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Case History:
A 56 years old man was
driving his car at 130 km per hour when
he struck an electric pole (head -on).
A bystander, male nurse, immediately pulled
him out of his crushed vehicle when he
noticed fire and smoke coming out of the
engine compartment. Ten minutes later,
the civil defence & the first ambulance
arrived at the scene.
On
Completion of initial assessment &
rapid trauma survey:
The victim was found
confused, irritable with the smell of
alcohol on his breath. Airway was opened
and cleared of broken teeth and some blood
clots. Breathing was shallow and fast
at 30/minute. The victim had a slow weak
pulse with warm and dry skin. On further
examination, he was found to have a lacerated
scalp wound, flat neck veins, central
trachea, and tenderness over the upper
cervical spine. Tender sternum but otherwise
a normal chest examination and audible
heart sounds. The abdomen was soft and
lax with a stable pelvis. A compound fracture
of the right femur with moderate external
bleeding was detected. Bleeding was controlled
by pressure dressing.
The patient was immediately
log rolled, fully immobilised on a long
backboard and was loaded to the ambulance
(No back injuries were found) on-site
time was 30 minutes. Estimated time of
arrival (ETA) to the hospital was 10 minutes
.
S.A.M.P.L.E.
history revealed:
Confused patient complaining
of chest and leg pain, hypertensive patient
on Tenormin 50mg O.D. Last meal 2 hours
ago. Unrestrained driver who claimed he
saw the devil and tried to avoid him when
he struck the electric pole .
Vitals were (B.P 80 /40,
Pulse 55 /m, R,R 30/m.) Patient spoke
incomprehensively, opened his eyes to
pain and only withdrew his right arm to
pain.
After
detailed examination:
Other injuries found
were: deep lacerated scalp wound right
temporal region, bleeding from the right
ear and the nose, broken right clavicle,
and pupils were equal and reactive to
light.
Patient received the
following treatment interventions in the
field and on the way to the hospital:
- Oxygen 6 litres per
minute by a non-rebreathing mask.
- Two 14 gauge intravenous
cannulas and Ringers Lactate (open rate),
500ml Ringers lactate was transfused on
the way to the hospital.
- Pressure dressing
over obvious wounds.
At the Trauma Room:
The patient received
another two litres of Ringers Lactate
but his blood pressure kept falling. A
traction splint was applied to the broken
leg. A nasogastric tube and Foleys catheter
were inserted.
Heart sounds slowed further,
became muffled and eventually disappeared.
Cardiac Arrest was diagnosed, his ECG
strip was as shown in Figure 1,
Endotrachial intubation performed, and
CPR started according ACLS protocols.
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Figure 1: ECG
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Figure 2: Chest X-Ray
of the Victim in A&E
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Figure 3: CT Scan Head
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Decompression of both sides of his chest
and Pericardiocenthesis were performed.
Another three litres of I.V fluids were
given including 1000cc of uncross- matched,
O-negative blood via a central line.
Unfortunately, the patient
was pronounced dead after one hour of
unsuccessful resuscitation
QUIZ
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