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EMS Team Effort Makes Survival Possible

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Optimal trauma care of critically ill patients requires a blending of excellent prehospital assessment, care and triage, combined with rapid delivery of the injured patient to an appropriate trauma receiving hospital. This month’s trauma case presents a young adult with a normally fatal thoracic injury
who survived because all the elements of care came together.

Prehospital Phase
Just after dawn one morning, three young adults were involved in a high-speed, single-car motor vehicle crash (MVC) in which their vehicle left the roadway, struck a tree and then rolled over. Arriving fire-rescue units were confronted with one occupant out of the vehicle and two still entrapped in the wreckage. On scene, law enforcement advised incident command that the occupants of the vehicle had a past history of illicit drug arrests.

The non-entrapped patient was transported by ground to the nearest Level II trauma center. Medical helicopters were requested for the two entrapped patients for transport to Level I trauma centers.
The pinned 23-year-old male driver of the vehicle was reported to be the most critically injured. His heart rate was 140; and he had no palpable blood pressure. He required constant suctioning of blood from his airway throughout the extrication efforts that lasted approximately 20 minutes. His Glasgow Coma Scale score (GCS) was 11. He wasn’t responding to questions, but complained throughout his entrapment that he couldn’t breathe. Cervical stabilization was maintained throughout the extrication and his transfer.

After extrication, he was secured to a long backboard and was moved to the ambulance on a non-rebreather mask with a continuous airway suctioning requirement due to clinically apparent facial injuries.

En route to the helicopter landing zone, one EMS provider’s attempt at a peripheral large-bore IV was unsuccessful because of extensive antecubital vein scarring from IV drug use. A tibial intraosseous (IO) line was then immediately placed and primed with lidocaine before fluid administration. His GCS remained at 11.

When the patient reached the landing zone, the patient underwent rapid sequence intubation by the flight crew via the IO access and was flown to the Hospital of the University of Pennsylvania (HUP).

Hospital Evaluation
On arrival in the trauma bay, the patient was quickly assessed per advanced trauma life support protocol. His vital signs demonstrated a systolic blood pressure in the 90s and a heart rate ranging from 100–120. His airway was well secured with the endotracheal tube that was placed by the flight crew.

It was clear from the secondary survey that the patient had extensive facial fractures. His focused abdominal sonography for trauma exam was negative for blood within the abdominal cavity.

His chest X-ray was consistent with a right-sided hemothorax (See Figure 1, p. 31). A large-bore chest tube was placed with an immediate output of 500 cc of gross blood. Nine minutes elapsed from the time the patient arrived to the trauma bay until the placement of the chest tube. Because of his mechanism of injury, a pelvic X-ray was obtained but showed no fractures.

A femoral central line was placed; the patient continued to undergo resuscitation; and, because he was hemodynamically stable, he was taken to the computed tomography scanner for evaluation of the head, neck, chest, abdomen and pelvis (a “pan-scan”).

The trauma team was actively reviewing the scans in real time, and noticed that the patient had a transected thoracic aorta that had ruptured into the right chest. In addition, the patient’s heart was shifted to the left. As he was brought back to the trauma bay in preparation for the operating room, urgent cardiovascular and vascular surgery consults took place, as well as activation of the massive transfusion protocol and continued ongoing resuscitation attempts.

Before transport to the operating room, the patient lost palpable pulses. An immediate resuscitative left thoracotomy was performed, exposing the patient’s heart and aorta. This was done with the thought that the heart was unable to fill secondary to compression of the heart by the right-sided hemothorax that was being inadequately drained by the chest tube.

After opening the chest, the operating team noticed that the pericardium was bulging and surgically opened the pericardium, resulting in the heart eviscerating up and out of the pericardium. With compression from the chest hematoma relieved, the heart was free to fill and the patient immediately regained his pulse. During the emergency department thoracotomy, a mediastinal hematoma was evident, but this wasn’t entered to prevent release of tamponade and subsequent exsanguinating hemorrhage.

The patient was taken to a hybrid operating room, where a thoracic endovascular repair of the aortic transection was performed (See Figure 2). A mini-right thoracotomy was also performed to evacuate the retained hematoma, and a laparotomy to rule out intra-abdominal injury. The left chest and abdomen were left open in “damage-control” fashion, and the patient was taken to
the surgical intensive care unit (SICU) in critical condition.

The patient was resuscitated in the SICU and taken back on post-operative day two for closure of his chest and abdomen. He eventually underwent a tracheostomy and repair of his mandible. The patient progressively improved throughout the SICU course and was discharged to a rehabilitation facility on post-operative day number 23.

Discussion
Blunt aortic injury is uncommon, and is seen in less than 1% of MVCs. Although it’s rarely seen, the mortality rate is quite high, reaching 80% in the prehospital setting, with another 30% 24-hour mortality rate in those patients who arrive alive at trauma centers.

These injuries often result from sudden deceleration injuries. The following factors have been found to be associated with an increased risk of aortic transection: change in velocity of more than 20 mph; intrusion of vehicle greater than 15" and a side impact on patient’s side.1 This patient experienced at least two of the three.

This case is even more fascinating and unique than the typical aortic transection for a few reasons. First, patients who usually survive an aortic transection have a contained hematoma, not a free rupture as this patient experienced. In addition, the survival of such severe blunt trauma requiring resuscitative thoracotomy is less than 2%.2

A number of factors played a vital role in this patient’s survival. The first is that the patient was brought to a Level I trauma center with a wide variety of surgical resources immediately available. In areas fortunate enough to have multiple levels of trauma centers available to prehospital providers, the current National Trauma Triage Protocol states that severely injured patients “be transported preferentially to the highest level of care within the trauma system.”3

The patient’s low GCS and hypotension met these triage criteria on scene. Having a senior trauma surgeon available played a key role in helping mobilize a multidisciplinary team to definitively manage the patient.

Furthermore, the advancement of technology used for aortic transections (i.e., endovascular techniques) was crucial for this patient, who clearly was in hemorrhagic shock. Twenty minutes elapsed from the time the patient arrived at the operating room to the time the endovascular aortic stent was deployed. This speed wouldn’t have been possible with the traditional aortic repair techniques that might have resulted in this patient circling the drain of the lethal triad of hypothermia, coagulopathy and acidosis.

Summary
Although most blunt aortic transection cases that present to the trauma bay have contained hematomas, this isn’t always the case. This case illustrates the advancement of trauma care in the 21st century. Cases of free aortic rupture rarely end with such positive results.
Providers can take home a few key points: Accurate field triage linked with a multi-disciplinary approach to such a complex injury is vital to patient survival, and the use of new technology can allow for prompt diagnosis and management. JEMS

 

References
1. Horton TG, Cohn SM, Heid MP, et al. Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma. 2000;48(6):1008–1013.
2. Neschis DG, Scalea TM, Flinn WR, et al. Blunt aortic injury. N Engl J Med. 2008;359(16):1708–1716.
3. Centers for Disease Control and Prevention. Accurate Field Triage of Injured Patients Saves Lives and Money. In Centers for Disease Control and Prevention. Retrieved in 2011 from www.cdc.gov/fieldtriage.
 

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