EM on the Edge: 2015

Hi Guys!!!!

Recently I realized something very strange: after attending, over the years, courses such as ATLS, ETC, PHTLS, PTC etc ... my mind became in such a way compartmentalized, schematized, excuse the term: protocollized; and if, on one hand this thing has been of great help giving me the cold blood to perform lifesaving maneuvers even in moments of extreme excitement and agitation, on the other hand in part made me lose flexibility in my way of thinking clinically, which in some cases could get me out of situations with no apparent way out.

Chest traumas for example:

when I think of a chest trauma my mind immediately set up on ATLS scheme: life-threatening injuries that require immediate treatment: pneumothorax, hemothorax, flail chest, Cardiac tamponade etc ... but the problem is that my mind tends to consider these lesions as separate entities !!!! ....What happens when all come together in the same patient ?? !!

Clinical case:

A military vehicle passes over a pressure plate and triggers an Improvised Explosive Device (IED); aftermath is a big explosion ... but well located: Endeed all the kinetic energy has been absorbed by anterior-left section of the vehicle ... .and then indirectly has invested in full the driver only.

When Medevac Helo arrives the patient's conditions are already extremely critical;

At first glance: Subject is conscious in extreme respiratory distress;

CatC.: no overt external bleedings;

A: airway patent;

B: the problem is purely in the chest (a very bad contusion)....In addition to a widespread bruising you notice multiple rib fractures on the right with feeble paradoxical movements of the chest cage: thoracic excursions are very limited ;
at palpation: widespread crackles with great pain evoked: in short words, you do not discern where there is subcutaneous emphysema or a broken rib!!!!
Auscultation: absolutely of no use (for background noise);
saturation nearly 76% in O2 mask;

C: FC. 120 bb / min. NBP: 80/50 mmHg, One 14 Gauge IV access.

At this point mind of Medevac doctor is fully in ATLS mode: the B is critical and requires action; Overt lesions are bilateral PNX and Flail chest and he focuses on those; Thus Bilateral chest tube and RSI, followed by endotracheal intubation and IPPV...

but the clinical situation seems to improve only slightly: the SatO2 goes up from 67% to 82%; the heart rate remains at 110 bb / min; NBP settles on 85 mmHg sys... Even if not copletely satisfied the doctor takes on board the patient for transport but still feels that something is missing ... the mind at this point goes for the tangent ... Head become a caldron of questions:

"the B is complete; I treated all that was to be treated !!!",

" maybe I missed internal bleedings?! but there are no signs of intraabdominal haemorragies !! ",

" No fractures evident ",

" but why heart rate doesn’t go down? "

... and so on ...Patient arrives at Role 2 hospital alive....
.... but what wasn’t right ?? !!:

A rib fragment had damaged the pericardium and was about to give cardiac tamponade... if transport had lasted more than 10 min. perhaps the wounded would die...

At this point a big question arises: "Why doctor had not thought of that?"...

very easy: his mind was so schematically focused on more obvious lesions to not be able to move with flexibility on the occult....

Bottom line: In certain situations such as those of extreme urgency, although the schematic way of thinking, given to us by courses such as ATLS, is often a necessary factor and essential to avoid falling into panic, however is always better to keep mind trained to a minimum of flexibility just in attempt to save the day even in these rare and complex clinical cases.

Just talking about thoracic traumas give a glimpse on how many underlying lesions a blunt thoracic trauma can hide:

not one, not two, not three but we could say an entire Fabulous world of chest injuries!!!!!

We start from the aforementioned life-threatening injuries:

1) Tension pneumothorax:

Most often a result of blunt thoracic trauma, the Tension PNX is consequence of a progressive accumulation of pressurized air in the pleural cavity with valve mechanism; air enters in the pleural space at each inspiratory phase but cannot get out, is trapped during the expiratory phase; The consequence of this mechanism is not only the complete collapse of the affected lung but also the compression, by air accumulated, on mediastinum and its shifting and compression on controlatheral Emithorax (thus on controlatheral lung and also vascular structures).

Clinical features:

the patient will show respiratory distress but also hypotension and tachycardia, due to the pressure exerted on great vessels and then due to all the pathophysiological consequences resulting from a reduced venous return to the heart.... could be also detected a reduced expansion of involved Hemithorax and absent breath sounds on auscultation (Mmmmhhh….try a little to auscultate a patient in an outdoor setting or in a crowded ED... .Mmmmmmmhhh….);
to all this stuff add open or closed hemorrhagic lesions almost constantly present in this type of trauma and...... going back to my opening speech ....What a mess !!!!!

Instrumental diagnosys:

Just two words: as soon as possible FAST US, FAST US, FAST US and again FAST US ...

Treatment:

In prehospital setting the classic needle decompression can really save the day;

There are specially crafted needles for this purpose ... ... fast, easy and comfortable to use .... (Thanks to my friends US Army paramedics to let me try those needles)....

.... unfortunately in Italy they are not available... .to us Italians if it's too easy we don’t like it right ???! So usually 14G needle in 2nd intercostal space on the midclavicular or better in 4th or 5th intercostal space lateral approach (I tried them both and I guarantee that the lateral positioning was successful in 98% of cases ... but it’s up to you!!!!).

More recently in the prehospital setting was introduced the so-called "Finger Thoracostomy" but I cannot express myself on this field not having tried it yet.

Clearly the needle is only a bridge leading to the insertion of the chest tube ... .a technique usually reserved for the ED ... .insertion in 4th or 5th intercostal space midaxillary .... recommend use in adults at least a 36F.

2) Open Pneumothorax:

A consequence of penetrating injuries of the chest and more in particular a result in the vast majority of cases of gunshot wounds.

The primary cause is the establishment of a pathophysiological link between the pleural space and outdoor environment with loss of pressure balance in thoracic cavity.

In practice, the lung will tend to collapse during inspiration and to expand slightly during expiration.

Clinical feature:

In severe cases, the wounded will be in respiratory distress and you will see clearly the picture of “sucking chest wound”: very noisy airflow mixed with blood (foam and bubbles ) going out from the lesion.

Treatment:

In prehospital setting an Ashermann’s dressing (fairly widespread also in our country)

or the classic bandage closed on three sides can save the day.

Obviously everything on hold for chest tube in ED.

However, keep in mind that when a bullet enter the chest will demage all organs that meets on his way and then comes out ... if goes well!!!! And again we go back to the initial speech ... .The open PNX will always be in good company !!!!