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Surviving the Cold: A Trauma Case Presentation

Surviving the Cold: A Trauma Case Presentation. Dells-Delton EMS Med Flight UW ER Level 1 Trauma. Interesting drive to work. Approximately 0645 in the morning Just past dawn Road curves to left and down a hill Car in the ditch to the south Covered in frost Had obviously rolled

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Surviving the Cold: A Trauma Case Presentation

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  1. Surviving the Cold: A Trauma Case Presentation Dells-Delton EMS Med Flight UW ER Level 1 Trauma

  2. Interesting drive to work • Approximately 0645 in the morning • Just past dawn • Road curves to left and down a hill • Car in the ditch to the south • Covered in frost • Had obviously rolled • No tag from Police Department

  3. Interesting Drive to Work…continued • Decision to call Dispatch • Arrived to work and paged to the scene • Requested to come emergently

  4. Scene • Arrived to scene 0657 • Police Department on scene • Police called for Med Flight already • Ejected vs Self-extricated • Car on tires—had rolled • Patient lying next to car • Marshy area; patient had wet clothes

  5. Patient assessment • Responsive to pain • Moaning • rocking • Cold to the touch • Airway patent • Adequate breathing • No external hemorrhage • Pale • Probable emesis noted to corner of mouth

  6. Interventions • Collar placed • Placed on backboard • Transferred to back of rig (0701) • Oxygen—NRB mask • PIV established in right hand

  7. Vital Signs • Cardiac monitor • NSR with some PACs • Unable to get good SpO2 reading • Blood pressure—Hypotensive • Initial set of VS: • 75/57 • Pulse 80 • RR 10 • GCS = 7

  8. The Drive • Drove to Med Flight Landing Zone • ¾ of mile • Attempted additional IV sites while driving • Calculating RSI drug dosages and preparing meds • IO into right tibial plateau • Good marrow return • Flushed well • Initially flowing well

  9. Intubation • Pushed lidocaine • Pushed Etomidate • Pushed Succynocoline • WAITING!!!! • Troubleshooting IV • How much of the dose did she get? • Intubated with 7.0 ETT using KingVision video layrngeoscope • Capnography • Normal appearing waveform, ETCO2 at 20 • Bilateral BS, absent epigastric sounds • Equal chest rise

  10. Continued Assessment & Interventions • Versed • Slow push • Veccuronium • Rectal temp= 84 degrees • BG = 241 • HR decreasing from 80’s to 50’s • Atropine 0.5 mg • HR Stabilized to upper 50s • IO problems! • 250 mL of NS had infused • Began to appear puffy • ? Fracture…clamped and stopped use

  11. Med Flight Arrives • Med Flight Arrives • Dr. Abernathy places IO to humeral head • Care transferred to Med Flight Crew

  12. Transition of Care • EMS Summary • Patient Vital Signs: • 70-80 systolic BP • RR bagged at 13 • ETCO2 19

  13. Patient Assessment • Patient is immobilized • 7.0 ET tube; good BS bilaterally • Pupils are 4mm; very slightly reactive • GCS: 3 (effects of paralytics/sedatives) • Pale • No obvious facial trauma • No obvious chest wall deformity • Abdomen is flat • Pelvis stable

  14. Patient Assessment…continued • Ecchymosis over medial aspect of left thigh; no obvious long bone deformity • Abrasions over iliac crest

  15. Initial Interventions • Placed right humeral head IO • Began infusing IV fluid through warmer • Pt became increasingly hypotensive; systolic in 30’s • Epinephrine 0.1 mg administered • Placed on our monitor • SPO2 now reading 95-100% • Loaded into helicopter

  16. First Arrest • Just prior to take off patient went into Ventricular Fibrillation • Pt on monitor, but no defib pads • Defibrillated once • Into a very bradycardic narrow complex rhythm with ROSC • Atropine 0.5 mg • Epinephrine 0.5 mg • HR in the 40’s, increasing towards 60 • BP now 70-80 systolic

  17. Report to UW Emergency Department

  18. Second Arrest • Just prior to landing, patient again went into Ventricular Fibrillation • Shocked with 120J; remained in V-Fib • 2nd shock of 200J • Into bradycardic narrow complex rhythm • Epinephrine 1 mg • Atropine 1 mg • HR increased to 70’s • BP also remained with systolic in 70’s

  19. Arrival to Emergency Department • Arrived at 0838 • Airway: Patent • ET Tube • Bilateral breath sounds • Breathing: Mechanically Ventilated • Circulation: Palpable central pulses, absent peripheral pulses • Unresponsive; Flaccid Extremities • GCS = 3 • Pupils 8mm & fixed ER

  20. ER….Continued • 3 liters of crystalloid pre-hospital • VS on arrival • BP 115/58 • HR 41 • Temp: unable to register temp rectally • Pt then became hypotensive again • Systolic 50’s • Warm fluids and blood given via rapid infuser

  21. ED…continued • Decreased BS right side • CXR shows large right sided pneumothorax with collapse of right lung • Chest tube inserted • FAST scan Positive • RUQ • 0853: Femoral/carotid pulses thready • Given atropine 0.5 mg (no response) • Given Epinephrine 1 mg (HR , pulses improved) • BP improving, 90’s systolic

  22. ED…continued • Tempurature sensing Foley placed • Temp: 77.9 F • Heating measures used: • Bear Hugger (top and bottom) • Room temp > 79 degrees • Fluid warmer • Warm air vent

  23. ED….Continued • Decision to get Head CT • To Operating Room @ 0911

  24. Operating Room….Day 1 • Exploratory Laparotomy • Midline incision • Packed all 4 quadrants • Explored the abdomen • Small Hematoma noted in the lesser sac • Small amount of clot removed • No active bleeding noted

  25. Operating Room….Day 1 • Intraperitoneal Lavage for Rewarming • Continuous lavage of warm NS • Room temp increased • Bair Hugger underneath & over anterior lower body • Temp increased to 31.5 C (88.7 degrees F) • Closure • Repacked • Closed with VAC dressing • To ICU for continued rewarming and resuscitation

  26. Operating Room….Day 2 • VAC Dressing removed • Abdominal cavity explored • No significant bleeding • Lap Sponges removed • Hematoma in lesser sac NOT expanding • Noted large clot anterior to the tail of the pancreas • Clot removed, no further active bleeding • Pancreatic tail ecchymotic (Pancreatic contusion) • 2 abdominal drains placed • Incision closed

  27. Hospital Course…continued • Day 2: • OR for ORIF of right knee fracture • Chest tube removed • Day 3: • Sedation weaned, moving all 4 extremities purposefully • Day 4: • Extubated • Day 6: • Tachycardic in 130’s • Agitated • CT Chest: Right sided PE • Anticoagulation • Day 12: • Discharge to Rehabilitation Facility

  28. Review of Injuries: • Subdural Hematoma • Intraparenchymal hemorrhage • Pneumothorax • 9 Rib Fractures • Right scapular fracture • Femoral condyle fracture & Tibial plateau fracture (right knee) • Frostbite : right hand • Contusion of pancreas • Pulmonary Embolism

  29. Review of Injuries: • Spine fractures • C4, T1(worst)-T9

  30. Stages of Hypothermia Clinical features of hypothermia differ among patients Core temp measurement is imprecise

  31. Treatment of Hypothermia • All Providers: • General Patient Care Protocol—Adult • Remove wet clothing • Measure core temperature, If < 95 ̊F, handle gently • Warm blankets/Warm Temperature

  32. Cardiac arrest and hypothermia • Rough handling can precipitate arrhythmias---BE GENTLE! • Arrhythmias not typically responsive to defibrillation or ACLS meds • Corner stone of care is QUALITY CPR until patient is warmed (86-90 ̊F) • After warmed, then ACLS

  33. Recognition of Hypothermia • It’s not always obvious! • It can occur in warmer temperatures—70’s • Wet clothing accelerates heat transfer • How do you measure temperature?

  34. Outcome: • Alive!!! • Completely neurologically intact • Recovering from her orthopedic injuries: • Physical therapy • Lives at home with family

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