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New Case Redux

Andrew J Bowman trauma-list@trauma.org
Mon, 11 Feb 2002 07:56:31 -0500 

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Greetings,

18 year old male, driver of pick up, no restraints, lost control, rolled =
over with ejection of driver.

First responders found awake, c/o diff breathing, no lower extremity =
movement, becoming more obtunded until medics arrive.

Medics find decreasing LOC, airway compromise with blood, no lower =
extremity movement, hypotensive at 70 systolic, lungs equal with =
bilateral rhonchi.

Intubated with RSI, IV x 1, spinal immobilization.

Trauma alert called at my ED.

On arrival, anectine has worn off, moving upper extremities to pain, no =
lower extremity movement, blood in oropharynx and out of ETT (good color =
change on colorimetric EtCO2 and breath sounds still equal and rhonchi).

Abdomen flat with diaphragmatic breathing, no priapism, no sphincter =
tone, no meatal blood, no extremity trauma.  BP still 70, pulse weak at =
120, sinus with PAC's.

Start LR and blood and add levophed for presumed neurogenic shock =
component, still hypotensive, neuro and general surgeons enroute (this =
is how our system works, EDP's assess patient then call surgeons, this =
is per surgery committee decision).  Solumedrol for spinal cord injury =
started.

Still hypotensive, CXR hazy lung fields but no clear hemo/pneumo (supine =
film), pelvis film OK.

DPL done, no gross blood, barely pink on return of fluid.  BP now coming =
up with blood, fluids and levophed at 4mcg/min.  Monitor now a-fib at =
140-150 (previously healthy teenager)

Off to CT, head OK, abdomen OK ( no liver/spleen, + free fluid but had =
just had DPL) Chest with massive bilateral pulmo contusions and 20% =
right hemo/pneumo and T6 fx with frags in canal

Back to ED, BP stabilizing but still a-fib 140ish.  Right chest tube =
placed, 300 cc blood and slow trickle after that.

Waiting for aortogram, patient suddenly bradycardic at 40, no pulses or =
BP, lungs without change, ETT in place, abdomen still flat, no increase =
blood out of chest tube.

CPR, blood, fluids, ACLS drugs.

Ultrasound machine from L/D, no pericardial effusion/tamponade. ( our =
single FAST certified doc had just come on duty)

Pulses return, back to a-fib 120-140, BP 80.  Off to aortogram, normal =
aortogram.

Continues to be hypotensive, more difficult to oxygenate/ventilate.  =
Getting cool despite fluid warmers and warming vent circuit and Bair =
Hugger.

blood alcohol =3D 0, no drugs of abuse on tox screen.

Arrests twice more and resuscitation halted.

Thoughts, comments, suggestions.

I am thinking blunt cardiac injury in combination with massive pulmo =
contusions as probable cause of demise. No big source found for =
hypovolemia.

Thanks for responses.

Andrew J Bowman

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<BODY bgColor=3D#ffffff>
<DIV>
<DIV><STRONG><FONT face=3DTahoma =
size=3D2>Greetings,</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>18 year old male, driver of =
pick up, no=20
restraints, lost control, rolled over with ejection of=20
driver.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>First responders found awake, =
c/o diff=20
breathing, no lower extremity movement, becoming more obtunded until =
medics=20
arrive.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Medics find decreasing LOC, =
airway=20
compromise with blood, no lower extremity movement, hypotensive at 70 =
systolic,=20
lungs equal with bilateral rhonchi.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Intubated with RSI, IV x 1, =
spinal=20
immobilization.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Trauma alert called at my=20
ED.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>On arrival, anectine has worn =
off, moving=20
upper extremities to pain, no lower extremity movement, blood in =
oropharynx and=20
out of ETT (good color change on colorimetric EtCO2 and breath sounds =
still=20
equal and rhonchi).</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Abdomen flat with =
diaphragmatic breathing,=20
no priapism, no sphincter tone, no meatal blood, no extremity =
trauma.&nbsp; BP=20
still 70, pulse weak at 120, sinus with PAC's.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Start LR and blood and add =
levophed for=20
presumed neurogenic shock component, still hypotensive, neuro and =
general=20
surgeons enroute (this is how our system works, EDP's assess patient =
then call=20
surgeons, this is per surgery committee decision).&nbsp; Solumedrol for =
spinal=20
cord injury started.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Still hypotensive, CXR hazy =
lung fields=20
but no clear hemo/pneumo (supine film), pelvis film =
OK.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>DPL done, no gross blood, =
barely pink on=20
return of fluid.&nbsp; BP now coming up with blood, fluids and levophed =
at=20
4mcg/min.&nbsp; Monitor now a-fib at 140-150 (previously healthy=20
teenager)</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Off to CT, head OK, abdomen OK =
( no=20
liver/spleen, + free fluid but had just&nbsp;had DPL) Chest with massive =

bilateral pulmo contusions and 20% right hemo/pneumo&nbsp;and T6 fx with =
frags=20
in canal</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Back to ED, BP stabilizing but =
still a-fib=20
140ish.&nbsp; Right chest tube placed, 300 cc blood and slow trickle =
after=20
that.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Waiting for aortogram, patient =
suddenly=20
bradycardic at 40, no pulses or BP, lungs without change, ETT in place, =
abdomen=20
still flat, no increase blood out of chest tube.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>CPR, blood, fluids, ACLS=20
drugs.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Ultrasound machine from L/D, =
no=20
pericardial effusion/tamponade. ( our single FAST certified doc had just =
come on=20
duty)</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Pulses return, back to a-fib =
120-140, BP=20
80.&nbsp; Off to aortogram, normal aortogram.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Continues to be hypotensive, =
more=20
difficult to oxygenate/ventilate.&nbsp; Getting cool despite fluid =
warmers and=20
warming vent circuit and Bair Hugger.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>blood alcohol =3D 0, no drugs =
of abuse on=20
tox screen.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Arrests twice more and =
resuscitation=20
halted.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Thoughts, comments,=20
suggestions.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>I am thinking blunt cardiac =
injury in=20
combination with massive pulmo contusions as probable cause of demise. =
No big=20
source found for hypovolemia.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Thanks for=20
responses.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Andrew J=20
Bowman</FONT></STRONG></DIV></DIV></BODY></HTML>

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