chest tube placement, the patient was emergently  intubated, and shipped to ICU. Numerous posterior rib fractures, sternal fracture, and pulmonary contusions, as well as abnormal lab values were found upon evaluation at the trauma center. The patient remained intubated in STICU for several days before being discharged to rehab.

Talking Points

Due to the patient being outside for prolonged time and shocky condition, do you feel as though the pulse oximeter reading was correct at 78% on room air, or do you think that the patient’s actual SpO2 was higher?

  • Here is a link to an article discussing how to properly use pulse oximetry, as well as how to monitor pleth waves.

Do you agree with your partners request of wanting to wait to decompress the patient, or do you think that decompression was warranted with the given presentation and assessment?

  • How do you handle clinical disagreements surrounding procedures that you deem to be time sensitive?

Had you decompressed the patient and saw no improvement in the patients condition, would you have intubated the patient prior to arrival to the hospital?

  • What are the potential benefits or downsides of intubation in this circumstance?

Here’s a link to an article from the Western Journal of Emergency Medicine discussing the use of POCUS to identify pneumothorax.

Jugular vein distention and tracheal deviation are some of the latest signs to occur in pneumothorax; common dogmatic teaching about these signs should be taught with a grain of salt.

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