Case Presentation #1: Pole runs out in front of car.

[Robert F]

Case Presentation #1
1) Initial Presentation
A 39 year old female is transported via ambulance to your adult emergency department after slamming her car into a telephone pole. The car hit the pole on the passenger side. Her husband shows you a pic of the wrecked car on his cell phone that he took on the scene. (See Below).



EMS tells you the woman’s vitals:
Accucheck: 101 (Patient doesn’t remember accident but is now Alert & Oriented)

BP: 90/70 Pulse: 110 Resps: 23 Heart Rate: 130

Chief Complaint: Right Tibia fx, with obvious deformity and bleeding, seemingly controlled by bandage.

2) History/Allergies/Medications
NKDA
Patient is prescribed to: Lasix & Metoprolol for a prior heart condition.

4) Clinical Findings
You notice obvious bruising from the seatbelt on the patients chest.


5) Discussion Points

- What is your next step?

[WinterInED]

oxygen, 2 large bore IVs (weight bearing bone fx with significant imact), immobolize (c-spine precautions r/t altered mentation of accident), monitor (significant bruising on chest - r/o cardiac tamponade...also ausc breath sounds bilat for pneumo),palpate distal pulses and document during transport...pain control if avail

On arrival to ED - rainbow labs to include blood bank tube to hold, c-spine to clear, CT head, EKG, fluids titrated to vital signs, close observation for any changes ...PAIN control

[AmandaWIRN]

I agree with the above, but would do things in this order:

auscultate breath sounds, oxygen, continue to maintain c-spine precautions that should have already been instituted per EMS, assess CMTS to affected extremity, second IV (if not done by EMS), chest x-ray, labs, other x-rays/CT scans....

Without knowing any of the test results, my first hunch is that she had a syncople episode. Her BP on scene was slightly low, and she's on a Beta blocker.... I would want to know her cardiac rhythm, though... she was tachy on scene- is she still tachy in the ER? Rapid a-fib maybe??? That could also lead to syncope. Or could just be sinus tach compensating for a low BP, but if her pressure is coming up, I would expect the HR to be lower by the time she gets to the ER.

Would need to be careful about what she's getting for pain control if her BP is still low.

[Robert F]

Cannula 02 or NRB? How many LPM?

Spinal immobilization device was put on by EMS at the scene.

Breath Sounds: Clear, Bilateral.

PMS: Positive on all extremities.

What kind of pain control? (Morphine, Fentanyl, Hydromorphone)?

Labs ordered so far: CMP with Phosphate and Mag, CBC, PTT, CK-MB.

• Results pending in MediTech.

Tubes Collected: Red, Green, Blue, EDTA, Yellow. @ 11:30 AM

Current Vitals @ 11:41 AM

BP: 101/90 Pulse: 100 Resp: 16 Heart Rate: 100


Ekg:

EKG:
http://meded.ucsd.edu/isp/1994/im-quiz/images/infmi.jpg

[AmandaWIRN]

If breath sounds are clear, and O2 sat is OK, I'd go with 2L by NC. The rhythm strip is small, but looks like sinus tach, and the rate and blood pressure are improving. For analgesia, I'd stay away from Morphine, as it tends to bottom people out more than the other two... Dilaudid or Fentanyl might be OK, but I'd give them very sloooooooow....

[Robert F]

2 liters 02 by Nasal Cannula applied to patient,

Patient's pressure is maintaining on fluids, but for some reason the heart rate is not going down but pulse is increasing, along with heart rate.

Morphine administered slow IV Push.

CMP

• All Chemistries WNL.

PTT

• Normal

CBC:

• RBC - 5.0
• Hemoglobin - 14.5 g/dL
• Hematocrit - 31%
• WBC - 9.6
• Neutrophils - 1.9
• Monocytes - 1.4
• Eosinophils - 0.73
• Basophils - 0.3
• Platelets - 102

CK-MB

• 6.1 ng/mL

10 minutes in you realize that your patient is turning a bit cyanotic, you administer 15 Liters 02 NRB, what next?

Any ideas what is causing this?

P.S.
************************************************** *********************
I replaced the EKG with a larger version showing the exact same finding.
************************************************** *********************

[AmandaWIRN]

OK- now that I can actually see the EKG, looks like she is having a big-ass STEMI!!! Get that woman to the cath lab!

[WinterInED]

Oh, Yes...finally could see the EKG and the STEMI is quite obvious! Thanks, This was so fun!! Great Case Study...Next please...

[Robert F]

THE DISCUSSION

Were there any other indicators other than the ST Elevation on the EKG?

For instance, did you stop and wonder why the CK-MB was 6.1 ng/mL, even though the patient had an MI?

Why did the heart rate go higher along with the pulse, while the blood pressure remained low?

Why did this patients BP not hit 200/##?

Could this all be related to the low Hematocrit(31%)?

What of the Metoprolol and Lasix?

Why would the CMP + Phos, Mag be WNL while the patient is obviously
suffering from an ST Elevation MI?

Why did the patient crash?

Don't you want to do a DCAP-BTLS assessment?

Could the pain of the tibia be taking the patients mind of the pain somewhere else?


The Answer is yet to come. Any ideas?

[AmandaWIRN]

Were there any other indicators other than the ST Elevation on the EKG?

---Of MI? Other than the bruising on the chest from the seatbelt, no..... she was not c/o chest pain, not diaphoretic or SOB.

For instance, did you stop and wonder why the CK-MB was 6.1 ng/mL, even though the patient had an MI?

---Might be too soon after the MI for the CKMB to go up.....

Why did the heart rate go higher along with the pulse, while the blood pressure remained low?

---She could be bleeding somewhere. Hct was low... would want CT of abd/elvis to check for internal bleeding. Head CT also, since she's amnesic of the event.

Why did this patients BP not hit 200/##?

---Well, if she's bleeding somewhere... Also, she's on a beta blocker- that might be keeping the BP down (if she's not bleeding). And finally, she has had an MI- BP does not always go up with an MI, in fact, sometimes it goes down, as the pump of the heart becomes less efficient.

Could this all be related to the low Hematocrit(31%)?

---Could be.... would need to check for internal bleeding...

What of the Metoprolol and Lasix?

---Could be causing electrolyte imbalance, which could also be the cause of the MI.

Why would the CMP + Phos, Mag be WNL while the patient is obviously
suffering from an ST Elevation MI?

---Well, she's on Lasix- maybe her K & Mg were out of whack before the MI, and the MI has caused them to go back to "normal" levels. Her MI could also have been caused by a pre-existing electrolyte imbalance.

Why did the patient crash?

---I still think syncope- who knows whether the syncope was due to the MI, or if she had the MI after she crashed... kind of a "chicken or the egg" type situation.

Don't you want to do a DCAP-BTLS assessment?

---That would be part of her trauma assessment. We already know she has bruising on her chest from the seatbelt. With her regular trauma assessment, would have also assess abd tenderness, pelvic stability, and other extremities.

Could the pain of the tibia be taking the patients mind of the pain somewhere else?

---Yes- perhaps why she is not feeling crushing chest pain, or abd pain...