2. You receive a call for an
elderly male that was found
unresponsive in the hot tub
3. Case Study
• What does this have to do
with trauma?
• Is he sick, is he injured, is
he sick and injured?
• Need more INFORMATION!
4. Case Study
• What questions do you have?
• How long has he been in the hot
tub?
• How hot is the water?
• How old is he?
• Any medical Hx?
5. Case Study
• When you arrive you find an 85 yr old male
sitting in the hot tub with agonal breathing and a
weak pulse
• GCS is 3
• He has a history of a CVA
• He has lost control of his bowel and bladder
• Hot tub water is 105 degrees
• The pt was last seen, last night with no complaints
WHAT DO YOU DO?
WHAT IS YOUR DX?
6. Case Study
• What is your initial Diagnosis?
• Unconscious patient due to???
• CVA?
• MI?
• Heat stroke/exposure?
• Drug ingestion?
• ETOH intoxication?
7. Case Study
• Could be any one of the
aforementioned diagnoses or
a combination of two or
more…BUT a more pressing
matter would be
8. Case Study
• The patient is extricated from the hot tub
• Agonal respirations at 6-8
• Intubated
• Large bore IV’s are started and 2 liters of NS are rapidly
infused
• Vital signs
• BP is 60P
• HR 140
• His skin is hot and shriveled
• He has pressure ulcers on his heels
• Crackles are auscultated in all lung fields
• Pupils are 2mm and sluggish
Any Thoughts? What to do next?
9. Case Study
• While en route to the hospital the
patient remained hypotensive
• Dopamine gtt initiated
• Patient weight is 180 lbs
• What is the dose for Dopamine?
• How much should you give?
10. Case Study
• 10mcg/kg/min of Dopamine initiated
• SBP increased to 80
• The quick down and dirty method to calculate
Dopamine
• Take the wt - 180
• Drop the 0 and subtract 2
• Now you have 16
• That is your cc/hr for 5 mcg/kg/min
• Administer 32 cc/hr for 10mcg/kg/min
11. Case Study
• Why is the patient hypotensive?
• Is the patient in Shock?
• Distributive?
• Hypovolemic?
• Obstructive?
• Cardiogenic?
12. Case Study
Distributive Shock
Decreased systemic vasomotor tone which
can result in end-organ dysfunction
Causes
Sepsis
Anaphylaxis
Drug reactions
Neurogenic (Brain or Spinal Cord)
13. Case Study
Hypovolemic Shock
Decreased systemic vascular resistance
which can result in end-organ dysfunction
Causes
Bloodloss
Severe burns
Third spacing and loss of plasma
Dehydration
14. Case Study
Obstructive Shock
Decreased systemic vascular resistance
which can result in end-organ dysfunction
Causes
Cardiac Tamponade
Tension Pneumothorax
15. Case Study
Cardiogenic Shock
The heart is unable to pump enough blood
(both force and volume) for the needs of the
body
Causes
Massive MI
Heart Failure
Left or right sided**
16. Case Study
What type of shock do you think our
patient is in?
Distributive?
Hypovolemic?
Obstructive?
Cardiogenic?
17. Case Study
• Pt arrives in the ED
• GCS remains 3
• Systolic pressure at 80
• HR remains in the 140’s
• Rectal temp is 107
• Placed on the ventilator
• Additional tests and treatments
• CT of the head
• CXR
• EKG
• ABG’s
• A cooling blanket is applied
What are your thoughts?
18. Case Study
• CT of the head revealed a lacunar
nonhemorrhagic infarct (age unknown)
• EKG reveals ST depression in all of the lateral
leads
• ABG’s
• ph 7.3
• pC02 25.1
• HCO3 12.8
• BE -11.5
• CXR – LLL infiltrates
Now what do you think? What to do next?
19. Case Study
• Levophed initiated to increase BP (15mcg/
min)
• Pressure not responsive
• He received 3 liters of NS when we got the
call to transfer this pt to a higher level of
care
Why is the pt still hypotensive?
Have we missed anything?
20. Case Study
• Remember the ABG
• ph 7.3 and BE-11.5
• Acidotic patients DO NOT respond well to
vasopressors
• Given 1 amp of bicarb
• Another liter of NS
• Temperature reduced with a cooling blanket to 99.1
• 6000 unit heparin bolus and a gtt was initiated at 1500
units/hr
21. Case Study
Arrival at the tertiary care facility
BP was 122/49
RR via the ventilator was increased from 12 to
16 to keep his C02 in the low 30’s
The pt was admitted to the ICU
22. Discussion
Admitting Diagnosis
MI
CVA
Hyperthermia
Due to heat exposure
Dehydration
Secondary to heat exposure
Acute Renal Failure
28. Report from First Responders
75 yr old male (driver)
+ Seatbelt
Airbag deployed
Trapped with prolonged extrication
Pt c/o CP
No surface trauma observed
GCS is 10
Eyes open to pain
Withdraws to pain
Disoriented and conversant
NOW WHAT?
29. ABC’s
Airway
Open and clear
Breathing
Respirations are 16 and shallow
Circulation
Skin is pale
Diaphoretic
Capillary refill is at 5 sec
Pulses are thready and slow
30. Vital Signs
BP: 70/30
HR: 30’s
Pulse Ox was 94% but now does
not read
GCS is now 8 and pt becomes
combative
31. Pre-hospital Course
Airway management with DAI
Ventilated with 100% 02
2 IV’s were established with 2800 ml IV bolus
25 grams of Albumin was infused
Gastric tube was passed for decompression
3 mgs of Atropine
Without effect
Two Epi injections (0.5mg)
Increase HR and BP achieved
32. In Hospital Course
VS on arrival were:
BP 93/38
HR 115
EtCO2 30
GCS 3 (DAI)
Trauma protocol started
CXR
Pelvis Xray done (fractured pelvis seen)
Blood transfusion started
Foley inserted with gross bloody urine returned
33. Outcome
Patient’s BP and HR steadily declined
Patient coded in spite of all resuscitation
efforts
Continued resuscitation was not successful
Diagnosis
Blunt Chest Trauma
Cardiac and pulmonary contusions
Pelvic Fractures
36. The Trauma Call
Call is received for a single vehicle accident (MV
vs Tree)
There are multiple patients and reports of people
trapped in the vehicle
2 EMS units and Fire/Rescue are dispatched
You are one of the medics enroute
What are you thinking?
What are you preparing for?
37. First to Arrive
You find a total of 4 patients, with 1
trapped
You are 1 and ½ hours from the closest
trauma center
What do you do?
What do you want?
38. Triage
You find 1 patient trapped and 3 outside
the vehicle
You classify 2 major and 2 minor
WHO YA GONNA CALL?
39. ABC’s
You call for 2 EMS helicopters for the 2
majors
Further assessment reveals one of the
patients has a severe head injury
The patient that is trapped c/o severe CP and
SOB
Treatment and stabilization is initiated by the
ground units
44. BIG PICTURE ⇒ Focused
assessment
The pt with the severe head injury is flown
to the closest trauma center
The 2 minor trauma pt’s are ground
transported to the closest appropriate
facility
The 4th pt that remains trapped inside of
the vehicle becomes our focus
45. Trauma Assessment
Our Patient
36 yr old male who is awake, talking and c/
o severe CP, back pain and SOB
Remains in the vehicle on his side with his
lower extremities trapped
46. Primary Assessment
AIRWAY
Patient is vocalizing
BREATHING
Spontaneous breathing
RR 36 and labored
Grunting respirations.
Course rhonchi to all lung fields
Skin is pale
48. Primary Assessment
CIRCULATION
Central and peripheral pulses are present
HR 88
Skin remains pale and clammy
No uncontrolled bleeding is observed
Intervention: 18g IV started with bolus
50. Secondary Assessment
Extrication is complete
Patient is secured on a backboard with a C-Collar and
headblocks are in place
Abdomen soft and nontender
Pelvis stable and nontender
MAE well with 4 point pulses
Surface trauma observed
Full thickness lower lip laceration with bleeding
controlled
51. Secondary Assessment
Vital Signs
HR is 88
RR at 36-40 labored
SpO2 at 80% on 02 NRB
BP not available at this time
Patient is agitated and restless
Do you continue with your secondary?
52. Interventions
Breathing continues to be ineffective?
Airway management with DAI is performed after
the patient has been moved to the aircraft
Prior to lift off
Unsuccessful after three attempts
Failed airway
Combitube rescue device used to successfully secure
the airway
53. In Flight
Patient had expulsion of gastric contents via the
combitube
Suctioning performed
During BV ventilation we observed bloody
pulmonary secretions
Suctioning performed
Patient’s EtCO2 started at 63
Down to 39 by arrival to the ED with hyperventilation
54. In Flight
The pt remained normotensive
Sp02 increased to 99%
Remained sedated and chemically
paralyzed
Received 800cc bolus while enroute to the
ED
55. Diagnosis
Why are the pt’s pulmonary secretions
bloody?
Why was the pt’s breathing ineffective?
Pneumothorax?
Hemothorax?
Pulmonary Contusions?
Rib Fractures?
60. Our Patient
Subdural hematoma
Pulmonary Contusions
Left sided rib fractures
Ribs three – seven
Left Pneumothorax
Right Scapular Fracture
Splenic laceration
61. Hospital Course
Admitted to the trauma ICU
A chest tube was placed for his
pneumothorax
Pulmonology consult for respiratory failure
Due to massive pulmonary contusions
Bronchoscopy to remove a mucous plug
62. Patient Outcome
Significant improvement over the next 3
days
Discharged to home on the 3rd day with a
PT and OT consult
QUESTIONS??
63. Thank You!
Please ensure that you have signed the
roster and submitted your evaluation to
the instructor!
Editor's Notes
The teaching points of this case study will be the different types of shock. This pt will be in both hypovolemic and cardiogenic shock so go over the S/S for each of the 4 shock states. There will be slides for each type of shock.
This case study will also have several major problems going on at the same time so stress the importance of not to just focus on the first one you find but continue to predict and treat based on the circumstances surrounding the patient. He will ultimately be dx with CVA, MI, Renal Failure, hyperthermia and hypovolemia due to exposure and dehydration.
Stress the importance of a good history, 85% of all diagnosis are based on this alone.
Talk about the increased risk and higher mortality rate associated with trauma in the elderly
While you are performing your ABC’s stress the importance of thinking ahead concerning MOI and the predicted injuries and conditions you may have to treat.
Stress the importance of treating all life threatening conditions found during the primary survey before proceeding to the secondary survey.
This is a quick street method to get started on the Dopamine, it will be very close. Share more exact way as well. EMS field guide, PDA, etc… Discuss fluids vs vasopressors for controlling BP.
Get input from the class and then the following slides will cover each type of shock
Dehydration due to exposure and tempature
Predicted injury due to pt’s age and circumstances. Discuss MI coming first and then the exposure or the possiblilty of the MI following the stress on the heart after the exposure. Does it really matter. Discuss the treatment for.
Hypovolemic and Cardiogenic and continue appropriate treatments
The pt later died from his injuries and never regained consciousness, reiterate the extremely high mortality rates associated with major trauma/illness and the elderly
Discuss the importance of MOI and the forces involved to cause this much damage.
Was there intrusion into the passenger compartment ? Yes Is the vehicle drivable? No Is there more then 12 inches of intrusion into the passenger compartment? Yes Was the accident at highway speeds (over 40mph)? Yes All these yes questions are predictors of major trauma and the trauma center staff will be asking these questions so they can predict injuries and prepare for the pt’s arrival.
Don’t forget your scene safety before the history and start your ABC’s
Key points: Elderly, trapped with prolonged extrication, c/o CP what are the predicted injuries? GCS of 10, what could be causing his decreased mental status, head injury ? Hypoxemia? Both?
Rapidly deteriorating pt requires aggressive treatment/interventions during your ABC’s. Do you take his airway? Discuss risk vs benefit.
Albumin is controversial for use in trauma as a volume expander, has been shown to be associated with poorer outcomes and increased renal failure for trauma pts. The 2 epi injections were done as last ditch effort (thinking outside the box) to prevent the trauma arrest. My partner and I saw the pulse dropping fast and new the pt was seconds away from a CPR situation. It worked!
At a Level II trauma center
Discuss mass causality situations and the importance of triage and soliciting additional resources when needed.
Discuss Ground vs Air transport. Additional resources needed. Discuss the importance of time driven trauma care.
Discuss the prediction of injuries based on MOI and S/S of the pt.
Discuss forces involved, highway speeds. What is the speed limit of the roadway in which the accident occurred?
The vehicle is facing the same direction from which it had come. The tire marks on the shoulder up to the tree suggests that the vehicle left the roadway in a gradual turn. No sharp curves in the roadway and no other vehicles were involved. Vehicle malfunction, driver fell asleep, had a seizure, diabetic problem, all need to be considered along with the obvious.
ABC’s while being extricated.
Predicted injuries? How and what do you treat while the pt is still trapped.
Is breathing effective or ineffective? If ineffective what interventions should you do.
We were in the direct sunlight when we attempted intubation on this pt and the sun made it very difficult to observe the airway. Make sure you are out of the direct sunlight when attempted intubation to avoid this problem. Discuss rescue airways.
What are bloody pulmonary secretions a sign of : massive pulmonary contusions (in trauma) What is the treatment?
All are predicted injuries for this pt. When is the decision to needle a pt’s chest made? After the tension has developed, no that might be to late, before the tension when it is a simple pneumothorax, no to that time as well. The time to decompress is after the pneumothorax and/or hemothorax has caused your breathing to be ineffective in spite of all of your airway and breathing interventions but before the tension develops with the clinical signs present.
Level II trauma center. What do these ABG’s reflect and should there be any vent adjustments?
Discuss vent changes and why.
Discuss the injuries and the associated treatments
Mention the amount of force that is needed to break the scapula and the predicted injuries assoc with this much energy.