1. Missouri EMS Central Region February 2013 Webinar Case Review Jeffrey Coughenour MD FACS Assistant Professor of Surgery Medical Director, Missouri EMS Central Region

2. Patient 1 Young male, ejected from motor vehicle Awake, alert, complains of shortness of breath Bilateral hip pain and numbness right leg 150 80/60 28 85% on NRB GCS 15 What immediate care are you preparing for?

3. Patient 1 Rapid immobilization and transport Worsening tachycardia and hypoxemia Assisted with BVM, some improvement 155 78/58 30 83% on NRB GCS 14 Intubation or needle decompression?

4. Patient 1 Improved with intervention Transfusion, limitation of crystalloid Rapid assessment in the EC, direct to the OR Short-duration arrest on anesthesia induction RSI may blunt the last sympathetic drive the patient has… leading to death!

5. Patient 1 Immediate post-op CT with perihepatic and perisplenic packing

6. Patient 1 ERCP showing right hepatic duct injury

7. Biliary Leak after Hepatic Injury Incidence of 3 – 20% Increases with increasing grade of injury Abnormal LFTs, distention, feeding intolerance ERCP with CBD stent Percutaneous or open drainage

8. Hemobilia – A Rare Complication First described in 1871 Less common with increase in non-operative management Right upper quadrant pain, jaundice, UGI bleeding after hepatic injury Angiography and embolization study of choice

9. Patient 2 Rollover MVC, culvert Partial submersion, by-stander rescue Awake, alert, intoxicated, cough 110 148/78 20 90% GCS 14 Destination?

10. Patient 2 Transport to local ED Less than cooperative but awake, alert Cough, oxygenation better with therapy 105 135/75 22 95% GCS 14 What are you worried about? Care plan?

11. Patient 2 Admission chest radiograph

12. Patient 2 Aspirated prior to transfer Emergently intubated Severe hypoxemia during transport 105 135/75 22 95% GCS 14 What are you worried about? Care plan?

13. Patient 2 Chest radiograph day of death

14. ALI/ARDS Defined as P/F ratio <300 (ALI) or <200 (ARDS) Despite advances, mortality remains 40-60% Hypoxemia despite high concentrations of inspired oxygen, increased shunt, decreased compliance, increased deadspace ventilation

15. ALI/ARDS Lung-protective ventilation Fluid: Euvolemia Prone positioning High-risk of organ system dysfunction “Two-Hit Hypothesis”

16. Patient 3 Family called 911 for new-onset mental status changes On arrival, flaccid left side Positive Cincinnati screen What do you need to know?

17. Patient 3 Vital signs normal POC glucose 27 (recheck 33) IV established, D50, slowly improving Helicopter is on the way… local hospital is 20 miles away. Big place is 45 miles away. Family is headed to the big place. Now what?

18. Patient 3 Normal neurologic examination after 15 minutes, no residual deficits Taken to big place, CT and labs normal, discharged home No CT scanner in the ambulance? Complexity of rural EMS destination determination