Patient Care, Trauma

Don’t Underestimate the Value of a Trauma Assessment

Issue 10 and Volume 39.

At 4:12 p.m. on a sunny summer day, Ambulance 5 is dispatched for a “sick person.” Dispatch notes advise the patient is a 25-year-old male who’s had abdominal pain for two days. While responding to the initial dispatch, the police radio crackles with an officer requesting paramedics to expedite to a motor vehicle crash involving a motorcycle. The location of the crash is three blocks ahead, directly in your path to the initial dispatch.

As you approach the scene you notice police have the road blocked and are frantically waving you down to treat the seriously injured motorcyclist. You notify the 9-1-1 center you’re on location with police and request the next due BLS ambulance be dispatched to your initial call.

Police direct you to an area of high grass behind the guardrail, where you find the 34-year-old helmeted male, whose motorcycle struck the driver’s side of a small, two-door car, ejecting him from the bike and over the car, where he struck the guardrail with his left side and landed in the grass.

As you approach the supine patient you notice a severely angulated left arm and left leg and immediately think, “This isn’t going to be good.”

Expecting the worst, you’re surprised to find an adequate respiratory effort at a rate of 24 as you kneel by the patient’s head in order to quickly stabilize the C-spine before calling out to the patient to check responsiveness.

“Hello! Can you hear me?” you ask.

“Yeah,” he groans. You’re again amazed; he’s awake, alert and fully oriented to person, place, time and events. He tells you he was driving the posted 40 mph speed limit when the car pulled out in front of him. Police confirm this with a statement from the driver of the car.

At the risk of sounding stupid, you ask him what hurts. “Everything!” he replies. “Is my leg still there?”

Your rapid trauma assessment reveals cervical point tenderness in the area of C-5. His pupils are equal, round and reactive, and he has equal chest expansion with full, clear breath sounds. His abdomen is soft, non-tender and his pelvis is stable. His right arm is intact with a radial pulse of 124 and you notice his right thigh is swollen and tender with crepitus indicative of a femur fracture, but you do note distal pulse, motor and sensation.

The extremities on the left side are much worse. The left arm has multiple open fractures with profuse bleeding and you can’t feel a distal pulse. His left leg has a deep laceration from the knee to the hip with the fascia of the muscle clearly visible. His left foot is severely angulated, positioned roughly adjacent to the left knee, with multiple open fractures of the tibia and fibula. You can’t feel distal pulses and are worried that any movement may cause the few threads of tissue connecting the foot to tear and the foot to fall off.

At this time ALS arrives on scene, quickly eyeballs the patient and begins to set up the ambulance while your crew finishes packaging the patient.

Prehospital Treatment
Your partner and police assist in cutting away the patient’s clothes while you secure a C-collar. Another member of your crew quickly places trauma dressings over the gaping wounds and positions the backboard. The logroll allows you to examine the spine and you’re surprised to find no further injuries.

The patient is secured to a backboard, a cervical immobilization device is applied and the patient is transferred to the ambulance. You place a non-rebreather mask on him with O2 at 15 Lpm while your partner obtains a blood pressure of 96/60. The paramedic supervisor says she’ll notify the trauma center. During the four-minute transport to the Level 2 trauma center ALS initiates a 14-gauge large bore IV in the right antecubital fossa and infuses a 500 cc fluid bolus. You continue to dress the wounds to the patient’s left extremities and actually manage to obtain a SAMPLE (signs and sympyoms, allergies, medications, past history, last meal, events leading to injury) history.

Hospital Treatment
The trauma team is awaiting your arrival and quickly transfers the patient to a trauma resuscitation bed. After quickly confirming your SAMPLE history, the anesthesiologist uses rapid sequence intubation to paralyze and sedate the patient in order to pass an 8.0 endotracheal tube and secure
his airway.

The trauma team completes its primary assessment, places a large bore femoral line and begins rapid transfusion of three units of blood. This causes a rise in blood pressure that reveals three small lacerations to the left brachial artery, which is now clearly visible.

A Combat Application Tourniquet is placed high on the left humerus and the bleeding is controlled. The left arm and left leg are quickly bandaged and splinted before taking the patient to get a CT scan then directly to the operating room.

The CT scan confirms the C-spine X-ray that shows a compression fracture of C-5 without neurological impairment. Initial surgeries included a below-knee amputation of the left leg, vascular repair of the left arm, external fixation of the left arm and placement of a halo brace for the C-spine fracture.

The hospital and rehabilitation stays were lengthy, but uneventful. Six months later the patient walks into your station to thank you and the crew for saving his life.

Discussion
There’s a very good reason trauma assessment is taught as a skill that needs to be completed the same way every time. Deviation from standard trauma assessment during Advanced Trauma Life Support (ATLS), which is mirrored in Prehospital Trauma Life Support (PHTLS), provides an opportunity for important findings to be missed.

The primary assessment of airway, breathing, circulation, disability and exposure addresses the most life-threatening issues in order of importance and also provides an easy-to-remember standard that serves to minimize mistakes. This patient had a potentially life-threatening cervical spine fracture. Had the first arriving ambulance crew not taken the precautions to protect the C-spine while they progressed through the primary assessment this patient may not have survived.

EMTs and paramedics also need to acknowledge the impact of distracting injuries. It’s easy to internalize the pain upon seeing a grossly deformed arm and leg, to get tunnel vision and hyper-focus on these injuries. The reality is that extremity trauma is rarely life-threatening. Most hemorrhage from extremity fractures can be treated with direct pressure and, in extreme cases such as this, a tourniquet.

An organized, thorough and rapid secondary assessment assures that severe, possibly life-threatening injuries are found and treated. Although there’s often some variation among EMS and medical professional with the assessment of a medical patient, trauma assessments are generally done head to toe in order to provide consistency of results.

Field treatment for the multisystem trauma patient needs to be focused on addressing life threats, stabilizing the C-spine and rapidly transporting to the appropriate facility. Due to the short scene and transport times, pain management wasn’t a factor in this case.

Lastly, does your department have a policy on how to address the need to triage calls when presented with a life-threatening situation while responding to a different initial call? Some departments require you to proceed to the initial dispatch, others allow you to stop if you make sure a back-up unit is dispatched to the initial call for which you were responding.

Conclusion
This case illustrates how trauma care is a team effort. Every person who touched this patient contributed to the successful outcome of this case. From the first police officer on scene, to the EMTs, paramedics, trauma physicians, nurses, radiology technicians, operating room staff, shock-trauma ICU, rehabilitation personnel and many others, there were many opportunities for a poor outcome, but when we do what we do well, every time, we can rest assured that these results are the norm. jems

Resource
Dickinson E, Politis J. Painful distractions: The importance of splinting and managing the pain associated with fractures. JEMS. 2011;36(1):50–57.