MVC with Tension Pneumothorax

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

This case is a great example of challenging junior learners to a place that is just outside their comfort zone. Becoming comfortable with a primary and secondary survey is an important part of training in Emergency Medicine. Further, this case highlights the following:

  • The need to clinically recognize a possible tension pneumothorax and intervene immediately with needle decompression or finger thoracostomy
  • The challenge of performing/delegating multiple simultaneous interventions in a trauma patient
  • The importance of reassessing the patient and searching for multiple possible causes of hypotension

Clinical Vignette

EMS arrives with a 44-year-old male to your tertiary care ED. The trauma team has been activated. He was the driver in a single vehicle MVC at highway speed. There was extensive damage to the car. He is currently screaming and moaning.

Case Summary

A 44 year-old male arrives by EMS to a tertiary care ED where the trauma team has been activated. He was the driver in a single-vehicle MVC. He presents screaming and moaning with a GCS of 13. He has an obvious open fracture of his right forearm. He also has decreased air entry to the right side of his chest. The team will need to recognize the tension pneumothorax as part of their primary survey. They will then need to irrigate and splint the right arm after they have completed their secondary survey. As the secondary survey is being completed, the patient will become hypotensive again. This time, the team will find free fluid in the RUQ.

Download the case here: MVC with Tension PTX

ECG for the case found here:

sinus-tachycardia

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

Initial CXR for the case found here:

Tension PTX

(CXR source: https://radiopaedia.org/cases/tension-pneumothorax-9)

PXR for the case found here:

normal-pelvis-male

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

Second CXR for the case (post chest-tube insertion) found here:

R chest tube post PTX

(CXR source: http://jtd.amegroups.com/article/view/663/html)

FAST showing free fluid in the RUQ found here:

RUQ FF

U/S showing no PCE 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)

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)