David Sanko, BA, NR-Paramedic Trauma Case Reviews EMS Coordinator Financial Disclosure Case 1-EMS Course for the Advanced ◼ Called to an MVA

◼ No relevant financial relationships with ◼ 39 y/o male restrained driver of car traveling roughly Provider-7.0 any commercial interests exists. 70 mph on E-470 ◼ Impacted a guard rail which flipped the car over ◼ We will not be discussing any “off-label” uses of products or medications ◼ Part of the wooden guardrail penetrated the engine compartment, through the firewall and into ◼ Be sure to always default to your local the passenger compartment where the patient medical direction and protocols in place. legs were impacted. ◼ + A/B deployment, + SW broken with the driver’s David Sanko, BA, NRP seat actually displaced by the impact. EMS Coordinator of Education & Training

Case 1- EMS Course Case 1-EMS Course Case 1 –EMS Course

◼ EMS VS : Reported unable to obtain a blood ◼ EMS Treatment:

pressure, HR=70, RR=20, EKG= STACH ◼ Tourniquet application

◼ GEN: No LOC, AAOx3, C/P right leg pain, Skin ◼ Extricated to LSB

pale, cool, dry, + EtOH on breath noted. Morbidly ◼ IV access x 2 with IVF x 400 ml infused

obese at 5’10” and 333 lbs (151 kg) ◼ O2 via NC

◼ HEENT: 5 cm laceration above the right eye, ◼ EMS reported unable to utilized SNC due to body habitus so they manually stabilized the cervical spine ◼ EXT: Right leg is mangled and almost completely fully amputated below the knee with both tibia throughout the transport with towels and hands. and fibula visible just above the ankle, the foot is ◼ ED VS= 110/50, 67, 22, 94%, 36.6 mangle and actually folded up under the leg itself, ◼ PMHx= congenital single left kidney, left ankle problems the leg had significant oozing bleeding with no with left talocalcaneal fusion, Leukemia in remission with overt arterial spurting noted, EBL=500 ml on residual UE neuropathy from chemotherapy scene according to EMS.

1 Case 1- ED Course

◼ LABs=

◼ Wht#=10.7H (4.1-10.0)

◼ K=3.2L (3.5-5.3)

◼ BGL=149 (60-100)

◼ BAC= 0.233 (0)

◼ Lactate =4.1 (0) ◼ CT-C spine=

◼ Minimally displaced comminuted Fx along the posterior lip of the left superior articular facet of C1

◼ Mild prevertebral soft-tissue thickening at C1-C2 with DJD. CT-C spine= minimally displaced comminuted Fx along the posterior lip of the left www.combattourniquet.com superior articular facet of C1, mild prevertebral soft-tissue thickening at C1-C2 with DJD.

Case 1-ED Course Case 1 –ED Course Case 1 –Hospital Course

◼ ED treatment

◼ IVF x 1 liter

◼ Blood x 2 units

◼ Rocephin

◼ MSO4 ◼ The C1 burst Fx was deemed to be non-operative

Near complete amputation of the right lower extremity at the level and was immobilized via SNC. of the distal tibia and fibula. The distal tibia and fibula are ◼ To the OR and the right leg was determined to be fractured at this site. The soft tissues past the level of the tibial non-viable with massive degloving and crush injury and fibular fractures are very abnormal. All of the bones of the foot and ankle are fragmented. The soft tissues are macerated and there are along with missing bone fragments and was innumerable radiopaque foreign bodies of varying sizes scattered amputated. ◼ HD #11 ; Transferred to Rehab throughout them.

2 Case 2:ED Course Case 2: ED Course Case 2: ED Course

◼ 20 y/o male doing a jump on a BMX bike while turning the handlebars ◼ GEN: Ill-appearing, Pale and diaphoretic, AAOX3, CN II-XII intact ◼ Trauma Alert is called while in mid air (“Bar Spin”) ◼ HEENT: Normocphalic, atraumatic, PERL, EM intact ◼ NECK: Atraumatic,  JVD, trachea supple and midline, C-spine NTTP ◼ IV lines x 2 placed ◼ Landed with the front wheel still turned and atraumatic 90o ◼ CHEST: BS CTA=Bilat, Atraumatic ◼ High flow oxygen ◼ ABD: SNTTPx4, atraumatic ◼ Pitching him forward into the ◼ GENITALIA: 3.5 cm laceration to mid right inguinal region ◼ FAST U/S: Questionable trace free fluid handlebar (“OTB”) immediately superior to inguinal ligament. Minimal dark red bleeding without pulsatile bleeding. Appears to track superiorly and posteriorly. in Morison’s Pouch, no evidence of ◼ Impaling the inguinal area resulting in Some grass and debris noted at entrance of wound. a puncture wound and significant pain developing intrabdominal hematoma ◼ PELVIS: Stable and NTTP ◼ Friends grabbed him and put him ◼ EXT: MSOEx4 with some pain trying to lift right leg, Distal CSM intact ◼ Ancef, Morphine, and Zofran ◼ POST: Atraumatic,  deformity or step-off’s noted to palpation into car for POV Tx to closest facility ◼ Tetanus booster ( Level II Trauma Center). http://www.spike.com/video-clips/20yvzr/bmx- Treatment Plan ? injuries

Morison’s Pouch Case 2: ED Course

◼ Trauma Surgeon explored the wound under local anesthesia

◼ Tracks posteriorly and superiorly towards the iliac crest / iliac wing ◼ Labs:

◼ K=3.1 (3.5-5.3) ◼ BGL=122 (60-100) ◼ CT-Scan

3 Case 2: ED Course Bike Stats

◼ Friends now show up with the handlebar ◼ Consumer Products Safety Commission (2000) contents that they have removed ◼ 627,170 Bike related injuries ◼ 2 cm circular punch/ plug of clothing, underwear, skin, SQ fat and a circular core of bone which ◼ National Center for Injury Prevention and Control appears to be from the inner table of patient’s ◼ Ages 15 and under account for 59% of these injuries right iliac wing ◼ Insurance Institute for Highway Safety

◼ Stable fracture that does not require internal ◼ 140,000 children are treated in emergency fixation departments every year for head injuries ◼ ◼ Taken to the OR for incision and debridement National Institute for Highway Safety by Ortho ◼ In 2003= 668 bike related deaths

More Bike Stats & demographics Case 3- EMS Course Case 3 –EMS Course

◼ GEN: Skin was pale/warm/dry, AAO x3 ◼ 6.3% of BMX riders sustain injuries ◼ 50 y/o male C/O stab wound to the chest with associated ◼ HEENT: Circumoral cyanosis present, PERL with an old bruise ◼ Mountain bikers account for only 3.7% of bike C/P and paresthesia of the extremities. note @ OS, otherwise atraumatic injuries overall ◼ Pt reported stabbing himself in the chest because he ◼ NECK:  JVD, trachea is supple and midline, stable to A/P/Lat ◼ Age group = 9-15 y/o wanted his “medications back”. palpation

◼ Male (2-3:1 ratio) ◼ Stab wounds were from a paring knife, Pt did have ◼ CHEST: Penetrating wound to left chest with multiple “nicks” old injuries from previous attempts around the wound. BS= CTA bilaterally, ◼ Unhelmeted, under the influence, pre-existing  ◼ ABD: +TTP in upper quadrants, non distended or rigid. condition, from an unstable family environment ◼ Pt admitted to EtOH and drug use and both were found in the Pt’s room upon EMS arrival→ admitted to ◼ PELVIS: Stable to A/P/Lat palp, atraumatic ◼ POST: Unremarkable Brøgger-Jensen T, Hvass I, Bugge S. Injuries at the BMX cycling European championship, 1989. Br J Sports stopping all meds and EtOH 2 days earlier Med. 1990;24:269–70. ◼ EXT: MSOEx4, CMS intact. Senturia YD, Morehead T, LeBailly S, Horwitz E, Kharasch M, Fisher J, Christoffel KK. Bicycle-riding ◼ LEO’s on scene holding pressure to the Pt’s chest upon circumstances and injuries in school-aged children. Arch Pediatr Adolesc Med. 1997;151:485–9. EMS arrival, Pt AAOx4 with his clothing completely Illingworth CM. Injuries to children riding BMX bikes. Br Med J. 1984;289:956–7. soaked with blood

4 Case 3-EMS Course Case 3 – EMS Course Case 3-ED Course

◼ ED Physician Exam: ◼ O2 via NRB ◼ PMHx=  with previous SI / attempts, bipolar, ◼ Distended neck veins, BS: Decreased breath sounds on the ADHD, HTN, Alcohol and drug use (Meth), ◼ IV access x 2 left, absent on the right, Tachycardia with HR= 140, decreased heart sounds. ◼ IV Fluids x 1000 ml infused Smoker x 271ppd ◼ FAST U/S = + pericardial fluid , pericardial tamponade, RV ◼ LSB for extrication collapse, + free fluid in Morison’s pouch ◼ Allergies: NKA ◼ ED VS: BP= 98/78, P= 131, RR= 28, Sa0 = 100%/ NRB ◼ Emergent transport to Level II Trauma Center 2 ◼ LABs ◼ MEDs= Lisinopril (ACE inhibitor for HTN), Ritalin ◼ 11 min On Scene time ◼ Wht # =15.2H (4.1-11.0) ◼ EMS VS= ◼ 24 min Transport time ◼ RBCs =3.22L ( 3.95-5.40) ◼ 88/50, 60, 20/shallow, 93%/RA→ 94%/ O , ◼ Hgb = 10.3L (11.9-15.9) 2 ◼ Entire call from Dispatch to Hospital = 50 ◼ Hct= 31.0 BGL=338 min (35-49) Treatment Options? ◼ Trended  to 29.3 and then 28.4 ◼ UTOX = +Opiates & + Benzos

“Beck’s Triad”

Acute Cardiac Tamponade Beck’s Triad Pericardiocentesis

Physical Findings: 1. Tachycardia – allowing for at least partial maintenance of the pt’s cardiac output. 2. Elevated JVD – is almost always elevated in cardiac tamponade and is associated with venous distension of the forehead and scalp. 3. Pulsus paradoxus – abnormally large decrease in SBP (>10 mmHg) on inspiration is a common finding in moderate to severe cardiac tamponade and is the direct consequence of ventricular interdependence. 4. Pericardial rub - may be heard in pt’s with cardiac tamponade due to inflammatory pericarditis. 5. Distant or muffled heart sounds 6. Hypotension

https://www.grepmed.com/images/5140/pericardial-cardiology-tamponade-diagnosis-cardiac-becks-triad

5 PERICARDIOCENTESIS SITES Subxiphoid Approach Parasternal Approach

Apical Approach Case 3- ED Course

◼ Trauma Surgeon performed bedside pericardiocentesis,

◼ 30 ml of blood removed

◼ Foley inserted, no output.

◼ Central Line placement.

◼ IVF =2,650 ml IV infused

◼ Chest Films:

6 Case 3- Hospital Course Surgical Photo ED Thoracotomy

Operative Note: ◼ Been around since 1900’s Cardiac laceration x 2 from self-inflicted stab wound. ◼ Drastic, last ditch effort to save a life Anterior central diaphragmatic laceration. Procedure: Clam shell thoracotomy with repair of the right ◼ “60% survival rate” ventricular stab wounds. Diagnostic laparoscopy of Abdomen. ◼ Futile ? Findings: ◼ Expensive procedure that places heath • Anterior right ventricular stab wounds x 2; 7-10 mm care works are significant risk of exposure • Large hemoperitoneum, no abdominal visceral injury identified.

• B/L chest tubes inserted. PRBC x 3 units , & FFP x 1 unit

• EBL: 1500 ml

Thoracotomy

◼ Indications ◼ What to do

◼ Recent prehospital ◼ Evacuate pericardial cardiac arrest in a patient tamponade

with a precordial wound ◼ Control hemorrhage from ◼ Cardiac Arrest in trauma heart, lung, or vessel

patient occurring U/A in ◼ Cross-clamp descending ED, during resuscitation thoracic aorta to improve or observation coronary / cerebral ◼ Profound hypotension arterial blood flow

(BP<70 mmHg) due to ◼ Allow for internal cardiac truncal wound in an massage unconscious patient, and distant or unavailable OR suite.

7 Case 3- Hospital Course Case 4- EMS Course

◼ HD #7: Pt was transferred to in-patient ◼ 59 y/o female riding a 16.3 hand (5 ½ feet) sized psychiatric facility for evaluation horse in an arena when the horse reared up backwards throwing the rider from the horse and ◼ HD #9: Pt was discharged home then the horse collapsed back upon her. ◼ Out-Patient Psychiatric treatment referral ◼ Horse weight = 600 kg (1320 lbs) ◼ Surgical Follow-Up: 10-14 days with ◼ Helmeted and denies LOC and immediately felt and Trauma Surgeon. heard a pop in her pelvis with immediate pain.

◼ Pt attempted to crawl several yards immediately afterward.

8 Case 4- EMS Course Case 4- EMS Course Case 4- EMS Course

◼ GEN: C/O ABD pain, pelvic pain, neck pain, right shoulder pain, ◼ EMS treatment ◼ EMS VS= 128/78, 90, 16 initially right leg pain. AAOx3, full recall of all events. Denies any blood ◼ Pelvic splinting / sling, ◼ thinner use. Skin; P/W/D. Pt is a nurse. On Repeat: dropped to 92/72, 75, 24, ◼ O2 @ 3 lpm/ NC ◼ HEENT: PERLA @4 mm, Atraumatic 97%/O2, EtCO2=16. ◼ IV access with 20 ga with IVF x 250 ml infused, ◼ NECK:  JVD, trachea is supple and midline, no step-offs or ◼ EKG = NSR ◼ PMHx significant for lumbar spinal deformities ◼ Zofran x 4 mg x 2 doses for repeated nausea ◼ CHEST: + BS CTA bilaterally,  A/P/Lat palpation fusion ◼ Fentanyl x 200 mcg ◼ ABD: SNTTP x 4, nd ◼ Pain reduction to 5/10 after first 100 mcg, back to 5/10 after 2 100 mcg ◼ ◼ PELVIS: + TTP A/P/Lat palp, 10/10 sharp pain and unstable to MEDs= none ◼ Non-emergent transport to Level II Trauma center. palpation ◼ Allergies= ACE inhibitors ◼ Given the MOI coupled with the suspected unstable pelvic fracture ◼ POST: atraumatic,  deformities, or midline pain pushed this patient into the Trauma Activation category which was ◼ EXT: MSOE x 4 although guarded and non-ambulatory called by the ED Sick or Not Sick? Treatment plan?

Pelvic Immobilization Determine Pelvic Instability

◼ Sheet wrap for pelvic instability and hemodynamic instability, pain control, splinting ◼ Fold sheet smoothly (Do not roll it) ◼ Apply under the pelvis, centered on the greater trochanters ◼ Ensure pt.’s pockets are empty and/or remove clothing (painful when keys are driven into the thigh) ◼ Tighten the sheet and adjust tension to return the pelvis to normal anatomic position Compression against upper Grasping the anterior superior anterior pelvis OR Iliac crests between thumb & index finger

9 Position Sheet External Anatomy External Anatomy

Greater Trochanter of femur

In supine position, greater trochanter lies between the Anterior iliac spine distal wrist and thumb Wrapped around the pelvis & centered on greater trochanters

Apply stabilization Lock it place Clamp it Down

Twist sheet to tighten Friction Lock

10 Tie it Down Can Apply in Vehicle Pelvic Immobilization

Case 4- ED Course Case 4- Hospital Course

◼ Trauma Activation called by ◼ LABs= ◼ OR for Ex-Lap surgery and external the ED ◼ Wht#=20.4H (4.1-11.0) fixation of the pelvic injuries. ◼ ED VS= ◼ Hct =39 →to 23.8L (35-49)

◼ BGL=216H ◼ Small bowel injury required resection ◼ 108/71, 75, 25, 100%/O2. (60-100) ◼ Lactate= 2.0H ◼ ED placed stiff neck collar (0) ◼ Required Levophed gtt to maintain her ◼ CK= 27,737 → 30,214H immobilization upon arrival in (20-198) BP the ED. ◼ FAST U/S = ◼ X-ray shoulder= ◼ ◼ ABD & Pelvis = diffusely Transfusion protocol ◼ CT-Head=  tender to palpation and non- ◼ ◼ CXR= PRBCs x 5 units distended. ◼ Pelvic Films= ◼ FFP x 2 units. ◼ RLE= externally rotated, LLE= internally rotated. ◼ Minimal urine output.

11 Case 4- Hospital Course

◼ Very unstable post operatively

◼ Requiring dialysis for acute renal failure / acute tubular necrosis

◼ Metabolic acidosis

◼ Hyperkalemia

◼ Acute blood loss anemia

◼ Hypernatremia

◼ Hyperphosphatemia

◼ Rhabdomyolysis

◼ Hypovolemic shock.

◼ Acute respiratory failure

◼ Still intubated on HD#6

Physiology Case 4- Hospital Course Compartment Syndrome

◼ HD #14: Tx’d to Level 1 Trauma Center for ◼ A continuation in the ▪ Normal muscle cell function. complex orthopedic repair disease spectrum of • Arterial blood supply provides glucose, ◼ Left calf iliac vein injury & thromboembolism crush injury oxygen and nutrients. to her left calf with ischemia and the ◼ Usually results from • Cell membrane “sequesters” cellular compressive forces or contents with specialized transport across development of compartment syndrome blunt trauma to muscle resulting in significant nerve injury to her left groups confined in tight the membrane. leg and renal failure fibrous sheaths with • Myoglobin binds & transports oxygen within minimal ability to stretch Prolonged crushing, as the muscle cells. ◼ Fasciotomy. (below the knee, above when an unconscious the elbow) • Venous blood transports CO2 and waste ◼ HD# 15: left below the knee amputation person lies on a body part products (i.e., lactic acid). for several hours.

12 Crush Injury: Crush Injury: Cellular Response Cellular Response Rhabdomyolysis

▪ Continued pressure impairs circulation ◼ The breakdown of muscle fibers resulting in ▪ Damage results in loss of cell membrane the release of muscle fiber contents into the integrity • Local tissue hypoxia circulation. ▪ Anaerobic metabolism→ Lactic Acid production • Intracellular contents spill into surrounding ◼ Clinical sequelae of rhabdomyolysis include tissues and spaces (Interstitial spaces) • Build up of cellular toxins in injured tissues the following: ◼ Hypovolemia (sequestration of plasma water within injured • Histamine is released & causes vasodilation & ▪ Lactic acid, Uric acid (product of protein metabolism), Potassium, Phosphates, Myoglobin myocytes (a muscle tissue cell)) increased capillary permeability ◼ Hyperkalemia (release of cellular potassium into the systemic (a form of hemoglobin within the muscle cell) circulation) • “Leaky” allowing an increased amount of • Re-oxygenation causes the formation of toxins ◼ Metabolic acidosis (release of cellular phosphate and sulfate) blood serum to extrude into the tissue. ◼ Acute renal failure (nephrotoxic effects of liberated myocyte such as free radicals, superoxides and components) →Increased edema thromboxanes. ◼ Disseminated intravascular coagulation (DIC)

Compartment Syndrome: Pathophysiology Summary Pathophysiology Results of crush injury “bad juice.” Less overall pressure

• Lactic acid production. but over longer periods of time • Electrolyte release (potassium).

• Myoglobin release. Fluids re-perfuse • Other toxins released (superoxide, free radicals, damaged areas Compartments of etc.) ▪ Muscle tissues become Lower Extremity • Lysozyme release. swollen inside fibrous sheaths • Uric acid production. ▪ Increased swelling • Capillary leak. results in increased • Muscle enzyme release (CPK) used as marker for pressure the extent of tissue damage. ▪ Similar to pericardial tamponade

13 Compartment Syndrome: Hyperkalemia – Signs and Symptoms Fasciotomies Pharmacological Treatment

◼ Calcium Chloride (antagonism) General findings – 5 “P” s ◼ Increases the threshold potential, reverses depolarization and restores normal membrane excitability, increases • Pallor speed of conduction. • Paralysis ◼ 5-10 mg /kg of 10% solution (1 gm usually) • Pulselessness ◼ NaHCO3 (antagonism & redistribution) ◼ Adults: 50 mEq IV over 5 mins • Pain on passive stretch ◼ Children: 1-2 mEq/kg/dose slow IV • Paresthesia ◼ Dextrose (redistribution) Most significant findings ◼ Should be given in conjunction with insulin ◼ 50 gm + 10 units of Regular insulin • Pain on passive stretch ◼ Insulin (redistribution) • Sensory impairment ◼ Nebulized Albuterol (redistribution) ◼ 10-20 mg in 4 ml NS GPN over 15 mins

“C BIG K DROP” Case 4- Hospital Course Henry VIII

◼ Very charismatic ◼ Recovery was also complicated by a labial wound with communication ◼ C- Calcium gluconate (10%) 10 ml over 10 mins = ◼ Good looking to the pelvis hardware. cardiac stabilizer ◼ 6’2” in height ◼ HD#48: She had multiple washouts and skin grafting. ◼ 210 lbs ◼ B-Beta agonists; Albuterol and/or Bicarbonate 8.4% ◼ Infectious disease followed her closely. ◼ 32 inch waist ◼ She had transfusions for blood loss anemia secondary to trauma and a (50 mEq) IV over 5 minutes ◼ Academically and athletically talented GI bleed→ had cautery on HD#47. ◼ I- Insulin; short acting insulin 10 units IVP followed ◼ “Adonis” ◼ Required short term dialysis for renal failure. ◼ Jousting accident in January, 1536- unseated by… ◼ Required enteral feedings to support her nutrition. and horse then fell back upon him ◼ G- Glucose; D50 x1 amp with insulin ◼ HD #107: Stabilized and was transferred to subacute rehab ◼ Severe concussion with + LOC for 2 hours ◼ She continued to have intensive wound care for her labial skin graft ◼ K- Kayexalate ( mainly for chronic renal failure , not and IV antibiotics. She was transitioned of tube feedings. Her activity ◼ Burst varicose ulcer on left leg vs DVT for the acute phase) tolerance gradually improved and she could tolerate increased intensity ◼ Died at age 55 in 1547 of therapies. ◼ Close to 400 lbs ◼ D-Diuretics; Lasix 40-80 mg IV push ◼ 54 inch waist ◼ HD #140: DC’d to inpatient rehabilitation ◼ ROP- Renal unit for Dialysis Of patient ◼ HD #161: DC’d to home, PT/OT Requirements, Follow-ups

14 Parting Thoughts

◼ MVA extremity trauma, References tourniquet use ◼ American College of Surgeons. Thoracotomy in the Emergency Department. David V Feliciano, MD, FACS. Committee on Trauma. Subcommittee on Publications 2004 ◼ Put rubber grips on the ◼ Up-To-Date .com. Emergency Pericardiocentesis. handlebars ◼ http://www.spike.com/video-clips/20yvzr/bmx-injuries ◼ www.combattourniquet.com ◼ S/W to chest; cardiac ◼ https://www.google.com/search?biw=1394&bih=867&tbm=isch&sa=1&ei=SMyoXdLGNs_S- gTTsZoY&q=hepatorenal+pouch&oq=hep&gs_l=img.1.0.0i67j0l9.66017.66813..68420...0.0..0.69.195.3..... tamponade, pericardcentisis .0....1..gws-wiz-img...... 0i131.3hrKMDkyGC8#imgrc=midJXpv0fBA1nM: ◼ https://www.google.com/search?biw=1394&bih=867&tbm=isch&sa=1&ei=SMyoXdLGNs_S- and thoracotomies gTTsZoY&q=hepatorenal+pouch&oq=hep&gs_l=img.1.0.0i67j0l9.66017.66813..68420...0.0..0.69.195.3...... 0....1..gws-wiz-img...... 0i131.3hrKMDkyGC8#imgrc=midJXpv0fBA1nM: ◼ Unscheduled equine dismount ◼ Brogger-Jensen T, Hvass I, Bugge S. Injuries at the BMX cycling European championship, 1989. Br J Sports Med 1990;24:269-70 with pelvic fracture ◼ Senturia YD, Morehead T, LeBailly S, Horvitz E, Kharasch M, Fisher J, Christoffl KK. Bicycle-riding circumstances and injuries in school-aged children. Arch Pediatr Adolsec Med. 1997;151:485-9.

◼ Illingworth CM. Injuries to children riding BMX bikes. Br Med J. 1984;289:956-7.

◼ Consumer Products Safety Commission (2000)

◼ National Center for Injury Prevention and Control

◼ Insurance Institute for Highway Safety

[email protected] ◼ National Institute for Highway Safety Office =303.269.4296 ◼ https://medcomic.com/medcomic/cardiac-tamponade/ ◼ https://www.grepmed.com/images/5140/pericardial-cardiology-tamponade-diagnosis-cardiac-becks-triad

◼ Trauma.org image modified by @ermedoc.com

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