A 19-year-old male patient is referred to the ICU from the emergency department. He presented with some friends from a nearby house party, where he was the victim of an alleged assault approximately 20 minutes ago. During this event, he was stabbed in the neck. He and his friends walked into the emergency department, and he was triaged as Category 1.
On your assessment, this young man is diaphoretic and pale, holding pressure on a bloodstained towel to his neck, with the following vital signs:
- BP 100/35
- HR 135
- RR 32
- SpO2 92% on room air
How will you assess this patient? What are your immediate concerns?
(This is not a real CICM viva)
This is a question about the primary survey in trauma.
The candidate should describe how they will systematically assess the patient:
- Talk to them to rapidly assess airway patency
- This is the point where you should look for evidence of airway laceration
- When their ability to maintain an airway is at all in doubt, intubate them
- This is also a good point to assess the wound
- Expose the chest
- Watch chest excursion: symmetrical?
- Auscultate: equal air entry?
- Palpate the midline-ness of the trachea and the rest of the chest, looking for surgical emphysema
- Percuss the chest looking for hyper-resonance of tension pneumothorax, or dullness of haemothorax.
- Tension pneumothorax, open pneumothorax, massive haemothorax, flail chest - these should be identified during the primary survey
- High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.
- Features of hypovolemia (eg. cool peripheries, pallor) should be sought. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia.
- Wide-bore access is established; bloods should be sent: FBC, EUC, CMP, LFT, coags and crossmatch.
- Blood products should be preferentially used for resuscitation, with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg.
- GCS level of consciousness
- Lateralising signs (if the patient is obeying commands)
- Pupil diameter, reactivity and equality
- Somebody should probably do the BSL
- Expose all of the patient
- Look for other injuries
- At this point, a log roll should happen to examine the back
- After that, warm blanket and warm fluids to restore temperature
If they keep going on and on, please interrupt them with:
How does the location of the wound influence your level of concern?
(prompt: what are the zones of the neck?)
This injury is in Zone 1, a 5cm linear laceration approximately 2cm superior to the head of the left clavicle, or 2cm below the cricoid cartilage. It is bleeding vigorously. What are the structures of greatest concern?
- subclavian and innominate vessels
- common carotids
- lower vertebral arteries
- jugular veins
- Thoracic duct
- Brachial plexus
You start by assessing the airway. What are the specific features of airway injury?
- Features suggestive of airway injury
- hoarse voice
- subcutaneous emphysema
- Features suggestive of impending airway catastrophe
- Large haemoatoma
- Expanding haematoma
- Pulsatile haematoma
The patient has a hoarse voice and haemoptysis, but no stridor or subcutaneous emphysema. What would you recommend we do with the airway?
- The right answer is to leave it alone.
- Manipulation of the partially transected airway could lead to complete transection. Ergo, ideally an ENT surgeon or somebody equally skilled in surgical airways should do the instrumentation.
- This patient will likely go to theatre, where skilled eyes can anaesthetise the patient and explore the subglottic trachea before sticking a tube into it.
- At this stage, the best move is:
- Regularly re-assess for expanding haematoma
- Assess for airway injury (eg. subcutaneous emphysema)
Organise expert help.
You assess the anterior chest. Trachea is midline. The patient has markedly decreased air entry and chest expansion on the left. What could be the cause of this?
- Phrenic nerve injury
An ICC is being prepared while you assess the circulatory system. What specific features will you look for?
- All the standard features of haemorrhagic shock
- Assess the circulation in the arm on the affected side. There may be vascular compromise.
The patient is conscious, with a GCS of 15. What other neurological findings will you look for?
- Brachial plexus injuries are fairly common, especially if a vascular injury is present (Zone I trauma)
- Recurrent laryngeal nerve trauma will manifest as hoarseness
- Phrenic nerve trauma will manifest as an elevated hemidiaphragm
- Horner's syndrome may develop
When you sit the patient up to examine and auscultate his back, he suddenly falls unconscious. His pulse cannot be palpated. What are the possible causes?
- Syncope (and the pulse is too brady)
- Haemorrhagic shock and PEA
- Tension pneumothorax and PEA
- Hypoxia due to pneumothorax
- Gas embolism from deep breaths during auscultation and IJ laceration
- Cardiac arrhythmia (eg. from party sympathomimetic)
The patient remains in cardiac arrest. CPR is commenced. What reversible causes will you focus on?
- Drain the left chest (could be tension pneumothorax/haemothorax)
- Correct hypoxia
- Correct hypovolaemia
After two cycles and one dose of adrenaline, ROSC is achieved. There is a new murmur on auscultation, and the ECG demonstrates tachycardia with features of right heart strain. How does this change your differentials?
- The possibility of gas embolism should be raised at this stage, if it has not already appeared.
What investigations or physical examination findings could make the diagnosis of gas embolism?
- "mill wheel" murmur
- Gas bubbles in the retina (on ophthalmoscopy)
- ECG features of right heart strain
- Pulmonary hypertension on TTE
- Gas bubbles on TTE
- Gas bubbles on CT
The patient's ROSC is sustained, but he has not recovered consciousness. What are your management priorities at this stage?
- Commence 100% FiO2 via NRBM
- Transfer to OT for a definitive airway with ENT
- Damage control exploration of neck wound
- Formalise finger thoracostomy
- Then, CT trauma series to investigate further injuries, including cerebral injuries