Emergency Medical Services-CE34
CASE OF THE MONTH — September 2020
Paramedics respond to a traffic collision on the freeway. A 22-year-old male was driving alone at high speed when he lost control and crashed with a tractor-trailer before colliding into the median. There is severe damage and significant intrusion into the passenger space. He appears to have multiple injuries and is awaiting extrication from the vehicle. On initial assessment, severe facial trauma is notable, likely sustained when his head struck the steering wheel. His initial vital signs are BP 75/42 HR 145 RR 20 O2Sat 89% GCS E 2, V 3, M 4.
This patient has sustained multi-system trauma and should be treated in accordance with TP-1244, Traumatic Injury. After assessing for and controlling any major hemorrhage, one should proceed to managing the airway, assessing for adequate breathing, circulation and disability. Once extricated, the patient will need to be exposed to assess for major injuries and then transported as soon as possible to the nearest trauma center.
All trauma patients should be assessed in a systematic manner called the primary survey:
Airway – Assess for airway patency. Trauma to the face may distort the airway. Blood or foreign bodies from the trauma may occlude the airway. While preserving Spinal Motion Restriction (SMR), a jaw thrust can open an occluded airway. Suction as needed to remove blood or secretions from the airway. Ventilatory assistance should be provided as needed with consideration for intubation or supraglottic airway placement if bag-mask-ventilation (BMV) is ineffective in accordance with MCG 1302, Airway Management.
Breathing – Determine if adequate oxygenation and ventilation is occurring. Consider a tension pneumothorax if this patient has obvious chest trauma with decreased/absent breath sounds on one side, is hypotensive, in respiratory distress (RR > 30 or <10, hypoxic, etc.) or has signs of poor perfusion (altered mental status or cool, pale, moist skin) in accordance with MCG 1335, Needle Thoracostomy. Open chest wounds should be covered.
Circulation – Control any active bleeding. Evaluate for signs of poor perfusion including altered mental status and skin signs. Permissive hypotension is recommended in multisystem trauma patients. One can withhold fluids for SBP ≥ 70 mmHg IF the patient has normal mental status. If a patient is altered/has signs of poor perfusion, fluids should be given to maintain SBP ≥ 90 mmHg.
Disability – Assess for neurologic deficits and maintain SMR in accordance with MCG 1360, Spinal Motion Restriction.
Exposure – expose the patient to evaluate for major injuries. After exposure, keep the patient warm.
The patient will require extrication from the vehicle. Only his upper body, from head to mid-abdomen is accessible for assessment and treatment. Several facial bones appear to be fractured with distortion of his anatomy. There is blood in his airway. The patient is breathing spontaneously, but remains hypoxic. There is trauma to the chest with decreased breath sounds on the left. The patient is altered, GCS 9 as indicated above, with skin signs consistent with poor perfusion. He is withdrawing to pain in both upper extremities. Notable injuries include the significant facial trauma and a flail segment to the left chest on exposure.
wo priorities are evident for this patient:
(1) His significant facial trauma will make airway management difficult. His anatomy is distorted so BMV may be difficult or impossible. He has blood in the airway and multiple facial fractures, which would make endotracheal intubation and even supraglottic airway placement challenging. At this time, the patient is breathing spontaneously but is hypoxic. Perform suctioning, position the airway while maintaining SMR, and administer High-flow Oxygen 15L/min. Monitor for signs of airway compromise and the need for advanced airway maneuvers.
(2) The patient has signs and symptoms of a tension pneumothorax. He has evidence of chest trauma with a flail segment. He is hypoxic and hypotensive with signs of poor perfusion to include altered mental status and cool, pale, moist skin. Perform a needle thoracostomy. Approved indications and techniques for needle thoracostomy can be reviewed here.
Initiate these interventions and then continue with the remainder of the primary survey. If hypotension persists after the needle thoracostomy, fluids should be administered. Confirm that your needle thoracostomy is successful (i.e., a rush of air and improvement in perfusion); a second needle thoracostomy can be performed adjacent to the first if needed.
Paramedics immediately address the patient’s airway. The patient’s mouth is suctioned, the airway is optimally positioned, and he is placed on High-flow Oxygen 15L/min with improvement of his oxygen saturation to 96%. The patient still requires extrication; and the treating paramedics recognize that his positioning within the vehicle would make BMV or endotracheal intubation technically challenging should he decompensate. Supraglottic airway placement may be successful but could be difficult due to the multiple facial fractures and potential for trauma to the airway causing anatomic distortion.
A needle thoracostomy is performed on the left side with improvement in the patient’s blood pressure. Repeat vital signs are BP 100/76 HR 120 RR 18 O2Sat 96% on NRB GCS 9
It is estimated that extrication will take at least 45 minutes given the complexity of the scene.
In situations where additional medical or surgical expertise is needed on scene, a Hospital Emergency Response Team (HERT) should be activated to respond as soon as possible once entrapment is recognized. In this case, the patient will have a prolonged extrication, which will necessitate extended scene care. He has an airway that may become unmanageable on short notice. In addition, given the prolonged scene time, he may become hemodynamically unstable secondary to trauma and may need advanced resuscitation pending extrication.
To date, HERTs in Los Angeles County have been activated for entrapped extremities requiring field amputation and for extended scene care for patient’s requiring definitive rescue. A HERT can be activated for situations where additional expertise is required including but not limited to:
1. A life-saving procedure, such as an amputation, is required due to the inability to extricate a patient by any other means.
2. Prolonged entrapment of a patient requiring extended scene care.
3. Need for assistance with analgesia, sedation, and difficult airway management.
4. A mass casualty incident with need for field triage of a large number of patients.
This patient meets criteria 1, 2 and 3.
Procedures for activating a HERT are described in Ref. No. 817, Regional Mobile Response Teams. The Incident Commander (or designee) shall contact the Los Angeles County Medical Alert Center (MAC) and the MAC will coordinate the arrival of the HERT. It is important to request the HERT as soon as possible so that the team can mobilize; typically the minimum time to arrival will be at least 30 minutes. The mode of transportation for the HERT will be mutually agreed upon. If the HERT is arriving by air, the incident commander must identify the landing zone. On arrival, the HERT Leader reports directly to the Incident Commander. The HERT will work with the crews on scene in the management of the patient. Medical Control for the incident follows Ref. No. 816, Physician at the Scene.
Paramedics at the scene recognize that the patient will require extended scene care and that an unmanageable airway may be imminent. The Incident Commander activates a HERT that responds to the incident. The HERT arrives 35 minutes from the time of activation. The patient requires definitive airway management due progressing decompensation. The HERT is able to intubate the patient pending extrication. The patient also becomes hypotensive and necessitates blood product resuscitation, which the HERT is able to provide. The patient is extricated and transported to the Trauma Center. His injuries include multiple facial fractures, bilateral hemothoraces, left pneumothorax, and multiple extremity fractures. There was no evidence of crush injury, based on scene findings and patient assessment, though the treatment team considered this diagnosis prior to extrication.
1. All trauma patients should be evaluated and treated systematically in accordance with a primary survey including addressing airway, breathing, circulation, disability and exposure.
2. Consider the need and indications for emergent lifesaving procedures including airway management, tourniquet placement, and needle thoracostomy in trauma patients.
3. If prolonged extrication of a patient is anticipated and/or additional medical or surgical expertise is needed on scene, know the procedures to activate a HERT.
Author: Dr. Denise Whitfield, MD