Thanks to everyone who chimed in for our first ever "Flight"!! If you didn't get a chance to read the case, take a look here. There was some excellent discussion on how best to care for the blunt polytrauma patient. Below is the curated comments from the community and Dr. Hinckley's take on the questions posed to the community.
Q1 Walk through your initial assessment of this patient. What are the critical aspects of the assessment of this patient?
In responding to this question, Dr. Titone and Thompson pointed out a couple of key concepts. First, as brought up by Dr. Titone, a standardized approach to the initial assessment of the patient is crucial. It is very easy (as Dr. Titone points out) to get mentally distracted by dramatic physical exam findings. In addition, performing these assessments in an unfamiliar environment is an added challenge that could lead to missed injuries or inattention to the basics of prehospital resuscitation. Dr. Thompson very nicely addressed this by listing out an ABCD outline of the patient’s problems. For some more reading on the basic approach to the blunt trauma patient in the prehospital environment, check out this podcast done with Dr. Steuerwald that outlines his, quite rigorous, approach to these patients.
Second, most everyone was in strong agreement that this patient would need to have their airway managed. Indeed this patient does have several reasons that might lead you take secure his airway. As pointed out by Dr. Titone and Thompson, both the patient’s current mental status and his predicted clinical course would suggest intubation is warranted. Dr. O’Brien however brought up the possibility of using an extraglottic device to manage the patient’s airway, at least initially. Indeed, there were several varied opinions on how best to proceed with airway management, which were highlighted in the responses to questions 2 and 3.
Q2 Do any procedures need to be performed on this patient? If so, who performs the procedures? In what order should they be done? Where do you do these procedures (squad/in flight/receiving hospital)?
Most commenters leaned towards intubation and RSI for this patient. Dr. Renne was rightly concerned about the administration of an induction agent and a paralytic in a patient, who is presumed to be deep in the throws of hemorrhagic shock and currently hypotensive. He brings up the possibility of beginning aggressive resuscitation with product first before going forward with RSI. Indeed hemodynamics as well as oxygenation are going to be incredibly important in this patient who we presume to have a significant TBI. Wanting to avoid hypotension and hypoxia at all costs, several commenters brought up the preference for using ketamine as their induction agent (and potentially at a slightly lower dose as pointed out by Dr. Renne) and brought up the importance of pre-oxygenation. While no one it up, apneic oxygenation is going to be a crucial component of this patient’s eventual intubation. Dr. O’Brien brought up the possibility of using an extra-glottic device like an i-Gel. The idea of a “rapid-sequence airway” is interesting primarily because it is exceptionally fast and may be just as effective as placing an endotracheal tube. Given this patient’s mental status, one should expect that, just like after intubation, some sedative medication would be required in order to maintain the EGD.
Other Procedures Mentioned in the Discussion
Q3 What medications should be used in the care of this patient? Should this patient receive blood products? If so, what type and in what order?
As pointed out by Dr. Lagasse, all the commenters “agree about giving blood products 1:1 and giving TXA in our hypotensive polytrauma patient.” Few commenters, however, delineated the sequence of product administration (plasma first or PRBCs first). Everyone, however, rightly expressed the need for TXA to run in a dedicated line or, if no dedicated line were available to hold on administration until some blood product was administered.
Another medication mentioned in the course of the discussion was ketamine for induction during RSI. Dr. Renne brought up the concern of elevated ICP with he administration of ketamine and that he considered this particular concern to be largely debunked. Though the issue is complicated, there is truly no direct evidence on the effect of ketamine on ICP that applies to this particular patient in this particular clinical situation. Check out this post by Dr. Zammit and this podcast we recently recorded with Dr. Zammit and Dr. Minh Le Cong for more information on the subject.
Q4 Shortly after your arrival, during your primary assessment, the patient loses a pulse. What do you do for the patient now? What do you do if he does not have a return of spontaneous circulation after your efforts? What if he does have a return of spontaneous circulation?
To quote Dr. Shah, “I think this is the scenario many of us envision walking up to on our first scene flight…” Dr. Shah and Dr. Gorder both highlighted that this cause of this patient’s arrest should be presumed to be hypovolemia or obstructive (tension pneumothorax or pericardial tamponade). Both Dr. Shah and Dr. Gorder elected to start off with needle thoracotomy, though in this particular situation, it would not be wrong to start with finger thoracostomy (to be more sure that had actually entered the thorax). Dr. Shah and Gorder both correctly assume that the patient would be PEA if he was attached to the monitor. And, unless there was suspicion of a medical cause of the car crash, traditional ACLS medications won’t have a role in the resuscitation of this patient. As for pericardiocentesis, both Dr. Shah and Dr. Gorder list it lower on their priority of procedures in the blunt traumatic arrest.
If the patient were to have ROSC, Dr. Gorder correctly points out that continued aggressive resuscitation, intubation, and rapid transport to the nearest Level 1 trauma center are the key next steps for this patient. Without ROSC, Dr. Shah brought up the possibility of rapid transport to have a thoracotomy performed. As pointed out by Dr. Chinn, field thoracotomy isn’t in the scope of practice for Air Care and Mobile Care at this point, and, since thoractomy should be performed within 15 minutes of witnessed arrest it is highly unlikely that you would be able to load, transfer, and unload the patient in time for the procedure to be performed. In addition, thoracotomy is best known to be effective in the setting of penetrating trauma (especially stabbing injuries that result in cardiac injury). The evidence for its effectiveness in blunt trauma is much less inspiring.