Not Just an Average Fall

Elderly patient’s case proves more complex than expected

 

 
 
 

Fred W. Wurster III, AAS, NREMT-P | | Monday, October 24, 2011


It’s 3:50 p.m., and your unit is dispatched for a person injured from a fall. As you are responding, the 9-1-1 center provides the following additional information: A 78-year-old female has fallen down the steps in front of her home and is reported to be bleeding from her head. An elderly neighbor is the one who called 9-1-1, and she is unable to go outside and obtain any further information. You arrive on location in a suburban neighborhood in six minutes and see the patient lying supine on the concrete walkway leading to her home. You exit the ambulance and grab your jump bag, and your partner says he’ll get the immobilization equipment.

You arrive on the scene and find what looks like a 80-ish year-old female lying supine on the walkway. As you survey the scene, you notice a grocery bag full of food and another bag that is soaked. Suddenly, you note an odor of what you believe to be wine. The patient doesn’t respond to verbal or painful stimuli, and you note agonal respirations. You immediately notify your partner that your patient appears to be in severe distress, so you ask your partner to hurry up. You also note a moderate amount of blood coming from underneath the patient’s head.

Your next step is to take in-line C-spine stabilization as you simultaneously open the patient’s airway with a jaw thrust. Your partner arrives, and he performs a rapid trauma assessment. He indicates a “soft area” on the patient’s occipital area of her head and notes no other trauma other than blood coming from the patient’s mouth. The patient was noted to have a weak rapid radial pulse, and her respirations were noted to be about eight per minute. Your partner measures an oral airway and inserts it. No gag reflex is noted from the patient. The patient is classified as a priority patient, indicating rapid transport is needed.

You request assistance from the fire department and request an aeromedical helicopter be alerted because the closest trauma center is 45 minutes away. The patient continues to remain unresponsive, and now you note decerebrate posturing. Next, you start to ventilate the patient with a bag-valve mask (BVM) attached to oxygen at 15 liters per minute. You now request the helicopter to be dispatched to the scene due to the extent of the patient’s injuries. You begin to immobilize the patient, and during the immobilization process you note large pieces of broken glass next to her. You apply an adjustable C-collar and move the patient onto the long board. Once the patient is secured in place with straps and Cervical Immobilization Device (CID), you move the patient onto the stretcher and into the ambulance for transport to the landing zone.


Patient Assessment
Your partner inserts a #16 gauge IV in the patient’s left arm with normal saline being administered at TKO rate. You obtain a complete set of vital signs, which reveal agonal respirations at 6 per minute; HR=130 and a sinus tachycardia is noted. Her pulse is weak, and she has a BP of 108/76 and pulse oximetry (SpO2) of 76%. You immediately recheck the SpO2 reading and note that you have good waveform, and it correlates to the pulse. The patient requires immediate endotracheal intubation (ETI). As you insert the laryngoscope, you notice a large amount of bright red blood in the patient’s mouth and larynx. You begin suctioning and remove more than 100 cc of blood as well as several large blood clots.

You easily visualize the vocal cords and pass a styleted 7.5 endotracheal (ET) tube without complication. You remove the stylet, keeping a tight grasp on the tube, and inflate the cuff. You apply a colormetric EtCO2 detector and note minimal color change. You attach the BVM and begin to ventilate the patient while your partner listens for epigastric and lung sounds. No sounds were noted over the epigastrium, and your partner states, “I don’t hear anything in either of the lungs.” You tell your partner you’re 100% sure the tube is in, but because you don’t hear any lung sounds, you immediately extubate the patient and try again.
You pre-oxygenate the patient with 100% oxygen via the BVM and still note no increase in the SpO2 reading. You complete the same process again for intubation and visualize the tube pass through the cords. You state to your partner, “I watched the tube pass through the cords; I know it’s in.”

Once again, no corresponding lung sounds are detected, and you don’t hear any sounds over the epigastrium. When you begin to ventilate the patient this time, you suddenly note a large amount of subcutaneous air develop on the left side of the patients’ neck.

The patient’s neck continues to swell with subcutaneous air, and upon palpation of the neck, you feel a large deformity just superior to the cricothyroid cartilage, and then you palpate what you believe to be the tip of the ET tube. You know that these findings can only be one thing: a fractured trachea. You immediately identify this to your partner and request an ETA of the helicopter, which is still eight minutes away. The patient is rapidly prepared for a surgical cricothyrotomy.

You and your partner have never completed this procedure on a live patient, but only in training scenarios, but you complete the procedure without any difficulties, and the patient’s airway is secured with a 5.5 ET tube and tape. You ventilate the patient without any issues and note a dramatic increase in the patient’s SpO2 readings.

A repeat set of vital signs includes absent respirations. The patient’s heart rate is 50, and a sinus is noted. The pulse is weak; BP is now 198/156, and SpO2 is 98% while being ventilated. The helicopter arrives on location, and you give a brief patient report and assist the flight crew with moving the patient to the helicopter. The patient is transferred to a Level 1 trauma center, where she subsequently passes away from her injuries an hour later. After you follow up with the trauma center, you learn that the patient was found to have a complete transection of her trachea as well as a fractured skull and an extensive brain injury at the base of her brain.

Remembering that although you may consider yourself to be a well-seasoned provider that feels you have mastery of much of the paramedic skillset, it’s always important to rely on your basic EMS education. Being able to immediately identify a failed intervention and continuing to rule out possibilities for causes is an important skill.

Conclusion
The probability of encountering a patient with a completely transected trachea is extremely rare; thus, being able to quickly identify this “once-in-a-career” case and rapidly being able to appropriately provide medical care is paramount to the patient’s survival. With a known mortality of anywhere between 30% to as high as 60%, it’s safe to say that caring for these patients quickly and adequately will greatly increase their chances of survival.

 

 




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Related Topics: Patient Care, Special Patients, geriatrics, Fred Wurster, ETI, Case of the Month

 

Fred W. Wurster III, AAS, NREMT-PFred W. Wurster III, AAS, NREMT-P, has spent 20 years in emergency services both as a career and volunteer provider. He’s currently the Director of Training for the Good Fellowship Training Institute in West Chester, Pa. and a flight paramedic with PennSTAR, the Hospital of the University of Pennsylvania, in Philadelphia, Pa. He is also a technical editor for JEMS. Contact him at sgtmedic4@comcast.net.

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