Emergency Medicine Interactive Case Management

 1989-1999 D. Collman, M.D.

Diplomate of the American Board of Emergency Medicine

CASE:  ANDY MICHAELS

DIAGNOSES:

•  Polytrauma

SUMMARY OF THE CASE:

Andy Michaels is a 12 year-old boy who was involved in an automobile-pedestrian collision approximately 15 minutes ago and was transported to your institution by the paramedics who placed a soft cervical collar, immobilized the patient on a long padded spine board, and administered oxygen by face mask.  Pt weighs 5Okg.

This child sustained multiple injuries after colliding with a car:

  Airway obstruction and hypoventilation

  Left pneumothorax and lung contusion.

  Scalp laceration on the left occiput.

  Closed head injury.

  Abdominal distension secondary to a ruptured spleen.

  Closed fracture of the left femur.

VITAL SIGNS:

BP: 50 Systolic (Dias. Unobtainable)          P: 165        R: 50 & Noisy

PROGRESSION OF THE CASE:

This child should be managed strictly according to ATLS protocol, with initial efforts to clear the airway resulting in partial only relief of the noisy respirations. Additionaly, there is persistent hypoventilation and cyanosis.  Because of this, the patient should be rapidly orotracheally intubated, after a brief period of oxygenation.

In addition, simutaneous cervical spine immobilization should be undertaken.  After the patient is appropriately intubated, there is continued cyanosis and a decrease in chest wall movement and now developed breath sounds on the left hand side, due to a pneumothorax.  This rapidly develops into a tension pneumothorax. This should be decompressed appropriately with a 12G  in the L 2^nd ICS MCL.  Following this a chest tube should be placed on the left side.

Signs which the candidate may request include:

  Distended neck veins.

  Hyperresonance on the left side.

  Diminished breath sounds on the left side.

  Tracheal shift to the right.

In addition the patient is clearly in hypovolemic shock with only a palpable systolic BP of 50 and tachycardia of 175.  This should be managed by aggressive fluid resuscitation with two large bore IV s, EKG monitor, type and crossmatch of the patients blood, and appropriate fluid therapy with rapid sequential 20mL/kg boluses (x 3 boluses NS or LR) plus 10 mL/kg pRBCs  

The patient’s blood pressure improves minimally (60/40).  Total blood volume should be estimated to be 4250cc (50 kg x 85cc/kg). Blood loss should be estimated to be at least 25% (1000-1100 cc) because of significant hypotension, and the physician should begin administration of 1/2 total blood loss as pRBCs (500-550 cc).  Shortly after the onset of transfusion, the patient’s bp improves to 80/40 and the heart rate drops to 125.

Because the patient has a closed head injury (Glasgow Coma. Score-8) the patient should also be hyperventilated, with the pCO₂ in the 25-30 torr range.  Other appropriate therapy includes elevation of the head in a midline position, maintenance of C-spine immobilization, appropriate aggressive fluid therapy to avoid hypotension, maintenance of the airway to avoid hypoxia, and aggressive management of the patient’s systemic injuries.

The patient also has abdominal distention, and may have a peritoneal lavage performed after the bladder and stomach are decompressed.  This reveals grossly bloody fluid that is aspirated out of the abdominal cavity without lavage being performed.  A bedside US FAST study, is grossly positive for free blood and negates the need for DPL if requested first.  In addition there is a fracture of the left femur which requires splinting.

AMPLIFIEDD.HISTORY:

The history is not available except minimal history from a paramedic (EMT) regarding the accident.

SECONDARY SURVEY (PHYSICAL EXAMINATION):

General Impression and Mental Status:

    The patient is a well developed well nourished 12 year-old male who is unconscious, but making non-purposeful movements of his extremities.

    There is a dressing on the left occiput which is soaked with blood. 

Skin:

    Quite pale with prolonged capillary refill.  

    There are large abrasions on the left forearm and the left lateral thigh.  In addition, there are some abrasions across the left face. 

Head:

    A large scalp laceration in the left occipital region, examination of the eyes shows reactive 3 mm pupils and a normal funduscopic exam. Gaze is conjugate. 

Nose:

    Normal. 

Throat:

    Normal.

Tympanic Membranes:

    Normal.

Neck:

    Shows no tracheal deviation or neck vein distention.  Posteriorly, there is no C-spine boggyness, or stepoff deformity. 

Chest:

      Contusion left upper chest wall, decreased breath sounds on the left hand side, hyperresonance of the left chest and decreased chest wall rise.  Following decompression of the tension pneumothorax and placement of a chest tube, breath sounds are clear and equal on both sides. 

Abdomen:

    Shows a slightly distended abdomen with some bruising on the left hand side.

    When the left upper quadrant is palpated, there is clearly some pain there.  Bowel sounds are absent.  Rectal exam is normal without occult blood. 

Back:

  Normal.

Genitalia:

  Normal. 

Extremities:

  There is an abrasion on the left forearm and bruising of the left thigh with marked swelling of the midthigh region.  Palpation of the left thigh causes the patient react (as if he is experiencing pain).

Neurologic Examination:

  The patient does not open his eyes even to painful stimuli, makes incomprehensible sounds and withdraws. He does not localize painful stimuli (GCS = 7).  The remainder of the neurologic exam is unremarkable, with the exception that there is a slight decrease in spontaneous venous pulsations on funduscopic examination. 

Laboratory/Xray:

CBC:

WBC: 10,800/mm³ Hgb:  11.8 G/dL       HCT:  34.0%

Electrolytes/Chemistries:

Normal.

Urinalysis:

Normal. 

Arterial Blood Gases:

After intubation and appropriate ventilation          

p0₂:  200 mmHg pC0₂: 36  mmHg pH: 7.31

C-Spine Films:

Normal. 

Skull Films:

Normal.

CXR:

If obtained prior to a needle decompression, a left tension pneumothorax is visible.

After Decompression

Shows a left pulmonary contusion.  The left lung has Re-expanded. 

Abdominal Films:

Normal. 

Extremity Films:

Normal with the exception of the left femur film, which demonstrates a midshaft fracture. 

CT Scan of Head:

Diffuse cerebral hyperemia but no mass lesions.  CT scanning should be available only after appropriate resuscitation and consultation with the neurosurgeon. Results are available only if the emergency physician accompanies the patient. 

CT Scan of Abdomen:

Transverse fracture of the spleen.  CT scanning may be available only after an appropriate fluid resuscitation

POSSIBLE CRITICAL ACTIONS:

  Airway intervention in tandem with C-spine stabilization. 

  Recognition of hypovolemia. 

  Appropriate fluid/transfusion therapy.

  Recognition of tension pneumothorax. 

  Tube thoracostomy. 

  Bedside FAST vs Peritoneal lavage vs. (Abdominal CT scan).

  General Surgical consultation. 

  Hyperventilation and neurosurgical consultation/head CT. 

  Splinting and orthopedic referral for femoral fracture.

PATHOPHYSIOLOGY QUESTIONS:

Q:  What is the appropriate initial fluid therapy for a pediatric trauma patient?

A.  For mild symptoms of shock (tachycardia, decreased pulse pressure, tachypnea) 10cc/kg fluid challenge over five-ten minutes i.e., as fast as possible.  Evaluate response.

For moderate symptoms of shock (hypotension, acidosis) 20-40cc/kg fluid challenge over five-ten minutes i.e., as fast as possible.  Evaluate response.

For exsanguinating hemorrhage 40cc/kg LR plus pRBCs as quickly as possible.

Q:  What are the initial methods of treatment of the pediatric patient with a closed head injury?

A: •  Intubation/hyperventilation:  

  pC0₂ 28-30 torr (reduces cerebral blood flow without undue vasoconstriction) or other complication. 

•  Fluid restriction:  

  Avoid hypotonic solutions. 

•  Elevation of the head (direct hydrostatic effect)

•  Osmotic Diuretics:  

  Mannitol—Diuresis & decreases CSF production. 

•  Loop diuretics : 

Lasix—Reduces formation of CSF. 

•  Barbiturates—Reduce cerebral metabolism and blood flow.

Q:  What are the indications for immediate endotracheal intubation in the child with polytrauma?

A:  •  Any disturbance in the level of consciousness.  

•  Systolic blood pressure of <20 mmHg below expected normal.             

•  Severe facial, neck, or chest injuries. 

•  In addition when ABG’s are available a PaO2 ≤80 torr