Dell Delton Case

Surviving the Cold: A Trauma Case PresentationDells-Delton EMSMed FlightUW ERLevel 1 Trauma1Interesting drive to workApproximately 0645 in the morningJust past dawnRoad curves to left and down a hillCar in the ditch to the southCovered in frostHad obviously rolledNo tag from Police Department

Interesting Drive to WorkcontinuedDecision to call Dispatch

Arrived to work and paged to the scene

Requested to come emergently

SceneArrived to scene 0657Police Department on scenePolice called for Med Flight already

Ejected vs Self-extricatedCar on tireshad rolledPatient lying next to carMarshy area; patient had wet clothes

Patient assessmentResponsive to painMoaningrockingCold to the touchAirway patentAdequate breathingNo external hemorrhage PaleProbable emesis noted to corner of mouth

InterventionsCollar placedPlaced on backboardTransferred to back of rig (0701)OxygenNRB maskPIV established in right hand

Vital SignsCardiac monitorNSR with some PACs

Unable to get good SpO2 reading

Blood pressureHypotensive

Initial set of VS:75/57Pulse 80RR 10GCS = 7

The DriveDrove to Med Flight Landing Zone of mileAttempted additional IV sites while drivingCalculating RSI drug dosages and preparing medsIO into right tibial plateauGood marrow returnFlushed wellInitially flowing well

IntubationPushed lidocainePushed EtomidatePushed Succynocoline WAITING!!!!Troubleshooting IVHow much of the dose did she get?Intubated with 7.0 ETT using KingVision video layrngeoscope CapnographyNormal appearing waveform, ETCO2 at 20Bilateral BS, absent epigastric soundsEqual chest rise

Continued Assessment & InterventionsVersedSlow pushVeccuroniumRectal temp= 84 degreesBG = 241HR decreasing from 80s to 50sAtropine 0.5 mgHR Stabilized to upper 50sIO problems!250 mL of NS had infusedBegan to appear puffy? Fractureclamped and stopped use

Med Flight ArrivesMed Flight Arrives

Dr. Abernathy places IO to humeral headCare transferred to Med Flight Crew

Transition of CareEMS Summary

Patient Vital Signs:70-80 systolic BPRR bagged at 13ETCO2 19

Patient AssessmentPatient is immobilized7.0 ET tube; good BS bilaterallyPupils are 4mm; very slightly reactiveGCS: 3 (effects of paralytics/sedatives)PaleNo obvious facial traumaNo obvious chest wall deformityAbdomen is flatPelvis stable

Patient AssessmentcontinuedEcchymosis over medial aspect of left thigh; no obvious long bone deformity

Abrasions over iliac crest

Initial InterventionsPlaced right humeral head IOBegan infusing IV fluid through warmerPt became increasingly hypotensive; systolic in 30sEpinephrine 0.1 mg administeredPlaced on our monitorSPO2 now reading 95-100%Loaded into helicopter

First ArrestJust prior to take off patient went into Ventricular Fibrillation

Pt on monitor, but no defib padsDefibrillated onceInto a very bradycardic narrow complex rhythm with ROSCAtropine 0.5 mg Epinephrine 0.5 mgHR in the 40s, increasing towards 60BP now 70-80 systolic

Report to UW Emergency Department

Second ArrestJust prior to landing, patient again went into Ventricular FibrillationShocked with 120J; remained in V-Fib2nd shock of 200JInto bradycardic narrow complex rhythmEpinephrine 1 mgAtropine 1 mgHR increased to 70sBP also remained with systolic in 70s

Arrival to Emergency DepartmentArrived at 0838Airway: Patent ET TubeBilateral breath soundsBreathing: Mechanically VentilatedCirculation: Palpable central pulses, absent peripheral pulsesUnresponsive; Flaccid ExtremitiesGCS = 3Pupils 8mm & fixedER

20ER.Continued3 liters of crystalloid pre-hospitalVS on arrival BP 115/58 HR 41Temp: unable to register temp rectallyPt then became hypotensive againSystolic 50sWarm fluids and blood given via rapid infuser

21EDcontinuedDecreased BS right sideCXR shows large right sided pneumothorax with collapse of right lungChest tube insertedFAST scan PositiveRUQ 0853: Femoral/carotid pulses threadyGiven atropine 0.5 mg (no response)Given Epinephrine 1 mg (HR , pulses improved)BP improving, 90s systolic

22

23EDcontinuedTempurature sensing Foley placedTemp: 77.9 FHeating measures used:Bear Hugger (top and bottom)Room temp > 79 degreesFluid warmerWarm air vent

24ED.ContinuedDecision to get Head CT

To Operating Room @ 0911

25Operating Room.Day 1Exploratory LaparotomyMidline incisionPacked all 4 quadrantsExplored the abdomenSmall Hematoma noted in the lesser sacSmall amount of clot removedNo active bleeding noted

26Operating Room.Day 1Intraperitoneal Lavage for RewarmingContinuous lavage of warm NSRoom temp increasedBair Hugger underneath & over anterior lower bodyTemp increased to 31.5 C (88.7 degrees F)ClosureRepacked Closed with VAC dressingTo ICU for continued rewarming and resuscitation

27Operating Room.Day 2VAC Dressing removedAbdominal cavity exploredNo significant bleedingLap Sponges removedHematoma in lesser sac NOT expandingNoted large clot anterior to the tail of the pancreasClot removed, no further active bleedingPancreatic tail ecchymotic (Pancreatic contusion)2 abdominal drains placedIncision closed

28 Hospital CoursecontinuedDay 2: OR for ORIF of right knee fractureChest tube removedDay 3: Sedation weaned, moving all 4 extremities purposefullyDay 4:Extubated

Day 6:Tachycardic in 130sAgitatedCT Chest: Right sided PEAnticoagulationDay 12:Discharge to Rehabilitation Facility

29Review of Injuries:Subdural HematomaIntraparenchymal hemorrhagePneumothorax9 Rib FracturesRight scapular fractureFemoral condyle fracture & Tibial plateau fracture (right knee)Frostbite : right handContusion of pancreas Pulmonary Embolism30Review of Injuries:Spine fracturesC4, T1(worst)-T9

31Stages of HypothermiaClinical features of hypothermia differ among patients

Core temp measurement is imprecise

Treatment of HypothermiaAll Providers:General Patient Care ProtocolAdultRemove wet clothingMeasure core temperature, If < 95 F, handle gentlyWarm blankets/Warm Temperature

Cardiac arrest and hypothermiaRough handling can precipitate arrhythmias---BE GENTLE!Arrhythmias not typically responsive to defibrillation or ACLS medsCorner stone of care is QUALITY CPR until patient is warmed (86-90 F)After warmed, then ACLS

Recognition of HypothermiaIts not always obvious!It can occur in warmer temperatures70sWet clothing accelerates heat transferHow do you measure temperature?

Outcome:Alive!!!Completely neurologically intactRecovering from her orthopedic injuries:Physical therapyLives at home with family