Failure on the Board

Scene

Attack One responds to an MVA with several persons injured. One of the injured is a 72-year-old female with a facial laceration from contact with the steering wheel. She was a restrained driver; her vehicle incurred moderate front-end damage. She has lacerations to both the lower and upper lips, with moderate bleeding. The patient is immobilized on a long backboard, and gauze dressings are placed on her lacerations. While other patients are tended to, she is placed on the stretcher in the medic unit. She has a pulse rate of 72, a blood pressure of 160/90, a respiratory rate of 18, and is perfusing well. She has no other signs of trauma on complete assessment, and bleeding is controlled.

The patient begins to complain of discomfort from lying on the board, and becomes progressively anxious. She says she’s short of breath, and her respiratory rate increases to 28. She is attached to the cardiac monitor and pulse oximeter; the latter reads 85%, so she is provided 15 lpm/O2 via mask. The patient deteriorates rapidly, and after a short transport to the hospital, she is in respiratory distress. On arrival at the ED, Attack One’s crew assists the ED staff by intubating the patient with an orotracheal tube and providing positive pressure ventilation.

Impressions

Stable patient, rapid downhill course, deteriorating until ventilatory support is needed—what happened? Responders would have to consider hypovolemic shock, acute myocardial infarction from trauma, and pulmonary edema as possible sources of the respiratory failure.

Hospital

After oral intubation, the patient’s oxygen saturation increases to 100%, and her mental status clears to where she motions she wants off the backboard. Her vitals upon arrival at the ED are HR 128, BP 160/100, and respirations assisted at 20 per minute. Bleeding from the lacerations was controlled in the field, her cervical spine is cleared at the ED with x-rays, and no other injuries are found. Her back exam reveals no tenderness. She has significant pedal edema, and her cardiac exam reveals enlargement of the heart and jugular venous distention.

She is removed from the backboard and allowed to sit up on the stretcher. An upright chest x-ray confirms an enlarged heart and pulmonary edema. Her EKG reveals no acute myocardial infarction, and cardiac enzymes are not elevated on initial or follow-up testing. She receives nitroglycerin, furosemide (Lasix), an ACE inhibitor and oxygen. After an hour, her endotracheal tube is removed, and her lacerations repaired. She is kept in the Clinical Decision Unit for several hours, then released home. Further interview of the patient after extubation reveals she has had significant symptoms of congestive heart failure (CHF) for the preceding months. She’s noted swelling in her ankles, and “hasn’t been able to lie on her bed to sleep” for weeks.

Discussion

The patient in this case had an underlying history of congestive heart failure due to lifelong hypertension. She did not share her preceding symptoms with the EMS crew, and she was immobilized in routine fashion due to her facial trauma. Her respiratory status diminished, and she complained only of the discomfort of being on the backboard. She deteriorated rapidly to frank respiratory failure and required intubation, but then cleared quickly after she could be placed in an upright position and her heart function assisted with critical medications. After this treatment, she could finally reveal that she had not been able to lie down for several weeks prior to the accident.

Patients with congestive heart failure have a pump dysfunction that results in fluid overload. The fluid often presents as edema in the lower extremities. As the patient lies down, that fluid is mobilized and returned to the vascular system and, in a full reclining position, will fill the vascular system in the lungs. The patient gets progressively dyspneic in a reclining position, and in early cases, this may present as sudden shortness of breath that wakes the patient at night (paroxysmal nocturnal dyspnea, or PND). The patient will eventually quit trying to lie flat, and instead prop himself up on pillows or sleep in a chair. This is referred to as orthopnea.

CHF can worsen when a person takes in more sodium, and some of the higher loads of sodium come from prepared foods such as canned soup. This patient had forgotten to remain on her low-sodium diet, and this extra load of salt and water exacerbated her chronic heart failure.

Further, positional change into a full reclining position, especially when this position is reinforced with a backboard and immobilizing straps, will exacerbate the symptoms of congestive heart failure in some patients, as it did with this one.

After a trauma event, how can we immobilize persons who have severe CHF that could be exacerbated by placing them in a reclining position? Short-board packaging can adequately immobilize the patient’s cervical and thoracic spine, and still permit the patient to sit with an upright torso on the stretcher. If the crew must immobilize the lumbar spine as well, the patient can be packaged on a long backboard and the backboard then propped up on the stretcher, using straps to maintain the patient for a safe transport.

In the non-trauma EMS encounter, the patient with severe CHF or pulmonary edema must be allowed to sit up. A patient with critical pulmonary edema may even insist on sitting over the edge of the stretcher. Placing the patient in the position he/she prefers may prevent acute respiratory failure and the need for crisis intubation, and allow emergency therapy to restore critical cardiac function.