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DartmouthDave

Seat Belt Follies

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Hello City,

You are part of a fix-wing critical transport team.

You are diverted from a previous mission for a trauma patient.

You receive a brief patient update: A 67 year-old male was involved in a high speed MVC. He has sustained blunt trauma to his neck. He has been assessed by the community hospital’s trauma team and a CT and a CT-A has been done.

The scans have noted a transection of the right carotid artery, right superior thyroid artery, and a transection of the right innominate vein.

His VS are: HR 50 BP 90/50 Resp 24 SpO2 95% on NRB.

You arrive in the ED and your patient is sitting up, in pain, and anxious. Blood soaked gauze is wrapped around the patient right hand. His neck is brusied on both sides and you see bulging on the right side!

In the room next door, the driver is yelling profanities, while the staff is splinting his fractured ankles.

The ED staff seems quite pleased to see you.

Cheers,

Dave

Edited by DartmouthDave

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What do you have available to you for blood products? What has been done with the patient thus far (ie. has the patient received TXA or perhaps octaplex)? Past medical history, allergies, medications?

Regardless, the picture you've painted so far tells me this gentleman requires a vascular surgeon yesterday.

Oh and what about the other patient? Anything to indicate the other patient may also require medevac?

Edited by rock_shoes

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What actually happened to the patient?

When did it happen?

Other than a CT what other interventions and tests, if any, have been done?

What has been the trend in his vitals?

What size plane do you have?

What will your door to door travel time be?

Start with your own exam; any other injuries or abnormalities to the entire body? Chest injuries? Lung sounds (and review the x-ray if it was done; 95% on a NRB isn't right)? If you are good at ultrasound pulling that out might be nice, but really that can wait until you are airborne.

What is the injury to his hand? How much is it bleeding, and how much has it bled? Is it possible to staunch the flow with proper wound packaging, or can you clamp off individual vessels (if you can see them) or maybe a tourniquet if needed?

What is the patients medical history, including meds? Is there something on board keeping his pulse that low, or is that due to the carotid injury and other damage to the neck?

Are there any neuro deficiets? A shear force strong enough to cause that type of damage may also have damaged the spinal cord, not to mention the loss of blood to the brain will cause problems eventually.

Not that it's going to matter in a minute, but can the patient lay flat? If they CT'd him he must, but how did he react when that happened?

To recap: you have a patient with known major vascular injury to the neck, a compromised airway and hemodynamics, and possible unfound injuries (lung damage, spinal damage, the hand injury, other traumatic injuries to the body).

Confirm you have patent, appropriate lines in place (or place your own), give a single fluid bolus to start (if this has been done hold off for now)

Sedate, paralyze, and intubate. The bleeding into the neck is already causing swelling; with that and circumferential bruising you should be very concerned about losing the airway on the flight, AND this being a difficult intubation. So do it, but be well prepped and have all your backups ready.

Have epi drawn up in a push dose concentration (10-20mcg/ml); the changes in pulse and BP could be due to the neck trauma; this would be the best way to intially fix that, especially during the intubation.

If you have a plane that could potentially take 2 patients (one of whom will be supine and another who should be) maybe take a quick look at the other guy, but if it can't this patient is still the priority.

That should be enough to start.

Edited by triemal04

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Hello All,

The patient has a history of IHD, HTN and methadone use for chronic pain. He also suffered two previous head injuries (#1 was a MVC #2 was from an assault). Also, the patient has an ETOH history. He takes ASA daily, a round pill to control his mood, and Ativan for his nerves.

The hospital did a FAST, CT and a CT-A and they only found the vascular injuries. The CT reports says, "...transection of right superior thyroidal artery with large hematoma that is displacing the larynx leftward....." and "....right innonimate vein transection with large hematoma that extends below the aortic arch...".

Initally, in the ED, the patient was stable. He tolerated the CT/CT-A without issue. Unfortunately, he has been getting restless over the last 30 minutes or so. On arrivial, he was hypertensive (140-130/89-90) and tacychardic (100's). Now, his HR is in the 50-60 and his BP 80-90/40-50ish.

The right hand was lacerated when the coffee cup he was holding shattered. There is a large laceration on the top of his hand that is oozing blood. The whole right arm is cool to the touch and looks swollen. The BP cuff is on his right arm.

On exam, the patient is anxious but following commands. The left side of his head is covered in sweat while the right is dry with ptosis. He says his back, neck and hisp hurt. His voice sounds hoarse and it hurts to swollow. Lungs are clear. Abdomen is soft with a selt belt bruise.

Labs are pending and they have cross matching for blood. The patient has been given Ancef 2gm IV, Morphine 2.5mg IV PRN, and NS1000cc.

They have not considered TXA.

In addition, they are not keen on intubation. They think he should go as is.

The neck patient has been accepted at the local university hospital for a trauma team activation (to reassess before the OR).

The second patient has not been accepted for transfer yet (....however they would love for you to take both patients!!!!.....the pane can fit two BTW)

Cheers

Edited by DartmouthDave

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has his family been called to make funeral arrangements?

Odds are high he will exsanguinate internally during any prolonged transport to higher level care.

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How long is intermediate transport to the aircraft? How long is the flight? How long is intermediate transport to the destination facility?

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Well he's certainly having a bad day.

I'd still like to know what your total door to door time will be.

What resources does the hospital have immedietly available? ie is anesthesia and ENT in house and available?

Start by moving the BP cuff and pulse ox to the left arm and recheck the values.

If the sat is still only 95% it's very likely that you are either missing a pneumo/hemo or blood flow to the lungs has been compromised.

I would still be very concerned for additional injuries, or damage to major vessels that has been missed due to the other internal bleeding; unfortunately, there isn't a lot you can do right now.

If the BP is still low with a low pulse I would say it's a combination of blood loss, and with the description of the hematomas have to wonder if they aren't directly impinging on the heart and/or the aorta and impeding flow, OR putting enough pressure on the carotid bodies to trick the body into thinking it's hypertensive and needs to compensate; either way the treatment will be the same.

The condition of the right arm...with those injuries and the hematomas that's to be expected; nothing to be done until you get to a vascular surgeon. What about his right leg, and the whole right side of his body?

TXA would good, blood would be very good; he does need volume and blood would be best.

An epi drip would also be good.

Now the hard part...keen or not, look the doctors square in the eye and remind them that this is a patient with a KNOWN compromised airway who is KNOWN to be a difficult (potentially very difficult) intubation. Ask them if they really, really want to take a person like that and put them into a small, cramped plane where the emergent crich that will be needed if nothing is done now will be very difficult to do. Or just tell them that he has to be intubated...like yesterday.

If anesthesia and ENT are available I would confer with them and think about deferring to them; if the anesthesiologist can do an awake intubation, or a fiberoptic intubation that would be best. His crichoid membrane needs to be marked and ENT (if available) needs to be standing by with a scalpel if anything goes wrong.

If they aren't available...make your plan and be ready for a bad failure. Have a backup ready (LMA and bougie), if you are good with video laryngoscopy go with that to start, if not then go with DL. Have someone available to assist with manipulating the larynx, again, have the crich marked and a designated person standing by with a scalpel. Go with sux and a very small dose of ketamine. If you can't intubate but the LMA works try passing either a bougie (or tube if it's and intubating LMA) through it; if you can't do that you still have to cut, but the pressure is off somewhat.

So to recap: TXA, blood and pressors for support, a tube in the trachea by intubation or crich, keep him sedated with fentanyl (that'd help with any potential withdrawal too) ketamine, and rocuronium if it becomes neccasary. Take only this guy; your hands are going to be full.

Edited by triemal04
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Hello, Sorry, I forgot to add this in my last post. It is about 15 minutes to the airport. The flight time is 45 minutes followed by a 15 minute drive to the university hospital. So, out of hospital time will be around an hour. I will more later. Triemal04.....very nice post. Cheers

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Looking at it from the other side (sending facility and receiving facility), this guy should be tubed prior to transfer by the most skilled person (probably the ER doc, but I may be biased). This pt will be spending at least an hour in non-ideal intubation conditions. Let's tube him in a controlled environment with back up devices at the ready (I'm grabbing the Glideoscope). I'm a little concerned about the pt's vitals. He needs fluid resuscitation/blood products going. As for the other guy, at least here in the US, he isn't going anywhere until he has been accepted and the forms have been filled out (seriously, had a tubed head trauma pt that the helicopter was initially responding to the scene for (2 miles from hospital, but got worse so EMS transported to local hospital) and they wouldn't leave the ground until the EMTALA form was completed and they had their copy). Not enough info on the other guy to really make any calls at this point.

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