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A Challenging Penetrating Trauma Case
Air Medical Journal 35 (2016) 88e92
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Case Study
A Challenging Penetrating Trauma Case Seetal Snoek, MBBS, BSC, MRCA, FRCA 1, *, Benjamin Butson, BSc (hons), BMBS (hons), FACEM, FACRRM, Grad dip rural GP, GCertsportmed, CCPU 2, Mark Wittenberg, MBChB, BSc (hons), FRCA 3 1
Specialty Registrar, Careflight Medical Services, Queensland, Australia Consultant Emergency Physician, Careflight Medical Services, Queensland, Australia 3 Essex and Herts. Air Ambulance (c/o London HEMS) 2
a b s t r a c t We present the prehospital management of a 23-year-old Australian Aboriginal man with an isolated knife stab wound to the posterior right chest. The lead author attended to the prehospital management of this young man during tenure as a registrar in retrieval medicine for CareFlight Medical Services (CMS) in North Queensland, Australia. The case is noteworthy because it involved a combination of a lifethreatening injury with a superimposed iatrogenic injury. The case will be of interest to physicians and clinicians in prehospital medicine as well as those in low-volume emergency departments or facilities in which major trauma may present infrequently. Crown Copyright © 2016 Published by Elsevier Inc. on behalf of Air Medical Journal Associates. All rights reserved.
CareFlight Medical Services (CMS) is an Australian air medical charity established in 1986. Their mission statement is to save lives, speed recovery, and serve the community by providing the highest standard of rapid critical care response. Services are split into statewide provision and encompass the use of helicopters, airplanes, and medi-jets to bring a hospital level of care to the critically ill and injured. The crew onboard include pilots, aircrew, medical teams, and paramedics with coordinators in land-based centers all working closely together to ensure that patients receive the best care as soon as possible. They care for severely injured patients who need emergency treatment at the scene and transport seriously ill patients who need to be moved to the hospital. Presently, CareFlight air medical teams care for over 5,000 patients annually. CareFlight holds teaching accreditation with the Australian critical care colleges of anesthesia, intensive care, and emergency medicine. Rigorous biannual training plus weekly case review and audit take place to ensure CareFlight doctors and nurses are continually trained and updated in prehospital and transport medicine. Further state-ofthe-art education at designated training centers includes underwater escape training and winch training to ensure all-around team safety. CareFlight is a leader in innovation. The practice of flying critical care physicians to the seriously ill and injured, introducing night * Address for correspondence: Seetal Snoek, MBBS, BSC, MRCA, FRCA, 3 Midholm Hampstead Garden Suburb NW11 6LL, United Kingdom. E-mail address: [email protected] (S. Snoek).
vision goggle technology for safer night flight, and conducting a clinical trial to investigate the benefits of early physician intervention for patients with head injuries all represent Australian “firsts.” The Queensland Townsville team, in particular, is mandatorily composed of a pilot, an air medical officer, and a rescue medical officer. There is 1 doctor and 1 advanced paramedic for every single mission. Further secondary teams wait at base in the event of a second task being issued, and a separate team is also on call for the Learjet. The aircraft used at Townsville (Rescue 521) is a Bell 412 EP model with a PT6T-3D engine, with a secondary craft available for maintenance periods. The company also operates with fixed wing aircraft at other bases and the Learjet 45 for longer missions. The entire team is based air side at Townsville airport in 2 designated hangars. The area served by the Townsville team encompasses 1.853 million km2 and 6,793 km of coastline. There are 2 main bases (Cairns and Townsville) operating with Rio Tintoesponsored aircraft, with other missions performed by the Royal Automobile Club of Queensland CareFlight Rescue aircraft (Sikorsky S-76), which operates 6 helicopters out of Bundaberg, Gladstone, Roma, Sunshine Coast, Gold Coast, and Toowoomba bases. Further missions may be undertaken to repatriate Australian citizens or in other circumstances from nearby islands such as Papa New Guinea or the Solomon Islands. The geography of the state is vast and varied from the sparsely populated upper poles of the Cape York Peninsula and the Torres Strait through the tropic of
1067-991X/$36.00 Crown Copyright © 2016 Published by Elsevier Inc. on behalf of Air Medical Journal Associates. All rights reserved. http://dx.doi.org/10.1016/j.amj.2015.12.007
S. Snoek et al. / Air Medical Journal 35 (2016) 88e92
89
Table 1 Plan for Transfer Airway/breathing
Cuffed oral endotracheal tube, peripheral oxygen saturations 98%, FiO2 ¼ 1.0, CO2 35-40 mm Hg, good air entry bilaterally and bilateral chest drains Tactile compliance revealed it much easier to ventilate the patient manually via a bag valve tube, so this method was continued for the remainder of the transport
Plan: continue manual ventilation using 100% oxygen Caution with drains and endotracheal tube during transfer
Circulation
Noninvasive blood pressure 90/80, heart rate 110 beats/min sinus tachycardia, cold peripherally, radial pulse palpable, intravenous fluids (2,000 mL) to replace estimated loss, space blanket applied
Plan: continue fluid resuscitation, monitor pulse throughout mission Expedite to major cardiothoracic capable trauma center (only 20 minutes away)
FiO2 ¼ fraction of inspired oxygen.
Capricorn to urban Brisbane. It includes tropical islands, sandy beaches, flat river plains, elevated terrain, dry deserts, rich agricultural belts, and densely populated urban areas. A unique geographic feature of the state is the Great Barrier Reef, which presents its very own unique pathology. The variety of patient population and presentation is extensive, ranging from a standard myocardial infarct with a 3-hour flight time to the nearest percutaneous coronary angiographyecapable unit to tropical medicine involving deadly Irukandji jellyfish stings and coastal Taipan snakebites. Case Report The initial report received from the Queensland retrieval services coordination center just before midnight was brief and succinctd“Priority 1: (specific location deleted here for patient confidentiality)eyoung male, intoxicated, stabbed in back. Cardiovascular/respiratory stable.” The patient was located on a small tropical island of the Great Barrier Reef, 20 minutes by helicopter from the Careflight Medical Services helipad. The island has a troubled and tumultuous history and is marred by extensive violence, suicide, and social disadvantage. In 1999, The Guinness Book of Records named it the most violent place on earth outside a combat zone based on the high rate of per capita violent injury. Upon scene arrival and after ensuring scene safety, we exited the aircraft; entered a small, ill-equipped clinic room; and rapidly assessed the patient to be much worse than anticipated. He was unresponsive with a partially obstructed airway and asymmetric chest movement. Oxygen was applied with a nonrebreathing face mask with reservoir; the decision was made that urgent intubation was necessary to maintain a patent airway and further manage a clearly life-threatening penetrating chest wound. The team promptly set about to perform a “kit dump” and prepare drugs for rapid sequence intubation in accordance with the well-honed standard operating procedures (SOPs) used by the CMS. (Kit dump is the term used by the CMS to describe the urgent setup of the standard SOP intubation and backup equipment for securing a definitive airway. In this well-drilled process, the doctor, paramedic, or even the rescue medical officer can prepare a clean, organized area where a standard equipment setup [such as the laryngoscope and bougie] can be laid out in a set format. This allows for conformity, and every team member understands the process and location of equipment in a standard manner. CMS has well-practiced routines for advanced interventions, and a preintubation drill is mandated before all anesthesia or airway procedures. In this process, all equipment [ventilator and so on] is double-checked and prepared, with the precise location known to team members for use in an emergency. Upon assessment of breathing, the patient was found to have reduced air entry on the right hemithorax (side of injury) with dullness to percussion. He had good air entry of the left hemithorax with a bubbling chest drain on the left (uninjured side). The bedside nurse confirmed that the last remaining chest drain in the
clinic had been placed on the incorrect side by a medical officer inexperienced in trauma management. Subsequent assessment of circulation revealed signs of circulatory shock with a pulse rate of 110 beats/min despite a systolic blood pressure of 110 mm Hg. Using a standard “rapid sequence induction” following the CMS SOP, the patient's trachea was intubated approximately 1 hour after injury. It was a Cormack and Lehane Class 1 visualization using a size 8.0 cuffed oral endotracheal tube and was secured at 21 cm at the lips. There did not appear to be any gross hemodynamic instability through this time. Air entry was confirmed bilaterally, albeit very poor on his right side, where a hemothorax was suspected. After intubation, we were concerned with frequent “highpressure” alarms from our portable transport ventilator. Subsequently, the patient was removed from the ventilator in a timely manner and hand ventilated via a bag valve tube. This improved his ventilation (SaO2 ¼ 98%, end-tidal carbon dioxide ¼ 35-40 mm Hg): however, it was not immediately recognized that the high ventilator pressures originated from a massive hemothorax that had filled the right side of the chest. Seven minutes after intubation, the right chest was prepared; through a single incision, a 32F intercostal drain was inserted in the lateral chest wall. Two thousand milliliters of blood immediately filled the collection bag to capacity. The drain was clamped, and clinical staff were directed to place an additional 16-G intravenous cannula and bolus crystalloid because we had no immediate access to blood. CMS routinely has ready access to blood, but it had inadvertently not been packed before departure on this transport. The primary survey continued, with the intention of expediting our departure from the island (Table 1). The patient was packaged for transfer and in-flight treatment planned (Fig. 1). After a reasonably uneventful transport, we arrived and transferred care over to a “Red Blanket Team” in the trauma resuscitation room. [The ‘Red Blanket Team’ is an emergency code activated in the recipient hospital to mobilize specialist teams, massive transfusion policies, and operating theatres for the imminent arrival of a critically ill patient.] The laboratory results are provided in Table 2 and Figure 2. This author's clinical role technically ended here, but her professional interest did not. Subsequent follow-up noted that the patient spent an additional 2.5 hours in the resuscitation room before admission to the operating room. In the resuscitation room, he had 8 units of blood transfused, with close observation for ongoing bleeding and otherwise conservative management. He later underwent a right thoracotomy, which revealed bleeding intercostal vessels. After appropriate surgical management, the patient improved, was extubated on postoperative day 3 in the intensive care unit, and reportedly continued to recover.
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Figure 1. Goals for Transfer
Table 2 Initial Laboratory Measurements Patient's Measured Values Hb Hct Platelets International normalized ratio APTT Bicarbonate Lactate
5.5g/dL 0.17 60 109/L 3.5 133 13 mmol/L 7.2 mmol/L
pH pCO2 Base excess
6.86 72 mm Hg 21.0
APTT ¼ Activated Partial Thromboplastin Time; Hb ¼ hemoglobin; Hct ¼ hematocrit.
Discussion Incorrect Placement of a Left-sided Drain Chronologically, 1 of the first things that occurred was the placement of a drain on the incorrect side. The emergency department physician who performed this was extremely junior and was in training to become a general practitioner. Provider anxiety, clinical inexperience, and potential haste may have been contributing factors toward this particular scenario. On review of the case, it was found that a chest radiograph had been taken, and the laterality was confused at this point. In Australia, there is yet to be a parallel to the UK's National Patient Safety Agency Never Events Framework 2009/10.1,2 There are many case reports of a range of malpositioned chest tubes in the current literature, and a robust learning process should take place from such reports.9 There is also an argument to be made for the implementation of checklists for low-volume/high-risk procedures, such as intercostal drain insertion, at clinical sites where major trauma is not frequently encountered. Position of the Chest Drain A further learning point arises in the actual position of chest drains. On review of the resuscitation room chest x-ray, it was clearly identified that the right chest drain was placed in the 6th intercostal space and the left was placed in the 8th. The UK's National Patient Safety Agency addressed this problem in 2005, and the National Reporting and Learning System was activated. The National Reporting and Learning System is a voluntary reporting system (which avoids natural bias); they reported 2,152 incidents of harm related to the insertion of chest drains over a 39-month study period spanning from 2005 to 2008. Twelve cases resulted in death, and 15 resulted in serious harm. The cases in which death occurred were reviewed in detail and are included in the national database. These incidences recorded injury to the liver and heart, with resultant catastrophic
Figure 2. A chest radiograph taken in the resuscitation room. Of note are the 2 chest drains (1 with a clamp in situ) and an endotracheal tube (in the right main stem bronchus).
hemorrhage. Additionally, there were over 50 litigation claims against the National Health Service for chest drainerelated injury over a 10-year period. Factors highlighted as needing addressing included inexperience of the operator, lack of supervision, site chosen, lack of anatomic knowledge, inadequate clinical diagnosis, equipment issues, and lack of clinical guidelines. A UK-based agency issuing national guidance and advice to improve health and social care (ie, the National Institute for Clinical Excellence) and the UK specialist society (the British Thoracic Society) have released guidelines on this. Removal of the Other Chest Drain Regardless of the factors contributing to the placement of the chest drain on the left (incorrect) side, reassessment was required to evaluate the potential merits and disadvantages of removing this chest drain and transporting with a simple finger thoracostomy on this side. No blood was noted from this drain, so issues of aircraft contamination were irrelevant. It would have been an option to simplify the transfer by simply removing this intercostal drain. Although significant primary injury to the left hemithorax did not appear clinically evident, the fact remained that there was now an actual pneumothorax adding to the patient's dire respiratory physiology. It was decided to maintain the drain in situ. Clamping the Chest Drain The sudden gush of a large volume of blood upon placement of the right intercostal drain was unnerving. The initial reaction was to clamp the chest drain. This author's justification for this was that “clamping will allow a tamponade effect and reduce further bleeding inside the chest, allowing time for adequate IV [intravenous] resuscitation, and locating an additional bag for chest drainage.” The chest clamp was left in situ during the entire transfer period, with judicious monitoring of lung mechanics. The practice of
S. Snoek et al. / Air Medical Journal 35 (2016) 88e92
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Figure 3. Dutton Article Recommendations.5
clamping the chest drain continued in the resuscitation room where the cardiothoracic registrar who presumed care instructed for it to remain in place. A subsequent review of the literature concerning chest drain clamping has revealed that it is not advisable to do so.10,11 The thorax can hold a considerable volume of blood. A clamped intercostal drain will not tamponade a massive hemothorax. A 1995 study conducted by Ali et al11 found that clamping a chest drain did not decrease hemorrhage or mortality; additionally, gas exchange was decreased. Not only will a clamped intercostal drain not tamponade the bleeding, it may actually convert a simple pneumothorax to a tension pneumothorax. In addition, gas exchange is impeded as the lung is collapsed by the filling blood volume. Clamping a chest drain in a case of a massive hemothorax conceals blood loss, compromises pulmonary function in a patient already in shock, and prevents the measurement of initial and ongoing loss relevant to decisions regarding the urgency of a thoracotomy. Chest Drain Availability in Isolated Sites Retrieval and remote area physicians need to be aware of challenges posed by limited equipment availability. In small units or on the roadside, the presence of large stocks of items is unfeasible. Blood and blood products are also rarely available in remote medical clinics, and the retrievalist needs to consider taking blood for trauma cases in particular. In the United Kingdom, the London and Kent helicopter emergency medical services carry blood and chest drains on all missions. Finger Thoracostomy Versus Chest Drain In the prehospital environment, there is a debate regarding the need for a formal intercostal drain, with finger thoracostomy being advocated as a viable alternative in a ventilated patient. Time and resource constraints, clinical urgency, equipment complications (such as drain kinks), and blood contamination of the aircraft are all factors to consider when deciding whether, and/or when, to place a formal intercostal drain. The alternative option is to simply fly the ventilated patient with finger thoracostomies. CMS has extensive protocols to guide clinical practice. The SOP issued by CMS on finger thoracostomy provides clear guidance and is revised in weekly audit and morbidity and mortality meetings. Advantages and disadvantages exist upon comparison of chest drain placement versus the performance of finger thoracostomy. Finger thoracostomy allows for rapid decompression of the pleural space in limited time with limited resources. The placement of a chest drain is more involved and generally requires a higher degree of clinical expertise
to perform. However, a chest drain allows for subsequent blood collection to facilitate more accurate estimation of blood loss. The current policy for the London helicopter emergency service is to perform a finger thoracostomy, primarily in cases of significant chest trauma. If there is isolated chest trauma that compromises oxygenation in the spontaneously ventilating patient, then chest drain remains a viable alternative. Troubleshooting the Ventilator Problem Because of the frequent high-pressure alarm, the ventilator became a hindrance during the management of this patient. When initially attached, the usual thorough anesthetic check of the airway and circuit from the patient end to the ventilator end was completed. At the time, no resolvable problem was noted; to facilitate patient safety, the clinician elected to manually ventilate the patient via a bag valve tube. With calm retrospect, it is probable that the ventilator problem was caused by high pressures resulting from a massive hemothorax that reaccumulated when the chest drain was clamped. It is also possible the cuffed oral endotracheal tube was in the right main stem bronchus as shown in the chest radiograph upon emergency room arrival. However, this author believes it more likely that the tube migrated into the right main stem during the transfer process. In any case, a systematic process for causal discovery, from patient to machine end, of a failing piece of equipment should be well rehearsed for every piece of equipment,3 especially in the retrieval environment. Examination of the Patient ATLS keeps it simple; examine the site of the injury. The stab wound to this gentleman's posterior chest, the nature of injury, the presence of multiple medical hardware items, and his supine position contributed to examination of the knife wound being overlooked. A more extensive examination may have prompted this author to consider alternative and novel techniques aimed at hemostasis in massive chest bleeding. There is evidence in the literature that suggests an inflated Foley catheter can help to stem hemorrhage from intercostal vessels.4 Hypotensive/Hemostatic Resuscitation Hemorrhagic shock results in hypoperfusion and inadequate oxygen delivery to the tissues. The goals of resuscitation should include the identification and control of the bleeding source as well as restoration of perfusion and oxygen delivery. It has been shown5-7 that inappropriate or unmeasured vigorous fluid resuscitation may
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S. Snoek et al. / Air Medical Journal 35 (2016) 88e92
Figure 4. European Guidelines Recommendation 18.8
be detrimental. In 2002, Dutton et al5 showed that overzealous fluid administration worsened morbidity and mortality in trauma patients with hemorrhagic shock. There were several other excellent recommendations made by the authors (Fig. 3). International leading body consensus on fluid regimes in trauma are as follows: helicopter emergency medical services: limited regimen, advanced trauma life support: resuscitate to organ perfusion, international trauma life support: limited fluid resuscitation protocols, US military: limited fluid resuscitation, US trauma centers: highly variable with mixed results emerging, and Israeli Army: limited fluid resuscitation with extremely positive results. Learning Points The following should be performed: Rigorously perform airway breathing circulation (primary) assessment and treat life-threatening conditions as they are found. Do not clamp chest drains. Consider patient instability in addition to equipment failure.
Further Reading Originally published in 2007 and updated in 2010, the Trauma Task Force has delineated the European Guidelines resuscitation
recommendation 18 as an excellent reference for prehospital trauma clinicians (Fig. 4).
References 1. Risk of chest drain insertion, NRLS/NPSA. http://www.nrls.npsa.nhs.uk/resources/ ?entryid45¼59887. Accessed July 21, 2014. 2. National Patient Safety Agency. Never Events Framework 2009/10. www.nrls. npsa.nhs.uk/neverevents/?entryid45¼59859. Accessed June 2014. 3. Oxylog 3000 User Manual. http://www.emed.ie/Procedures/_img/Oxylog% 203000_v2%2002.pdf. Accessed June 2014. 4. Chao BF, Jian YJ, Hao HZ, et al. Balloon Foley catheter compression as a treatment for intercostal vessel bleeding. Injury. 2011;42:958e959. 5. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002;52:1141e1146. 6. Dutton RP. Fluid management for trauma; where are we now? CEACCP. 2006;6: 144e147. 7. Bickell WH, Wall Jr MF, Pepe PE, et al. Mattox. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105e1109. 8. Rossaint R, Bouillon B, Cerny V, et al. Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14:R52. 9. Gayer G, Rozenman J, Hoffmann C, et al. CT diagnosis of mal-positioned chest tubes. Br J Radiol. 2000;73:786e790. 10. Laws D, Neville E, Duffy J. Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58:ii53eii59. 11. Ali J, Qi W. Effectiveness of chest tube clamping in massive hemothorax. J Trauma. 1995;38:59e62. discussion 62-63.
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Case Study
A Challenging Penetrating Trauma Case Seetal Snoek, MBBS, BSC, MRCA, FRCA 1, *, Benjamin Butson, BSc (hons), BMBS (hons), FACEM, FACRRM, Grad dip rural GP, GCertsportmed, CCPU 2, Mark Wittenberg, MBChB, BSc (hons), FRCA 3 1
Specialty Registrar, Careflight Medical Services, Queensland, Australia Consultant Emergency Physician, Careflight Medical Services, Queensland, Australia 3 Essex and Herts. Air Ambulance (c/o London HEMS) 2
a b s t r a c t We present the prehospital management of a 23-year-old Australian Aboriginal man with an isolated knife stab wound to the posterior right chest. The lead author attended to the prehospital management of this young man during tenure as a registrar in retrieval medicine for CareFlight Medical Services (CMS) in North Queensland, Australia. The case is noteworthy because it involved a combination of a lifethreatening injury with a superimposed iatrogenic injury. The case will be of interest to physicians and clinicians in prehospital medicine as well as those in low-volume emergency departments or facilities in which major trauma may present infrequently. Crown Copyright © 2016 Published by Elsevier Inc. on behalf of Air Medical Journal Associates. All rights reserved.
CareFlight Medical Services (CMS) is an Australian air medical charity established in 1986. Their mission statement is to save lives, speed recovery, and serve the community by providing the highest standard of rapid critical care response. Services are split into statewide provision and encompass the use of helicopters, airplanes, and medi-jets to bring a hospital level of care to the critically ill and injured. The crew onboard include pilots, aircrew, medical teams, and paramedics with coordinators in land-based centers all working closely together to ensure that patients receive the best care as soon as possible. They care for severely injured patients who need emergency treatment at the scene and transport seriously ill patients who need to be moved to the hospital. Presently, CareFlight air medical teams care for over 5,000 patients annually. CareFlight holds teaching accreditation with the Australian critical care colleges of anesthesia, intensive care, and emergency medicine. Rigorous biannual training plus weekly case review and audit take place to ensure CareFlight doctors and nurses are continually trained and updated in prehospital and transport medicine. Further state-ofthe-art education at designated training centers includes underwater escape training and winch training to ensure all-around team safety. CareFlight is a leader in innovation. The practice of flying critical care physicians to the seriously ill and injured, introducing night * Address for correspondence: Seetal Snoek, MBBS, BSC, MRCA, FRCA, 3 Midholm Hampstead Garden Suburb NW11 6LL, United Kingdom. E-mail address: [email protected] (S. Snoek).
vision goggle technology for safer night flight, and conducting a clinical trial to investigate the benefits of early physician intervention for patients with head injuries all represent Australian “firsts.” The Queensland Townsville team, in particular, is mandatorily composed of a pilot, an air medical officer, and a rescue medical officer. There is 1 doctor and 1 advanced paramedic for every single mission. Further secondary teams wait at base in the event of a second task being issued, and a separate team is also on call for the Learjet. The aircraft used at Townsville (Rescue 521) is a Bell 412 EP model with a PT6T-3D engine, with a secondary craft available for maintenance periods. The company also operates with fixed wing aircraft at other bases and the Learjet 45 for longer missions. The entire team is based air side at Townsville airport in 2 designated hangars. The area served by the Townsville team encompasses 1.853 million km2 and 6,793 km of coastline. There are 2 main bases (Cairns and Townsville) operating with Rio Tintoesponsored aircraft, with other missions performed by the Royal Automobile Club of Queensland CareFlight Rescue aircraft (Sikorsky S-76), which operates 6 helicopters out of Bundaberg, Gladstone, Roma, Sunshine Coast, Gold Coast, and Toowoomba bases. Further missions may be undertaken to repatriate Australian citizens or in other circumstances from nearby islands such as Papa New Guinea or the Solomon Islands. The geography of the state is vast and varied from the sparsely populated upper poles of the Cape York Peninsula and the Torres Strait through the tropic of
1067-991X/$36.00 Crown Copyright © 2016 Published by Elsevier Inc. on behalf of Air Medical Journal Associates. All rights reserved. http://dx.doi.org/10.1016/j.amj.2015.12.007
S. Snoek et al. / Air Medical Journal 35 (2016) 88e92
89
Table 1 Plan for Transfer Airway/breathing
Cuffed oral endotracheal tube, peripheral oxygen saturations 98%, FiO2 ¼ 1.0, CO2 35-40 mm Hg, good air entry bilaterally and bilateral chest drains Tactile compliance revealed it much easier to ventilate the patient manually via a bag valve tube, so this method was continued for the remainder of the transport
Plan: continue manual ventilation using 100% oxygen Caution with drains and endotracheal tube during transfer
Circulation
Noninvasive blood pressure 90/80, heart rate 110 beats/min sinus tachycardia, cold peripherally, radial pulse palpable, intravenous fluids (2,000 mL) to replace estimated loss, space blanket applied
Plan: continue fluid resuscitation, monitor pulse throughout mission Expedite to major cardiothoracic capable trauma center (only 20 minutes away)
FiO2 ¼ fraction of inspired oxygen.
Capricorn to urban Brisbane. It includes tropical islands, sandy beaches, flat river plains, elevated terrain, dry deserts, rich agricultural belts, and densely populated urban areas. A unique geographic feature of the state is the Great Barrier Reef, which presents its very own unique pathology. The variety of patient population and presentation is extensive, ranging from a standard myocardial infarct with a 3-hour flight time to the nearest percutaneous coronary angiographyecapable unit to tropical medicine involving deadly Irukandji jellyfish stings and coastal Taipan snakebites. Case Report The initial report received from the Queensland retrieval services coordination center just before midnight was brief and succinctd“Priority 1: (specific location deleted here for patient confidentiality)eyoung male, intoxicated, stabbed in back. Cardiovascular/respiratory stable.” The patient was located on a small tropical island of the Great Barrier Reef, 20 minutes by helicopter from the Careflight Medical Services helipad. The island has a troubled and tumultuous history and is marred by extensive violence, suicide, and social disadvantage. In 1999, The Guinness Book of Records named it the most violent place on earth outside a combat zone based on the high rate of per capita violent injury. Upon scene arrival and after ensuring scene safety, we exited the aircraft; entered a small, ill-equipped clinic room; and rapidly assessed the patient to be much worse than anticipated. He was unresponsive with a partially obstructed airway and asymmetric chest movement. Oxygen was applied with a nonrebreathing face mask with reservoir; the decision was made that urgent intubation was necessary to maintain a patent airway and further manage a clearly life-threatening penetrating chest wound. The team promptly set about to perform a “kit dump” and prepare drugs for rapid sequence intubation in accordance with the well-honed standard operating procedures (SOPs) used by the CMS. (Kit dump is the term used by the CMS to describe the urgent setup of the standard SOP intubation and backup equipment for securing a definitive airway. In this well-drilled process, the doctor, paramedic, or even the rescue medical officer can prepare a clean, organized area where a standard equipment setup [such as the laryngoscope and bougie] can be laid out in a set format. This allows for conformity, and every team member understands the process and location of equipment in a standard manner. CMS has well-practiced routines for advanced interventions, and a preintubation drill is mandated before all anesthesia or airway procedures. In this process, all equipment [ventilator and so on] is double-checked and prepared, with the precise location known to team members for use in an emergency. Upon assessment of breathing, the patient was found to have reduced air entry on the right hemithorax (side of injury) with dullness to percussion. He had good air entry of the left hemithorax with a bubbling chest drain on the left (uninjured side). The bedside nurse confirmed that the last remaining chest drain in the
clinic had been placed on the incorrect side by a medical officer inexperienced in trauma management. Subsequent assessment of circulation revealed signs of circulatory shock with a pulse rate of 110 beats/min despite a systolic blood pressure of 110 mm Hg. Using a standard “rapid sequence induction” following the CMS SOP, the patient's trachea was intubated approximately 1 hour after injury. It was a Cormack and Lehane Class 1 visualization using a size 8.0 cuffed oral endotracheal tube and was secured at 21 cm at the lips. There did not appear to be any gross hemodynamic instability through this time. Air entry was confirmed bilaterally, albeit very poor on his right side, where a hemothorax was suspected. After intubation, we were concerned with frequent “highpressure” alarms from our portable transport ventilator. Subsequently, the patient was removed from the ventilator in a timely manner and hand ventilated via a bag valve tube. This improved his ventilation (SaO2 ¼ 98%, end-tidal carbon dioxide ¼ 35-40 mm Hg): however, it was not immediately recognized that the high ventilator pressures originated from a massive hemothorax that had filled the right side of the chest. Seven minutes after intubation, the right chest was prepared; through a single incision, a 32F intercostal drain was inserted in the lateral chest wall. Two thousand milliliters of blood immediately filled the collection bag to capacity. The drain was clamped, and clinical staff were directed to place an additional 16-G intravenous cannula and bolus crystalloid because we had no immediate access to blood. CMS routinely has ready access to blood, but it had inadvertently not been packed before departure on this transport. The primary survey continued, with the intention of expediting our departure from the island (Table 1). The patient was packaged for transfer and in-flight treatment planned (Fig. 1). After a reasonably uneventful transport, we arrived and transferred care over to a “Red Blanket Team” in the trauma resuscitation room. [The ‘Red Blanket Team’ is an emergency code activated in the recipient hospital to mobilize specialist teams, massive transfusion policies, and operating theatres for the imminent arrival of a critically ill patient.] The laboratory results are provided in Table 2 and Figure 2. This author's clinical role technically ended here, but her professional interest did not. Subsequent follow-up noted that the patient spent an additional 2.5 hours in the resuscitation room before admission to the operating room. In the resuscitation room, he had 8 units of blood transfused, with close observation for ongoing bleeding and otherwise conservative management. He later underwent a right thoracotomy, which revealed bleeding intercostal vessels. After appropriate surgical management, the patient improved, was extubated on postoperative day 3 in the intensive care unit, and reportedly continued to recover.
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Figure 1. Goals for Transfer
Table 2 Initial Laboratory Measurements Patient's Measured Values Hb Hct Platelets International normalized ratio APTT Bicarbonate Lactate
5.5g/dL 0.17 60 109/L 3.5 133 13 mmol/L 7.2 mmol/L
pH pCO2 Base excess
6.86 72 mm Hg 21.0
APTT ¼ Activated Partial Thromboplastin Time; Hb ¼ hemoglobin; Hct ¼ hematocrit.
Discussion Incorrect Placement of a Left-sided Drain Chronologically, 1 of the first things that occurred was the placement of a drain on the incorrect side. The emergency department physician who performed this was extremely junior and was in training to become a general practitioner. Provider anxiety, clinical inexperience, and potential haste may have been contributing factors toward this particular scenario. On review of the case, it was found that a chest radiograph had been taken, and the laterality was confused at this point. In Australia, there is yet to be a parallel to the UK's National Patient Safety Agency Never Events Framework 2009/10.1,2 There are many case reports of a range of malpositioned chest tubes in the current literature, and a robust learning process should take place from such reports.9 There is also an argument to be made for the implementation of checklists for low-volume/high-risk procedures, such as intercostal drain insertion, at clinical sites where major trauma is not frequently encountered. Position of the Chest Drain A further learning point arises in the actual position of chest drains. On review of the resuscitation room chest x-ray, it was clearly identified that the right chest drain was placed in the 6th intercostal space and the left was placed in the 8th. The UK's National Patient Safety Agency addressed this problem in 2005, and the National Reporting and Learning System was activated. The National Reporting and Learning System is a voluntary reporting system (which avoids natural bias); they reported 2,152 incidents of harm related to the insertion of chest drains over a 39-month study period spanning from 2005 to 2008. Twelve cases resulted in death, and 15 resulted in serious harm. The cases in which death occurred were reviewed in detail and are included in the national database. These incidences recorded injury to the liver and heart, with resultant catastrophic
Figure 2. A chest radiograph taken in the resuscitation room. Of note are the 2 chest drains (1 with a clamp in situ) and an endotracheal tube (in the right main stem bronchus).
hemorrhage. Additionally, there were over 50 litigation claims against the National Health Service for chest drainerelated injury over a 10-year period. Factors highlighted as needing addressing included inexperience of the operator, lack of supervision, site chosen, lack of anatomic knowledge, inadequate clinical diagnosis, equipment issues, and lack of clinical guidelines. A UK-based agency issuing national guidance and advice to improve health and social care (ie, the National Institute for Clinical Excellence) and the UK specialist society (the British Thoracic Society) have released guidelines on this. Removal of the Other Chest Drain Regardless of the factors contributing to the placement of the chest drain on the left (incorrect) side, reassessment was required to evaluate the potential merits and disadvantages of removing this chest drain and transporting with a simple finger thoracostomy on this side. No blood was noted from this drain, so issues of aircraft contamination were irrelevant. It would have been an option to simplify the transfer by simply removing this intercostal drain. Although significant primary injury to the left hemithorax did not appear clinically evident, the fact remained that there was now an actual pneumothorax adding to the patient's dire respiratory physiology. It was decided to maintain the drain in situ. Clamping the Chest Drain The sudden gush of a large volume of blood upon placement of the right intercostal drain was unnerving. The initial reaction was to clamp the chest drain. This author's justification for this was that “clamping will allow a tamponade effect and reduce further bleeding inside the chest, allowing time for adequate IV [intravenous] resuscitation, and locating an additional bag for chest drainage.” The chest clamp was left in situ during the entire transfer period, with judicious monitoring of lung mechanics. The practice of
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Figure 3. Dutton Article Recommendations.5
clamping the chest drain continued in the resuscitation room where the cardiothoracic registrar who presumed care instructed for it to remain in place. A subsequent review of the literature concerning chest drain clamping has revealed that it is not advisable to do so.10,11 The thorax can hold a considerable volume of blood. A clamped intercostal drain will not tamponade a massive hemothorax. A 1995 study conducted by Ali et al11 found that clamping a chest drain did not decrease hemorrhage or mortality; additionally, gas exchange was decreased. Not only will a clamped intercostal drain not tamponade the bleeding, it may actually convert a simple pneumothorax to a tension pneumothorax. In addition, gas exchange is impeded as the lung is collapsed by the filling blood volume. Clamping a chest drain in a case of a massive hemothorax conceals blood loss, compromises pulmonary function in a patient already in shock, and prevents the measurement of initial and ongoing loss relevant to decisions regarding the urgency of a thoracotomy. Chest Drain Availability in Isolated Sites Retrieval and remote area physicians need to be aware of challenges posed by limited equipment availability. In small units or on the roadside, the presence of large stocks of items is unfeasible. Blood and blood products are also rarely available in remote medical clinics, and the retrievalist needs to consider taking blood for trauma cases in particular. In the United Kingdom, the London and Kent helicopter emergency medical services carry blood and chest drains on all missions. Finger Thoracostomy Versus Chest Drain In the prehospital environment, there is a debate regarding the need for a formal intercostal drain, with finger thoracostomy being advocated as a viable alternative in a ventilated patient. Time and resource constraints, clinical urgency, equipment complications (such as drain kinks), and blood contamination of the aircraft are all factors to consider when deciding whether, and/or when, to place a formal intercostal drain. The alternative option is to simply fly the ventilated patient with finger thoracostomies. CMS has extensive protocols to guide clinical practice. The SOP issued by CMS on finger thoracostomy provides clear guidance and is revised in weekly audit and morbidity and mortality meetings. Advantages and disadvantages exist upon comparison of chest drain placement versus the performance of finger thoracostomy. Finger thoracostomy allows for rapid decompression of the pleural space in limited time with limited resources. The placement of a chest drain is more involved and generally requires a higher degree of clinical expertise
to perform. However, a chest drain allows for subsequent blood collection to facilitate more accurate estimation of blood loss. The current policy for the London helicopter emergency service is to perform a finger thoracostomy, primarily in cases of significant chest trauma. If there is isolated chest trauma that compromises oxygenation in the spontaneously ventilating patient, then chest drain remains a viable alternative. Troubleshooting the Ventilator Problem Because of the frequent high-pressure alarm, the ventilator became a hindrance during the management of this patient. When initially attached, the usual thorough anesthetic check of the airway and circuit from the patient end to the ventilator end was completed. At the time, no resolvable problem was noted; to facilitate patient safety, the clinician elected to manually ventilate the patient via a bag valve tube. With calm retrospect, it is probable that the ventilator problem was caused by high pressures resulting from a massive hemothorax that reaccumulated when the chest drain was clamped. It is also possible the cuffed oral endotracheal tube was in the right main stem bronchus as shown in the chest radiograph upon emergency room arrival. However, this author believes it more likely that the tube migrated into the right main stem during the transfer process. In any case, a systematic process for causal discovery, from patient to machine end, of a failing piece of equipment should be well rehearsed for every piece of equipment,3 especially in the retrieval environment. Examination of the Patient ATLS keeps it simple; examine the site of the injury. The stab wound to this gentleman's posterior chest, the nature of injury, the presence of multiple medical hardware items, and his supine position contributed to examination of the knife wound being overlooked. A more extensive examination may have prompted this author to consider alternative and novel techniques aimed at hemostasis in massive chest bleeding. There is evidence in the literature that suggests an inflated Foley catheter can help to stem hemorrhage from intercostal vessels.4 Hypotensive/Hemostatic Resuscitation Hemorrhagic shock results in hypoperfusion and inadequate oxygen delivery to the tissues. The goals of resuscitation should include the identification and control of the bleeding source as well as restoration of perfusion and oxygen delivery. It has been shown5-7 that inappropriate or unmeasured vigorous fluid resuscitation may
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Figure 4. European Guidelines Recommendation 18.8
be detrimental. In 2002, Dutton et al5 showed that overzealous fluid administration worsened morbidity and mortality in trauma patients with hemorrhagic shock. There were several other excellent recommendations made by the authors (Fig. 3). International leading body consensus on fluid regimes in trauma are as follows: helicopter emergency medical services: limited regimen, advanced trauma life support: resuscitate to organ perfusion, international trauma life support: limited fluid resuscitation protocols, US military: limited fluid resuscitation, US trauma centers: highly variable with mixed results emerging, and Israeli Army: limited fluid resuscitation with extremely positive results. Learning Points The following should be performed: Rigorously perform airway breathing circulation (primary) assessment and treat life-threatening conditions as they are found. Do not clamp chest drains. Consider patient instability in addition to equipment failure.
Further Reading Originally published in 2007 and updated in 2010, the Trauma Task Force has delineated the European Guidelines resuscitation
recommendation 18 as an excellent reference for prehospital trauma clinicians (Fig. 4).
References 1. Risk of chest drain insertion, NRLS/NPSA. http://www.nrls.npsa.nhs.uk/resources/ ?entryid45¼59887. Accessed July 21, 2014. 2. National Patient Safety Agency. Never Events Framework 2009/10. www.nrls. npsa.nhs.uk/neverevents/?entryid45¼59859. Accessed June 2014. 3. Oxylog 3000 User Manual. http://www.emed.ie/Procedures/_img/Oxylog% 203000_v2%2002.pdf. Accessed June 2014. 4. Chao BF, Jian YJ, Hao HZ, et al. Balloon Foley catheter compression as a treatment for intercostal vessel bleeding. Injury. 2011;42:958e959. 5. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002;52:1141e1146. 6. Dutton RP. Fluid management for trauma; where are we now? CEACCP. 2006;6: 144e147. 7. Bickell WH, Wall Jr MF, Pepe PE, et al. Mattox. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105e1109. 8. Rossaint R, Bouillon B, Cerny V, et al. Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14:R52. 9. Gayer G, Rozenman J, Hoffmann C, et al. CT diagnosis of mal-positioned chest tubes. Br J Radiol. 2000;73:786e790. 10. Laws D, Neville E, Duffy J. Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58:ii53eii59. 11. Ali J, Qi W. Effectiveness of chest tube clamping in massive hemothorax. J Trauma. 1995;38:59e62. discussion 62-63.