Admission time: 00:00
ED Physician Note at 00:22
53 yo M brought via EMS for MVC rollover. Pt was the restrained driver. EMS reported 2ft intrusion requiring prolonged extrication. Obvious L ankle and L wrist deformity. Unknown LOC. Has had 10 mg Morphine by EMS. Repetitive questioning en route, asking to sit up. Rolled 2x. 77% RA improved w/ 4lpm NC.
Trauma
Mechanism of injury: motor vehicle crash
Injury location: shoulder/arm and leg
Injury location detail: L wrist and L ankle
Incident location: in the street
Arrived directly from scene: yes
Patient position: driver's seat
Patient's vehicle type: car
Collision type: roll over
Speed of patient's vehicle: city
Compartment intrusion: yes
Extrication required: yes
Ejection: none
Airbags deployed: driver's front, driver's side, passenger's front and passenger's side
Restraint: lap/shoulder belt
EMS/PTA data:
Bystander interventions: none
Ambulatory at scene: no
Responsiveness: alert
Loss of consciousness: yes
Airway interventions: none
Breathing condition since incident: worsening
Circulation condition since incident: worsening
Mental status condition since incident: worsening
Disability condition since incident: worsening
Review of Systems
Unable to perform ROS: Mental status change
Constitutional: Negative for chills, diaphoresis, fatigue and fever.
HENT: Negative for congestion, postnasal drip, rhinorrhea, sinus pain and sore throat.
Eyes: Negative for photophobia, pain and discharge.
Respiratory: Negative for cough, chest tightness, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain, palpitations and leg swelling.
Gastrointestinal: Negative for abdominal pain, constipation, diarrhea, nausea and vomiting.
Genitourinary: Negative for decreased urine volume, dysuria, flank pain, frequency, hematuria and urgency.
Musculoskeletal: Negative for arthralgias, back pain, myalgias and neck pain.
Skin: Negative for color change, pallor, rash and wound.
Neurological: Positive for loss of consciousness. Negative for dizziness, seizures, syncope, weakness, lightheadedness,
numbness and headaches.
Psychiatric/Behavioral: Negative for confusion and hallucinations. The patient is not nervous/anxious.
Vital signs upon initiating note
BP (!) 152/100
Pulse (!) 120
SpO2 (!) 77% [no further SpO2 documented]
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: Pt is in acute distress.
Appearance: Pt is well-developed. Pt is not diaphoretic.
Interventions: Cervical collar and backboard in place.
Comments: Moaning in pain
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat:
Pharynx: No oropharyngeal exudate.
Eyes:
General: No scleral icterus.
Right eye: No discharge.
Left eye: No discharge.
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Neck:
Thyroid: No thyromegaly.
Vascular: No JVD.
Trachea: No tracheal deviation.
Cardiovascular:
Rate and Rhythm: Regular rhythm. Tachycardia present.
Pulses:
Radial pulses are 0 on the left side.
Heart sounds: Normal heart sounds. No murmur heard.
No friction rub. No gallop.
Pulmonary:
Effort: Pulmonary effort is normal. Tachypnea present. No respiratory distress.
Breath sounds: Normal breath sounds. No wheezing or rales.
Chest:
Chest wall: Tenderness present.
Comments: R chest contusion
Abdominal:
General: Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness.
Musculoskeletal:
Right elbow: Laceration present. Decreased range of motion. Tenderness present.
Left wrist: Deformity, laceration, tenderness and bony tenderness present. Decreased range of motion.
Cervical back: Normal, normal range of motion and neck supple.
Thoracic back: Normal.
Lumbar back: Normal.
Left ankle: Deformity and laceration present. Tenderness present. Decreased range of motion.
Left foot: Decreased range of motion. Swelling, laceration, tenderness and bony tenderness present.
Comments: 2 CM LACERATION R ELBOW 2 CM LAC L FOOT
Lymphadenopathy:
Cervical: No cervical adenopathy.
Skin:
General: Skin is warm and dry.
Coloration: Skin is not pale.
Findings: No erythema or rash.
Neurological:
Mental Status: Pt is alert and oriented to person, place, and time.
Cranial Nerves: No cranial nerve deficit.
Motor: No abnormal muscle tone.
Coordination: Coordination normal.
Psychiatric:
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.
DIFFERENTIAL DIAGNOSIS: INTRAABDOMINAL INJURY, FRACTURE(S), CONTUSION(S), HEAD INJURY,
CONCUSSION, LACERATION(S), DISLOCATION(S)
Abdominal Ultrasound at 00:25
Procedure details:
Indications comment: Trauma
Assessment for: Intra-abdominal fluid
Left renal: Visualized
Right renal: Visualized
Bladder: Visualized
Left renal findings:
Intra-abdominal fluid: not identified
Perinephric fluid: not identified
Right renal findings:
Intra-abdominal fluid: not identified
Perinephric fluid: not identified
Bladder findings:
Free pelvic fluid: not identified
Comments:
Negative Fast
Intubation at Unknown Time
Consent: The procedure was performed in an emergent situation.
Indications: respiratory failure and airway protection
Intubation method: direct
Patient status: paralyzed (RSI)
Preoxygenation: BVM
Sedatives: etomidate
Paralytic: rocuronium
Laryngoscope size: Mac 4
Tube size: 7.0 mm
Tube type: cuffed
Number of attempts: 5 or more
Difficult intubation: yes
Ventilation between attempts: BVM
Cricoid pressure: yes
Cords visualized: yes
Post-procedure assessment: chest rise, ETCO2 monitor and CO2 detector
Breath sounds: equal
Cuff inflated: yes
ETT to teeth: 24 cm
Tube secured with: ETT holder
: : :
Pt became unresponsive during evaluation. His pupils were asymmetric and he was pulseless. CPR was initiated. Please see code sheet. Once chest compressions began, copious amounts of emesis began pouring from his mouth making intubation very difficult. Pt remained in PEA throughout the code. Time of death 00:58.
Flowsheet shows the following:
At 00:21, airway patent, breathing effort spontaneous, trachea midline, chest wall symmetrical, skin clammy, pulses present, peripheral pulses present, capillary refill less than/equal to 2 seconds, GCS 15, obeys commands, best verbal response is oriented.
At 00:33, GCS 14, obeys commands, best verbal response is confused.
At 00:37, GCS 4, withdraws from pain, best verbal response is none.
Trauma surgery note:
Trauma History and Physical
Level of Activation: Level 2
HPI: Pt is a 53 yo M s/p MVC rollover, intrusion, restrained, - LOC, GCS 15. Patient presented to trauma bay with GCS 15 and pupils 3 mm reactive bilaterally. Abrasion with depression noted over R upper chest. Obvious L ankle and L wrist deformity. Laceration on R elbow. ABCs were clear. Fast & eFAST were negative x2. Palpable DP pulses. In the trauma patient's status slowly deteriorated. GCS status declined as patient's dyspnea progressed, O2 sats remained unchanged despite non rebreather mask application. His pupils began to dilate bilaterally and became unresponsive. GCS declined to 3. BLS and ACLS initiated. Patient intubated. IV accessed achieved. Despite prolonged ACLS patient pronounced dead with PEA.
Patient arrived. Obvious left wrist and ankle. Possible rib fractures. Negative E FAST. Rapid decline in mental status in trauma bay. Became pulseless. ACLS began. Bilateral chest vent. Intubated. Remained pulseless during 20 minute code. Post traumatic arrest.
Past Medical History: HTN
Past Surgical History: unable to obtain secondary to patient condition
Medications: unable to obtain secondary to patient condition
Anticoagulant Therapy: none
Family History: unable to obtain secondary to patient condition
Social History: unable to obtain secondary to patient condition
Allergies: NKDA
Primary Survey:
A intact
B clear bilaterally
C 2+ distal pulses
D obvious
In addition to description above: epinephrine, rocuronium, etomidate, haloperidol, succinylcholine, magnesium
Chest vented bilaterally. Bilateral finger thoracostomy performed. No blood or air present bilaterally.
R Femoral Cordis Placed
AUTOPSY SUMMARY OF FINDINGS (in setting of mild to moderate decomposition of body):
I. BLUNT FORCE INJURIES
a. Subgaleal hemorrhage across the occipital scalp with associated edema
b. Fractures of sternum, multiple ribs, pelvis, left radius and ulna, left fibula
c. Hemoperitoneum (150 ml)
d. Multiple contusions, abrasions, and lacerations
II. OBESITY
a. Body mass index 39.4 kg/m2
Ill. HYPERTENSIVE CARDIOVASCULAR DISEASE
a. Cardiomegaly (420 grams)
b. Granular surface of kidneys
CAUSE OF DEATH:
Blunt force injuries including sternal fracture and multiple rib fractures
CONTRIBUTING CAUSE OF DEATH:
Obesity and hypertensive cardiovascular disease
Files:
No questions yet!
Do you believe there might have been medical error?
The exact events and timeline are somewhat difficult to reconstruct. However, it appears that the patient very quickly declined from a near-normal mental status to cardiac arrest (however, even with a normal mental status, he was noted as "clammy' = in distress). There are some important discrepancies that raise concern, nonetheless. The patient was hypoxic and agitated en route and upon arrival to the ED. The ED physician documented that the Spo2 "improved with 4l nasal cannula" but no further SpO2 is documented and the trauma surgery note says that he did not improve with nonrebreather mask. It is possible that valuable time was lost here to intervene earlier to prevent a respiratory arrest. He then vomited and the airway was now difficult with five intubation attempts and almost certainly prolonged profound hypoxia contributing to death. It does not seem that a difficult airway team was activated or that a more experienced intubator was available/took over. After three failed attempts, a surgical airway should have been performed. I also do no see documentation that the trauma alert was upgraded from a level 2 to a level 1.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
1) Failure to timely address persistent hypoxemia prior to potentially preventable respiratory arrest 2) Failure to upgrade to a level 1 trauma alert which would typically lead to a larger response, might bring an anesthesiologist to the case et cetera 3) Failure to adequately address a difficult airway (more experienced operator, surgical airway etc.) All these factors potentially contributed significantly to the patient's death.
What makes you a good expert for this case?
I am one of less than ten physicians in the US who is triple board certified in emergency medicine, critical care medicine, and emergency medical services (prehospital medicine).I practice in all three areas at a level 1 trauma center. I see major trauma patients regularly when working in the ED and the ICU.
How often do you encounter cases similar to this one in your practice?
I see patients as the ED physician in charge of the airway 2-4 times per shifts. I also take care of trauma patients in the ICU and when working prehospitally as an EMS physician. I teach residents and fellows at a major academic medical center when taking care of trauma patients.
Do you believe there might have been medical error?
Unfortunately, there is a lot of information missing. The patient had multiple trauma but came in to the ED hemodynamically stable. The only gross physiologic abnormality was the severe hypoxemia of 77 %. Seeking the cause of the hypoxemia should have been a priority. Causes of hypoxemia in a trauma patient includes but is not limited to pulmonary contusions, pneumothorax, hemothorax, pulmonary embolism, intracardiac shunting, etc. A chest x-ray should have been one of the first diagnostic procedures to be performed yet the results of a chest x-ray are not reported in the case overview. Also not reported is whether there was a traumatic pericardial effusion on FAST scan. The patient apparently deteriorated quickly between 0033 hours and 0037 hours when his GCS deteriorated from 14 to 4. The autopsy "cause of death" is not helpful in determining the immediate cause of death and is worthless in this evaluation. There is no mention of lung findings of possible pulmonary emboli nor is there mention of whether there was pericardial effusion/pericardial tamponade. There is no mention of an examination of the aorta for possible trauma. A sudden, rapid deterioration in a trauma patient could be due to a number of anatomic and physiologic abnormalities such as pulmonary emboli, myocardial infarction, myocardial contusions, aortic dissection/rupture, tension pneumothorax, hemorrhagic shock, pericardial tamponade, and others. There is not enough information to rule out any of those abnormalities which could have been the true cause of death. All of them should have been in the differential diagnosis and appropriate diagnostic studies should have been performed. Absent more information however, it is not possible to provide a definitive opinion regarding whether or not there was a medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
More information is needed as discussed above.
What makes you a good expert for this case?
I am an emergency medicine physician with substantial professional experience over the past forty plus years while assigned to provide emergency medical coverage in a general acute care hospital level 1 trauma center emergency department. I have also relied upon my education, training and substantial experience as a practitioner and teacher for more than forty years. By virtue of my education, training, and continued substantial experience as an emergency medicine physician, I am intimately familiar with the standard of care for general acute care hospital emergency department physicians providing emergency medical coverage in the same or similar locality, in like cases, and under circumstances similar to those present in this case. During that time, I have taught emergency medicine to physicians in training and in practice, as well as to students, interns, residents, fellows, nurses, paramedics, nurse practitioners and physician assistants in all stages of their training. I am intimately familiar with the standard of care for emergency department physicians and nurses who assess patients with complaints of multiple trauma from motor vehicle accidents. I am intimately familiar with the standard of care for the diagnostic workup and treatment of patients involved in motor vehicle accidents who present to the emergency department with multiple trauma.
How often do you encounter cases similar to this one in your practice?
Several trauma cases every week.
Do you believe there might have been medical error?
Based on the available information above, there was significant opportunity for improvement in how this patient was managed. Pre-hospital, the patient had a significant mechanism - rollover MVC. In addition to this, he was altered, hypoxic, prolonged extrication. All of these pieces of information need to raise a high suspicion for hemorrhagic shock until proven otherwise in addition to traumatic brain injury. When the patient arrives to the ER, there is additional information available including tachycardia, continued hypoxia, and right chest wall external signs of trauma including bruising and chest wall deformity per the above documentation. At this point, if the airway was patent, the patient should have underwent right sided chest tube placement to rule out hemopneumothorax as the cause of his symptomatology and part of cavitary triage and is a significant opportunity for improvement in this case. The documentation states "ABC's intact" but clearly the patient's breathing was not intact. Additionally, after primary survey, the patient should have underwent chest x-ray and pelvic x-ray as part of the cavitary triage as the patient had distracting injuries (extremity deformity and suspected fractures) in addition to tachycardia and hypoxia which again is hemorrhagic shock until proven otherwise. Hemopneumothorax needed to be ruled out as well as an open book pelvic fracture; neither of these were done according to the above information available. Additionally, the note mentions that the patient had a gradual decline in GCS with worsening hypoxia. This was a change in the patient's clinical status and the standard of care is to go back and repeat the ABCs, during which time the patient's airway would have not been protected due to his worsening mental status and it would have been indicated to intubate the patient both to secure the airway and attempt to improve the oxygenation. Instead, the patient continued to worsen and eventually sustained cardiac arrest. Only after this was the patient intubated and bilateral pleural space decompression was attempted. All of these were opportunities for improvement at the patient's presentation and during the trauma team's evaluation. Without additional information regarding the autopsy and more detailed medical chart review, I cannot ascertain at this time if this was an anticipated mortality with opportunity for improvement or an unanticipated mortality with opportunity for improvement, but either way this patient's care was not managed according to standard of care within the ATLS algorithm.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the above information, I do not think that a medical error resulted in an injury to the patient that was not already present on presentation from the MVC. However, the question becomes whether a more organized approach to the primary and secondary survey within the trauma bay regarding more expeditious intubation and addressing the patient's hypoxia may have prevented the patient's cardiac arrest and given the team more time to diagnose and potentially intervene on the traumatic pathology. I would need to review the patient's chart further to determine this.
What makes you a good expert for this case?
I am a board certified acute care (trauma) surgeon that has managed over 2,000 patients in the trauma bay in my career. I have extensive experience in both blunt and penetrating trauma and am intricately familiar with the approach in managing these patients. I also have over 5 years of experience with hospital performance improvement and case review of similar cases where there was opportunity for improvement in patient care.
How often do you encounter cases similar to this one in your practice?
I manage similar cases to this every day of my career and as above, I have managed over 2000 patients with significant blunt trauma.
Want to open a case or submit response?
Comments from similar speciality or otherwise pertinent to the case may also be accepted.