# Usalsfyre's Train Wrecks #3



## usalsfyre (Sep 9, 2011)

Been a heck of a week, I know this one's a little late. It's not as train wreckish as the last one, so I'm sure y'all will get it quick.

Dispatched to a 32 YOM c/o chest pain after a traumatic injury. Pt was playing hockey and took a hard hot against the boards.  

You find a tall, thin male c/o left sided chest pain. You notice as you walk up he's pale "as a ghost". Go...


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## Aidey (Sep 9, 2011)

Vitals? Lung sounds? EKG? 

1. Pneumo 
2. V-Tach from commotio cordis


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## silver (Sep 9, 2011)

Aidey said:


> Vitals? Lung sounds? EKG?
> 
> 1. Pneumo
> 2. V-Tach from commotio cordis



to go along with that do you see anything else on physical assessment like hows my JVD, trachea alignment, how are the rib segments, contusions, percussion? Where is the pain, can it be localized?

additional differentials: pulm/myocard contusions, aortic tears, tamponade, myocardial ruptures, and splenic rupture.

You also said in previous ones we could do sonos. I'd do one (though your results for the purpose of this scenario will likely be non-diagnostic).


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## silver (Sep 9, 2011)

usalsfyre said:


> You find a tall, thin male c/o left sided chest pain. You notice as you walk up he's pale "as a ghost". Go...



how tall and thin is this gentleman? Does he have a history of Marfan's?


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## fast65 (Sep 9, 2011)

Is the pt. experiencing any SOB, respiratory distress? Does he have any other injuries/complaints?

I want to assess:
-Lung sounds
-JVD, tracheal deviation
-Chest wall, any flail segments?
-4-lead

Vitals? I would like to take a BP on both arms as well.


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## EMT-IT753 (Sep 9, 2011)

Spontaneous pneumothorax


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## fast65 (Sep 9, 2011)

EMT-IT753 said:


> Spontaneous pneumothorax



Is it really spontaneous if there was a traumatic injury to the chest wall?


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## EMT-IT753 (Sep 9, 2011)

fast65 said:


> Is it really spontaneous if there was a traumatic injury to the chest wall?



Tongue-in-cheek 

While I don't completely think it is a spontaneous pneumo, he fits the physical aspect of one. Hockey players have pretty good protective gear. Just because he took a hard shot, does not necessarily mean that is what caused his condition.

Others have already mentioned other possible differential diagnosis and that was just another one to consider


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## fast65 (Sep 9, 2011)

EMT-IT753 said:


> Tongue-in-cheek
> 
> While I don't completely think it is a spontaneous pneumo, he fits the physical aspect of one. Hockey players have pretty good protective gear. Just because he took a hard shot, does not necessarily mean that is what caused his condition.
> 
> Others have already mentioned other possible differential diagnosis and that was just another one to consider


Oh, I have no doubt that a pneumo is a large possibility, I was just wondering about the whole spontaneous part.


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## Katy (Sep 10, 2011)

-Lung sounds ?
-Fresh set of vitals ? 
-Any other complaints such as shortness of breath or any other signs of respiratory distress i.e. elevated RR. 
-EKG ? 
Assess and palpate chest for any bone damage to the ribs or sternum, by the way, where exactly was the patient hit at ?


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## Melclin (Sep 10, 2011)

Ask him whats happened first of all. Chief complaint? SOB? Pain? Dizzy? 

Expose the chest. What are we seeing? Obvious injuries, signs of resp distress, JVD.

Chest auscultation. Vitals. Monitor.


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## usalsfyre (Sep 10, 2011)

Ok, sorry for the delayed update, Houston traffic and a car breakdown put me out of commission yesterday.

Patient is a 32 YOM who was playing hockey and was checked hard from behind into the boards. Pt noted he was short of breath and "something felt wrong in his chest" as soon as he got up. The coach and other players noted he looked pale and called an ambulance. The patient states he has no significant history other than "when I was a kid I had a heart murmur", takes no medications, has no allergies and has not been to a physician since he stopped needing physicals for high school sports. 

The patient is conscious alert and oriented, denies loss of consciousness or neck and back pain. Physical exam as follows. The patient is pale and cool to the touch, seems very anxious and has significant air hunger.

*HEENT:* Intact with no deformities noted. Pupils are PERLA, no facial droop is noted and the patient's speech is clear. No JVD is apparent with the patient standing or sitting upright, the trachea is midline. 

*Chest:* Pt is tachypneic, accessory muscle use is noted. Lung sounds are diminished in the left apex. Lung sounds are otherwise clear. The patient's left chest is tender but appears to be stable and intact. A loud diastolic murmur is noted over the 5th intercostal space, midclavicular line.

*Abdomen and Pelvis:* Intact, non-tender, non-distended. Normal bowel sounds are noted. Pelvis is stable. GU exam is deferred   

*Extremities:* Intact, good PMS is noted with a stronger pulse noted on the right than on the left. 

Vitals are as follows *BP:*136/104 *HR:*132 ST on the monitor *RR:*28 and labored *SpO2*91% on RA 

12 lead EKG: 
	

	
	
		
		

		
			





Since fast65 asked, B/P in the right arm is notably higher than in the left. 

Your on a B/P ALS truck, there's a level III community ED 5 minutes away and big mega bad mamma jamma academic Level I center 20 minutes away by air. It's 10:00 in the morning on a Tuesday so all specialties are in house at both places.


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## fast65 (Sep 10, 2011)

With the diastolic murmur and the differing blood pressure/pulses (can someone remind me of the term), I suspect we have the start of an aortic dissection with this gentleman, so I want to get him loaded into the ambulance ASAP and we'll get the helicopter to meet us at the level III center for a flight to the level I center. 

In the ambulance we'll put a NC on to start, and consider a NRB later on if things don't improve. We'll get two large-bore IV's established. 

I suspect he has a pneumo as well, so I'll keep a close eye on that and consider decompressing it if things get worse and his resp. distress doesn't resolve. Then we're gonna get going to the level III ASAP.

There are probably some things I want to add, but I'm on my phone so that'll have to wait.

Sent from my mobile command center


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## Melclin (Sep 11, 2011)

I'll say pneumo or haemo. Maybe a traumatic aortic tear with a developing L haemothorax.

-Transport without delay for anything. 
-We'll whack couple of lines in on the way. 
-Probably hold of fluids for the time being. 
-Pain relief as required. 
-Keep him warm.
-O2 by NRBM.
-Mark him up for decompression and get our stuff ready for that should his conscious state drop off. 

How does his SpO2 fair with supplemental O2?

I think our job is more logistical now. Let the level 3 know you're coming before you even load. I reckon he's ganna need a level 1 but if we play our cards right we could have this guy x-ray'd and resuscitated before the chopper even got off the ground. I'll have a chat to the chopper and the hospital. See how they wanna play things.


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## DESERTDOC (Sep 11, 2011)

Working DX's of Pneumo and Disecting Aorta.

The usual O2, lines, reassess, scanned, chest film etc.

This person has never been to a cardiologist and never had an MI?

At this point we are going to the closest facility.

Oh yeah, how does this persons Clavicle and Scapula look, any deformity, crepitus etc?


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## usalsfyre (Sep 11, 2011)

*Y'all know your stuff....*

...you correctly pulled out the working diagnosis of aortic disection complicated by pneumothorax. Kudo's to silver for picking up on the "tall and thin" reference to Marfan's, which is a risk factor for both disection and pneumothorax. Another big clue is the diastolic murmur which is present in slightly over 50% of aortic root disections.

So, two lines, very conservative fluid resucitation. Another consideration would be to get med control on the horn for beta-blockers, his hypertension is not helping the aorta hold together. Pnuemo is a simple penumo and doesn't require treatment other than supplemental O2 which improves his sats. Pt undergoes emergency surgery at the LIII who happens to have a thoracic guy in house where the disection is repaired just prior to bursting. The patient makes a full recovery but sadly his hockey career is over h34r:.

Check out WTEngel's pediatric scenario, you won't find very many paramedics with more kid-specific knowledge than he has, much better than me trying to muddle through one . Next instalment of train wrecks coming soon, but after the completion of that scenario.


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## fast65 (Sep 12, 2011)

Another good scenario usalsfyre, keep them coming ^_^

WTEngel's scenario was definitely a great way to keep me thinking this weekend.


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