"Vision is the art of seeing things invisible." -Jonathan Swift, Thoughts on Various Subjects
It seems that nowadays everything comes with a safety warning or a disclaimer. We can understand why guns come equipped with trigger safeties. Ladders sold at home improvement stores have placards warning of the perils of misuse. Even coffee cups come with the warning that "contents are hot," to ostensibly avoid litigation should someone dump said contents on their lap. Wouldn't it be nice if our critical patients came with similar warnings and disclaimers to raise our caution level? This month's case features a patient who clearly could have used one.
Scenario
You've been dispatched to "a motor vehicle collision on O'Connor Street between Daniel Place and Golemme Boulevard. Time out: 1501." Dispatch sends a BLS unit to assist.
On arrival, you find a car has hit a utility pole and observe at least one victim on the roadway. No electrical hazards appear present, so you approach the vehicle. A police officer alerts you to the presence of two patients, one of whom was ejected and is now "likely"-police parlance for likely to die. She also tells you the patients weren't wearing seatbelts at the time of the crash.
Your partner quickly evaluates the ejected passenger. The patient, a 20-year-old male, hit a concrete retaining wall after being ejected. He sustained a catastrophic open head injury and is in cardio/respiratory arrest. Your partner notes brain matter and blood coming from the man's nose, mouth and ears, as well as a large defect in his skull, and quickly deems this a mortal injury. He decides not to attempt resuscitation.
Your patient, a 30-year-old male, complains of back and chest pain. He describes the back pain, located exactly between his shoulder blades, as worse than the chest pain. He also has slight shortness of breath, with bruising over his sternum and epigastric area, but none on his back.
While your partner obtains this patient's vital signs and places him on high-flow oxygen via non-rebreather mask, you obtain a complete history. Vital signs: pulse 110, blood pressure 178/100 and respiratory rate 30.
The patient claims he has no pertinent medical history and denies taking any medications. The police tell you the vehicle was traveling at about 55 mph when your patient lost control and skidded off the road, striking the pole. The steering column is bent. You find a pulse in both arms, but femoral pulses are diminished. His relatively high BP strikes you as odd for a trauma patient. You rapidly extricate him from the vehicle.
By this time, the BLS unit has arrived on scene and offers to take your patient to the hospital so you can go back in service. You decide to remain with the patient because of the associated fatality, mechanism of injury and his elevated BP. You start a large-bore IV of normal saline at a keep-vein-open rate while en route to the trauma center.
On your arrival at the emergency department, the trauma team begins assessing the patient and hears your presentation. The surgeon quickly examines him and requests an ultrasound of the chest. The results show an aortic rupture, so blood is ordered STAT, and he's whisked off to the bright lights and cold steel of the operating room-all within 15 minutes.
Discussion
Later, you learn your patient survived an injury that carries an 80-90% mortality rate in the first hour. The surgeon tells you that overhydration and further BP increases might have prompted complete rupture and lethal bleeding within the chest.
Traumatic aortic rupture usual results after falls from great heights and high-speed MVAs. These forces on the body's trunk cause the aorta to partially tear where it attaches to the chest wall. Sometimes (as with this patient), the outer layer of the artery remains intact, allowing for repair in the operating room. Other times, it's completely severed, and the patient dies quickly. (See If the Bubble Bursts, January JEMS)
Chest and back pain prove the most common presentations. Patients often describe the back pain as worse. This patient's BP was so high because the injury basically shut off half the blood supply to the lower body. The bleeding within the vessel's lumen compresses the artery. This subsequently increases flow to the arms and upper body and reduces flow below the injury site-not an uncommon finding in aortic ruptures.
Conclusion
Patients often have such occult and perilous conditions that we may wish they had an early warning system flashing on their body to alert us to their problem. An early warning system does exist. It's called knowledge and clinical judgment. Listen to your inner voice, and let it guide your decisions.
Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.
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