August 2016 Trauma Case Study

This case study was donated by a friend of the show that works in a large metropolitan area. Let us know what you think!

HPI

You and your partner work for an urban EMS system and are dispatched to a reported “jumper” from a bridge nearby. As you enter the scene, you and the responding fire crew are guided to the back of an industrial park with no obvious hazards noted. A few bystanders that are present inform you that the patient, an approximate 20yom, jumped off of a nearby bridge into a ditch. The bridge was estimated to be fifty feet high. You and your partner set up your stretcher at the nearest access point. After hiking down into the ditch with a few members of the fire crew, you note that the patient is lying supine on the ground and is only responsive to painful stimuli, occasionally opening his left eye and groaning. You rapidly immobilize the patient with a c-collar and extricate him out of the ditch on a scoop stretcher. Transferring him to the pram, you note the patient has an approximate baseball-sized indentation in the posterior region of the head, bilaterally deformity to the ankles, left-sided deformity to the lower leg, and right-sided depression to the chest with clear and equal lung sounds that are maintained throughout care. There is notable dilation in the left pupil and the right is constricted. Blood and clear fluid are noted from the left ear canal.

INITIAL ASSESSMENT

  • Patient remains only responsive to painful stimuli and is given a GCS of 9
  • Skin is profoundly pale, diaphoretic, and cool
  • Respirations appear shallow and irregular ranging from 10-28
  • Strong, regular radial pulses in the 70s

VITAL SIGNS

  • BP: 152/86
  • HR: 76
  • SpO2: 91% on room air
  • RR: Irregular; ranging from 10-28
  • EtCO2: 39mmHg
  • BGL: 157mg/dl

TRANSPORT AND TREATMENT

Patient transported to a local Level I trauma center that is approximately 15 minutes away from the scene. En route, patient mentation decreases to a GCS of 8 with markedly reduced respiratory rate at 6bpm. Nasal airway placed and BVM ventilation commenced with improved SpO2% to 98 and an EtCO2 maintaining between 36-39mmHg. Crew considered advanced airway placement, but withheld due to lack of paralytics and significant trismus noted. Two large bore IV lines established. Patient maintains clear and equal bilateral breath sounds. Pelvis is splinted prophylactically. Left lower leg, left ankle, and right ankle splinted.

VITAL SIGNS AT TRANSFER OF CARE

  • BP: 164/92
  • HR: 64
  • SpO2: 98% with BVM Ventilation
  • RR: Pt is now apneic and being ventilated at 20bpm
  • EtCO2: 38mmHg

FOLLOW UP

Patient is diagnosed with a subarachnoid hemorrhage, basilar skull fracture, three broken ribs on the right side and two on the left, bilateral ankle fractures, a left-sided tibia/fibula fracture, and an L4-L5 fracture. Patient rapidly transferred to the surgical department where he arrested and was later pronounced.

DISCUSSION

  • What would be your first priority for this patient?
  • How would your care change if you were a rural provider as opposed to an urban medic?
  • If you had access to paralytics or induction agents, would you have attempted to chemically facilitated intubation?
  • What would you have done differently?

April 2016 Case Study

In honor of our Pizza and Peds event coming up on May 2nd, we are going to be going over a pediatric case study today. This was donated to us by a friend of the blog. 

You and your partner are dispatched to a private residence for a report of difficulty breathing on a three month old. As you arrive on scene, and officer yells, “I’m carrying her out to you!” You look at the officer’s arms and see a limp, unresponsive, and undersized child that has a back brace on. The patient’s mother refuses to exit the home to tell the crew any type of history, medications, allergies, etc. The officer on the scene tells you that the only thing that he knows that she was premature (born at 24 weeks) and had spinal surgery for an unknown problem last week at a children’s specialty hospital.The patient is approximately 3kg.

ASSESSMENT

  • Pt is a GCS of 4 (Occasionally moaning to painful stimuli, but with no movement)
  • Skin is cool, pale, and dry
  • Absent brachial pulses, but irregular and weak carotid pulses noted in the 80s
  • Respiration is shallow, bradypneic (rate of 4-8bpm)
    • L/S are clear bilaterally
  • No obvious DCAP-BTLS noted
  • Pupils are dilated/=/sluggish bilaterally
  • Patient’s diaper is dry

VITAL SIGNS

  • HR: 80/irregular
  • RR: 4bpm/irregular/shallow
  • SpO2: 76% on R/A
  • Unable to determine B/P
  • Glucose: 86mg/dl
  • EtCO2: 16mmHg
  • Temp: 96.4°F

TREATMENT

  • Evidence of trismus noted; BVM ventilation initiated; crew has no access to paralytics
  • EKG monitor placed revealing sinus arrhythmia and not ST abnormalities
  • Manual IO established in the L medial tibia
  • Initiated 20cc/kg bolus
  • Transported emergently to local community hospital approximately ten minutes away from scene

FOLLOW UP

  • Follow up with community hospital reveals elevated white count and lactate levels
  • Patient underwent RSI and intubated in ED
  • Flown to children’s specialty hospital; en route patient arrests
  • Ongoing resuscitation at specialty hospital for approximately forty minutes where patient was later pronounced dead

DISCUSSION

  • What would you have done differently?
  • If s/s of shock persist despite fluid boluses, which pressor agent would you consider?
  • How much fluid would you consider before initiating a pressor agent?
  • What is the role of RSI in pediatrics?

March 2016 Trauma Case Study

You are working for a rural county service and dispatched to local interstate for a motor vehicle accident with unknown injuries.  Roadways are slick and hazardous due to a recent snow storm that has passed through the area. While en route, dispatch advises that a state plow is on scene advising that this is a head-on semi vs semi accident with one confirmed severely pinned occupant in one of the semis.  While en route you request air- medical transport to come up on stand-by due to the prolonged extrication and time to closest trauma center (approximately 45-60 minutes, however it could be longer depending on roadway conditions).

You are the first arriving unit on scene. You find two semis involved in a collision. One semi (semi A) was traveling westbound on the interstate and crossed the center median striking the other semi (semi B) head on. Semi A was on top of Semi B. Significant front-end and significant intrusion noted to the cab of semi B. No patient was found in semi A. Bystanders reported that the driver of semi A walked down the roadway for help. Driver of semi B was found to be heavily entrapped in the semi. Significant intrusion noted to the drivers side door as well as cabin room. The dashboard was crushed onto patient’s lap and the steering wheel was broken and bent upwards.

The patient, a mid-40s male, was alert and oriented  upon contact and has slight facial swelling and dried blood to the face.  He complained of no head, neck, or back pain, and denied any loss of consciousness as the result of the accident. The crew placed patient in a C-collar as precaution and noted a deformity to the left forearm. The patient also complained of lower leg pain, however due to the crushed dashboard, assessment could not be performed at this time. The patient had blood on his pants and what looked like a possible impalement from dashboard plastic, but advised that he was able to still move both his feet. Due to limited access to the patient, interventions could not be performed at this time. Patient was kept warm with warm blankets. Fire Rescue arrived on scene and started extrication on the semi. Air-medical transport requested at this time with ETA of 15mins. Landing zone was established on the interstate by fire personnel.  Due to poor access to the patient, wrecker was requested to pull Semi A from on top of Semi B to allow for better access. Dashboard was able to be “rolled” off the patients lap, and relief cuts made to the “A post” to allow for pt to be freed. Patient was not impaled at present time, however significant amounts of blood could be noted on patient’s pants. He was placed on a spine board while inside the semi and removed out of the passenger’s side.

Patient carried to ambulance for assessment and treatment by flight team. Clothing was removed revealing bilateral femur fractures and a blow out of the right knee. Patient had an open tib/fib fracture on left leg with significant bleeding. Bleeding controlled with use of tourniquet. IV access was obtained and crystalloid fluids administered with a 1G bolus of Tranexamic Acid with all extremity injuries splinted.  BP remained around 90 systolic and sinus tach on the monitor with a rate in the 110s. The patient was transported by flight from scene to a local Level II trauma center.

The patient is now recovering in a rehab facility, and was found to have mandibular fracture, nasal fracture, C7 fracture, pelvis fracture, radius/ulnar fracture, bilateral femur fractures, and left tib-fib fracture. Patient had a grade III liver lac and received several blood transfusions due to low blood count, and is expected to make a full recovery.

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?

FEBRUARY 2016 CASE STUDY

HISTORY

You are your partner are working an ALS rig in an urban setting, when you are dispatched to an assisted living community for a reported unresponsive party. When you enter the dwelling, you see a late 60s male lying in the door jam between the bedroom and the living room. The patient’s wife is on scene and hysterical, but is able to tell you that the patient was acting “weak” at dinner which was approximately 1700; she states that the patient excused himself early from the dining room, going back to their apartment. Around 1815, the wife states that she returned to the room, and found the patient “slumped over” on the ground next to his bed not responding when she would shout his name. There are no obvious signs of trauma, and the three nurses on scene all state that this is their first night with the patient, and do not know what type of medical problems that he has.

INITIAL ASSESSMENT

  • Patient is a GCS of 6
    • Does not open eyes
    • Occasionally moans to painful stimuli
    • Occasionally flails right arm, batting at NRB
  • Absent radial pulses; irregular carotid pulses; fluctuates between 60-220
  • Cheyne-Stokes breathing pattern
    • L/S are clear= in all fields
    • = Rise/fall of chest
  • No obvious indicators of trauma
  • Pupils are dilated/= bilaterally
  • Patient has a demand pacemaker
  • Patient has a drainage shunt from a recent cholecystectomy; does not appear to be red, inflamed, or have any obvious drainage
  • Jaw is clenched

VITAL SIGNS

  • Unable to palpate radial pulses
    • Automatic BP cuff gives readings of 110/60-220/178…
  • HR: Irregular; fluctuates between 60-220; maintains primarily around the 80-90
  • RR: Fluctuates between 2-40
  • Skin is pale, cool, and moist
  • BGL: 349mg/dl
  • SpO2: 85% on R/A

INITIAL DIAGNOSTICS AND TREATMENT

  • NPA placed; 15lpm O2 via NRB until patient could be transferred to commission; transitioned to BVM once in commission
  • Requested first responders for man power due to patient condition
  • Bilateral large bore IVs with fluid boluses started
  • C-Collar placed due to unknown etiology of unresponsiveness

70YOM Feb Case Study 001

TRANSPORT DECISION

The crew opted to transport to the nearest facility which is a verified PCI/Stroke facility, but does not have any trauma resources, and is 4-5 minutes away from the scene. The crew opted to maintain a BLS airway with an NPA, suction, and a BVM. No paralytics were available; the only induction agents available are midazolam and fentanyl. Due to the obvious poor state of cardiac output, crew withholds induction agents. Patient delivered to ED with continued absent radial pulses (maintains irregular carotids) despite 750ml 0.09% NS bolus. SpO2 increases to 98% with a BVM; EtCO2 maintains around 15mmHg. Patient is inducted with etomidate/succinylcholine in the ED and intubated. Follow up reveals that the patient has an ejection fraction of 10% with a non-elevated white count. CT head/chest negative for thrombosis. Troponin is negative.

DISCUSSION

  • Are there any other diagnostic tests you would have run? 
  • Would your treatment have differed had there been an extended transport time? 
  • Do you feel that push dose pressors have a role in prehospital intubation? 
  • If an extended transport time would have happened, would you consider a pressor agent? What would have been your first choice? 

 

JANUARY 2016 CASE STUDY

HPI

You and your partner are working on an ALS rig in an urban setting. You’re dispatched to a breathing problem at a private residence for 35yom complaining of shortness of breath and “stabbing” chest pain on the right side that is not exacerbated by palpation or deep inspiration. The patient states that he had an acute onset of chest pain approximately two hours ago while he was at rest, and it progressed into severe dyspnea. The patient is ambulatory on your arrival, appears markedly anxious, and is mildly dyspneic.

MEDICAL HISTORY

  • COPD
  • DVTs/PE
  • Cardiac Arrest due to PE
  • Four cardiac stents
  • Diabetes

MEDICATIONS

  • Lantus
  • Novolog
  • Lisinopril
  • Metoprolol
  • Clopidogrel
  • Albuterol
  • Symbicort

ALLERGIES

  • Penicillin
  • Vicodin
  • Morphine

ASSESSMENT

  • Strong, regular, and rapid radial pulses
  • Skin is warm, pale, and dry
  • Respirations appear mildly dyspneic
    • L/S reveal mild expiratory wheeze in the R upper lobe, and clear but diminished in the L side
    • Respirations of 28; 4-5 word sentences
  • Pupils PERRL
  • No obvious trauma noted
  • Patient is a GCS

VITAL SIGNS AND DIAGNOSTICS

IMG_20160105_154713

IMG_20160105_154732

  • BP: 180/132
  • HR: 124
  • RR: 28/mildly labored
  • SpO2: 98% R/A and 99% on NRB @15lpm
  • Blood glucose: 285mg/dl
  • EtCO2: 39
  • Dyspnea does not improve with NRB

Are you suspecting more of a cardiac or respiratory presentation? Combination of both? 

What interventions would you do for this patient? 

 

 

DECEMBER 2015 CASE STUDY

You and your partner are working in an urban ALS service and are dispatched to a cardiac arrest at a private residence. On arrival to the scene, the fire department is breaking down a door into an upstairs bathroom. Patient’s wife states that she and the patient, a 25YOM, fell asleep together around 2000; she states that she woke up at 2045 to find the patient had left the bedroom; the upstairs bathroom door is locked, and the patient is not responding while the patient’s wife or fire department is calling out for him. According to the wife, the patient has not taken his Prozac in over two weeks. Crews break down the door to find the patient naked, covered in vomit, and alert to loud verbal stimuli. No obvious signs of trauma, drug paraphernalia, medication bottles, or alcohol noted.

ASSESSMENT

  • Patient is a GCS of 11
    • Opens eyes to verbal commands
    • Inappropriate answers to questioning
    • Localizes pain
  • Respirations appear within normal rate, shallow
    • L/S are clear= in the upper lobes w/coarse rhonchi in the lower lobes
  • Strong/Regular radial pulses noted
  • Skin is hot, flush, and diaphoretic
  • Pupils are fixed and dilated

VITAL SIGNS

  • BP: 124/76
  • HR: 64/regular; NSR on the monitor w/no ectopy or ST abnormalities
  • BGL: 113 mg/dl
  • RR: 12/shallow
  • SpO2: 97% on R/A

Any considerations for specialty hospitals?

Where would you start with your treatment?

NOVEMBER 2015 CASE STUDY

You and your partner are working an ALS rig for an urban service, when you are dispatched to a private residence for a mid-50s YOF c/o dyspnea. The pt is wrapped up in blankets on the bed, and states that she was recently (within the last week) diagnosed with bronchitis. The pt is restless and has a harsh, productive cough. The pt also states that despite frequent use of her inhaler, she is not getting any relief from the shortness of breath. Pt is asking repetitive questions, and only follows commands after several attempts at instructing her.

ASSESSMENT

  • Pt is a GCS of 13
  • Skin is hot, ashen, and moist
  • Weak/regular/rapid radial pulses
  • Resp appear to be elevated @28bpm
    • Audible rhonchi w/dark phlegm produced
    • Expiratory wheeze noted in the anterior fields
    • Pt demands to sit up and is very restless
  • No obvious trauma noted

VITAL SIGNS:

  • SpO2: 92% R/A
  • RR: 28/mildly labored
  • H/R: 136/regular; narrow complex ECG w/no ectopy or ST abnormality
  • B/P: 88/50
  • BGL: 186
  • Tympanic Temp: 101.9F

TREATMENT

  • Where do you start?
  • What are some possible concerns you have?
  • Specific facility you would transport to?
  • Does your treatment change depending on whether or not you work in an urban v. rural setting?

OCTOBER 2015 CASE STUDY

You and your partner are working for an ALS service and are called at 0200 to a private residence for approx. a 45 YOM. The pt’s wife meets you at the door and advises you that the pt was “shaking in bed” for about five minutes, and is now not waking up. The pt is lying supine in bed w/no obvious trauma noted. He is a GCS of 5; occasionally moans and movement w/deep painful stimuli. Pt is incontinent of bowel and urine; no recent drug use or ETOH consumption reported. He was reported last seen normal at approx. 1900 the evening before with no complaints.

HISTORY

  • Cocaine usage
  • HTN

MEDICATIONS

Prescribed Lisinopril; has not taken it in months

ASSESSMENT

  • Eyes: Dilated bilaterally
  • Skin: Cool, pale, moist
  • Resp: Irregular, shallow, and bradypneic @4-6bpm
  • Pulse: Bounding, regular, rate of 64
  • BP: 212/124
  • BGL: 118mg/dl
  • SpO2: 90% R/A
  • EKG: Reveals no ST abnormalities/ectopy

You are 10 mins away from a community hospital and 20 mins away from a PCI/Level II Trauma Center.

What are your priorities? What facility would you take him to?

SEPTEMBER 2015 CASE STUDY

You and your partner are working for an Urban ALS service. You are dispatched to non-emergent abdominal pain for a roughly 50 yom at a private residence. The pt states that approximately an hour ago, he was sitting at rest watching t.v., when he felt a “tearing” pain in his lumbo-sacral back. The pt states that since then, he has been feeling “lightheaded” and “dizzy”. He is lying supine on his bed and is very drowsy.

ASSESSMENT

  • Pt is a GCS of 15
  • Skin is Cool, Ashen, and Diaphoretic
  • No radial pulses present bilaterally
  • No obvious trauma noted
  • Resp appear rapid, shallow, and unlabored with no audible B/S

VITAL SIGNS

  • BP: 60/30HR: 72/reg
  • Resp: 24
  • Pain: 10/10 with movement; 0/10 while lying still
  • BGL: 164 mg/dl
  • EKG: NSR w/no ST segment abnormalities; occasional PVCs

AVAILABLE RESOURCES

  • Community hospital – 3 mins away
  • Level II Trauma/PCI Facility- 15 mins away

TREATMENT

Where do you go? What do you do?