Let's review the imaging findings. Imaging Findings CXR: - Bilateral pulmonary contusions - Left sided hemopneumothorax CT Chest: - 5 left sided rib fractures - Left hemopneumothorax - Bilateral pulmonary contusions - No aortic injury - No cardiac tamponade CT Head: - No acute intracranial injury CT C-Spine/Chest: - No cervical spine injury CT Abdomen/Pelvis: - No intra-abdominal injury - Stable pelvis The imaging confirms pulmonary contusions and hemopneumothorax

1. Trauma Unleashed!
Case Studies from the Field
Air Evac EMS, Inc.
Outreach Education Module

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

23. Questions

24. Ready for Another??

25. Truck vs Car BROADSIDE

26. Your Patient is the Driver of the
Truck

27. Extrication Completed
 Patient has full spinal restriction
 What do you do?
 What further information do you want?

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

34. Discussion

35. Last but not least

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

40. The Scene

41. The Scene

42. The Scene

43. The Scene

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

47. Primary Assessment
 Is breathing effective?
 What interventions are required?

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

49. Primary Assessment
 DISABILITY
 A0x4
 GCS 15
 Pupils - PERL

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?

56. Trauma Room
 Intubation/ Combitube removal
 Foley
 Gastric tube
 Trauma protocol
 EKG
 ABG’s
 CXR
 CT’s
 Head
 Neck
 Chest
 Abdomen and Pelvis
 ABG Results
 Ph 7.30,PC02 46, P02 198 HC03 22.6
 Vent Settings
 Fi02 100%, Vt 700, AC@12, No PEEP

57. ABG’s
 Vent settings were changed to
 Fi02 55%
 Vt 700
 AC@14
 PEEP of 5
 4 hour ABG results
 Ph 7.40
 PC02 38
 P02 147
 HCO3 23.5

58. Predicted Injuries
 MOI suggests
 Blunt Trauma
 Primary Survey suggests
 Blunt Chest Trauma

59. Predicted Injuries
 Possible injuries with blunt chest trauma
 Pneumothorax/ Tension Pneumothorax
 Hemothorax
 Aortic Injuries
 Cardiac Tamponade
 Rib Fractures
 Myocardial and Pulmonary Contusions
 Flail segments
 Scapular Fractures
 Sternal 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!