Case Summary:

An ALS crew was dispatched to a middle-aged man involved in a single vehicle motor vehicle collision vs a tree.  They found a car wrapped around the tree on the driver’s side with severe intrusion.  They found the patient with his pelvis and legs pinned between the driver’s door and the dash.  The patient was conscious but agitated with incomprehensible words.  They assessed the patient as best they could while extrication efforts were underway and found him to have a weak radial pulse and elevated WOB.  Crew requested a helicopter to the scene and notified the nearby local level three trauma center.  Crew placed the patient in a C-collar but the patient became combative and was inhibiting care and extrication efforts.  Given patient did not have capacity and was preventing lifesaving efforts, the crew sedated the patient with 250mg IM ketamine.  The patient began to having snoring respirations, so an OPA was placed. After 35 minutes, the patient was successfully extricated.  Crew noticed pelvic instability and immediately placed a pelvic binder and moved patient to rig to initiate transport since helicopter had not arrived on scene.  Crew initiated transport and began further assessment while in route to the level 3 trauma center.  Crew noticed decreased breath sounds bilaterally and performed bilateral needle decompression due to concern for tension pneumothorax.  Crew obtained vitals and placed a humoral IO was placed as well as treated the patient with tranexamic acid.

Vitals just prior to arrival at trauma center: BP 121/63,  HR 86,  RR 24,  Sat 99% NRB,  ETCO2 46

Highlights of the case:

Start assessment and care for a pinned/entrapped patient ASAP

Once scene safety is determined, we want to initiate treatment for the entrapped or pinned patient as soon as possible since these are often critical patients at risk of hemodynamic collapse if we do not intervene immediately.  We way be limited in what can do for patients due to cramped spaces and limited access to the head and veins.  This crew felt a weak fast radial pulse pointing towards hypotension likely from hemorrhagic shock as well as assessed mental status.  While they were not able to get a full set of vitals, they were able to gather enough physiologic information to determine how sick the patient was and guide initial care.

Place spinal motion restriction before extrication

This patient is altered in the setting of blunt trauma with a high mechanism of injury.  This patient is at very high risk for a cervical spine injury and given the patient is altered and likely has a distracting injury, we are unable to clinically clear his cervical spine and he requires cervical motion restriction with a C-collar.  The crew recognized this and placed in the patient in a collar as soon as possible and prior to ever moving the patient.

Sedate the combative trauma patient

This patient happened to be very agitated to the point where he was inhibiting the crews ability to provide lifesaving care.  Given this patient was so altered, he did not have the capacity to refuse the crew’s care.  In this situation, we do not know if the patient is altered due to head trauma, underlying substance use or something else.  In reality, it does not matter what the cause is since we need to assume the worst-case scenario until proven otherwise.  The best thing for the patient is to quickly sedate him to facilitate extrication, resuscitation, and transport to a trauma center.  The crew used IM ketamine here which was the drug of choice since its onset is rapid and preserves most patients’ respiratory effort.

Early activation of trauma resources

Given the patients mechanism of injury, that the patient was pinned, the low GCS and the weak radial pulse, the crew realized that this patient was a critical trauma patient and mobilized extra resources.  This included notifying the nearby level 3 trauma center as well as requesting a helicopter to the scene.  This patient’s low GCS in the setting of trauma meets our regional guidelines for requesting a helicopter to the scene to rapidly transport the patient to the highest-level trauma center in the region as quickly as possible.  It takes time for a helicopter to arrive at the scene as well as for trauma centers to mobilize their team and prepare blood products.  The earlier that these resources are mobilized, the better.

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.  Once this patient was extricated, they placed a pelvic binder and immediately started transporting leading to the shortest possible scene time.

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 bilateral needle decompression.  While the patient likely did not have, bilateral tension pneumothorax, it was still the correct choice to decompress both sides.  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.

Tranexamic Acid (TXA) for hemorrhagic shock

TXA works by preventing the breakdown of formed clots.  In the setting of trauma, this can help decrease internal bleeding.  There is a risk of too much clot formation leading to DVTs and PEs, however, the risk of immediate death from massive hemorrhage is much higher than this risk.  Our protocol recommends giving TXA to trauma patient with current or previous uncontrolled bleeding with a HR >120 or SBP <90.  We should never delay transport or more critical interventions to give TXA, but we should attempt to administer it as soon as possible.  This crew correctly gave TXA to a patient that met our inclusion criteria after transport and more critical interventions were performed.