Old 05-04-2019, 08:03   #1
Eagle5US
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Interesting case...

Some VERY interesting cases at work over the past few days....

- Shark bite
- Speargun through the eye AND THE BRAIN (pulled out at a depth of 40ft in salt water) with no residual neural deficit
- Forklift vs human (forklift wins)

And an injury I had never seen before under the circumstance...

*95 y/o male, motor vehicle crash, broken tib/fib and femur on the left.
30 minute transport time, vitals stable, alert and oriented, FAST negative, other signs of trauma, no seat belt sign, chest pain or contusion.

To CT for trauma pan scan-
RESULT
Left hemothorax, 30% all else negative. No rib fractures, no active etravasation (bleeding)

Back to trauma bay....chest tube tray being set up, I am working on admission orders...BP drops to 60/40, HR 140, pt unconscious.

Emergent Chest tube placed, frank blood, 1200 cc immediate out, intubate, ordered massive transfusion protocol and TXA, pressure comes back, called the OR.

10 units PRBC, 4 FFP, 2 platelets, lose pressures again, pleurevac now full (2000cc) and changed out, CPR started, I open his chest thinking an aortic injury gave way post CT scan.

*INSTEAD - the patient had a RUPTURED LEFT VENTRICLE*

The splitwas too large for a foley insertion, Trauma SGN's attempts to clamp the ventricular defect just shredded the pericardium (like trying to clamp a cooked roast) and when I tried throwing stitch into it, everything pulled through and the blood could not be contained.

The patient expired.

While I had seen this IN THE PRESENCE of chest trauma in the past...never had I seen it with isolated long bone injury. The reason FAST was negative on heart view was because when he ruptured the ventricle, he BLEW OUT HIS PERICARDIAL SAC as well so there was no blood collection around the heart.

Incredible learning case.

While I can open a chest I I cannot seem to be smart enough to upload a photo - if anyone can do so, I will send it to you via e-mail.
Thanks...
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Last edited by Eagle5US; 05-04-2019 at 08:09.
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Old 05-04-2019, 09:09   #2
ender18d
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Out of curiosity, what caused the crash? Was the patient driving? Makes me wonder if he had acute MI with subsequent wall rupture... have seen plenty of "trauma codes" that were actually medically precipitated.

That said with the pericardium blown out it sounds like it must have been some kind of shear injury from the trauma even in the absence of other signs of chest trauma.

Interesting case!
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Old 05-04-2019, 09:25   #3
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Very interesting cases! But I am curious as to why a shark with a spear from a spear gun in its eye would be brought into your ER? Or did I misinterpret something?
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Old 05-04-2019, 10:01   #4
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The patient was the driver, ran a red light and was T-boned on the driver’s side (hence the Left sided leg fractures)

There has been much discussion amongst the service and the consensus was that at one time he may have had an ischemic event with “dead heart” along the ventricle where it ruptured and why it wouldn’t hold a stitch or clamp.

Autopsy will tell- would love to post a photo...


As far as the shark with the speargun through his eye with no brain damage ... I’ll take all the practice I can get 😁
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"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.

Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
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Old 05-04-2019, 10:34   #5
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Old 05-04-2019, 10:41   #6
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Thumbs up

Thx Buddy👍
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"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.

Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
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Old 05-05-2019, 16:47   #7
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Very interesting, thanks for sharing this.
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Old 05-06-2019, 12:54   #8
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Thanks for sharing for our learning. Crazy case. My guess is the negative FAST suggests he blew out the left ventricle probably between FAST and CT since you most likely would have seen fluid (blood) in the left hemithorax on your LUQ view. The vitals correlate too.

For those 18Ds interested in ultrasound- this is why serial FAST exams are so important especially if your trauma patient's clinical status changes. In this case Eagle knew there was a problem in the left chest and put in a diagnostic/therapeutic chest tube, but in a forward location or MASCAL without CT available the bedside serial E-FAST is your friend.

Keep 'em coming Doc!
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Old 05-06-2019, 13:52   #9
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Interesting case for sure. Any of the other more professional Doc’s think maybe just his advanced age (95) with a possible heart condition from long long ago even at birth may have just been waiting for the perfect trauma impact?

I’d hate to get T-Boned at 56 let alone 40 more years from now.

He was dead man rolling around on a gurney!

How fast was road speed limit at time of accident?
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Old 05-06-2019, 14:54   #10
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Is that a "wet paper bag" rupture?
I've heard of them from free fall parachutists that free fell face down into the ground.
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Old 05-06-2019, 23:47   #11
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what an interesting thread. Reminds me of why I went to law school instead of med school.
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Old 05-07-2019, 08:53   #12
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CSB:
Unsure of the wet paper bag term. A quick Googleing did not reveal any reference. Interestingterm and would certainly fit into this scenario.

I am certain the heart view of his FAST was negative because the pericardium was essentially fused to the heart - so when his ventricle blew, it blew the pericardium out as well thereby not allowing blood between the pericardial sac and the the heart itself (going directly into the chest vs the pericardium). Violated pericardium - no tamponade.

*Disclaimer*
FAST IS EXTREMELY OPERATOR DEPENDENT

I have not ever seen a hemothorax from the Splenorenal recess (LLQ US) but I have never looked for one eithe. Perhaps I should start. Something I will read on for certain. Thanks Patriot.

In the absence of Chest X-Ray (especially with the advent of US in the forward environment) a pneumothorax can readily be diagnosed with the "beach sign" or "lightning sign" indicating the visceral and parietal pleura interacting with one another - absence this sign indicates that there is air between the two pleura.

An excellent app which I recommend to my students is RESUS-US for those who are interested.
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"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.

Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
The Reaper-3 Sep 04

Last edited by Eagle5US; 05-07-2019 at 08:56.
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Old 05-13-2019, 10:23   #13
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WOW!
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Old 05-13-2019, 19:42   #14
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Nice case, Joe - thanks for posting. I agree, that's a pretty abnormal looking heart...

Kudos to you for thoracotomizing a 95 year-old - not sure I would have...

This is a good example of trusting your gut and not relying on a negative FAST.

In penetrating trauma, it's well recognized that a cardiac injury can present with a negative pericardial view due to decompression into the left chest (hemothorax). I'll be damned if I can figure out how that happened with your guy, though, I've never heard of a blunt _pericardial_ rupture as well...

Thats the fun thing about trauma and why I do it - the patients dont read the textbooks...

Nice case - thanks for presenting it!

R
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Old 05-13-2019, 21:00   #15
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Thanks for the great post and Pics!
My take aways,
1.) Don't take on a shark with spear gun.
2.) Don't get T-Boned at 95y/o
3.) Heavy metal wins

Hope you're close by when I'm in need!
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