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)

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)