Complex Assessment
Providers respond to the scene of a motor vehicle collision with multiple patients. Photo Rick Roach
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While they were resting on a Sunday morning, the crews from Rescue 4 and Engine 4 are jolted to attention by dispatch tones advising of the need to respond to a severe motor vehicle collision. The units are called as mutual aid to a neighboring agency that arrived and began vehicle extrication. Engine 4 arrives first and ensures that the Rescue 4 crew members have protection from oncoming traffic. Multiple patients are found in three severely mangled vehicles.
Response
The first-arriving unit has already established command and directs Rescue 4 to the driver of a vehicle that has been involved in a side-impact collision. The crew forces open the door with hydraulic spreaders, and a paramedic is able to enter the vehicle to hold the driver’s C-spine.
During the ongoing extrication efforts, the other crew members work to prepare the C-collar, backboard and cervical immobilization device. Another responder enters the back of the ambulance to prepare a non-rebreather mask and spike two 1,000 mL bags of normal saline in preparation for the patient’s arrival. The driver responds to verbal stimuli only, but has a patent airway, is breathing rapidly, and has a rapid carotid pulse.
Removal & Transport
After nearly 20 minutes, the injured driver is able to be removed from the vehicle. He’s quickly immobilized and moved to the nearby ambulance. While one crew member performs a rapid trauma exam, oxygen is applied via non-rebreather mask, and the driver begins to head toward the trauma center. Although it’s difficult to hear in the ambulance, it becomes apparent that breath sounds are absent on the left side of his chest.
Marked jugular venous distention is detected, and it appears that the trachea is shifted slightly toward the right. At this point, the patient’s respiratory rate is well over 30. The patient’s Glagow Coma Score (GCS) is calculated at 8, with his eyes opening only to pain, incomprehensible sounds and withdrawal to painful stimuli.
Patient Transport
The lead paramedic determines that a pleural decompression is warranted. As per local protocol, he locates the 2nd intercostal space, midclavicular, prepares the site, and inserts a 3.5 inch 14-gauge angiocatheter into the pleural space just superior to the 3rd rib. The needle is removed. Only a slight amount of air is noted escaping from the catheter. A one-way valve is attached, and the paramedic reassesses to find little to no improvement despite the proper placement of the catheter.
Other interventions performed included rapid placement of a King Airway, and insertion of two large bore IVs. The crew arrives at the trauma center after 11 minutes. Care is transferred, and the lead paramedic advises the trauma surgeon that a pleural decompression was performed with no significant improvement.
In a short while, the paramedic learns that the patient had a diaphragmatic rupture on the left side, which shifted the stomach and intestines in the patient’s left pleural cavity. The paramedic inquires as to the appropriateness of the pleural decompression, and the trauma surgeon advises that he made the right decision because the accompanying pneumothorax would have resulted in the placement of a chest tube—irrespective of the paramedic’s intervention.
Discussion
Diaphragmatic ruptures are relatively uncommon, and are nearly impossible to diagnose in the field setting (1, 2).The key focus for prehospital care is to attend to airway, breathing and circulation (ABCs) compromises and correct life threats as discovered. This case involved a rupture caused by blunt trauma, but rupture of the diaphragm can also occur in situations involving penetrating trauma.
Lessons Learned
The provider should assess the mechanism of injury, perform an initial assessment, and conduct a rapid trauma exam when it’s feasible. Early control of the C-spine was indicated in this case because of the high risk of concurrent spinal injury owing to the lateral forces involved in a side-impact collision. Spinal motion restriction was also warranted under the circumstances. Making the assessment of the rupture more difficult is the fact that it’s often accompanied by a hemo- and/or pneumothorax (3). There may be findings similar to a tension pneumothorax when the rupture is severe, as in the current case. The presence of hollow organs as well as air within the pleural space account for the signs and symptoms the patient displayed.
Although it’s possible that bowel sounds may be auscultated in the pleural cavity, the sounds are often difficult to detect in the prehospital environment; moreover, diagnosing the condition will not change the treatment in the prehospital setting.
Providers faced with a patient displaying signs of a severe pneumothorax should not hesitate to perform pleural decompression when protocols permit the intervention. If the patient does have a diaphragmatic rupture, it is highly likely that a chest tube will be placed irrespective of the prehospital intervention.
It would be more dangerous for the provider to assume that only a rupture was present and not intervene, when in fact the patient had a tension pneumothorax. In other words, they should focus on the likely outcomes: Miss the tension pneumothorax, and the patient would likely die. Decompress in the setting of a diaphragmatic rupture, and the patient will get the chest tube that would have likely been placed despite the prehospital care.
Summary
Prehospital providers are often called to render care in dire circumstances without the benefit of good-lighting, a quiet environment, or a plethora of diagnostic tools. The main goal in caring for an abdominothoracic trauma patient is to rapidly assess the ABCs, correct life threats, and rapidly transport to the appropriate facility. Prevention of secondary injuries by applying high-flow oxygen early, restricting the motion of the spine, ensuring airway protection and patency, as well as establishing IV access remain foundations of prehospital trauma care.
Fortunately, more elaborate measures like pleural decompression are limited to specific situations. Keep in mind that the “golden hour” principles remain constant despite the different types of abdominal and thoracic insults that may occur. We, as providers, can help decrease morbidity and mortality by adhering to these basic principles.
References
1. Sanger G., Ventura VP, Carbo A, et al. Diphragmatic rupture: A frequently missed injury in blunt thoracoabdominal trauma patients. Emerg Radiol. 2007;13(5):225–230.
2. Welsford M. Diaphragmatic Injuries in Emergency Medicine. Retrieved February 5, 2012, from http://emedicine.medscape.com/article/822999-overview.
3. Hanna WC, Ferri LE, Fata P, et al. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85(3):1044–1048.
