A Lonely Road - Recap and Expert Commentary

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A couple of weeks back, we kicked off our “Flights” portion of our Air Care Orientation Curriculum.  Dr. Latimer outlined a challenging patient case for use to consider and an excellent discussion ensued.  As a reminder of the case, here’s how it was posed:

Your patient is a 56 year-old male with unknown medical history who was an un-helmeted motorcyclist found in a ditch roughly 40 feet from his motorcycle which was discovered in the middle of the road by a passing motorist. The accident was un-witnessed, but the bike was found just beyond a sharp downhill curve in the rural farm road. EMS has BLS capabilities only and they have placed the patient on a backboard and loaded him into the unit.

PHYSICAL EXAM

Vitals: P: 122, BP: 84/52, RR: 24, O2 Sat: 84%, ventilations being assisted with a BVM
General: Patient is in acute distress, multiple abrasions and contusions throughout with diffuse anterior body road rash. The ambulance smells like emesis.
HEENT: Mid-face grossly stable, although face covered in abrasions. Large boggy area to the R anterior/superior temple with a large laceration that is actively bleeding.
Cardiovascular: Tachycardic
Pulmonary: Decreased BS on the Left, crepitus palpable over the left chest wall with some subtle paradoxical movements
Abdomen: Abdomen rigid.
Musculoskeletal: Shortened and internally rotated left leg, left arm obviously fractured at the mid-humerus and appears to be closed, pelvis without clear instability
Neurologic: With deep painful stimuli, will grunt, open the L eye, and withdraw all four extremities to pain.
 
Interventions PTA
Patient back-boarded and C-collared
Ventilations being assisted with BVM on 25 LPM O2

Take a listen to the podcast below to find out how ACMC Medical Director Bill Hinckley and ACMC Resident Assistant Medical Director Andrew Latimer would handle the preparation and intubation of the patient.

And here’s the questions we posed with the curated answers from the group:

Q1: WALK THROUGH YOUR INITIAL ASSESSMENT OF THIS PATIENT. WHAT ARE YOUR PRIORITIES WITH THIS PATIENT? DISCUSS THE PATHOLOGY/PATHOLOGIES THAT YOU ARE WORRIED ABOUT IN THIS PATIENT. WHAT ARE THE CRITICAL ACTIONS/INTERVENTIONS THAT WE CAN TAKE THAT CAN IMPROVE THIS PATIENT’S CHANCES OF BOTH SURVIVAL AND MEANINGFUL SURVIVAL.

Q2: WHAT ARE THE ACTIONS THAT YOU WISH TO TAKE FIRST AND IN WHAT ORDER? HOW DO YOU HOPE TO ACCOMPLISH THESE ACTIONS AND HOW CAN YOU USE THE RESOURCES AT YOUR DISPOSAL IN THE BACK OF THIS AMBULANCE AND IN THE AIRCRAFT TO ACCOMPLISH THESE THINGS RAPIDLY TO BEST SERVE YOUR PATIENT? ARE THERE PROCEDURES NEED TO BE PERFORMED ON THIS PATIENT AND IF SO, IN WHAT ORDER AND WHERE (SQUAD/AIRCRAFT/RECEIVING HOSPITAL)?  

Assessment:
56 yo male victim of a MCC with ejection who is tachycardic, hypotensive, tachypneic, with decreased oxygen saturations as well as likely significant TBI, as well as abdominal and chest trauma.

Possible Pathologies:
TBI (?tSAH, tSDH, epidural hemorrhage, DAI?)
Chest trauma - Tension pneumothorax vs hemo/pneumothorax, flail chest
Abdominal trauma - likely intraperitoneal bleeding due to findings of rigid abdomen on examination
Orthopedic trauma - left hip fracture (? dislocation vs acetabular fracture vs proximal femur fracture?), left mid-shaft humerus fracture

Priorities and interventions:
The group heavily favored an ABCD approach to this patient’s problems.  As pointed out by many, this patient is not protecting his airway well enough (due to depressed mental status), not oxygenating well enough (O2 sat of 85%), and has a clinical course that would predict deterioration, making establishing a definitive airway a priority.  The biggest point of contention was how to do it and how to resuscitate the patient before intubation.  Dr. Summers nicely highlighted the importance of good BVM technique as an initial step in the management of this patient’s airway:

“If at first you can’t bag, bag better!” - Steve Carleton, MD PhD

There was some expected practice variation in the next steps taken for the patient.  Many wanted to immediately decompress the chest with needle thoracostomy and progress to finger thoracostomy if that proved ineffective.  Others ideally wanted to start transfusing blood/plasma in a 1:1 ratio immediately and others would have supported the patient’s blood pressure through the intubation with push dose pressors.  

And this is where this case gets truly tricky.  Indeed, many if not all of these actions need to be taken, but the question is how to sequence them so that the care is efficient and effective?  

With regards to intubation, the question of how to properly induce and paralyze the patient came up with some concerned about the use of ketamine in TBI.  While it would be a touch overly simplistic to call the concern about the use of ketamine in the non-intubated and non-sedated TBI patient completely debunked, for this already hypotensive patient, ketamine has the most favorable hemodynamic profile of any induction agent.  For more reading/listening on the topic check out these posts (http://www.tamingthesru.com/blog/prehospital-medicine/ketamineintbi http://www.tamingthesru.com/blog/acmc/prehospital-tbi-beyond-the-code).

Q3: ARE THERE MEDICATIONS THAT WE CAN/SHOULD ADMINISTER TO THIS PATIENT? BLOOD PRODUCTS? IF SO, WHAT KIND AND IN WHAT ORDER? IS THERE A ROLE FOR VASOACTIVE AGENTS (EPI/NOREPI/PHENYLEPHRINE) IN ANY FORM AT ANY TIME IN THIS PATIENT?

The etiology of the patient’s shock was found by the group to likely be multifactorial (obstructive + hemorrhagic).  As such, everyone was inclined to start blood product resuscitation as soon as feasible.  As we carry liquid plasma (aka never frozen plasma) on the aircraft, we can start the resuscitation of the patient immediately with plasma and immediately follow it with blood, transfusing in a 1:1 ratio.

The group also favored giving this patient TXA as a part of his resuscitation.  Indeed, administering this within 3 hours of the time of injury is beneficial as we have seen from the CRASH-2 trial.  Remember that TXA can’t be administered in the same line as blood product, so, if you are limited in terms of your access points, prioritizing the blood product administration over TXA is reasonable.

What about vasoactive medications? Several mentioned the possible role of push dose pressors in the peri-intubation period.  As we know that hypotension (even as low as less than 110 mmHg SBP) has a significant deleterious impacts on mortality in patient’s with TBI, aggressive volume resuscitation and even the use of push dose pressors is reasonable in this patient especially when they are in the fragile peri-intubation phase of resuscitation. (http://www.tamingthesru.com/blog/acmc/prehospital-tbi-beyond-the-code).

Hypertonic saline was also mentioned several times and would be an excellent addition to the resuscitation of this patient given the presence of a significantly depressed GCS.

Q4: NOW, WHAT IF YOUR PATIENT IS A 7 YEAR-OLD THAT WAS TOSSED OFF OF AN ATV THAT THEN ROLLED OVER HIM CAUSING SIMILAR INJURIES. HOW DOES THIS CHANGE YOUR MANAGEMENT IF ANY?

As pointed out by Dr. McKee, resuscitation aspects aside, the fact that this is now a pediatric patient, instantly complicates the situation.  Where is the family? Are they already at the patient’s side? Is is safe/feasible to have them fly in the helicopter with you and the patient to the Level 1 pediatric trauma center?  Whenever possible it is best to have a family member fly with the patient to the trauma center.  Some factors to consider would be the mental state of the family member - are they going to be safe in the helicopter?  Will the weights and balances of the helicopter allow us to fly an additional passenger? Ultimately the pilot will have the final discretion as to whether or not they are able to come with on the return trip.

From a resuscitation standpoint, many of the principles of resuscitation are similar in the adult vs pediatric patient (just complicated by math).  Dr. McKee all rightly pointed out the utility of a cognitive offloading tool like the Broslow tape in this situation.  

Two other things to consider for the pediatric patient as pointed out by Dr. Latimer in his dialogue with Dr. Whitford:

1.) We shouldn’t administer our liquid plasma to kids.
Why you say?
Here’s what Dr. Gerecht eloquently stated in the liquid plasma protocol:
“Type AB is the universal donor plasma but we use type A on Air Care (and in our trauma center) because type AB is so hard to come by. Type A is much more plentiful in the general population. The Anti-B antibodies in type A plasma are recognized as not being that strong/potent in comparison to other antibodies. In addition, the Anti-B antibodies in type A plasma are thought to be diluted out in the recipients circulation and could be bound to the recipients own soluble antigens since 80% of the population makes soluble A and B antigens. The literature supports the safe transfusion of type A plasma.  However, in patients < 50kg giving potentially incompatible plasma could result in an adverse event simply because there is not as much blood volume in these patients to dilute the transfused anti-B antibodies. In other words, Anti-B present in type A plasma has an increased chance of an adverse event (transfusion reactions) in a patient half the size of an adult. Thus it is the specific request of Hoxworth and transfusion medicine that we do NOT administer Air Care plasma to patients < 50kg.”

2.) No TXA in kids.  There is simply not enough evidence for benefit in this patient population.

Q5: BACK TO YOUR INITIAL PATIENT (THE 56 YEAR-OLD MALE). WHAT IF THE PATIENT LOSES PULSES AS YOU PREPARE TO TRANSFER HIM TO YOUR COT? HOW WOULD YOU MANAGE THIS SITUATION? HOW DOES THE RHYTHM ON THE MONITOR CHANGE YOUR MANAGEMENT (IF ANY?). DOES THIS CHANGE YOUR TRANSPORT DESTINATION / MODALITY? WHAT IF YOU GET ROSC AFTER SEVERAL MINUTES OF RESUSCITATIVE MEASURES? DOES THAT CHANGE YOUR MANAGEMENT?

The patient who loses pulses as you transfer him to your cot is always a tough situation.  As pointed out by Dr. Murphy, the initial rhythm on the monitor may give you some idea as to whether or not to chalk this up to a traumatic etiology of arrest (tension pneumothorax, pericardial tamponade, massive hemorrhage) or a medical cause of arrest (more likely if you see V fib or Vtac).  As pointed out by Dr. Hinckley in the discussion, traditional ACLS protocols don’t have a role in the victim of a traumatic arrest (thus epinephrine would be contraindicated in this case).  Transporting the patient actively under CPR on the helicopter is logistically challenging to say the least (just ask anyone who has done it or take a look at the video below for a brief glimpse into the madness…).  As such, as pointed out by Dr. Hinckley “we generally don’t *load* pulseless patients” with some exceptions. The exceptions to this “rule” he tends to look for?
“Now, factors that would make us at least consider loading patients even if pulseless: pt is a kid, pt is police / fire / EMS provider, fairly short downtime, narrow complex PEA, higher than expected ETCO2 (>20ish), organized cardiac activity seen on ultrasound (if available), or (very rarely) agitated/angry mob on scene that may make not transporting potentially unsafe.”
For most of the respondents to the question, any ROSC would result in the rapid and efficient transport of the patient from the scene to the appropriate accepting facility.