Patient Care, Trauma

Which Came First, the Trauma or the STEMI?

Issue 4 and Volume 40.

A car crash occurs in a small, suburban community in the middle of the night. The Gold Cross Ambulance crew is paged to a single motor vehicle crash (MVC) at 1:45 a.m. on a typical September night in northern Wisconsin—mild weather and clear streets. The small town’s police department is the first responder group in that area, so resources on scene are limited. The crew responds lights and sirens without difficulty.

When paramedics arrive, the police report a 40-year-old male traveling down a residential street with a posted 25 mph speed limit struck a tree head-on. Police note a lack of skid marks or any signs of an attempt to avoid collision. The amount of vehicle damage from the impact indicates the driver was driving at a high rate of speed. He doesn’t appear to be wearing a seat belt, although the front airbags are deployed. The font end of the vehicle, an SUV, shows significant damage. A responding police officer had taken a manual C-spine.

Patient Assessment

The approximate 325-pound patient is unconscious and unresponsive in the driver’s seat. On initial assessment, he scores a 3 on the Glascow Coma Scale (GCS), with respirations eight per minute and very shallow. The patient occasionally takes a very deep breath.

During rapid trauma assessment, the crew notes the patient is missing teeth (potentially missing prior to accident). Pupils are 6 mm and PERRL (pupils equal, round, reactive to light), there’s no tracheal deviation or jugular venous distension, carotid pulses are present and there are no visible injuries to the neck and shoulders. Additionally, the patient displays equal chest rise, no crepitus, a soft abdomen, no grimace or guarding with palpation, pelvis stable upon palpation, and no priapism noted. Paramedics do note several abrasions over lower extremities.

Prehospital Treatment

Paramedics extricate the patient and fully immobilize him at the accident scene. Upon extrication and movement to the ambulance, the patient becomes semiconscious.

The Gold Cross team places oxygen via a non-rebreather mask at 15 Lpm. Paramedics place a cardiac monitor and attempt to insert an IV, but are unsuccessful. Vitals are: 169/135, pulse 156 regular and weak at the radius, respirations now 14 and SpO2 of 93% on high-flow oxygen. Glucose is 434 mg/dL. Painful stimuli (sternal rub) now yields results and patient is awake with a GCS of 13 (E3, V4, M6). Exposure also reveals a large red area to the center of the chest. Cardiac monitor shows a wide complex tachycardia. The team places defibrillator pads and acquires a 12-lead, which reveals an acute myocardial infarction showing elevation in leads II, III and AVF, as well as depression in V1 and V2. The patient denies any chest pain, but is confused. He’s unable to accept oral medications, so aspirin and Plavix (clopidogrel) aren’t administered.

Clues from the scene of the crash, shown here, suggested an underlying medical condition in the patient.

 

Transport

The responders have three choices of hospitals for patient transport. The closest hospital is a percutaneous coronary intervention (PCI) center and a Level 3 trauma center. The hospital in the middle is the same. The hospital the furthest distance is PCI capable and a Level 2 trauma center. With three suitable choices, the crew needs to make a decision.

They call the closest facility and an ST elevation myocardial infarction (STEMI) alert is activated. However, the crew doesn’t think the person taking the report hears all the information regarding the trauma. They take extra time to call back and make sure the facility fully understands what the crew is dealing with so the patient can get to the most appropriate destination. Although this may seem like a no-brainer, a 14-mile difference for a patient who could arrest at any moment is a lifetime when you’re alone in the back of an ambulance on the highway. After confirming the staff heard the full report, the crew and hospital decide to divert to the Level 2 trauma center.

During transport, the patient moves in and out of consciousness and his blood pressure trends downwards from 167/133 to 84/49 to 69/46. The patient is delivered to the trauma team with the report.

Hospital Course

Upon arrival, a FAST (focused assessment with sonography for trauma) exam reveals pericardial blood. Additional imaging and testing identify the following injuries:

>> Sternal fracture;

>> Left 2nd–7th rib fractures;

>> Cardiac contusion;

>> Anterior mediastinal hemorrhage; and

>> Left second metacarpal fracture.

Consults

Members from trauma, pulmonary and cardiology and a cardiothoracic surgeon are initially consulted in the ED. The patient undergoes a sub-xyphoid pericardial window with evacuation of clot. Three days later, he undergoes exploratory laparotomy, splenectomy, lysis of adhesions and a right chest tube placement. Still in the hospital seven days later, the patient meets with an orthopedic surgeon. The patient leaves the hospital against medical advice on day 12.

Discussion

It’s the old “chicken and egg” story. Did the trauma cause a STEMI (or what looks like a STEMI) or did the STEMI cause the trauma (car crash)? Deciding the root cause of the crash can be difficult, but can mean a world of difference in the patient’s outcome.

This is an interesting case because it takes a significant amount of chest trauma to develop a cardiac contusion/tamponade. This patient’s signs and symptoms were almost a textbook example of this—which first responders always learn about in trauma classes but typically don’t see often enough in the field to put two-and-two together. The patient’s MI was due to the trauma sustained—cardiac contusions mimic the signs and symptoms of an MI, not a precipitating STEMI. Many times, however, this isn’t so immediate that paramedics see it.

The discharge diagnosis indicated an MVC with the following injuries:

  1. Anterior rib fracture;
  2. Posterior sternal fracture;
  3. Hemopericardium, resolved;
  4. Right pleural effusion, resolved;
  5. Hemorrhagic shock from spleen laceration, resolved;
  6. Alcohol intoxication, resolved;
  7. Acute respiratory failure, resolved; and
  8. Left second metacarpal fracture with minimal displacement.

Conclusion

Paramedics on scene thought the clues of the crash suggested a medical issue caused the trauma, and their actions and decisions were calculated to provide the patient the best chance for survival, as well as the best chance for long-term health. They noticed, and factored into their decisions, the car was traveling at a high rate of speed in a residential area, the driver wasn’t wearing a seat belt, there were no skid marks, and there was no evidence of alcohol or drug intoxication found on scene.

Their big-picture approach prompted them to proceed carefully, understanding that getting to the root cause of a potential medical issue was the priority.

So, with three options for transport, the paramedics had enough foresight to discuss which hospital was the best destination for the patient based on the scenario and the myriad problems they found. That sensitivity carried over to their first phone call to the hospital, when they detected the nurse taking the initial report didn’t seem to fully hear the report or appreciate the extent of the trauma. Continuing to act prudently, they called back, and ultimately made a decision to transport to a Level 2 trauma center. They understood there was too much unknown at that point, and they needed to allow the patient every opportunity for getting the right care.

Unfortunately, based on information provided through patient interviews conducted in the hospital, the MVC likely was a deliberate attempt to end the patient’s own life. Nevertheless, paramedics on scene made the correct assumptions about the cause of the crash, and most importantly, made the appropriate decisions for the patient’s care.