Multi-Trauma: Blunt VSA and Burn

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

This case is an excellent example of the challenges faced in Emergency Medicine. Not only are learners faced with a worst-case airway scenario, but they must also manage two critically ill patients at once. In particular, it draws attention to the following:

  • The need to plan for and manage resources appropriately when faced with two critically ill patients simultaneously
  • The importance of recognizing and adequately preparing for a difficult airway
  • The acknowledgement of a failed intubation/ventilation scenario requiring expedient placement of a surgical airway

Case Summary

The case will start with an EMS patch indicating that they are 2 minutes out with multi-trauma from a 2 car MVC. Two patients will then arrive within 1 minute of each other. The first will have gone VSA en route from presumed blunt trauma. This patient will not regain a pulse. The second patient will arrive with significant burns from a car fire, and will have GCS of 3 necessitating intubation. All attempts at intubation will be unsuccessful, and a surgical airway must be performed. The team will need to prioritize resources between the two patients and realize that an ED thoracotomy is not reasonable in the first patient.

Clinical Vignette

Before first patient:

You are working in a tertiary care trauma center. EMS patch: We have a 50ish M unbelted driver in a head-on MCV at about 60km/hr. He was ejected from the vehicle and found about 30m from the crash site with a GCS of 3. He has an obvious head injury, torso injury and unstable pelvis, which we’ve bound. Initially had RR 40, O2 85% on NRB, HR 150 and a questionable femoral pulse. Since then, he’s been pulseless. We’ve been en route about 5 minutes and should be there in about 2 min. He’s received 1mg Epi so far with no shocks advised x2. Smells of EtOH, but no other known history. There was one other car involved that caught on fire, so you’ll probably get them, too, if they survive. Please prepare for this patient.

Upon arrival of second patient:

EMS Handover: This 30ish male belted driver was in a head on MVC with both cars going ~60km/hr. His car was on fire when we got there, and he’s got 2nd/3rd degree burns everywhere. We found him outside the car, so he must have self-extricated. His GCS has been 3 the entire time with us. He’s tolerating an oral airway. His last vitals were HR 120, BP 130/80, RR 30, O2 95% NRB

How to Run the Case

At McMaster University, we successfully ran this case with our PGY4 residents. To do so, we had two confederate nurses at the bedside (one nurse per patient). We also had dedicated sim techs running each mannequin. Finally, we had three faculty instructors. One instructor to observe the management of each patient, and one instructor to play the role of the arriving paramedic and to coordinate between the two instructors and sim techs. We are able to run the case with four of our emergency medicine resident learners playing the roles of a trauma team (one team leader, one senior emerg resident, one senior anesthesia resident, and one surgical resident). It went very well and received positive feedback from the learners. Of note, this case is ripe with opportunity for incorporating other learners. In particular, inter-professional education using ED nurses, RT’s, and learners from other services could work as well.

 

Download the case here: Multitrauma Cric and Blunt VSA Case

Cardiac U/S for Patient 1 found here*:

FAST for Patient 1 found here:

RUQ FF

ECG for Patient 2 found here:

sinus-tachycardia

(ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)

Pre-intubation CXR for Patient 2 found here:

Normal CXR Male

(CXR source: https://radiopaedia.org/cases/normal-chest-x-ray)

PXR for Patient 2 found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Post-intubation CXR for Patient 2 found here:

Normal Post-Intubation CXR

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Cardiac U/S for Patient 2 found here*:

FAST for Patient 2 found here*:

no FF

Lung U/S for Patient 2 found here*:

*All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.

Trauma in a Hemophiliac

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

While Emergency physicians certainly see their fair share of trauma, managing a patient with hemophilia is quite infrequent. This case highlights some key management points, including:

  • The importance of administering early Factor VIII replacement
  • The need to monitor for delayed intra-cranial hemorrhage
  • The importance of determining capacity when a head-injured patient becomes agitated

Clinical Vignette

You are working in a level three trauma centre and are told that EMS just arrived from an MVC involving a 16-year-old female passenger who has known hemophilia. Vitals are stable. She has a laceration to her arm, and a bruise on her head, but has GCS 15 and only complains of arm pain.

Case Summary

A 16-year-old female presents following an MVC. Past medical history is significant for hemophilia A. She has a laceration on her arm and a bruise on her forehead, but denies HA/N/V. The learner should recognize high potential for bleeding, and implement immediate treatment with rVIII replacement, along with pan-CT imaging. The CT head will show a small ICH. The patient wants to leave AMA following normal CT results, and the learner must preform a capacity assessment and outline a plan of action for the incompetent patient. The patient should be sedated and/or intubated anticipating decline using neuroprotective measures. Consults should be made to the ICU and hematology.

Download the case here: Hemophilia Case

CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

PXR for the case found here:

normal-pxr

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Forearm x-ray for the case found here:

R forearm cropped

(X-ray source: http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=56736)

ECG for the case found here:

sinus-tachycardia

(ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)

FAST image for the case found here:

no FF

Cardiac U/S showing no pericardial effusion found here:

(U/S images courtesy of the McMaster PoCUS Subspecialty Training Program)

Multi-trauma (Kicked off a Horse)

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

Management of trauma patients with multiple intercurrent injuries can be challenging. This case provides an opportunity for junior learners to stretch themselves beyond their comfort zones. In particular, this case highlights the following:

  • The need for a systematic approach to the initial assessment and ongoing re-assessment of any complex trauma patient
  • The importance of prioritizing tasks and adjusting priorities as patient status changes
  • The complexity of managing a hypotensive, head-injured patient

Clinical Vignette

A 32-year-old female presents as a trauma activation with EMS after being bucked off of her horse. Her mom witnessed the episode and called EMS because she seemed groggy. She has had a low BP with EMS on route. Her current BP is 80/40.

Case Summary

A 32-year-old female presents after being bucked off of her horse. She is brought in as a trauma team activation because of a low BP. Her primary survey will reveal a boggy hematoma over her right temporal area as well as an unstable pelvis. Her initial GCS will be 8. The team will proceed through airway management in a hypotensive, head-injured trauma patient while also binding her pelvis. The patient eventually shows signs of brain herniation, which the team will need to manage prior to consultant arrival.

Download the case here: Pelvic Fracture and SDH

ECG for the case found here:

Sinus tachycardia

(ECG source: https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Pre-intubation CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

PXR for the case found here:

Pelvic fracture

(PXR source: https://littlemedic.files.wordpress.com/2013/01/pelvis_0_1.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Ultrasound showing free fluid in RUQ found here:

RUQ FF

Ultrasound showing normal lung sliding found here:

Ultrasound showing no pericardial effusion found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program)

Multi-trauma case: burn and head injury

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Too often in the Emergency Department, we are faced with the challenge of simultaneously managing two patients who each require immediate care. This case does an excellent job of highlighting the following issues that often arise as a result:

  • The importance of delegating any tasks that may be delegated
  • The need to clarify who is taking ownership of a patient’s management when there is help available from others (such as another ED MD or a trauma team leader)
  • How essential it is to call for help early

In addition, this case also features some key medical content, including:

  • The recognition and treatment of cyanide toxicity in the context of a house fire
  • The preparation and management of a potentially difficult airway
  • The need to perform an escharotomy in a patient with circumferential chest burns and high ventilation pressures
  • The importance of checking a blood glucose on all patients with an altered level of consciousness

Clinical Vignette

Patient A: “You are working in a tertiary care ED. A 33 year old male has just been brought in by EMS after being dragged out of a house fire. He has been unresponsive with EMS and has significant burns to his chest, arm, and leg. The etiology of the fire is unclear, but the home was severely damaged.”

Midway through the case, Patient B will arrive.

Patient B (To be stated by EMS in handover): “We have a 55 year old male here who was repeatedly kicked during an altercation outside a bar. His GCS was 15 on arrival, but it just decreased to 13 in the ambulance bay, and he has become combative. We put him in C-spine collar at the scene. He has lots of bruising to face and head, but no other obvious injuries. When he was more cooperative, the patient denied other medical history or allergies initially.”

Case Summary

The case will begin with the arrival of patient from a house fire who has 30%TBSA burns. The team will be expected to recognize the need for intubation and fluid resuscitation. After successful intubation, a second patient will arrive from an altercation outside a bar. He appears to have a blunt traumatic head injury after being repeatedly kicked. The team is expected to recognize hypoglycemia in the context of a minor head injury and provide immediate glucose replacement. During the management of the head injured patient, the burn patient will continue to by hypotensive. The team will need to recognize the possibility of CN toxicity. The patient will also become more difficult to ventilate and will require an escharotomy.

A Note on Technical Requirements

At McMaster, we recently ran this case for our senior residents. It was a huge success! It did, however, require many resources. We used one high fidelity mannequin and one standardized patient actor. We also had two confederate nurses (one per patient). We had three staff physicians as instructors. One instructor was assigned to observing each patient’s management. The third instructor briefly played the paramedic and also coordinated between the two instructors and the sim tech to ensure the case ran smoothly. We ran the case with five residents participating. We had them pre-assigned to roles of trauma team leader, senior emerg resident, senior anesthesia resident, senior general surgery resident, and senior orthopedic resident. (This is often the make-up of our trauma team.)

Download the case here: Multi-trauma Case: Burn and Head Injury

CXR for Patient B found here:

normal-cxr-patient-b

(CXR source: http://www.pharmacology2000.com/respiratory_anesthesiology/pulmonary_assessment/pulmonary_assessment2.htm)

PXR for Patient B found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Obstetrical Trauma

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who completed a fellowship in Simulation and Medical Education last year.

Why it Matters

The management of a late-term pregnant trauma patient poses unique challenges. In particular, this case highlights the following:

  • The need for manual uterine displacement
  • The importance of considering uterine rupture or abruption as part of the primary or secondary survey (and how this necessitates a pelvic exam)
  • The challenge associated with controlling the noise and chaos in the trauma bay when multiple consultants are present
  • How difficult it is to break bad news about two patients at once to the father

**Special note: please be aware that this case has the potentially to be distressing to learners. As such, if you are to run it, please have resources available to help learners should they be affected by the weight of this case.

Clinical Vignette

You are working in a tertiary care emergency department and receive an EMS Patch: “33F who appears quite pregnant coming to you from an MVC. Belted driver. Prolonged extrication at the scene (30mins). Altered LOC and hypotensive on scene. Current vitals: HR 150, BP 80/50, RR 40, O2 90% on NRB, CBG 6. 1L NS bolus going. ETA 5 minutes.”

Case Summary

A 33 year old G2P1 female at 32 weeks GA presents with blunt trauma following an MVC. She will be hypotensive due to both hypovolemic shock from a pelvic fracture and obstructive shock from a tension pneumothorax. Fetal monitoring will show the fetus in distress with tachycardia and late decelerations. Early airway intervention should be employed, with thoughtful selection of drugs for sedation and paralysis given the pregnancy. After intubation, the patient will remain hypotensive. She will require massive transfusion and coordination of care between orthopedics, general surgery, and obstetrics. The patient’s husband will also arrive after intubation and the team must give him the bad news.

Download the case here: Obstetrical trauma case

ECG for the case found here:

Sinus tachycardia

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for the case found here:

CXR Tension ptx

(CXR source: http://cdem.phpwebhosting.com/ssm/pulm/pneumothorax/images/cxr_ptx_3.png)

Pelvic XR for the case found here:

Pelvic X-ray post binder

(PXR source: https://drhem.files.wordpress.com/2011/11/5-4-6.jpg)

Normal pericardial U/S for the case found here: 

Left lung U/S with no lung sliding found here: 

RUQ U/S showing FF found here: RUQ FF

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program)

Hypothermia with Trauma

This case is written by Dr. Stephen Miller. He is an emergency physician in Halifax. He is also the former medical director of EM Simulation and the current director of the Skilled Clinician Program for UGME at Dalhousie University. He developed his interest in simulation while obtaining his Masters of Health Professions Education.

Why it Matters

Moderate to severe hypothermia can be quite challenging to correct. This case highlights several important features of hypothermia management:

  • The importance of searching for concurrent illness that may be causing the hypothermia or working against rewarming efforts
  • The effect of hypothermia on trauma management
  • Modifications to ACLS as required during hypothermic resuscitation
  • The multitude of ways in which one can attempt to actively re-warm a patient

Clinical Vignette

An approximately 30 year old female is brought into the ED at 4 AM by a man who found her lying at the side of the road. It is minus 30 degrees Celsius outside and she has no coat or shoes. The man does not know her and is unable to provide any additional history except that she was blue and having trouble breathing when he found her. She is noted to have a decreased LOC and laboured breathing. She has obvious deformities of her left forearm and right leg.

Case Summary

30 year-old female is brought into the ED at 4 AM by a man who found her lying at the side of the road with no coat or shoes. It is minus 30 degrees Celsius outside. On arrival she has a reduced LOC, laboured breathing, a right-sided pneumothorax, cyanotic extremities, a left radius & ulna fracture, and a right tib-fib fracture. The team is required to use both active and passive rewarming strategies. Regardless of the team’s efforts, the patient in this case will arrest. Upon ROSC, they are required to continue rewarming as well as to address the other traumatic injuries.

Download the case here: Hypothermia

CXR for the case found here:

PTX R with rib fractures

(CXR source: http://radiopaedia.org/cases/pneumothorax-due-to-rib-fractures-1)

ECG for the case found here:

hypothermia-shiver-artefact

(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/hypothermia-shiver-artefact.jpg)

Right lung U/S found here:

Left lung U/S found here:

RUQ FAST image found here:

RUQ FF

Pericardial U/S found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

Two Patient Trauma

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Emergency Medicine often requires care providers to be in multiple places at once. It is not uncommon to have two patients simultaneously require urgent or semi-urgent intervention. This case helps learners to develop this important skill by highlighting:

  • The challenges of triaging patients as immediately urgent or less urgent
  • The need to assign tasks to team members
  • The importance of adhering to the basics, even in a taxing situation

Clinical Vignette

Before entering the room: You are working the day shift in a tertiary care emergency department with full surgical capabilities. EMS is en-route to the hospital with two patients, a 37-year-old male and a 65 year old female, who were both drivers of a t-bone MVC of unknown speed. The ambulances will arrive in 2 minutes.

Upon entering the room: Each patient will be accompanied with a paramedic who will give this information and will be available to stay if asked.

Patient A: “37 year old male, belted driver, he got t-boned on the driver’s side. There was significant intrusion of his side door. We’re not sure if there was a loss of consciousness, we put him on a non-rebreather and his SAT was around 92%, tachy at 105 with an OK BP around 110 systolic during the ride.”

Patient B: “65 year old female, belted driver who t-boned the other car. The front of her car was totaled. Airbags were deployed and there was a brief loss of consciousness. We put on the collar ASAP. Vitals were stable en route but she was a bit confused during the ride. No vomiting.”

Case Summary

A young male and a middle-aged female are brought to the ED after a T-bone MVC at an unknown speed. Both patients were drivers. The emergency team is expected to triage the patients accordingly and to split the team so that both patients are treated.

Patient A: The team is expected to recognize respiratory compromise secondary to pneumothorax. Needle decompression and tube thoracostomy should be administered. The patient will in remain in respiratory compromise post-decompression and the team should consider intubation. If the pneumothorax is not recognized or treated, the patient will arrest. On secondary survey, the patient will complain of pelvic pain in addition to a positive eFAST evaluation. The team should activate the massive transfusion protocol (MTP) and activate the trauma/surgery team.

Patient B: The team is expected to recognize hypoglycemia in the context of a minor head injury. Immediate glucose replacement is required.

Download the case here:  Two for one MVC

CXR for Patient A found here:

left flail chest

(CXR source: http://learningradiology.com/archives2009/COW%20353-Flail%20Chest/caseoftheweek353page.htm)

Pelvic xray for Patient A found here:

open book # from radiopedia

(Xray source: http://radiopaedia.org/articles/open-book-fracture)

Left lung U/S for Patient A found here:

Right lung U/S for Patient A found here:

RUQ FAST image for Patient A found here:

RUQ FF

Pericardial U/S for Patient A found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

CXR for Patient B found here:

normal female CXR radiopedia

(CXR source: http://radiopaedia.org/articles/normal-position-of-diaphragms-on-chest-radiography)

Stab Wound to the Neck with Neurogenic Shock

This week’s case is written by Dr. Cheryl ffrench. She is the Simulation Director for Emergency Medicine at the University of Manitoba and is one of the advisory board members here at EMSimCases.

Why it Matters

Neurogenic shock is an important manifestation of spinal trauma. This case highlights several important aspects of neurogenic shock:

  • It can be difficult to recognize (especially in a multi-trauma patient)
  • At its presentation, vasopressors are often required to manage blood pressure
  • It should be suspected in trauma cases where the patient is hypotensive without tachycardia

Clinical Vignette

To be stated by EMS: “This is Jamal James. He’s a 21 year-old male who was found in his house by police after being stabbed by a friend. There was a lot of blood at the scene. We found a stab wound on his neck so we initiated spinal precautions. Before we arrived, the police started CPR briefly because they thought he didn’t have a pulse. He had a pulse when we got there but his respiratory effort was poor and he had a decreased LOC. Several attempts to intubate were unsuccessful so we bagged him on the way here. We don’t know anything about his allergies, medications, or past medical history.

Case Summary

A 21 year old male is brought to your tertiary care ED by EMS after being stabbed by a friend. EMS initiated spinal precautions and failed several attempts to intubate en route. On arrival, the patient is being bagged and has a single stab wound to the right posterolateral neck. He requires emergent intubation for airway protection. After intubation, his blood pressure drops but his heart rate remains in the 70s. His blood pressure will stabilize only after appropriate fluid resuscitation and vasopressor initiation.

Download the case here: Stab Wound to Neck

ECG for the case found here:

normal-sinus-rhythm

(ECG source: http://lifeinthefastlane.com/ecg-library/normal-sinus-rhythm/)

CXR for the case found here:

Post Intubation

Post Intubation

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

U/S image showing no free fluid in the abdomen found here:

no FF

(U/S image courtesy of McMaster POCUS Subspecialty Training Program)

U/S showing no pericardial effusion found here:

(U/S courtesy of McMaster POCUS Subspecialty Training Program)