Diaphragmatic Herniation in the Multisystem Trauma Patient

[BlueSkies]

I was thinking of odd scenarios I have seen in my career and just wanted to share this with you all. Of course any input or observations are welcomed and appreciated.

My aircraft was called to the scene of an MVA last summer. Two vehicle head on colision. My patient was the driver of the number two vehicle the was struck more toward the passenger side of the front. This was a moderate speed crash of <55mph with not much patient compartment intrusion. There was extensive windshield and steering wheel damage and the airbags did deploy.

Upon our landing and being driven a few hundred feet to the scene we made a quick assessment of the patient after taking report from the on scene paramedics. The patient was being extricated from the vehicle by the local rescue team.

After he was properly packaged and laid flat he began to C/O increasing dyspnea. After he was loaded into the EMS unit for the short transport to the aircraft his Spo2 began to decline. (Keep in mind that the time from extraction from the vehicle until transport time was less than 5 mins)

He was already receiving 15LPM 02 via an adult NRB. Lung sounds were decreased on the left. I attempted to due a reasonance test but the noise level was too great to make an educated call on what I was hearing. Also heart tones and lung sounds were equally hard to make out.

After we got closer to the aircraft and away from the noise of the scene the assessment became much easier and then I was able to make a determination on what the underlying cause of the dyspnea was all about.

Heart tones were muffled a little but no rubs, clicks or gallops were noted. No S3 or S4 sounds were noted. Percussion over the left lung field revealed hyporesonance. It literally sounded like I thudded on a watermelon. A little longer listening over the left lung revealed bowel sounds. I had been considering using a Wayne Pnuemothorax Kit prior to understanding what I was hearing.

All other injuries were fairly superficial. As I recall I think his left thigh had a laceration but nothing else major.

The point behind all this is I try to be as cautious as possible when faced with the need to be fairly invasive with my patients. Always take the time to be certain of what you are hearing and practice pratice practice the things you aren't familiar with like lung and heart sounds. We get so used to hearing wheeses and rales or rhonchi that we tend to get tunnel vision and often skip a throrough inspection sometimes. We can also fool ourselves into thinking we hear something that isn't there.

A part of this story that I left out is I asked my partner to listen to all of the above and we both agreed it was a diaphragmatic herniation and therefor we with held any further invasive treatment.

We were both hesitant to decompress the chest due to the clues not lining up to suggest a tension pneumothorax or a hemothorax. I would have suspected to see JVD, PVC's or some other sign of one or the other. (I am speaking here of when I couldn't hear so well)

This patient was flown to the Level One Trauma Center and received emergency surgery to repair the diaphragm. He spent 2 days in a step down unit and was D/C home on day 3.

This was kind of abbreviated to get to the point but I recall quite a bit about this and I have a pic I'll post to give you an idea of the scene but feel free to ask any more questions.

Thanks gang!!

Sorry I didn't mean to put multisystem, I just meant to write Trauma Patient.

[mobey]

Great scenario Gulf thx.

To begin discussion I will point out that many many times with pts whom cannot lye supine for various reasons I have used a KED and leave them semifowlers on the cot.

I also like it for chest injuries because you can splint the entire chest when you are faces with bilateral fractures.

[BlueSkies]

I have always been a proponent of, "If its bad enough to extricate its bad enough to need an XP-1." Which of course isn't always true but it seems that a bunch of advanced providers forget to utilize a great tool. I have talked to several medics who didn't know that it controlled C-Spine once secured into place.

Of course I do believe this is lack of education on their respective programs part. Everyone pushes the LSB for complete spinal immobilization when sometimes an XP-1 or KED is a better choice.

[chbare]

Gastric intubation and decompression is a potentially helpful intervention for suspected diaphragmatic hernias. It may be of particular importance when considering gas laws and patient transport.

[Kaisu]

I ran on a patient that had been duct taped to a chair and tortured with a box cutter. (They had tried to induce my patient to reveal the location of his meth stash). This patient had to the bone lacerations of the head, full thickness chest and back. I had to wrap kerlex around the O2 mask to keep it on his face because I could not wrap the elastic around the skull and cervical vertebrae exposed. One of his injuries was a perforation of the diaphragm with intestine in the thoracic cavity. I kept the patient upright. His vitals were good. He had more and better stimulant on board than I could legally give him and after approximately 1,800 stitches did just fine.