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A case for Physical Exam after blunt trauma

Gross, Ronald Ronald.Gross at baystatehealth.org
Wed Dec 26 17:41:47 GMT 2012


I see a couple of issues here, Juan:

1.  Foley placed in the face of a pelvic fracture without RUG - hopefully you aren't in the retroperitoneal pelvic hematoma
2.  Was there chest wall crepitus on examination of the chest prior to intubation?  If so then this scenario suggests a right sided PTX (with or without a tracheobroncheal injury) that became a tension PTX after intubation .  In that case a left chest tube would be useless, and lack of a right chest tube would be fatal (or damn near).
3.  A less likely alternative to #2 would be a right tension PTX along with esophageal intubation - the 02 at 100% can last for a while but capnography was suggestive of an esophageal intubation, both of which caught up to each other and the effect was additive and sudden.

The other thing to worry about this early in the patient's course is a hollow viscus injury in spite of a negative FAST.  At this stage of the resuscitation there might not be detectable succus in the abdominal cavity, and the FAST - and in fact a CT - will be very unreliable.

So, what really happened?

Ron

PS - "cold" in NOLA is a summer day in CT!!  :-)



-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Duchesne, Juan C
Sent: Wednesday, December 26, 2012 9:27 AM
To: Trauma-List [TRAUMA.ORG]
Subject: A case for Physical Exam after blunt trauma 

First of all I hope all of you guys had a very warm and nice holiday with
your family members and friends. I will like to share this learning case
from yesterday with you guys. Because is cold down here in NOLA there is a
myth that bullets don't work as well as in hot weather so our blunt trauma
cases volume is picking up :) Here is the initial presentation:

-25 year old intoxicated male was brought by EMS after t-bone a dumpster
truck 

Initial GCS 8, not protecting his airway, obvious facial trauma but
without any sign of hemorrhage
O2Sats: 92%, diminished auscultation bilateral
Heart Rate : 148
Systolic: 108
Diastolic: 92
2 large bore IV access with 2 units of blood/plasma running, no IV fluids
Abdomen: soft, not distended, pelvis stable at wings but with crepitus at
pubis
FAST: negative for intra-abdominal fluid
Rectal: negative for blood
Foley placed: gross blood
Skin: diaphoretic, cold
Angry RED SEAT BELT sign all over his torso and lower abdomen

Because of his low GCS patient was intubated with some
difficulty......there was no good CO2 color change but his o2sats remained
100%.... not for long.....suddenly his o2 sats started dropping and after
couple of good ambu-bag ventilation his heart rate drop down to 30, right
chest expanding, left chest not moving. ET tube mark at 22 from mouth.

What went wrong? ED wants to put a chest tube on left



  


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