- Email: [email protected]
Case review 1 conclusion: Motor vehicle crash with multiple injuries
Case Review
David W. Ross, DO, FACEP, and Carol Wichman, BSN, MSN
Case Review 1 Conclusion: Motor Vehicle Crash with Multiple Injuries
A 30-year-old male was involved in a major motor vehicle crash and sustained multiple life-threatening injuries, including an amputated left arm. The scene GCS was 3, the airway was inaccessible, and there was no palpable blood pressure. See Air Medical Journal January 2006 issue for a full case presentation. Editors’ Note: This Case Review concludes the case presented in the previous issue. We strongly encourage reader participation. If you have a case that might be suitable, please submit the details to David Ross at [email protected].
T
he patient’s airway was managed with a surgical cricothyrotomy at the scene. Because of the nature of the vehicle damage, neither a bag-valve mask (BVM) nor simple O2 mask could be applied to the patient’s face. The mouth could not be accessed for laryngoscope blade insertion. Extrication was complicated and required a total of 45 minutes. On-scene personnel thought that the only way to reach the patient’s airway was through the broken windshield. The patient’s respirations were minimal to agonal, and immediate airway intervention was required. His neck could be reached easily, and a cricothyrotomy was quickly accomplished. Injuries identified after prompt workup in the emergency department (ED) included (see attached radiographs): 1. Left occipital intracranial hemorrhage 2. Lacerated liver and spleen 3. Traumatic amputation of the left upper extremity 4. Bilateral pulmonary opacities and pleural effusions 5. Comminuted left femur fracture 6. Comminuted fracture/dislocation of the left tibia/fibula 7. Comminuted fracture of the right distal radius and ulna 54
8. Left foot fracture of metarsals 1, 3, 4 (LisFranc fracture/ dislocation) 9. Left cuboid fracture
Clinical Course Continued fluid resuscitation with blood products was carried out during the initial evaluation in the ED. He received 6 units packed red blood cells and multiple units fresh frozen plasma and platelets. The left brachial artery was clamped, and emergent reduction of a left tibial/talar dislocation was performed. Multiple central lines were placed. The initial chest radiograph suggested pulmonary contusions versus adult respiratory distress syndrome (ARDS) or both. Additionally, the film raised concern for possible traumatic aortic aneurysm (TRA). A computed tomography (CT) scan of the chest demonstrated only the findings listed above. No TRA was identified. An abdominal ultrasound noted suspected blood in the areas near the spleen and liver. The patient then was taken immediately to the operating room. The liver and spleen lacerations were repaired. A neurosurgeon felt that the intracranial hemorrhage required operative intervention. During the initial surgery, orthopedic stabilization was begun on the many bony injuries. Repair of the remaining left brachial artery was undertaken, and initial preparation for closure of the left humerus stump was begun. At surgery, a significant clot was identified in the left femoral artery, and a thrombectomy was performed. Air Medical Journal 25:2
Within 12 hours, a compartment syndrome of the left leg and thigh developed and required fasciotomy. The patient steadily improved afterward. ARDS occurred within 24 hours of admission but eventually resolved. Five days after admission, the cricothyrotomy was converted to a tracheostomy. Disseminated intravascular coagulopathy (DIC) was noted 6 days after admission. Appropriate treatment was instituted, and the patient subsequently recovered. Eighteen days after admission, the patient suffered a lower gastrointestinal bleed as a result of a colonic ulcer. He recovered from that, as well. The patient’s mental status improved steadily throughout his admission. One day after his admission, a neurosurgeon estimated the Glasgow Coma Scale to be 10. After his critical injuries and complications were resolved, the patient was discharged to the rehabilitation service. He steadily progressed and was discharged home 4 months after admission. At that time, the physical medicine specialist noted that the patient was partially weight bearing (50%) and able to ambulate on his own for 5 feet with a crutch. He was able to groom and bathe without assistance. He was scheduled to be fitted with a left arm prosthesis, and further home care was arranged. Eight months after admission, the patient was fully ambulatory and returned to work.
Discussion of the Questions Posed to Readers How would you manage this patient’s airway? This case raises several controversial points in the prehospital management of the patient. The first involves the choice of airway management. Currently, all prehospital critical care services should have alternate devices available when tracheal intubation is not feasible or possible. Responding paramedics quickly assessed this situation and thought that the only effective way to control the patient’s airway was via cricothyrotomy. Although surgical (and kit) cricothyrotomy is infrequently used by most agencies, there are rare occasions, such as this one, when the procedure may be lifesaving. In light of this, crews should be well trained in either the surgical or kit method as needed because either is typically used after most all other airway management techniques have failed and the situation has become highly stressful. Efficacy, various methods, complications, and alternatives in both hospital and prehospital settings have been evaluated. Paramedic success in cannulating the trachea range from 88% to 96%, with surgical cricothyrotomy.1,2 Survival to ED or hospital discharge averages about 15% to 20% of these patients. Despite the availability of newer kit methods, one study found that surgical cricothyrotomy, in the hands of paramedics, was still the most efficacious and quickest.3 Surgical cricothyrotomies are reported to carry a somewhat higher complication rate than kit methods but may be faster and less complicated to perform.4 Obtaining realistic training for cricothyrotomies can be problematic. A common option is to practice with sheep tracheas. Usually accessible and relatively cheap, they provide a reasonable approximation of human anatomy but lack overlyMarch-April 2006
Additional References for
Fluid Resuscitation Bickell WH, Pepe PE, Bailey ML, Wyatt CH, Mattox KL. Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 1987;16(6):653-8. Maningas P, Mattox KL, Pepe PE, Jones RL, Feliciano DV, Burch JM. Hypertonic-dextran solutions for the prehospital management of traumatic hypotension. Am J Surg 1989;157(5):528-33. Mattox KL, Bickell W, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients. J Trauma 1989;29(5):1104-12. Pepe P. Controversies in resuscitation: to infuse not to infuse. Resuscitation. 1996;3:7-10.
ing skin, soft tissue, and fat. Cadaver and animal laboratories may be options for programs that have access to them. Current human patient simulators may be useful, although some are more realistic than others. In all likelihood, the future of invasive procedures, including cricothyrotomy, lies in further refinement of human simulators. No matter what training technique is selected by an agency, at least yearly review of the procedure is needed to maintain a minimum competency level. How would you handle the issue of the on-scene emergency physician and his medication orders? This particular issue rarely occurs in flight and ground emergency medical services (EMS) operations in our area, but the potential for such a situation clearly exists. In this case, an individual claiming to be a local military emergency physician was on scene at the time of the flight crew’s arrival. The crew did not personally know this person. Additionally, it is likely that this physician was not aware of the specific existing protocols for both ground and air crews in the area. After the patient was thought to have a seizure and because of concern for pain, the physician ordered the crew to give the patient 150 g fentanyl and 10 mg diazepam. The crew proceeded to administer both drugs. Given the patient’s extreme hypotension, these drugs were not indicated (in fact, both medications may contribute to hypotension). The patient’s seizure was, in fact, likely a result of extremely low cerebral perfusion pressure. Critical care transport crews must constantly assess what is in the best interest of their patient, despite what others around them may think or suggest. The reality is that an onscene physician is essentially a Good Samaritan and has no clinical supervisory role over an EMS agency. As such, requests or orders from an individual physician should generally be disregarded, especially if they conflict with crew judgment and approved protocols or guidelines. Although such a situation may be awkward, a simple comment to the effect of “thanks, but we are required to follow our protocols,” will generally suffice to a well-intended bystander physician. How much fluid would you give this patient in the field and why? Primarily because of the prolonged extrication time, this patient received a total of 5.3 L saline in the field. His weight was estimated by the flight crew to be 150 pounds (68 kg). 55
Fluid resuscitation by prehospital personnel in trauma patients remains controversial and somewhat confusing. Review of the current literature suggests that prehospital personnel first may need to determine the most likely cause of the blood loss. Current fluid replacement strategies are based primarily on the presumed cause of blood loss. Fluid replacement clearly benefits patients presenting with significant but easily controlled external bleeding. In patients with internal bleeding, control is generally not possible in the field or ED. Evidence suggests that maintenance of a lower mean arterial pressure (MAP) (MAP [mmHg] ⫽ systolic BP [mmHg] ⫹ 2 ⫻ diastolic BP [mmHg]/3) of 30 to 40 has been suggested.5 Alternately, maintenance of a systolic blood pressure of approximately 80 to 90 mmHg in an adult patient would be an acceptable goal. Theoretically, a lower internal pressure may reduce the risk of continued extravasation of blood and maintain whatever vessel clot that may be formed. Therefore, fluid boluses may be smaller in such a case than in a patient with controlled external bleeding. The dangers of excessive fluid replacement include diminished fluid oxygen-carrying capability as hemoglobin concentration is decreased or pulmonary edema. There is therefore good reason to limit fluid replacement, even in the case of the patient not responding to resuscitation. Indeed, the nonresponding patient requires blood, and likely surgical intervention, for any hope to survive. In a recent phone discussion with Dr. Paul Pepe, professor and chairman of the Department of Emergency Medicine at the University of Texas Southwestern Medical School in Dallas and author of numerous journal articles on the subject of prehospital fluid resuscitation, he indicated that fluid replacement should be viewed differently based on the nature of the traumatic injury the patient has sustained. He said trauma patients should be divided into four groups: penetrating injury with “controlled hemorrhage”; penetrating with “uncontrolled hemorrhage”; blunt injury with “controlled hemorrhage”; and blunt with “uncontrolled hemorrhage.” “Most prehospital protocols do not break trauma patients into these categories in terms of fluid replacement strategies,” he said. In patients with penetrating injuries to the torso but maintaining a pulse (controlled), Pepe thinks the data suggest no fluid resuscitation is indicated. Even in patients with penetrating injuries and very unstable blood pressures, he suggests that “limited” or no fluid resuscitation preoperatively is associated with improved outcomes compared with similar patients receiving aggressive preoperative fluid therapy. Patients with penetrating injuries and no palpable blood pressure (uncontrolled) still may benefit from aggressive fluid therapy. Data involving patients with blunt injury are less clear, according to Pepe, who said, “When bleeding can be directly controlled in the prehospital setting (controlled), aggressive fluid replacement is reasonable. When in doubt, hypoperfusion is almost always preferred in any trauma patient. When bleeding cannot be directly controlled in the blunt injury patient (uncontrolled) and blood pressure is palpable, as is often the case, much more cautious replacement is indicated.” A reasonable target in this case may be the MAP of approximately 30 to 40 or systolic blood pressure of approximately 80 56
to 90 mmHg. More studies are needed to clarify the role of preoperative fluid replacement in blunt-injured trauma patients. The evidence is also unclear, at this time, for the prehospital use of colloids (albumin, concentrated sodium solutions, etc.) in the treatment of traumatic shock, according to Pepe. However, he holds out hope that future studies may identify a viable colloid solution or blood substitute. “Use of the pneumatic antishock garment (PASG) has generally fallen out of favor,” he said. Furthermore, in the limited space of some helicopters and other transport vehicles, PASG storage is not practical. However, there may still be some theoretic benefit in exsanguinating patients with pelvis or lower extremity fractures, especially in the case of a longer transport time. The patient in this case might have been a candidate, except that the very short transport time likely made the benefit of PASG negligible. An excellent summary article by Pepe and his colleagues on the current status of preoperative volume replacement research is cited at the end of this article. It is a good reference for flight crews, other prehospital providers, medical directors, and trauma programs.6 Whereas stratification of trauma patients as described may be the most appropriate mechanism to triage patients with regard to fluid resuscitation planning, it is also somewhat complex and hard to remember. In light of this concern for complexity, we have adopted a more simplistic approach to fluid replacement in trauma patients in our Colorado service area. We have simply adopted the pediatric formula for fluid resuscitation for all of our patients. In other words, we use the standard of 20 mL/kg for all trauma patients if we believe fluid replacement is needed. We repeat this rate one time, if needed. To our knowledge, this formula in the use of trauma patient fluid resuscitation has not been scientifically validated. However, we think it is a reasonable compromise between the strong suggestion that less fluid is better and the complexity of the triage algorithm suggested by Pepe’s research. Use of the above formula in the case of this patient suggests that 5.3 L fluid may have been excessive (68 kg [pt wt]) ⫻ maximum 40 mL/kg ⫽ 2.7 L). Refer to the sidebar for additional references relevant to this section of the discussion. What do you think of the urinalysis findings? What future complication(s) might be suggested? The finding of “blood” in the urine as detected chemically—without presence of microscopic red blood cells—suggests myoglobin in the urine. Chemical determination of blood in the urine because of actual hemoglobin would be accompanied by red blood cells. Myoglobin is an oxygen-binding protein similar to hemoglobin and is found in muscle cells. Although it contains heme, it is not found in red blood cells and, as such, has no direct relationship to blood. However, because of the presence of heme in myoglobin, a chemically positive result for blood in the urine will result, such as hemoglobin. Identifying the presence of myoglobin in the urine is useful. Patients at high risk for severe damage to skeletal muscle (such as in this case) are likely to develop myoglobinuria. In fact, numerous mechanisms may lead to severe muscle damage. Air Medical Journal 25:2
Some of these causes are related to traumatic injuries and others related to drug use or major illnesses. Myoglobinuria may herald the presence of rhabdomyolysis, injury of skeletal muscle with the subsequent release of intracellular contents. Other intracellular contents commonly released include creatine phophokinase (CPK). In addition to the detection of urinary myoglobin, at-risk patients should undergo serum testing for the presence of myoglobin and CPK. Patients suffering from rhabdomyolysis may develop acute renal failure (ARF) because myoglobin and other muscle cellular contents can physically obstruct renal tubules and cause direct toxicity to the kidneys. The key for critical care transport crews is recognition of patients clinically at risk for rhabdomyolysis and the associated potential for subsequent renal failure. Patients with a history or clinical findings raising suspicion for major muscle damage should be considered high risk for the presence of rhabdomyolysis. Clearly, such a patient with a urinalysis that tests positive for blood without the presence of red blood cells is a major concern. Prompt recognition and treatment is essential to reduce the risk of renal failure and resultant electrolyte disturbance in the rhabdomyolysis patient. The mainstay of therapy is intravenous fluid administration. The literature is unclear regarding specific replacement volumes, but some suggest that urine output should be as high as 2 mL/kg/h. Whatever fluid volume is selected, clearly the fluid requirements for a patient with suspected rhabdomyolysis would be greater than in a patient receiving resuscitative fluids because of trauma without the complication of rhabdomyolysis. Sodium bicarbonate may be considered to achieve a urine pH of greater than 6.5 in the rhabdomyolysis patient. The recommended dosage ranges between 44 and 271 mEq/L of bicarbonate. There is evidence that alkalinized urine reduces the risk of ARF in these patients.
Other treatment strategies include forced diuresis, usually with mannitol or another osmotic diuretic. In conclusion, the most important point is an awareness of the possible presence of myoglobinuria and rhabdomyolysis in the at-risk patient. Aggressive fluid therapy should be instituted by providers when the possibility of the disorder is recognized. The patient in this case developed a compartment syndrome in the left leg, requiring fasciotomy. Muscle damage associated with compartment syndrome is usually causative of rhabdomyolysis and likely explained much of the myoglobin in the urine. As it turned out, the patient never showed signs of ARF, despite evidence strongly suggesting rhabdomyolysis. The fluid volume of 5.3 L in the field was possibly instrumental in reducing the danger of ARF.
References 1. Johnson DR, Dunlap A, McFeeley P, Gaffney J, Busick B.Cricothyrotomy by prehospital personnel. A comparison of two techniques in the cadaver. Am J Emerg Med 1993;11(3):207-9. 2. Nugent WL, Rhee KJ, Wisner DH. Can nurses perform surgical cricothyrotomy with acceptable success and complication rates? Ann Emerg Med 1991:20(4):367-70. 3. Spaite DW, Joseph M. Prehospital cricothyrotomy: An investigation of the techniques, complications and patient outcomes. Ann Emerg Med 1990:19(3):279-85. 4. Salvino CK, Dries D, Gamelli R, Murphy-Macabobby M, Marshall W. Emergency cricothyrotomy in trauma victims. J Trauma 1993;34(4):503-5. 5. Shoemaker WC, Peitzman AB, Bellamy R, et al. Resuscitation from severe hemorrhage. Crit Care Med 1996;24(2)(Supp):S12-22. 6. Pepe P, Mosesso VN Jr, Falk JL. Prehospital fluid resuscitation of the patient with major trauma. Prehosp Emerg Care 2002;6(1):81-91.
David Ross, DO, FACEP, has served as the medical director of Flight for Life in Colorado Springs, Colorado, since 1996. He can be reached at [email protected]. Carol Wichman, BSN, MSN, is the clinical coordinator of the Colorado Springs base of the statewide Flight for Life program. 1067-991X/$32.00 Copyright 2006 Air Medical Journal Associates doi:10.1067/j.amj.2006.12.006
Reader Responses Reader Comments = RC Author Response = AR
The concern in this patient with any benzodiazepine administration is further decrease in existing hypotension.
RC: The article states the patient had an airway when the flight crew arrived, but it does not state what kind. Was it possible to get a nonrebreather on the patient with an oral or nasal airway while trapped? Could the patient have been approached from above or using a claw hammer technique? I would have intubated the patient enroute, if not on the way to the aircraft. This patient had potential for substantial hypoxia, if not anoxia which could cause seizure activity. I would have aggressively dealt with his airway. I realize paralytics do not stop seizures, but I would consider Ativan (our protocol enroute). AR: Unfortunately, the roof of the vehicle totally compressed the patient’s face, preventing any access to the mouth or nose from any angle; only the patient’s neck was accessible. So a nasal or oral airway or mask could not be applied. The “claw hammer technique” is an excellent suggestion, but it was not possible, either, since the mouth could not be approached. For those uncertain about the technique, it is simply the insertion of a laryngoscope blade while the operator is directly facing the patient. Significant downward pressure is applied (with the operator’s left hand holding the blade) to the jaw, until at least the epiglottis is visualized. The endotracheal tube is then inserted, essentially blindly, just posterior to the epiglottis. This is a useful approach in certain situations; however, significant room to open the mouth is required, so the presence of a cervical collar might restrict this technique. Like any other airway procedure, it should be practiced regularly, at least with a mannequin, before attempting it in the field.
RC: [Concerning] The on-scene MD, I would have to consider my own protocols first. I would be very gracious and humble, but I really think managing this guy’s airway and sedating him properly would help. [Concerning] Fluids, our protocols say 2 liters, then infuse packed red blood cells. 5 liters is a lot of fluid in a short time. The patient will probably be cold, too. I realize we don’t all carry blood, but these are just my thoughts and how I would deal with this patient if he were here. AR: We agree that starting blood in the field, if it were available, would be critically important in this patient. Unfortunately, due to the very short time to liftoff from the request for service and the very brief transport time, it was not possible to obtain blood before departure. Having O-negative blood near the helipad could be very useful in such cases. Hypothermia is a significant concern in a prolonged scene situation, as well as with the infusion of large amounts of fluids.
March-April 2006
RC: I would be very concerned about abdominal compartment syndrome, compartment syndrome with the fractures, coagulopathies (DIC), to name a few. AR: Exactly correct. Thank you to Susan Toberman, RN, CCRN, CFRN, EMT, with Lifestar Air Medical Services in Knoxville, TN, for these comments.
57
David W. Ross, DO, FACEP, and Carol Wichman, BSN, MSN
Case Review 1 Conclusion: Motor Vehicle Crash with Multiple Injuries
A 30-year-old male was involved in a major motor vehicle crash and sustained multiple life-threatening injuries, including an amputated left arm. The scene GCS was 3, the airway was inaccessible, and there was no palpable blood pressure. See Air Medical Journal January 2006 issue for a full case presentation. Editors’ Note: This Case Review concludes the case presented in the previous issue. We strongly encourage reader participation. If you have a case that might be suitable, please submit the details to David Ross at [email protected].
T
he patient’s airway was managed with a surgical cricothyrotomy at the scene. Because of the nature of the vehicle damage, neither a bag-valve mask (BVM) nor simple O2 mask could be applied to the patient’s face. The mouth could not be accessed for laryngoscope blade insertion. Extrication was complicated and required a total of 45 minutes. On-scene personnel thought that the only way to reach the patient’s airway was through the broken windshield. The patient’s respirations were minimal to agonal, and immediate airway intervention was required. His neck could be reached easily, and a cricothyrotomy was quickly accomplished. Injuries identified after prompt workup in the emergency department (ED) included (see attached radiographs): 1. Left occipital intracranial hemorrhage 2. Lacerated liver and spleen 3. Traumatic amputation of the left upper extremity 4. Bilateral pulmonary opacities and pleural effusions 5. Comminuted left femur fracture 6. Comminuted fracture/dislocation of the left tibia/fibula 7. Comminuted fracture of the right distal radius and ulna 54
8. Left foot fracture of metarsals 1, 3, 4 (LisFranc fracture/ dislocation) 9. Left cuboid fracture
Clinical Course Continued fluid resuscitation with blood products was carried out during the initial evaluation in the ED. He received 6 units packed red blood cells and multiple units fresh frozen plasma and platelets. The left brachial artery was clamped, and emergent reduction of a left tibial/talar dislocation was performed. Multiple central lines were placed. The initial chest radiograph suggested pulmonary contusions versus adult respiratory distress syndrome (ARDS) or both. Additionally, the film raised concern for possible traumatic aortic aneurysm (TRA). A computed tomography (CT) scan of the chest demonstrated only the findings listed above. No TRA was identified. An abdominal ultrasound noted suspected blood in the areas near the spleen and liver. The patient then was taken immediately to the operating room. The liver and spleen lacerations were repaired. A neurosurgeon felt that the intracranial hemorrhage required operative intervention. During the initial surgery, orthopedic stabilization was begun on the many bony injuries. Repair of the remaining left brachial artery was undertaken, and initial preparation for closure of the left humerus stump was begun. At surgery, a significant clot was identified in the left femoral artery, and a thrombectomy was performed. Air Medical Journal 25:2
Within 12 hours, a compartment syndrome of the left leg and thigh developed and required fasciotomy. The patient steadily improved afterward. ARDS occurred within 24 hours of admission but eventually resolved. Five days after admission, the cricothyrotomy was converted to a tracheostomy. Disseminated intravascular coagulopathy (DIC) was noted 6 days after admission. Appropriate treatment was instituted, and the patient subsequently recovered. Eighteen days after admission, the patient suffered a lower gastrointestinal bleed as a result of a colonic ulcer. He recovered from that, as well. The patient’s mental status improved steadily throughout his admission. One day after his admission, a neurosurgeon estimated the Glasgow Coma Scale to be 10. After his critical injuries and complications were resolved, the patient was discharged to the rehabilitation service. He steadily progressed and was discharged home 4 months after admission. At that time, the physical medicine specialist noted that the patient was partially weight bearing (50%) and able to ambulate on his own for 5 feet with a crutch. He was able to groom and bathe without assistance. He was scheduled to be fitted with a left arm prosthesis, and further home care was arranged. Eight months after admission, the patient was fully ambulatory and returned to work.
Discussion of the Questions Posed to Readers How would you manage this patient’s airway? This case raises several controversial points in the prehospital management of the patient. The first involves the choice of airway management. Currently, all prehospital critical care services should have alternate devices available when tracheal intubation is not feasible or possible. Responding paramedics quickly assessed this situation and thought that the only effective way to control the patient’s airway was via cricothyrotomy. Although surgical (and kit) cricothyrotomy is infrequently used by most agencies, there are rare occasions, such as this one, when the procedure may be lifesaving. In light of this, crews should be well trained in either the surgical or kit method as needed because either is typically used after most all other airway management techniques have failed and the situation has become highly stressful. Efficacy, various methods, complications, and alternatives in both hospital and prehospital settings have been evaluated. Paramedic success in cannulating the trachea range from 88% to 96%, with surgical cricothyrotomy.1,2 Survival to ED or hospital discharge averages about 15% to 20% of these patients. Despite the availability of newer kit methods, one study found that surgical cricothyrotomy, in the hands of paramedics, was still the most efficacious and quickest.3 Surgical cricothyrotomies are reported to carry a somewhat higher complication rate than kit methods but may be faster and less complicated to perform.4 Obtaining realistic training for cricothyrotomies can be problematic. A common option is to practice with sheep tracheas. Usually accessible and relatively cheap, they provide a reasonable approximation of human anatomy but lack overlyMarch-April 2006
Additional References for
Fluid Resuscitation Bickell WH, Pepe PE, Bailey ML, Wyatt CH, Mattox KL. Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 1987;16(6):653-8. Maningas P, Mattox KL, Pepe PE, Jones RL, Feliciano DV, Burch JM. Hypertonic-dextran solutions for the prehospital management of traumatic hypotension. Am J Surg 1989;157(5):528-33. Mattox KL, Bickell W, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients. J Trauma 1989;29(5):1104-12. Pepe P. Controversies in resuscitation: to infuse not to infuse. Resuscitation. 1996;3:7-10.
ing skin, soft tissue, and fat. Cadaver and animal laboratories may be options for programs that have access to them. Current human patient simulators may be useful, although some are more realistic than others. In all likelihood, the future of invasive procedures, including cricothyrotomy, lies in further refinement of human simulators. No matter what training technique is selected by an agency, at least yearly review of the procedure is needed to maintain a minimum competency level. How would you handle the issue of the on-scene emergency physician and his medication orders? This particular issue rarely occurs in flight and ground emergency medical services (EMS) operations in our area, but the potential for such a situation clearly exists. In this case, an individual claiming to be a local military emergency physician was on scene at the time of the flight crew’s arrival. The crew did not personally know this person. Additionally, it is likely that this physician was not aware of the specific existing protocols for both ground and air crews in the area. After the patient was thought to have a seizure and because of concern for pain, the physician ordered the crew to give the patient 150 g fentanyl and 10 mg diazepam. The crew proceeded to administer both drugs. Given the patient’s extreme hypotension, these drugs were not indicated (in fact, both medications may contribute to hypotension). The patient’s seizure was, in fact, likely a result of extremely low cerebral perfusion pressure. Critical care transport crews must constantly assess what is in the best interest of their patient, despite what others around them may think or suggest. The reality is that an onscene physician is essentially a Good Samaritan and has no clinical supervisory role over an EMS agency. As such, requests or orders from an individual physician should generally be disregarded, especially if they conflict with crew judgment and approved protocols or guidelines. Although such a situation may be awkward, a simple comment to the effect of “thanks, but we are required to follow our protocols,” will generally suffice to a well-intended bystander physician. How much fluid would you give this patient in the field and why? Primarily because of the prolonged extrication time, this patient received a total of 5.3 L saline in the field. His weight was estimated by the flight crew to be 150 pounds (68 kg). 55
Fluid resuscitation by prehospital personnel in trauma patients remains controversial and somewhat confusing. Review of the current literature suggests that prehospital personnel first may need to determine the most likely cause of the blood loss. Current fluid replacement strategies are based primarily on the presumed cause of blood loss. Fluid replacement clearly benefits patients presenting with significant but easily controlled external bleeding. In patients with internal bleeding, control is generally not possible in the field or ED. Evidence suggests that maintenance of a lower mean arterial pressure (MAP) (MAP [mmHg] ⫽ systolic BP [mmHg] ⫹ 2 ⫻ diastolic BP [mmHg]/3) of 30 to 40 has been suggested.5 Alternately, maintenance of a systolic blood pressure of approximately 80 to 90 mmHg in an adult patient would be an acceptable goal. Theoretically, a lower internal pressure may reduce the risk of continued extravasation of blood and maintain whatever vessel clot that may be formed. Therefore, fluid boluses may be smaller in such a case than in a patient with controlled external bleeding. The dangers of excessive fluid replacement include diminished fluid oxygen-carrying capability as hemoglobin concentration is decreased or pulmonary edema. There is therefore good reason to limit fluid replacement, even in the case of the patient not responding to resuscitation. Indeed, the nonresponding patient requires blood, and likely surgical intervention, for any hope to survive. In a recent phone discussion with Dr. Paul Pepe, professor and chairman of the Department of Emergency Medicine at the University of Texas Southwestern Medical School in Dallas and author of numerous journal articles on the subject of prehospital fluid resuscitation, he indicated that fluid replacement should be viewed differently based on the nature of the traumatic injury the patient has sustained. He said trauma patients should be divided into four groups: penetrating injury with “controlled hemorrhage”; penetrating with “uncontrolled hemorrhage”; blunt injury with “controlled hemorrhage”; and blunt with “uncontrolled hemorrhage.” “Most prehospital protocols do not break trauma patients into these categories in terms of fluid replacement strategies,” he said. In patients with penetrating injuries to the torso but maintaining a pulse (controlled), Pepe thinks the data suggest no fluid resuscitation is indicated. Even in patients with penetrating injuries and very unstable blood pressures, he suggests that “limited” or no fluid resuscitation preoperatively is associated with improved outcomes compared with similar patients receiving aggressive preoperative fluid therapy. Patients with penetrating injuries and no palpable blood pressure (uncontrolled) still may benefit from aggressive fluid therapy. Data involving patients with blunt injury are less clear, according to Pepe, who said, “When bleeding can be directly controlled in the prehospital setting (controlled), aggressive fluid replacement is reasonable. When in doubt, hypoperfusion is almost always preferred in any trauma patient. When bleeding cannot be directly controlled in the blunt injury patient (uncontrolled) and blood pressure is palpable, as is often the case, much more cautious replacement is indicated.” A reasonable target in this case may be the MAP of approximately 30 to 40 or systolic blood pressure of approximately 80 56
to 90 mmHg. More studies are needed to clarify the role of preoperative fluid replacement in blunt-injured trauma patients. The evidence is also unclear, at this time, for the prehospital use of colloids (albumin, concentrated sodium solutions, etc.) in the treatment of traumatic shock, according to Pepe. However, he holds out hope that future studies may identify a viable colloid solution or blood substitute. “Use of the pneumatic antishock garment (PASG) has generally fallen out of favor,” he said. Furthermore, in the limited space of some helicopters and other transport vehicles, PASG storage is not practical. However, there may still be some theoretic benefit in exsanguinating patients with pelvis or lower extremity fractures, especially in the case of a longer transport time. The patient in this case might have been a candidate, except that the very short transport time likely made the benefit of PASG negligible. An excellent summary article by Pepe and his colleagues on the current status of preoperative volume replacement research is cited at the end of this article. It is a good reference for flight crews, other prehospital providers, medical directors, and trauma programs.6 Whereas stratification of trauma patients as described may be the most appropriate mechanism to triage patients with regard to fluid resuscitation planning, it is also somewhat complex and hard to remember. In light of this concern for complexity, we have adopted a more simplistic approach to fluid replacement in trauma patients in our Colorado service area. We have simply adopted the pediatric formula for fluid resuscitation for all of our patients. In other words, we use the standard of 20 mL/kg for all trauma patients if we believe fluid replacement is needed. We repeat this rate one time, if needed. To our knowledge, this formula in the use of trauma patient fluid resuscitation has not been scientifically validated. However, we think it is a reasonable compromise between the strong suggestion that less fluid is better and the complexity of the triage algorithm suggested by Pepe’s research. Use of the above formula in the case of this patient suggests that 5.3 L fluid may have been excessive (68 kg [pt wt]) ⫻ maximum 40 mL/kg ⫽ 2.7 L). Refer to the sidebar for additional references relevant to this section of the discussion. What do you think of the urinalysis findings? What future complication(s) might be suggested? The finding of “blood” in the urine as detected chemically—without presence of microscopic red blood cells—suggests myoglobin in the urine. Chemical determination of blood in the urine because of actual hemoglobin would be accompanied by red blood cells. Myoglobin is an oxygen-binding protein similar to hemoglobin and is found in muscle cells. Although it contains heme, it is not found in red blood cells and, as such, has no direct relationship to blood. However, because of the presence of heme in myoglobin, a chemically positive result for blood in the urine will result, such as hemoglobin. Identifying the presence of myoglobin in the urine is useful. Patients at high risk for severe damage to skeletal muscle (such as in this case) are likely to develop myoglobinuria. In fact, numerous mechanisms may lead to severe muscle damage. Air Medical Journal 25:2
Some of these causes are related to traumatic injuries and others related to drug use or major illnesses. Myoglobinuria may herald the presence of rhabdomyolysis, injury of skeletal muscle with the subsequent release of intracellular contents. Other intracellular contents commonly released include creatine phophokinase (CPK). In addition to the detection of urinary myoglobin, at-risk patients should undergo serum testing for the presence of myoglobin and CPK. Patients suffering from rhabdomyolysis may develop acute renal failure (ARF) because myoglobin and other muscle cellular contents can physically obstruct renal tubules and cause direct toxicity to the kidneys. The key for critical care transport crews is recognition of patients clinically at risk for rhabdomyolysis and the associated potential for subsequent renal failure. Patients with a history or clinical findings raising suspicion for major muscle damage should be considered high risk for the presence of rhabdomyolysis. Clearly, such a patient with a urinalysis that tests positive for blood without the presence of red blood cells is a major concern. Prompt recognition and treatment is essential to reduce the risk of renal failure and resultant electrolyte disturbance in the rhabdomyolysis patient. The mainstay of therapy is intravenous fluid administration. The literature is unclear regarding specific replacement volumes, but some suggest that urine output should be as high as 2 mL/kg/h. Whatever fluid volume is selected, clearly the fluid requirements for a patient with suspected rhabdomyolysis would be greater than in a patient receiving resuscitative fluids because of trauma without the complication of rhabdomyolysis. Sodium bicarbonate may be considered to achieve a urine pH of greater than 6.5 in the rhabdomyolysis patient. The recommended dosage ranges between 44 and 271 mEq/L of bicarbonate. There is evidence that alkalinized urine reduces the risk of ARF in these patients.
Other treatment strategies include forced diuresis, usually with mannitol or another osmotic diuretic. In conclusion, the most important point is an awareness of the possible presence of myoglobinuria and rhabdomyolysis in the at-risk patient. Aggressive fluid therapy should be instituted by providers when the possibility of the disorder is recognized. The patient in this case developed a compartment syndrome in the left leg, requiring fasciotomy. Muscle damage associated with compartment syndrome is usually causative of rhabdomyolysis and likely explained much of the myoglobin in the urine. As it turned out, the patient never showed signs of ARF, despite evidence strongly suggesting rhabdomyolysis. The fluid volume of 5.3 L in the field was possibly instrumental in reducing the danger of ARF.
References 1. Johnson DR, Dunlap A, McFeeley P, Gaffney J, Busick B.Cricothyrotomy by prehospital personnel. A comparison of two techniques in the cadaver. Am J Emerg Med 1993;11(3):207-9. 2. Nugent WL, Rhee KJ, Wisner DH. Can nurses perform surgical cricothyrotomy with acceptable success and complication rates? Ann Emerg Med 1991:20(4):367-70. 3. Spaite DW, Joseph M. Prehospital cricothyrotomy: An investigation of the techniques, complications and patient outcomes. Ann Emerg Med 1990:19(3):279-85. 4. Salvino CK, Dries D, Gamelli R, Murphy-Macabobby M, Marshall W. Emergency cricothyrotomy in trauma victims. J Trauma 1993;34(4):503-5. 5. Shoemaker WC, Peitzman AB, Bellamy R, et al. Resuscitation from severe hemorrhage. Crit Care Med 1996;24(2)(Supp):S12-22. 6. Pepe P, Mosesso VN Jr, Falk JL. Prehospital fluid resuscitation of the patient with major trauma. Prehosp Emerg Care 2002;6(1):81-91.
David Ross, DO, FACEP, has served as the medical director of Flight for Life in Colorado Springs, Colorado, since 1996. He can be reached at [email protected]. Carol Wichman, BSN, MSN, is the clinical coordinator of the Colorado Springs base of the statewide Flight for Life program. 1067-991X/$32.00 Copyright 2006 Air Medical Journal Associates doi:10.1067/j.amj.2006.12.006
Reader Responses Reader Comments = RC Author Response = AR
The concern in this patient with any benzodiazepine administration is further decrease in existing hypotension.
RC: The article states the patient had an airway when the flight crew arrived, but it does not state what kind. Was it possible to get a nonrebreather on the patient with an oral or nasal airway while trapped? Could the patient have been approached from above or using a claw hammer technique? I would have intubated the patient enroute, if not on the way to the aircraft. This patient had potential for substantial hypoxia, if not anoxia which could cause seizure activity. I would have aggressively dealt with his airway. I realize paralytics do not stop seizures, but I would consider Ativan (our protocol enroute). AR: Unfortunately, the roof of the vehicle totally compressed the patient’s face, preventing any access to the mouth or nose from any angle; only the patient’s neck was accessible. So a nasal or oral airway or mask could not be applied. The “claw hammer technique” is an excellent suggestion, but it was not possible, either, since the mouth could not be approached. For those uncertain about the technique, it is simply the insertion of a laryngoscope blade while the operator is directly facing the patient. Significant downward pressure is applied (with the operator’s left hand holding the blade) to the jaw, until at least the epiglottis is visualized. The endotracheal tube is then inserted, essentially blindly, just posterior to the epiglottis. This is a useful approach in certain situations; however, significant room to open the mouth is required, so the presence of a cervical collar might restrict this technique. Like any other airway procedure, it should be practiced regularly, at least with a mannequin, before attempting it in the field.
RC: [Concerning] The on-scene MD, I would have to consider my own protocols first. I would be very gracious and humble, but I really think managing this guy’s airway and sedating him properly would help. [Concerning] Fluids, our protocols say 2 liters, then infuse packed red blood cells. 5 liters is a lot of fluid in a short time. The patient will probably be cold, too. I realize we don’t all carry blood, but these are just my thoughts and how I would deal with this patient if he were here. AR: We agree that starting blood in the field, if it were available, would be critically important in this patient. Unfortunately, due to the very short time to liftoff from the request for service and the very brief transport time, it was not possible to obtain blood before departure. Having O-negative blood near the helipad could be very useful in such cases. Hypothermia is a significant concern in a prolonged scene situation, as well as with the infusion of large amounts of fluids.
March-April 2006
RC: I would be very concerned about abdominal compartment syndrome, compartment syndrome with the fractures, coagulopathies (DIC), to name a few. AR: Exactly correct. Thank you to Susan Toberman, RN, CCRN, CFRN, EMT, with Lifestar Air Medical Services in Knoxville, TN, for these comments.
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