flail chest

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.