Case summary:

An ALS crew responded to 20s man who was was involved in a motor vehicle collision where his car struck a tree.  Crew noted heavy damage, airbag deployment, shattered windshield and the patient partially ejected from the vehicle.  He was unresponsive, had shallow snoring respirations, but had a strong pulse.  The vehicle was still smoking so the crew rapidly extricated and began ventilating with a bag valve mask as he was loaded in the ambulance.  The crew did a quick once over looking for life threats and obtained the following vitals:

Vitals: BP 132/67,  HR 67,  RR 8,  Sat 55%, ETCO2 8mmHg, glucose 210

The noted facial trauma, an open ankle fracture, bruising to the anterior chest wall, a stable pelvis and equal pupils.  Due to the refractory hypoxia, the crew attempted to place an advanced airway.  They were unable to place an endotracheal tube but were successful in placing a supraglottic device.  The patient became hypotensive with a BP of 68/35.  Fluids were run wide open, and the crew noted diminished breath sounds on the right side so needle decompression was performed.  The crew noted some improvement in the BP.  At this point the crew initiated transport to the closest trauma center.  While in route, the patient worsened so the crew performed a second needle decompression on the right with some improvement in his hemodynamics.  The crew also supported the patient’s blood pressure with intermittent push dose epinephrine.  The crew arrived at the trauma center and handed off care.

Vitals at the time of hand off were:

Vitals: BP 89/57,  HR 48,  RR 18,  Sat 88%, ETCO2 38mmHg

The total duration that this crew spent on scene between arrival and wheels rolling towards the trauma center was 11 minutes. 

Highlights of the case:

Transport is the priority in trauma

Trauma patients are load and go patients.  The only exception is airway intervention and stopping bleeding (tourniquet, pelvic binder, ect).  Everything else, including IV, full vitals, full assessment, ect, should occur after wheels are rolling to the hospital.  This is because trauma patients die of head injury and internal bleeding, neither of which we can fix in the field.  For this reason, the goal is transport to get the patient to the surgeons and blood as soon as possible.  This crew rapidly extricated and did a quick once over in the ambulance to determine that there was no treatable external sources of bleeding but that this patient had profound hypoxia in the setting of a head injury and was not protecting his airway.  They correctly delayed transport long enough to manage the airway and then immediately initiated transport to the nearest trauma center.  This crew managed to extricate the patient as well as perform key interventions very quickly in order to get this patient to the trauma center as soon as possible. 

Needle decompression in trauma

Tension pneumothorax is common cause of treatable cardiovascular collapse in blunt trauma and penetrating trauma to the chest.  While we cannot fix internal bleeding in the field, we can certainly treat tension pneumothorax.  If you are suspicious that your trauma patient is hypotensive due to tension pneumothorax, have a low threshold to attempt needle decompression.  If your suspicion for this is high and the patient fails to improve after you place the needle, consider decompressing the same side of the chest again or attempting to decompress the other side of the chest.  This crew noticed signs of potential tension pneumothorax and correctly performed needle decompression to the side they suspected had the pneumothorax.  Sometimes the catheter we use gets kinked or occluded with blood and tension physiology occurs again.  This is likely what occurred here, so the crew correctly attempted needle decompression a second time on the same side.  It would also have been reasonable for the crew to also needle the other side of the chest in case the patient had bilateral tension pneumothorax.  The reason is that failure to decompress the tension pneumothorax is worse for this patient than decompressing the side of the chest that did not need it.