# usalsfyre's Train Wreck #2



## usalsfyre (Aug 31, 2011)

I appologize, it's two days late but I got my gluteus handed to me Monday at work and was on Dad duty yesterday. So here goes....

You are working overnights as part of a double medic truck in a city of 100k. At appx 2200 you get dispatched just outside of the city limits to a MVC, report of one patient ejected. On arrival you see an undamaged Volkswagen convertible and a crowd of people standing around what appears to be a male teen 120+ feet away. 

What now?


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## abckidsmom (Aug 31, 2011)

usalsfyre said:


> I appologize, it's two days late but I got my gluteus handed to me Monday at work and was on Dad duty yesterday. So here goes....
> 
> You are working overnights as part of a double medic truck in a city of 100k. At appx 2200 you get dispatched just outside of the city limits to a MVC, report of one patient ejected. On arrival you see an undamaged Volkswagen convertible and a crowd of people standing around what appears to be a male teen 120+ feet away.
> 
> What now?



Look for the cops.  This smells like a shooting with the assailant on scene.  Otherwise, I am suspecting a bout of stupid that brought on a car surfing or some idiocy.


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## systemet (Aug 31, 2011)

Scene safe?

Make sure no one's under the car / no little kid under the seats, etc.  Anything exciting in there? Odour of alcohol / pot / crack?

Are we in the right place?  Are there any other vehicles around?

Environmental factors? Weather? Road conditions?

Skid marks on the road? Vehicle on the tarmac or in the ditch?

Available resources?


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## fast65 (Aug 31, 2011)

How far out is law enforcement? There's something quite odd going on here, and we just can't rule out some sort of shooting or other violent act. 

Is the top down on the convertible? Skid marks? Blood on the vehicle? Any alcohol or illicit substances in the vehicle? 

I'm thinking it could possibly be car surfing as well.


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## usalsfyre (Aug 31, 2011)

Wow, sharp folks, y'all hit an angle I hadn't even considered yet. 

Sheriff's deputies are on scene. Vehicle has the top down, two skidmarks of changing direction are behind it. A bystander that was in the following vehicle saw the patient attempt a "powerslide" at a high (90+mph) rate of speed in the middle of a straight section of road, be ejected from the drivers seat and strike a large oak tree with the anterior side of his body aproximately 100 feet away and then fall/slide to his current location. Initial assesment reveals an unconscious male in his late teens with the following:

*A:*Airway is obtunded, foamy, pink sputum is mixed with frank blood in the airway. He is missing most of the visible dentation. His face appears to be distorted. 

*B:*Agonal gurgling respirations are noted. The patient's chest rise is paradoxical and diminished on the right side. Breath sounds on the right are absent

*C:* A weak, rapid radial pulse is present. The patient has venous bleeding from an open fracture of the patient's left forearm and left tib/fib

*D:*Patient is unconscious and shows decorticate posturing. Skin is mottled. The patient was wearing a t-shirt and shorts, there's abrasions over most of the exposed skin. 

What now?


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## fast65 (Aug 31, 2011)

usalsfyre said:


> Wow, sharp folks, y'all hit an angle I hadn't even considered yet.
> 
> Sheriff's deputies are on scene. Vehicle has the top down, two skidmarks of changing direction are behind it. A bystander that was in the following vehicle saw the patient attempt a "powerslide" at a high (90+mph) rate of speed in the middle of a straight section of road, be ejected from the drivers seat and strike a large oak tree with the anterior side of his body aproximately 100 feet away and then fall/slide to his current location. Initial assesment reveals an unconscious male in his late teens with the following:
> 
> ...



Hmmm, this is quite odd. But, I'll do my best considering I'm relatively new at this 

At this point we're calling the chopper, is it available? We'll clear his airway of any debris (i.e. teeth) or secretions, I'm wanting to intubate ASAP, so, if he has no gag reflex I'll just intubate him, if gag reflex is present I'll RSI. Confirm placement, secure tube, and bag at a rate dependent upon our ETCO2 readings.

Now I'm guessing breath sounds are still unequal so we'll decompress the right side of his chest. Breath sounds present?

How much blood has he lost from the open fractures? If it's a substantial amount then we'll try to control that.

I'm gonna cut all his clothes off now, do a rapid trauma assessment, any other injuries? After that, we're gonna C-spine him and get him packaged for transport.

We'll keep monitoring his airway, get him on a cardiac monitor and my partner is getting a set of vitals. ETCO2 readings? He's getting two large bore IV's and probably a good amount of fluids. We'll splint his open fractures if time permits.


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## abckidsmom (Aug 31, 2011)

fast65 said:


> Hmmm, this is quite odd. But, I'll do my best considering I'm relatively new at this
> 
> At this point we're calling the chopper, is it available? We'll clear his airway of any debris (i.e. teeth) or secretions, I'm wanting to intubate ASAP, so, if he has no gag reflex I'll just intubate him, if gag reflex is present I'll RSI. Confirm placement, secure tube, and bag at a rate dependent upon our ETCO2 readings.
> 
> ...



Manual c spine
Decompress the chest
Cric him
Board him
Begin transport
Control bleeding
IVs 

Reassess.

Not wasting time with the helicoptor unless transport is >45 minutes.  It just doesn't save time around here.


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## fast65 (Aug 31, 2011)

abckidsmom said:


> Manual c spine
> Decompress the chest
> Cric him
> Board him
> ...



Are you doing a cric because of the facial deformity?

I went with helicopter out here, because the closest level II trauma center is about an hour away and the closest level I is 1.5 hours away on a good day. Although, thinking about it, I would have just had the chopper meet us at the local hospital.


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## abckidsmom (Aug 31, 2011)

fast65 said:


> Are you doing a cric because of the facial deformity?
> 
> I went with helicopter out here, because the closest level II trauma center is about an hour away and the closest level I is 1.5 hours away on a good day. Although, thinking about it, I would have just had the chopper meet us at the local hospital.



Yeah, digging into this airway will be a total mess.  I might possibly waste ONE attempt and one attempt only on an oral intubation, but he needs an airway, and pronto, and with the smushed up face and teeth, blood and tree bark obstructing his airway, he'll be fine with a cric.

Well, fine in the way that completely decimated, dead-but-young-enough-that-the-heart-hasn't-caught-up people are.

ETA:  And what better case to use as a skills training lab than a train wreck, huh?


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## fast65 (Aug 31, 2011)

abckidsmom said:


> Yeah, digging into this airway will be a total mess.  I might possibly waste ONE attempt and one attempt only on an oral intubation, but he needs an airway, and pronto, and with the smushed up face and teeth, blood and tree bark obstructing his airway, he'll be fine with a cric.
> 
> Well, fine in the way that completely decimated, dead-but-young-enough-that-the-heart-hasn't-caught-up people are.
> 
> ETA:  And what better case to use as a skills training lab than a train wreck, huh?



Alright, that makes sense. Thanks!


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## Handsome Robb (Aug 31, 2011)

Bah! I missed the beginning of this one  but I'll still play.

How far is the Trauma Center? What's the ETA on the chopper, can they fly considering you wouldn't let them in the last one  ? if the TC is to far to drive I want them to meet me en route. 

A) Suction secretions, clear debris and take control of the airway. Depending on how distorted his face is ETI could be relatively contraindicated but airway>jaw. They can fix the jaw later, his airway can't wait. This guy just bought himself a surgical cric.

B) Ventilate him and splint his chest. Paradoxical chest rise along with mechanism makes me think flail chest. Decompress the right side of the chest if splinting my suspected flail segment didn't help his breath sounds. This guy needs to be oxygenated.

C) If he is bleeding profusely even with it being venous I'll go direct pressure for a bit but would probably switch to tourniquets pretty quickly. 

Make him trauma naked like Fast said and do a rapid. Any fluid from ears/nose? The posturing makes me think increased ICP. Any crepitus in the neck? JVD? Tracheal deviation? How's his abdomen? Pelvis? Anything in the LEs besides the compound tib/fib? UEs besides the forearm?

I want a quick set of vitals, c-spine and lets go. I'll take a FF/EMT if they are on scene with me in the back in case this guy goes south. We can get the IVs en route and get some fluids going and get him on the monitor. If I had time I might consider dropping an OG/NG tube considering he may have swallowed a lot of blood and knowing my luck its gonna come right back out at me. This guy sounds like a trauma team activation.

Bah ABCkidsmom beat me too it! I guess thats what you get for trying to do hw and respond to this on and off.


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## usalsfyre (Aug 31, 2011)

A cric it is. BTW, you chose wisely. If you had attempted to use a laryengoscope his whole face would have moved (Lefort II&III fractures) and you would have visualized blood.  Generally mucking around with a patient who is already hypoxic and has frank facial injuries is a bad idea. There's not a lot of cases that call for cutting early. This is one. A cric is established and you needle his chest. Inital rush of air...now there's also blood coming out. What can you do about this? The patient improves slightly, but there's still COPIOUS amounts of pink, frothy sputum coming out of the tube. ETCO2 confirms placement but you can't get a number above 20mmHG. The patient is stripped and placed on a long board. You have two transport choices. A well equiped community Level II 25 minutes away by ground, and an academic Level One 45 minutes away by aircraft, it's clear blue and 22 tonight so you can defintely get an aircraft. Which one? 

Secondary assesment reveals....

*HEENT:* Crepitus and abrasions throughout the facial region. Exopthalmos. Blood coming from the ears and nose. Missing dentation. Pupils are a 6 and minimally reactive. JVD was noted on inital exam but now the jugular veins are not visible at all. 

*Chest:*Crepitus in multiple sections per rib, bruising and lack of stability from the third to the seventh intercostal space on the right (basicly the right side of his chest is mush), Flail segment is "splinted" by PPV. Breath sounds are present, but still very diminished on the right, relatively clear on the left. Blood is still coming from the 14ga you used to decompress the patient. 

*Abdomen:*Closed, and the beginings of some minor rigidity noted in the right upper quadrant. Bowel sounds are present. When the pelvis is palpated you note crepitus and it doesn't feel stable. You note a small amount of blood at the meatus

*Extremities:*Left tib/fib and radius and ulna are open. Deformity is noted in the kids left femur as well. Abraded all over. Bleeding of the open fractures is controled with direct pressure. Looks like moderate blood loss. 

*Neuro:*Decorticate posturing to painful stimulus. Moaning slightly occasionally, GCS is E1, V2, M3

Vitals are as follows: *BP:*82/70; *HR:*142;*RR:*(he's got a tube, you tell me);*SpO2:*84% by BVM on O2; *ETCO2:*24

Two lines will be established. What fluid and what are we running them at? While we're taking him to the truck, he goes into a grandmal seizure. What now?


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## abckidsmom (Aug 31, 2011)

usalsfyre said:


> A cric it is. BTW, you chose wisely. If you had attempted to use a laryengoscope his whole face would have moved (Lefort II&III fractures) and you would have visualized blood.  Generally mucking around with a patient who is already hypoxic and has frank facial injuries is a bad idea. There's not a lot of cases that call for cutting early. This is one. A cric is established and you needle his chest. Inital rush of air...now there's also blood coming out. What can you do about this? The patient improves slightly, but there's still COPIOUS amounts of pink, frothy sputum coming out of the tube. ETCO2 confirms placement but you can't get a number above 20mmHG. The patient is stripped and placed on a long board. You have two transport choices. A well equiped community Level II 25 minutes away by ground, and an academic Level One 45 minutes away by aircraft, it's clear blue and 22 tonight so you can defintely get an aircraft. Which one?
> 
> Secondary assesment reveals....
> 
> ...



When you say train wreck, you really mean it, right?  

I don't think the guy is stable for the longer transport to the LI trauma center.  I would take him to the LII where he can get more stable or reach terminal stability.

Let's summarize his injuries:

LaForte II and III fx, open head injuries (shearing or bleeding, his brain is in trouble) now with seizures and posturing

Right tension pneumo/hemo, flail segment, pulmonary contusions, etc.  

Liver lac?  Diaphragmatic abruption?

Bladder rupture?

Ortho: L tib/fib, radius, ulna, femur and pelvis.  Somebody's going to be getting a new boat out of this repair.

SO.  This guy will be one for the record books if he survives tonight.  For now, we'll head to the 25 min away LII facility and let them know that he's coming in enough time for them to call in the troops.  LII have on-call neuro and ortho, not necessarily in-house.  If he makes it to the OR, they'll need all the friends.

The fluid, ideally would be skillful and complicated combination of FFP, PRBCs, and isotonic crystalloids.  Alas, we're in an ambulance, not an ICU, so I'm going to run the NS or LR at a fast KVO, or maybe give him a couple of gentle 500 ml boluses.  This is one who will suffer badly from over-fluid-resuscitating initially, though he does need some fluid in his system, he still needs all the oxygen carrying capacity he can get.

He's seizing, I will give him benzos to stop that forthwith, and paralyze and sedate him for the ride because he absolutely, positively must not be moving around and hurting anything else.

Without another complicating event, I will be shocked if he arrives alive in the ER 25 minutes away.


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## Handsome Robb (Aug 31, 2011)

Hmm. The pinky frothy stuff is no good. Could you try a PEEP valve to try and force the fluid out of the aveoli and back into the vascular space? Although I was under the impression that you had to be spontaneously breathing to use PEEP. As for the rate I'd be aiming for an EtCO2 of somewhere around 30 mmHg if we can ever get it there. Hypercapnia will dilate cerebral blood vessels and increase blood volume in the cranial vault therefore increasing ICP which is exactly what we DON'T want.

What is the ETA of the chopper to me? If its any longer than 10-15 minutes I'm not even going to bother but if they are close my thoughts are that I can't do a whole lot about the Hemopneumothorax but a flight nurse might be able to place a chest tube and relieve that pressure and improve his SpO2?

As of now I want to go to the Level II. Shorter ETA and Level IIs are essentially the same as a Level I minus the academic portion and having everyone on-site. Let them know now that you are inbound with a trauma team activation so they can get all the boys and girls out of bed and to the facility to be waiting for you.

As for your fluids you have either Lactated Ringers or NS. I was always told LR is incompatible with blood products, which this guy is going to need, so I'd go for NS. I'd shoot to maintain his systolic above 80, it doesn't need to be WFO.

For the femur you cant do much for it with the open tib/fib below it. If he displays signs of bleeding into his thigh, even though a tourniquet would be contraindicated with the femur fracture I'd call med control and talk to them, if you don't stop that bleeding somehow this guy is going to die.


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## abckidsmom (Aug 31, 2011)

NVRob said:


> Hmm. The pinky frothy stuff is no good. Could you try a PEEP valve to try and force the fluid out of the aveoli and back into the vascular space? Although I was under the impression that you had to be spontaneously breathing to use PEEP. As for the rate I'd be aiming for an EtCO2 of somewhere around 30 mmHg if we can ever get it there. Hypercapnia will dilate cerebral blood vessels and increase blood volume in the cranial vault therefore increasing ICP which is exactly what we DON'T want.



He likely has a big hole in his lung as well, or even a leaky airway...subcu air, usals?  How's his neck feel around that tube?

You can always put some PEEP on the tube, but I would not expect it to make a big difference, and I might even see that it would drop his blood pressure a little.  Increasing intrathoracic pressure in this guy, even with a little bit of PEEP that will come from the device on the tube, might just be enough to stop whatever blood return is happening and kill his preload.  




> What is the ETA of the chopper to me? If its any longer than 10-15 minutes I'm not even going to bother but if they are close my thoughts are that I can't do a whole lot about the Hemopneumothorax but a flight nurse might be able to place a chest tube and relieve that pressure and improve his SpO2?



Evacuating this hemo/pneumo right now, on the side of the road, regardless of who you are is a risky endeavor, unless you're prepared to autotransfuse that blood back into the IV.  Sad to say, as long as there are *some* breath sounds on that right side, I would just let it be until he's in the presence of a lot of blood products, because that will just bleed and bleed once it's opened up.  




> As of now I want to go to the Level II. Shorter ETA and Level IIs are essentially the same as a Level I minus the academic portion and having everyone on-site. Let them know now that you are inbound with a trauma team activation so they can get all the boys and girls out of bed and to the facility to be waiting for you.
> 
> As for your fluids you have either Lactated Ringers or NS. I was always told LR is incompatible with blood products, which this guy is going to need, so I'd go for NS. I'd shoot to maintain his systolic above 80, it doesn't need to be WFO.
> 
> For the femur you cant do much for it with the open tib/fib below it. If he displays signs of bleeding into his thigh, even though a tourniquet would be contraindicated with the femur fracture I'd call med control and talk to them, if you don't stop that bleeding somehow this guy is going to die.



Tourniquet on the bad leg is a good idea.  Probably won't be much difference in the perfusion than he's getting right now.  Double check that there are pulses in there at all before placing it, and know that you are almost certainly making the decision about amputating that leg.  It will be a long time before he can re-establish perfusion to that foot.

I didn't mention it before, but it's really cold out, and he's really going to be cold.  This is a patient that you really, really want to take a second and put a blanket under him on the board, and keep as much of him covered as possible, with hot packs in his axillae and groin, and scattered about.  Letting him get too cold will also help him die.


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## fast65 (Aug 31, 2011)

Geez usalsfyre, you really know how to pick him  Are these actual calls you've had?

Well, I of course am regretting my initial decision to attempt ETI, but that being in the past, and my pt. being cric'd right now, I can move on. Obviously we don't have good gas exchange, so I'm gonna try to suction the tube real quick, and if I still can't get the ETCO2 up to 32 like I would prefer, then to the best of my knowledge there's not a whole lot I can do for this guy. A PEEP valve wouldn't be indicated in this case because it can cause in an increase in ICP, no use adding fuel to the fire. Honestly, I'm not real sure what to do about the blood coming out of the decompression. 

This guy is going to the level II center, and they're getting a notification really early so they can get all of their toys ready. I'd like to add more detail, but unfortunately I have to run.


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## Handsome Robb (Aug 31, 2011)

fast65 said:


> Geez usalsfyre, you really know how to pick him  Are these actual calls you've had?


Seconded



fast65 said:


> A PEEP valve wouldn't be indicated in this case because it can cause in an increase in ICP, no use adding fuel to the fire.



I'm interested in the physio behind this? Does slowing of the off gassing of CO2 play a roll in this? Still a baby student with too much to learn.



fast65 said:


> Honestly, I'm not real sure what to do about the blood coming out of the decompression.



I'm right there with ya! haha Possibly seal it to minimize blood loss? But then your going to compress the lung by not allowing the blood to escape which could move over to the other side of the chest as well and just make things worse, so never mind, bad idea


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## abckidsmom (Aug 31, 2011)

NVRob said:


> Seconded
> 
> 
> 
> ...



Throw a 3-way stopcock on that catheter and wait for another tension pneumo/hemo to develop, then let it bleed off again.

It's not going to be pretty, either way.


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## MrBrown (Sep 1, 2011)

You sure can pick em, candyman my ***, candyman would have Brown back at station watching telly 

This bloke is super, mega crook.

Provided we have decompressed his massive haemopneumothorax (uber want a chest tube into this bloke) Brown is going to RSI him, chuck a splint onto his nunngered tib/fib/arm and get transporting to the hospital.

Brown would give him up to one litre of fluid in 250ml cc boluses ... again, this bloke is mega, super crook and Brown doubts he will live >24 hours.

In hospital Brown would order a chest tube, blood replacement, plain film of c-spine, head, pelvis and chest, a CT scan, belly ultrasound and lets get him to the operating room for an ex-lap and repair/fixation of his buggered tummy, leg and arm then off to ICU.


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## Pelagic (Sep 1, 2011)

Concur with all the above - surgical airway, decompress chest etc - but would make sure he gets a Pelvic Binder when boarded - instability mentioned - probably the biggest cause of the hypovolemia?

My view is that this guy needs minimal interventions on scene (IV etc) and maximum diesel and right foot to the nearest Trauma centre?


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## MrBrown (Sep 1, 2011)

Pelagic said:


> Concur with all the above - surgical airway, decompress chest etc - but would make sure he gets a Pelvic Binder when boarded - instability mentioned - probably the biggest cause of the hypovolemia?



Good catch mate, pelvic wrap is a bloody fantastic idea.  

We have gotten the commerical binders recently but used a sheet for years.


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## systemet (Sep 1, 2011)

Seems a little sick.

A: Sounds like the surgical cric' was a good call.  I might have tried a laryngoscopy just to see if I could pass an ET, but it's going to be difficult to adequately secure if the face is that fractured, and it sounds like RSI may take too long, as it's questionable whether we can get adequate BVM ventilation if the face is smashed, the airway's bloody, and the patient's already severely hypoxic.

Let's be sure that the cric' is correctly placed, and that we haven't managed to channel it through the trachea and into the esophagus.  It sounds like we have CO2 and chest rise with ventilation through it.

B: SpO2 sucks.  How's compliance?  I'm guessing it sucks too.  We have decreased A/E unilaterally, on the segmented side, and an angio dripping blood.  

I know our JVD has gone since it's been placed, but did we hear air escape, did compliance improve?  Has our JVD just diminished because we have no volume and no CVP? Did we actually have a tension / simple pneumo?  Either case, I think we should attempt another decompression.  

Need to suction the trachea.  I'm thinking neurogenic pulmonary edema?  Or a tracheal tear.  

Should I trust the ETCO2, if the airways full of blood?  How's the waveform look?

C: MAP is 74 mmHg.  This isn't good.

D: Massive head trauma, multiple facial fractures, seizing / posturing, dilated poorly-reactive pupils, exopthalmus.  Looks like he's herniating as well.  He's missing the classic bradycardia, but perhaps this is a result of massive hypovolemia from the accompanying traumatic injuries.

Anything from the history to suggest possible illicit drug use?  Complicating hypoglycemia seems staggeringly unlikely, but we should get a glucose as a r/o.

Other injuries:  I think I agree with abckidsmom's suggestions.  I guess he's not getting catheterised.

---------------------------------------------------------------------

Treatment plan:

Hyperventilate @ 20/min.  Target ETCO2 is 30 mmHg.  

The MAP is way too low.  Aggressive fluid resuscitation to a MAP of >90 mmHg. So target systolic will probably be around 110-120 mmHg, if we assume ICP is around 25 mmHg (which is a big assumption).  I'd throw in a 20ml/kg bolus as fast as humanly possible.  Then I'm going to consider more fluids, with potential for a pressor.

Seizure might be due to herniation, might be due to hypoxia.  Assuming this person is something around normal body weight, lets throw in 5mg midazolam IV.  

[I recognise the potential for hypotension here.  If we were just sedating, I'd consider ketamine, despite the debate about it's use in patients with elevated ICP.  But we need an anticonvulsant here.]

I'm reluctant to paralyse here, because I'd like to know that I've controlled the seizure activity.  So I'm going to hold off on that, and give the versed a few minutes to work.  Then reassess my position.

[I recognise this is a huge judgment call.  Seizing and paralysed is going to hugely increase metabolic demands on the brain.  Not being paralysed is going to make this worse.]

I'd like to wrap the pelvis.  Sheet and a couple of hemostats will work.

Not worried about the extremities, if the bleedings controlled.  But we're going to have to re-assess that as we pressure infuse.  If the patient becomes more stable, we can look at whether altering the alignment might improve peripheral vascular function.

Transport:  Life threats here are herniation syndrome compressing the brainstem, and acute hemorrhage.  His cranial vault needs decompressing, and someone needs to rearrange his internal organs.  The Level II sounds good for now, as long as they can have someone there by the time the patient arrives.

If I can beat the chopper to the Level II, I'll transport.  Otherwise they take them.  Whatever gets him to a trauma surgeon quicker.


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## usalsfyre (Sep 1, 2011)

Update coming as soon as I can get to a computer, way too hard to do on TappaTalk.


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## fast65 (Sep 1, 2011)

NVRob said:


> I'm interested in the physio behind this? Does slowing of the off gassing of CO2 play a roll in this? Still a baby student with too much to learn.



Well from the research I've been doing this morning, it seems as though the increased ICP stems from an impedance of cerebral venous return and a decrease of MAP, which influences CPP and could increase ICP. However, the studies I've found also stated that higher levels of PEEP (<30-40 mmH2O) could actually decrease ICP. Now, I'm sure that I've said something wrong here, so please, somebody smarter than me come correct me 

Edit: Oh, and I completely forgot about the unstable pelvis, good catch pelagic.


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## usalsfyre (Sep 1, 2011)

So...

We put a pelvic binder on him and throw a three-way stopcock on the angio cath. There's a bit, not much sub-q air still noted. Waveform is present, but diminished. D stick is 106. A 250 ml bolus of fluid holds his pressure steady at least. 

NVRob-is a tension hemo possible? Why or why not? 

systemt-lorazepam might be a better seizure control medication in this case due to the hemodynamics, it tends to be a little stabler. 

To the group-Why might his ETCO2 be so diminished? Is this necessarily reflective of his PaCO2? Are we going to paralyze him? 

2mgs of lorazepam controls his seizure, but he's now totally out. Suctioning the tube out bumps his SpO2 into the mid 90s, but you can already see the beginings of the frothy stuff coming back. 

Level II is a good choice. It has most of the capabilities of a level I, just generally on 15 minute call and not on campus. 

Conclusion later on this evening or tommorow, and an explanation of what this call was based on.


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## systemet (Sep 2, 2011)

(1) Ativan vs. Versed -- I wasn't aware ativan was safer here.  Looks like I have a little reading to do!

(2) Fluid resus:  I've got to say again that it seems like we're under-resuscitating this patient.  

We know that CPP = MAP - ICP.  Right now, our MAP is only 74 mmHg.  If the patient is showing signs of herniation, and brain stem dysfunction, we can probably assume that ICP is at least 25mmHg.  It may be even higher.  We can't know the exact value until the patient's receiving ICU care and has an ICP monitor on board.

So given these numbers we're looking at a CPP of 49 mmHg.  This isn't enough to maintain cerebral perfusion.  Most of the literature suggests a target CPP of around 65 - 70 mmHg, although this area is a little controversial.  So we should be aiming for a MAP of at least 90.  [We should also bear in mind that this may still be under-resuscitation, as the actual ICP may be much higher than 25mmHg]

Permissive hypotension is a well accepted treatment for adult multi-system trauma.  I'm understand that aggressive crystalloid therapy is going to cause hemodilution, and that as we increase MAP our rate of internal hemorrhage is going to increase, and we risk popping thrombi.  But if we don't adequately resuscitate the brain, we're just saving organs for donation (and the pickings here are slim!).  Closed head injury is not the time for permissive hypotension.

Maybe something has changed and I'm out of date here?

(3)  The relation between ETCO2 and PaCO2 is dependent upon the V/Q.  If we have a low cardiac output state (as we have here), we may have many under-perfused lung units, which are being ventilated, but have minimal gas exchange occurring, and therefore minimal CO2 present.  Upon exhalation, gas from these units is going to mix with gas from normally perfused and ventilated units, and effectively dilute the proportion of CO2.  The loss of cardiac output from decreased CVP is probably also complicated by the effect of the neurogenic pulmonary edema on diffusion in the alveoli.  And we have traumatic injuries that are impacting upon both ventilation and perfusion, in addition.

(4) Paralysis:  If the patient's flat, and not fighting ventilation, I think I'll avoid it, so I can identify and treat further seizure activity.


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## MrBrown (Sep 2, 2011)

Brown agrees with everything that bloke said


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## systemet (Sep 2, 2011)

A couple of other thoughts:

(1) We have blunt chest injuries, and should do an ECG to see if we have conduction block / ST-T changes.  

(2) We need to measure the patient's temperature, and protect against hypothermia.  

(3) Can we do a FAST or iSTAT?

(4) We should give more consideration as to why the vehicle left the road.  Of course, the patient being a poor driver has to be high on the index of suspicion.  But do we have cointoxication with EtOH / other drugs?


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## usalsfyre (Sep 2, 2011)

systemet said:


> We know that CPP = MAP - ICP.  Right now, our MAP is only 74 mmHg.  If the patient is showing signs of herniation, and brain stem dysfunction, we can probably assume that ICP is at least 25mmHg.  It may be even higher.  We can't know the exact value until the patient's receiving ICU care and has an ICP monitor on board.
> 
> So given these numbers we're looking at a CPP of 49 mmHg.  This isn't enough to maintain cerebral perfusion.  Most of the literature suggests a target CPP of around 65 - 70 mmHg, although this area is a little controversial.  So we should be aiming for a MAP of at least 90.  [We should also bear in mind that this may still be under-resuscitation, as the actual ICP may be much higher than 25mmHg]
> 
> ...


Nope, quite simply, this guys jacked. Too much fluid will kill him, too low a MAP will kill him (or leave him ready to be planted in the cucumber patch). 



systemet said:


> (3)  The relation between ETCO2 and PaCO2 is dependent upon the V/Q.  If we have a low cardiac output state (as we have here), we may have many under-perfused lung units, which are being ventilated, but have minimal gas exchange occurring, and therefore minimal CO2 present.  Upon exhalation, gas from these units is going to mix with gas from normally perfused and ventilated units, and effectively dilute the proportion of CO2.  The loss of cardiac output from decreased CVP is probably also complicated by the effect of the neurogenic pulmonary edema on diffusion in the alveoli.  And we have traumatic injuries that are impacting upon both ventilation and perfusion, in addition.
> 
> (4) Paralysis:  If the patient's flat, and not fighting ventilation, I think I'll avoid it, so I can identify and treat further seizure activity.


In addition to the low output, remember he's got serious chest injuries, meaning the gas would have to diffuse through fluid as well. His PaCO2 is probably much higher than what is indicated by ETCO2.


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## usalsfyre (Sep 2, 2011)

*Conclusion*

So the patient is transported to the LII. Enroute he is suctioned frequently, appx 500mls of blood is suctioned from the ETT. He codes on arrival at the ED. After administration of blood products he has an ROSC, goes to surgery and lives through the inital surgery to repair the hemothorax. Pt has severe pulmonary contusions as well. Unfortunately an CT indicates little cereberal perfusion is present and and EEG is negative for brain activity. The patient fails multiple apnea test and is declared brain dead. 

The patient is "based" off of a female passenger I responded to with that exact mechanisim of injury. She had a much more minor head injury but massive, massive chest injuries. The facial fractures were designed to get you thinking about situations where it is approprite to cric right off the bat. 

Scenario #3 sometime next week, I've got another hellaciously busy week ahead.


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## abckidsmom (Sep 2, 2011)

usalsfyre said:


> So the patient is transported to the LII. Enroute he is suctioned frequently, appx 500mls of blood is suctioned from the ETT. He codes on arrival at the ED. After administration of blood products he has an ROSC, goes to surgery and lives through the inital surgery to repair the hemothorax. Pt has severe pulmonary contusions as well. Unfortunately an CT indicates little cereberal perfusion is present and and EEG is negative for brain activity. The patient fails multiple apnea test and is declared brain dead.
> 
> The patient is "based" off of a female passenger I responded to with that exact mechanisim of injury. She had a much more minor head injury but massive, massive chest injuries. The facial fractures were designed to get you thinking about situations where it is approprite to cric right off the bat.
> 
> Scenario #3 sometime next week, I've got another hellaciously busy week ahead.



This was a good one.  I learned something new- that bit about the pulmonary hypoperfusion causing ETCO2 to be off.  Worth it.

I once had a guy with similarly massive injuries, minus the head trauma.  He lasted for 6 incredibly long hours once he got to our unit, 3-to-1 nursing staff and the trauma attending at the foot of the bed.  It was a looooong, bloody shift.


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## fast65 (Sep 2, 2011)

Wow usalsfyre, that was an amazing scenario, it really got me thinking, thanks! I look forward to your next scenario.

Sent from my mobile command center


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## systemet (Sep 3, 2011)

usalsfyre said:


> Nope, quite simply, this guys jacked. Too much fluid will kill him, too low a MAP will kill him (or leave him ready to be planted in the cucumber patch).



This was a great scenario.  Thanks!

I agree that aggressive resuscitation is probably going to result in exsanguination.  On the other hand, I know that underresuscitation with that sort of transport time is going to result in profound disability if the patient is herniating. 

If the patient just has a simple head injury, or has a closed head injury wihout signs of herniation, then I'd be happy with a less aggressive approach with permissive hypotension.


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## MrBrown (Sep 3, 2011)

What would lead us to believe this bloke is herniating vs somebody who has a non herniation brain injury?


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## Aidey (Sep 3, 2011)

I believe that this guy is what is clinically known as "F*cked". 

I'd have to do some research on this, but I'm going to hazard a guess that very few patients survive* a herniation that happens in the field. Increased ICP is a self perpetuating problem. The body compensates for the increased ICP by increasing the ICP, which in turn causes the body to increase the ICP. We can not stop this in the field. Decreasing the pts CO2 provides a minimal transient effect on ICP and will not stop someone from herniating. 

Brutally and practically speaking this patient is going to die. You can either under resuscitate and possibly save his organs for donation** or you can flood him with saline in an attempt to achieve a higher MAP and hypoperfuse him into total organ failure. It is a crappy situation and there is no fixing this patient. 


*Non eggplant survival. 
** And/or give the family enough time to say goodbye.


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## Aidey (Sep 3, 2011)

MrBrown said:


> What would lead us to believe this bloke is herniating vs somebody who has a non herniation brain injury?



I think it is the posturing and decreased LOC, but that is just a guess.


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## triemal04 (Sep 3, 2011)

It's not something that I ever want to think about having to do, and would definetly be a time I'd be on the phone with the ER Doc (who'd probably be on the phone with an anesthesiologist who'd probably be on the phone with someone else) but this particular situation...might...maybe...be a time when using a pressor along with fluids could be beneficial to the patient.  There is some info out there that has looked at using phenylephrine and vasopressin (not routinely carried I know) in hemmorhagic shock with concurrent TBI to maintain MAP's and CPP with better outcomes for the patient than just fluids.  

No matter what you do, this guy is royally screwed, but, based on some info out there, using a pressor just might be somewhat beneficial...though probably only to the extent that he'd be a better organ donor.

Just more food for thought.


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## Melclin (Sep 4, 2011)

haemorrhagic shock + TBI = probable admission to the ECU.

Usal, stop posting these things when I'm at work. I can't keep up. 

Its an interesting ballance, the fluid resus in TBI versus, hypotensive resus in haemorrhage. Do you pick one and hope for the best or do you hedge your bets and risk ending up in no mans land where you've effectively done neither. 

My thoughts were to target a MAP or 80 based on what I've read in my trauma books. 

Also the BTF have some nice little guidelines complete with evidence on this. They've been consistently revising down the necessary CPP for the past 5 years.

Currently a CPP > 50 is the go and they actually discourage aggressive attempts at getting it above 70. If we assume a ICP of 25 like you mentioned systemet, then we're talking a minimum MAP of 75, so a MAP of 80-85 seems good. 

http://tbiguidelines.org/glHome.aspx?gl=1

I suppose it basically comes down to whose the bigger villein. The haemodilution or the hypotension. Off the top of my head, I'd guess hypotension. You can give a person PRBCs and FFP, but you can't give them back their brain. So maybe a higher target MAP might be a nice idea. I suppose it also depends on how much you have to infuse to achieve the target. If you gave 250mls and by pure magic the MAP hit 80, maybe you might think about more. If it took a 1500mls, maybe you leave it there. Just thinking out loud. What do we think?


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