Case summary

An ALS crew was called to a 40s man who was a pedestrian struck by a motor vehicle.  The crew found the patient in a large deep puddle of water roughly 10-20 feet from the place of impact.  The patient was cold, wet and had a weak radial pulse.  The crew removed the patient from the water, removed his wet clothing and placed him in a C collar before quickly loading him in the ambulance to begin transport to a trauma center.  Scene time was <5m from pulling up to wheels rolling to the hospital.  Vitals were obtained and thorough assessment was performed.

Vitals: HR 64,  BP 100/70,  RR 20,  Sat 88% on RA,  ETCO2 24mmHg, glucose 127, GCS 15

The crew noted evidence of 3 separate fractures to his upper extremity.  When they attempted to splint this extremity, the patient started to bleed briskly so a tourniquet was placed to control the bleeding.  The crew also noted that both lower extremities had evidence of long bone fractures but they were able to splint using the backboard the patient was on.  The crew covered the patient with a foil blanket to try and keep the patient as warm as possible.  An IV was placed.  Upon re-evaluation, the patient became more tachypneic with decreased breath sounds on the left so needle thoracostomy was performed to treat suspected tension pneumothorax.  The crew administered 2G of tranexamic acid (TXA) for hemorrhagic shock and 2G of cefazolin for suspected open fractures.  The crew arrived at the trauma center and handed off care to the trauma team.

Highlights of the case:

Place spinal motion restriction before extrication

This patient had multiple distracting injuries 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 the 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.

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 immediately started transporting leading to the shortest possible scene time.

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 patient never ended up having a HR or SBP that allowed for giving TXA per protocol, so this was a protocol deviation.  However, it was not medically wrong to give TXA here given the whole picture.  The crew should have called medical control to get an online order prior to giving TXA given it was outside the protocol.  The key to remember is that if an EMS provider thinks a patient needs something that is beyond the protocol, they should call med control ASAP to get the order to do this treatment since they are likely correct that it is indicated.

Prevent hypothermia in trauma patients

Hypothermia is very dangerous for trauma patients because our clotting system does not work as well the colder we get.  This is why hypothermia is part of the triad of death (along with acidosis and coagulopathy).  The three aspects of the triad of death synergize leading to massive hemorrhage.  We can help intervene and decrease blood loss by trying to keep patients as warm as possible in the setting trauma.  This crew found a patient in a puddle of water (in the middle of winter).  They quickly removed his wet clothing and covered him with a foil blanket as soon as they assessed for life threats that needed immediate treatment.  We should do everything we can to warm patients, or at the very least prevent further heat loss.