Belly Full of Trouble

     It's a warm, sunny afternoon when Attack One responds to a mutual aid call for assistance in a neighboring jurisdiction. The crew rolls up on a severe head-on collision between a sports car and a small pickup truck. Crews from the neighboring EMS agency are working on the driver of the sports car, whose head is protruding through his windshield. Attack One is directed by Command to care for the single victim in the pickup truck.

     The driver is alone, still belted in. He's a healthy man in his 20s. A single member of the other EMS agency has placed a cervical collar and is attempting to control the bleeding from a large laceration on the man's forehead. The patient is helping himself by placing direct pressure. He is awake, alert, oriented and expressing concern about the other car's driver. He remembers rounding the curve, finding the other driver in his lane and being unable to turn away. He saw the other driver come through his windshield, and fears for the man's life.

     The Attack One paramedic does a rapid trauma assessment and finds the doors on the truck won't open. They will require a quick extrication, but nothing as time-consuming as will be required to remove the other driver. He places a pulse oximeter on the man's finger and finds oxygen saturation in the high 90% range, the pulse rate regular. There's a lot of blood down the man's face, chest and in his lap, but he has no obvious chest, abdominal or extremity trauma. The laceration on his forehead is the site of all the bleeding, and it continues, rapidly. Only firm pressure directly on the wound edges slows it.

     The Attack One crew uses a few tools to quickly force open the driver's side door. The crew leader talks with Command; it appears the extrication of the car's critically injured driver will take some time, and an air ambulance has been called to transport him once he's free. Command suggests the patient from the truck be removed immediately in the ambulance, to clear the scene before the helicopter has to land.

     The Attack One crew performs a rapid extrication, places the young man on the backboard and stretcher, and loads him into the ambulance. They will leave immediately for the trauma center. The patient is still talking with the crew, but they note his heart rate increasing and oxygen saturation decreasing. Direct pressure still controls most of the bleeding from his forehead.

     "Are you uncomfortable in any other way?" the medic asks.

     "My head hurts where you're pressing on it, and my belly feels a little tight," the man says. "Can you loosen my belt?"

     The paramedic finds this request odd. "Sir," he tells the patient, "you don't have a belt on. You're wearing gym shorts."

     He decides to examine the man's abdomen again. As he presses around, the patient complains of some tenderness. There are no signs of trauma, but a faint line is visible where the seat belt had been. That's where the abdomen is tender.

Initial Assessment

     A 24-year-old male, restrained driver in a head-on collision. No air bag. Profuse bleeding from large laceration on forehead.

     Airway: Intact and uncompromised.

     Breathing: No distress.

     Circulation: Normal capillary refill, pink skin, neck veins flat.

     Disability: No neurologic deficits. Awake and alert, complaining only of forehead pain.

     Exposure of Other Major Problems: Significant blood loss from forehead laceration; bleeding is difficult to control even with direct pressure.

     AMPLE Assessment

     Allergies: None.

     Medications: None.

     Past Medical History: No problems.

     Last Intake: Large lunch an hour prior to incident.

     Event: Severe trauma from MVA.

Prehospital Management

     Based on the decreasing perfusion, the paramedic tells the patient he is concerned about his examination, and that he's going to increase the rate at which the intravenous fluids are going in. The perfusion status change is noted in the man's unusual request to loosen a belt he isn't wearing, his increased pulse rate, an increase in respiratory rate, and a decrease in pulse oximetry saturation. The patient's skin is still warm and dry, and most of the bleeding from the forehead wound has now stopped, but the abdominal examination has changed, and the patient may be bleeding internally.

     The crew pressure-infuses a liter of saline, which takes about six minutes, and the paramedic examines the patient again. His abdomen is now even more tender along the seat belt line, which is now more visible. The patient still complains only of "fullness" in his abdomen. His pulse rate is higher. As they complete transport, the crew infuses a second liter of saline.

Hospital Management

     The ED is prepared for the man's arrival. The crew transfers him onto the ED cart and reports on the progressive decrease in perfusion, evolving seat belt mark on the abdomen and infusion of two liters of fluids. Following a complete physical examination, the emergency physician performs a rapid bedside ultrasound, which shows a severe injury to the patient's spleen and a lot of blood in his abdomen. His perfusion continues to drop, and a blood transfusion is necessary in the ED. The bleeding from the forehead continues to be difficult to control.

     The patient goes to surgery, and a number of abdominal injuries are found. He has a relatively quick recovery and is released from the hospital. The other driver ultimately dies of his injuries-an outcome, everyone notes, that could have been much better had his seat belt been in place.

     Learning Point: Management of major trauma victims requires excellent patient assessment on arrival, then minute-to-minute reevaluation of the patient's condition, looking particularly for declining perfusion or oxygenation. A pulse oximeter can be a valuable tool here. Fluid resuscitation, if needed, should follow medical protocols, which often call for boluses of 20 cc/kg for children and up to 2 liters for healthy adults. Fluid can be pressure-infused through as large an IV catheter as possible, and should be accompanied by serial reassessments of the patient.

Case Discussion

     This case demonstrates the need for recognition of potentially serious injuries in all patients involved in motor vehicle collisions. This was a severe head-on collision, and one driver had obvious life-threatening injuries, with a dramatic presentation (trapped in the windshield). The Attack One crew recognized that identical force would have been applied to the young man they cared for, so they performed repeated assessments looking for internal injuries. As the patient showed signs of declining perfusion, they initiated fluid therapy. Clinical markers of perfusion are mental status, pulse rate, skin color and condition, capillary refill and blood pressure. In some cases of declining perfusion, pulse oximetry will decrease.

     Fluid resuscitation in a patient with compromised perfusion means boluses, not a drip. Bolus recommendations must follow local medical protocol, and typically are specified as 20 cc/kg in a child, and up to 2 liters in an adult with a healthy heart. There should be clear communication to ED staff regarding changes in the examination, evolving physical findings and how much fluid has been infused. It is possible to fluid-overload patients in shock from trauma, so ED staff must be made fully aware of prehospital fluids given.

     In documenting care of the trauma patient, it's always good to specify the mechanism of injury and vehicle damage, the nature of any serious injuries to anyone involved, the initial assessment, and changes in ongoing evaluations. In this patient, the most significant detail to document was his failure to improve with IV infusion of fluids, and the evolving tenderness and evidence of trauma in the abdomen.

     James J Augustine, MD, is the director of clinical operations at EMP Management in Canton, OH, and serves as assistant fire chief and medical director for Washington, DC Fire EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. Contact him at jaugustine@emp.com.