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Robodoc's Trauma Puzzle # 3

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  • Robodoc's Trauma Puzzle # 3

    22 year old man, found unconscious in AZ desert in August with crashed ATV. Length of time down unknown. Patient is unconscious responding only to pain. Brought in full spinal precautions as level I trauma. Upon arrival patient is awake, but has no memory for accident. He is complaining of headache, neck and chest pain, abdominal pain and bilateral knee pain.
    PMH & FH noncontributory. No meds, no allergies. Patient is a smoker and admits to "4 beers" prior to ATV excursion.

    Exam: Vitals: BP=160/90, P=120, R=22, T=101.4 F oral, SaO2 = 98% room air.
    Primary survey is intact
    Secondary trauma survey: abrasions and contusions to right frontal scalp, 1.5 cm laceration vertex scalp. Neck normal with midline trachea, lungs clear with splinted respirations, heart = tachycardia, chest wall tender to palpation right lateral ribs and costal margin; no crepitus or bruising. Abdomen = tender RUQ with voluntary guarding - no organomegaly. REctal normal heme negative stool, normal prostate. Pelvis normal. Extremities: road rash and abrasions bilateral shins and forearms, no deformity. full ROM. NEuro normal.

  • #2
    Why is this guy HYPERtensive? Makes me suspect significant intracranial pathology. He clearly needs his belly looked at (lavage, laparoscope) but would CT head first.
    - Sue

    End the chaos - kill the butterflies!

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    • #3
      Not just hypertensive, but febrile and tachy too...impending ETOH w/d on top of other things maybe as well? How are his lytes? CBC? Is he dehydrated? Sunstroked too? (coming from the desert...I wonder...) UDS? Based on Robodoc's "red herrings", I suspect some surprises here...but let's get some basic results for now (both labs and imaging too, of course).

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      • #4
        Monitor = sinus tachycardia; CT head = negative; CT C-spine = negative; Trauma CT abdomen/pelvis (IV but no PO contrast) = grade I liver laceration; CXR = fractured right ribs 4-7, midline trachea, and no apparent pneumothorax (PTX). CT chest with IV contrast = rib fractures, RLL pulmonary contusion & <10% PTX. Labs: WBC = 25.2K with 75 segs & 14 bands; platelets 92K; indices macrocytic; Hgb/Hct = 16 & 48 respectively; chemistries = Na = 136, Chloride 92, BUN = 24, Creatinine 1.1; K= 3.0; CO2 = 20; UA = dark urine with spec grav > 1.030, strongly positive for blood with 0-2 RBC's/HPF, 02-WBC's/HPF, 2+ protein. UDS = positive for amphetamines, cocaine, THC, & opioids on unconfirmed screening.

        Chest tube placed (right chest) in trauma suite. 2 large bore IV's with normal saline, foley catheter, 2 liters NS given in trauma suite; over first hour urine output 35 cc. Patient admitted to ICU. 5 hours after admission to ICU, patient complains of severe chest pain and becomes bradycardia (P=49) with drop in blood pressure to 90 systolic.

        Now what?
        Ragster

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        • #5
          Atropine IV fluids, has he got pericardial temponade?
          Bigdoc

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          • #6
            He's oozing blood, (maybe in the pericardium too, plus in possibly other spaces/places); kidneys are semi-shot. Drug abusing alcoholic. Septic. Is the liver holding? Or shot too? DIC? PT/PTT? What do blood cultures say? And is it time for intubation already? RR, pulseOX, blood gasses? Thank G-d he's in the ICU...but is it too late already?

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            • #7
              Sounds like he's got rhabdomyolysis with strong blood, 0-2 RBCs in urine. Would recheck K+ immediately, consider glucose/insulin and calcium while waiting if ECG evidence of hyperkalemia.

              Also need to consider PE and fat embolism.

              Is chest tube connected to suction?
              - Sue

              End the chaos - kill the butterflies!

              Comment


              • #8
                You've really got me with the bradycardia. Bleeding, tamponade, disconnected chest tube should all lead to tachy, not brady. What's going on with level of consciousness, and abdominal exam?

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                • #9
                  Good thoughts all! Patient indeed had rhabdo (mild) but CPK peaked at 5500, urine output remained good, and CKMB normal with relative index of 1. Given fever and diagnostic findings, sepsis was considered: cultures drawn and ultimately grew MRSA staph. IV Vancomycin and IV zosyn started after cultures drawn.

                  Regarding concerns for PE/tamponade - also reasonable dx possibilities given facts of this case: First trauma contrast chest CT did not show pericardial fluid. Radiology refused request for CT pulmonary angiogram because of patient's rhabdo, creatinine, and previous dye load. VQ scan reported as "low probability". Chest tube not hooked up to suction - gravity drainage only.

                  Oh, by the way: ICU nurse calls concerned: "This patient has funny heart tones that you need to come and evaluate. Also his road rash is getting worse. Can I get an order for increased sedation?"
                  Ragster

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                  • #10
                    Time for cardiac echo. Is he throwing septic emboli off his right heart from shooting funny things into his veins? Would account for the MRSA for sure.

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                    • #11
                      Ruptured papillary muscle would account for "funny cardiac sounds".

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                      • #12
                        Bingo, Phillip! Cadiac echo demonstrated vegetations on Mitral and aortic valves - subsequent blood cultures grew MRSA sensitive to Rifampin, Bactrim and Vanco - IV antibiotics "cured" this man's "trauma" problem.
                        Ragster

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                        • #13
                          Congratulations, Dr. Phillip!

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                          • #14
                            Hey, I missed all the fun, can we have another clinical puzzle?
                            I am the witchdoctor and I approve this message

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                            • #15
                              3b - your were correct re "common thread" - all three patients in this series were infectious emergencies masquerading as traumas.
                              Ragster

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