Israeli Paramedics Association
8
The Israeli Paramedics Emergency Medical Journal
Chief Editor - Paramedic Neomi Zvi
TRAUMA --> Case Report
Multi Trauma
By
Paramedic Neomi Zvi
Wednesday , evening-night shifts.
The shift started very quiet......too quiet I would say......19:01 ..it was already dark
outside and a bit rainy when we were dispatched to :"car hit a pedestrian".
Wayne , my South African ILS trainee , my favorite EMT Ellia and me , got to the
scene in 3.5 minute.
On the Scene: While Ellia parking the MICU , I looked around....
Minibus with broken front window 3-4 meters (about 120-160 inches) behind the - what
seems like unconscious pedestrian. No other Victims , no family. Brief report , asking
the bystanders to block the road till police will arrive.
Ellia brings the spinal -board ,the strips and the collar , Wayne with the AMBU bag ,
oxygen cylinder and I with the main drugs-equipment box .
The woman in her 50's , wasn't breathing , Wayne fixed her head + Jaw thrust , I pushed
the Oropharyngial A.W + Bag-Valve-Mask .Ventilating. About 110/min irregular thready
pulse, carotid only , "No Radial pulse" said the EMT."Femoralis neither" he added.
"No 8" I said , but Ellia already put the Laryngoscope set with 8mm tube next to me
(great guy).
The Anisocoria could easily noticed. The left pupil was dilated. A lot.
After 5 seconds the ETT was in - no reflexes... (less then 20 sec. since the first
ventilation -hope all JAMA's authors will forgive me for not following their guidelines).
BV to ETT ,Wayne still supporting the head/neck , Oxygen with the reservoir ,good air
entrance to both sides - but - crepitating at the left axillar line.
Cutting the shirt ... I almost missed the Flail Chest. Deformed fracture at her left
Clavicle. No open wound. Double checking for air entrance = Okay.
Wayne still fixing the head , I'm ventilating ,Ellia and the policeman rolling her to her
right, Putting the back part of the collar - quick check at her back parts - mild bleeding
wound behind the left ear , unstable left Scapula. Rolling her back on the spine board ,
putting the front part of the collar. No expanded Jugulars , no emphysema.
Ferno headevice , now Wayne is ventilating . I had just enough time to put an IV line ,
(medium vein -18 G) with no infusion bag , while Ellia tightening the strips.
I was just about to ask,,,,,But Ellia already answered:" 6 minutes...."
I entered the MICU preparing another infusion bag , while Ellia and the policeman are
loading the pt. in the vehicle. The policeman jammed her ID card to my pocket and off
we go.
On the way:
"Report the dispatch center we are on our way to Shiva Trauma Center" I said to Ellia
(30-35 minutes drive) "more details in few minutes" I added.
Wayne is ventilating and listening carefully to my explanations on each step despite the
loud siren .
Quick recheck - the tube in its place , and good bilateral air entrance (little little less on
her left + crepitations) , no measurable BP yet. Connecting Ringer's bag , opening a
second and a third IV lines (14 G this time).
Carotid pulse still about 110/min (bad,bad,bad) irregular.
Replacing the Oxygen source to the big cylinder
Connecting monitor - A.Fib of +- 110/min ,and replacing the first empty infusion bag.
Femoral pulse can be palpated , Systolic BP now about 65 mmHg / -- .
The heart rhythm converted by it self to Sinus of 105/min , regular . no acute abdomen.
One more time listening to breath sounds - the same as the my last auscultation.
Percussion- Hyporessonance left lower chest.
All this time I was thinking whether to give Dopamine (don't raise any brow)but decided
to consult the Hospital specialist.I grabbed the radio (quick look at her ID) and reported:
"Please , notify Shiva Trauma Center about 56 y/o woman , Multi-Trauma , tubed and
ventilated". Further details - on the phone, I need them anyway". I was trying to get the
Trauma ED on the phone with no luck.
I called the dispatch center on the phone and said: " I can't get the trauma doc , so try
to get the Trauma ED.,report about Head trauma, Flail chest, mild steady Hemothorax,
Spinal-Neurogenic Shock , Clavicle and Scapula broken" "and keep me updated" I
added. I prepared the Dopamine , inserted an Oral-gastric tube and I changed places
with Wayne, squeezing the BV. Poor Wayne , I didn't let him take any rest.....
BP was 70/40 mmHg , HR 105/min , replacing the 2nd and the 3rd Infusion bags , and
asked to slow down the running fluids , cutting what left of her clothes , covering her.
Listening again to both lungs - no change.
The right pupil is 1.5 mm less dilated then before.
No Doc on the phone yet , Dopamine at 5 mcg/kg/min , elevating the dose gradually
(raising brow again ?).
I noticed that the pt. is sucking the AW (primitive reflex..)
SaPO2 can read now = 96-7 %>.......Systolic BP is about 90-95 mmHg
1 minute to the Trauma Center - Wayne converting O2 source to a mobile cylinder..
preparing to go down. I ordered to stopp the Dopamine drip and one more re-evaluation.
Trauma Department , Shiva Medical Center:
The Trauma team was waiting us outside , escorting us from outside and following my
report. The Senior doc confirmed the ETT location and my diagnoses . In the Trauma
unit , converting our equipment with theirs.....
Ellia and Wayne are cleaning the equipment. I set down in the corner filling my reports.
The chest x-ray is already there: Flail e chest of 4 ribs on the left -with mild Hemothorax,
left lung contusion - but no Pneumothorax , left Scapula fracture, left Clavicle fracture.
"There is also Right Clavicle fracture" said the doc. "Sorry , I missed that" - I answered.
BP now is 110 / 60 mmHg. HR still 105/ min , Sinus......
We are getting back to the MICU , cleaning the vehicle , when we saw the doc
approaching us and call us back.
He wanted us to see the C-Spine CT scans: "Here's your definitive confirmation for your
Spinal-Neurogenic shock diagnosis"....
About 10 mm interval between the Atlas (1st Cervical Vertebra) and the Axis (2nd C-spine
vertebra The spinal cord was totally disconnected.
Paramedic Neomi Zvi - May 2000
URGENT - The Israeli Emergency Medical Journal - Volum No 8