# EMT-B Scenario - MVA



## DenverEMT

This is a scenario of a call I responded on as a brand new EMT-B. It was VERY confusing at the time and did not involve something that was taught in class. Just curious to see if those other EMT-B's can pinpoint "what killed him". This was a wonderful learning opportunity to me at the time and I am still fascinated at how sudden something like this happens....

It's about 23:00 and you're dispatched to an MVA w/injuries. Single engine, single ALS ambulance response. En route, your additional information is "2 car rear-end MVA. RP reporting that they are unable to get the driver of one of the vehicles out. Unknown extent of injuries". Due to the possibility of extrication, you start a rescue company. 

U/A you find a 2 car MVA with heavy rear end damage to one car, and heavy front end damage to the other. The driver of the front car was able to get out, but due to the intrusion on the second vehicle, the driver is trapped. You have two ambulatory patients as well. You start two more ALS ambulances emergent.

Vehicle 1: Occupied x2 adults. Both complain of neck/back pain and are fully oriented. No complaints otherwise, stable vitals. Both self-extricated and were walking around upon your arrival. These two are transported first non-emergent due to prolonged extrication on the other vehicle.

Vehicle 2: Occupied x1 adult. He is fully alert/oriented. You examine the vehicle to find the dash intruded into the pass. compartment, intern trapping your patient from the waist down. He complains of severe pain to his lower back and also to his legs. You are able to gain access into the vehicle via the back seat and start treatment on this patient while the Fire Dept. is extricating him. You establish C-Spine, start an IV, assess vitals etc. Vitals are 150/palp, 106 pulse rate, resp 20 and normal. This patient stays alert and oriented throughout the extrication, which lasted appx 20 minutes. They are able to roll the dash and pop open the driver side door. You place a backboard end-first in the car underneath the patient and plan to move him onto it by pivoting him and scooting him onto it. You move the torso towards the head of the backboard and are able to pull out the lower extremities from the dash. You scoot him completely on the backboard while still maintaining C-spine and your patient is suddenly unconscious/unresponsive/not breathing. Full COR. You begin CPR. Your EMT-P intubated this patient nasally and he is given 3 rounds of COR drugs throughout your emergent transport to the trauma center that is appx 10-15 minutes away. Patient is PEA on the monitor and does not improve throughout transport. U/A to the ER, your patient does have a pulse but is still unc/unresp. He is immediately taken to surgery. End of call


If he was AA0x4 throughout the whole extrication, but suddenly coded when extricated, what was the cause of his death?


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## Bosco578

Perhaps an Aortic shear that was being compressed by his postion,change of position releases the pressure and pt. bleeds out fast.


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## Sapphyre

Like Bosco, I'd go with some sort of internal bleed, probably aortic in origin, which was tamponade by the dash/position.  Did he code when the dash was rolled, or when you turned him?


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## Jon

Ummm... what is COR? I'm not familiar with that abbreviation. I assume you are discussing a condition of cardiac arrest?

If the extrication time was 20 minutes - I'm still going to guess that the time from incident to extrication is less than an hour. Crush syndrome is a POSSIBILITY - but I think it takes a few more hours to develop in most patients (at least by my Google-fu) - http://www.ncemsf.org/about/conf2003/lectures/bittenbender_crush.pdf

Given that crush syndrome would take longer - I'm going to go with some form of MASSIVE internal bleed that was controlled pre-extrication. If there was reason to believe that there was a multi-hour entrapment situation (car off the road and not seen until the morning, etc), then I thik ALS would need to proactivly treat for the potiential of crush syndrome... call command, and get some Squad 51 orders - an amp or 2 of BiCarb!

For the massive internal bleed - perhaps aortic, perhaps a major artery lacerated by a fractured pelvis or femur. Not much you can do.


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## Ridryder911

Acute traumatic arrest could be caused by multiple things, but the description in the scenario does appear to be that of a torn aorta. Transectional tears are not uncommon on rotational hits, as the aorta is torn by the inertia of the aorta and the ligaments and mesenteries holding it in place. Usually they may be asymptomatic at first and as soon as they are changed in position, will go out or die. 

I have had two such cases. One was a gentleman that was in a moderate MVC and when we laid him down to place onto the LSB, he immediately lost LOC. I for some reason, immediately raised him back up at a 45 degree angle. He immediately regained consciousness. I knew what I had at that time. We performed immediate rapid transportation while treatment en route. I gave him our company cell phone (they were not popular then) and had him talk to his family.. (I knew that he would die). 

Unfortunately, my prediction was right. He died in surgery. The descending aorta had torn and by sitting him in 45 degree angle compressed (clamped) it briefly to prevent further hemorrgaing. Usually most are dead before EMS arrives. 

Rr 911


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## YouthCorps1

i agree,,,did you also make sure that he wasnt choking on his tongue or if he vomited choked on that...nice job tho...just listing a possible...i think pressure was the key word here.


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## KEVD18

darn i cant figure out how to post video. i'll let jp handle it.


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## alexanderjbriggs

Personally, I don't believe this was an aortic tear because of the fact that the pt regained a pulse. Even if you were to pump the pt full of saline, his hypotension due to the lass of fluids internally probably wouldn't produce even a central pulse. In my opinion this pt had a similar condition like that of crush syndrome but due to the sudden onset It does not indicate crush syndrome. My guess Is do to the vehicle intrusion at the waist, the blood supply to the pt's legs for a prolong period of time, the blood that remainded in the legs became ischemic, so when the pt was released and that blood returned to the heart, the heart gets ticked because of the high ability and develops an arhythmia which leads to full cardiac event.


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## ZombieEMT

Might be a dumb question, but did you do a complete the entire assessment. You said everything you did do, I would assume you also checked ABCs? Intact airway? Breathing under control and normal? Major bleeding noted?


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## dixie_flatline

This sounds like an extended extrication we had several years ago.  It was a single vehicle vs a tree though, and we were cutting on that car for over an hour I think.  However, the outcome is really the same.  Patient was oriented and alert upon arrival, although he kept asking "Am I going to die?"  Almost as soon as he was freed from the pressure of the dash/intruding tree, his BP bottomed out, he lost consciousness, and never came back. I believe he had some severe pelvic trauma and bled out internally as soon as we took that pressure off.  It can be really disconcerting and tough to process when you lose one that fast.


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## Shishkabob

dixie_flatline said:


> I believe he had some severe pelvic trauma and bled out internally as soon as we took that pressure off.



Or a crush injury, though it usually takes a bit longer for that to set in.



If your patient says something along the lines of "I'm going to die" or "Don't let me die", you really need to be on your game as they very well might, soon.


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