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Assessing Trauma Patients Proves Difficult

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Las Vegas Fire and Rescue and MedicWest Ambulance were summoned to render care for a man who was found hanging by his foot from a fence. The patient was a 48-year-old male whom bystanders found east of the strip in Las Vegas. They reported finding a large amount of excrement and other body fluids on and around the patient.

The patient told EMS and police that he owed a friend $40 from a business transaction related to street drugs. He said that even though he paid his friend, they gave him a drug to “paralyze him” and another to “make his bowels move.” Then, he said they hung him by his right foot from the barbed wire atop a cinder block wall.

He was hanging high enough that he could barely touch the ground with his left hand. It was unclear how long he’d been there. The incident occurred in March, and temperatures in the desert were already in the 90s.

Prehospital Assessment
Firefighters wearing proper personal protective equipment washed away the debris and various body substances around the patient, and he was being removed from the fence. He complained of pain all over, but his primary complaint was the pain in his right leg. He was disheveled, partially dressed and covered with feces.

Paramedics completed a primary assessment and then turned their attention to the secondary assessment. The patient’s blood pressure was 104/82; pulse 114; respiratory rate 24, and his pulse oximetry 96% on ambient air. Although his mucous membranes were dry, his head was atraumatic.

His neck was nontender; his lungs were clear, and his heart sounds were normal. A tachycardia was noted on the monitor. His abdomen was soft and nontender but with multiple superficial abrasions and bruises.

Pulses in the extremities were normal, but considerable bruising and soft tissue damage to the right foot and leg were noted as a result of the hanging.

Despite the difficult position the patient was in, he was actually alert and oriented. He reportedly lived on the streets and had a history of depression and schizophrenia, and mixed, chronic substance abuse (methamphetamine, alcohol and tobacco). He was exhibiting some paranoia and stating, “They’re going to kill me.” He reported that he wasn’t allergic to any medications.

Paramedics started an IV because of his hypovolemia and tachycardia and administered a fluid bolus. The patient received 5 mg of morphine via IV for the pain and 4 mg of ondansetron (Zofran) via IV to control his nausea. A 12-lead ECG confirmed a sinus tachycardia, and peaked T waves were noted throughout all leads. He was then transported to the trauma center at University Medical Center (UMC).

Hospital Evaluation
The staff at UMC promptly evaluated the patient. A quick ultrasound examination of his right foot and leg revealed good dorsalis pedis and posterior tibial pulses. A CT scan of his head and abdomen were normal as was his chest X-ray.

Plain films of the foot and ankle didn’t reveal evidence of a fracture or dislocation. However, he was found to have multiple laboratory abnormalities:

> Sodium: 155 mmol/L (normal = 137–147);
> Potassium: 6.2 mmol/L (normal = 3.4–5.3);
> Chloride: 106 mmol/L (normal = 99–108);
> Carbon dioxide: 10 mmol/L (normal = 22–29);
> Blood urea nitrogen: 57 mg/dL (normal = 8–21);
> Creatinine: 2.0 mg/dL (normal = 0.6–1.3);
> Anion gap: 39 mmol/L (normal = 8–12);
> Glucose: 74 mg/dL (normal = 60–100), and
> Creatine kinase (CK): Greater than 42,670 ng/dL (normal = 38–120).

A Foley catheter was placed, and his urine was noted to be tea-colored, which is consistent with rhabdomyolysis and myoglobinurea. A second IV was started, and he was then given a large volume of IV fluids and 50 mEq of sodium bicarbonate.

He was then admitted to the intensive care unit. Over the next 24 hours, his right leg began to swell and become more painful. A diagnosis of compartment syndrome was made. He was taken to the operating room, where a four-compartment fasciotomy was performed. The patient had a rocky hospital course with multiple operations and was finally discharged weeks later. However, he didn’t obtain the required outpatient follow-up and developed an infection. Eventually, he underwent a below-knee amputation of the right lower extremity.

Discussion
Rhabdomyolysis is the breakdown of muscle tissue and the subsequent release of toxic substances. Trauma and ischemia (both present in our patient) are the most common causes of rhabdomyolysis.(1) It was first described in World War II in victims of crush injury during the German bombing of London.(2)

The common pathophysiological events that occur with rhabdomyolysis are hypovolemia, elevated potassium levels (hyperkalemia), metabolic acidosis, acute renal failure and coagulation problems (disseminated intravascular coagulation).

This patient exhibited four of these symptoms. His dry mucous membranes, elevated sodium level (hypernatremia) and elevated blood urea nitrogen all indicated hypovolemia (loss of free water). The elevated potassium level, as well as the peaked T waves on the ECG, indicated hyperkalemia, and the increased anion gap pointed to a metabolic acidosis. His elevated creatinine level was indicative of mild renal failure (the most serious complication of rhabdomyolysis). The markedly elevated creatine kinase (a substance released from damaged muscle) further confirmed the diagnosis.

The patient’s renal failure was evolving when he was found and treated. He was aggressively hydrated, which is the principal treatment of rhabdomyolysis. He received sodium bicarbonate to alkalinize the urine to help prevent myoglobin toxicity.

Once intravascular volume is restored, the diuretics mannitol and furosemide are often given in the treatment of rhabdomyolysis to promote the production of urine to clear the various toxins.

This patient also developed compartment syndrome, which further complicated his complex case. Compartment syndrome is an increase in the pressure within the various muscle compartments of an extremity and can be limb-threatening and commonly follows an ischemic injury.(3) Treatment is emergency surgery to open the fascia of the affected muscle compartments (fasciotomy).

Teaching Points
This was certainly a strange case—even by Las Vegas standards. Patients who suffer crush injuries or ischemia—such as trench collapse, entrapment and prolonged immobilization—are at increased risk of developing rhabdomyoloysis.

The most serious complication of rhabdomyolysis is renal failure, which can be mitigated by the aggressive administration of IV fluids to increase urine production. If the patient has tea-colored urine, providers should consider the likelihood of myoglobinurea and consider the administration of sodium bicarbonate. In our patient, paramedics didn’t know about the dark urine, but they did address the presumed volume depletion with IV fluids. They also provided pain relief.

His compartment syndrome didn’t develop in the prehospital phase of care; however, many conditions exist for which compartment syndrome may be encountered in prehospital care—especially in disasters and wilderness medicine situations. Prehospital providers should have a high index of suspicion for this condition, provide analgesia and transport the patient to a facility with surgical capabilities. The affected extremity should be maintained at the same level as the patient’s body. Although elevation of the extremity may decrease arterial pressure in the affected limb, it doesn’t appear to decrease compartmental pressures.(4)

Summary
This sad but interesting case illustrates just one of the many complications of trauma and serves as a reminder why prehospital providers should maintain a high index of awareness for rhabdomyolysis and compartment syndrome in patients who may be predisposed to these conditions. It was later learned that the patient may have been climbing over the fence and became entrapped and was not hung there by his drug dealer. His mental illness and the various electrolyte abnormalities may have caused him to create the drug dealer story. JEMS

References

1. Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med. 1988;148: 1553–1557.

2. Better OS. The crush syndrome revisited (1940–1990). Nephron. 1990;55:97–103.

3. Tekwani K, Sikka R. High-risk chief complaints III: Abdomen and extremities. Emerg Med Clin North Am. 2009;27:747–765.

4. Styf J, Wiger P. Abnormally increased intramuscular pressure in human legs: Comparison of two experimental models. J Trauma. 1998;45:133–139.

This article originally appeared in February 2011 JEMS as “Hanging out in Vegas: How to respond to complex trauma cases.”

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