I don’t get many traditional weekends, but this last Saturday and Sunday were pretty fantastic. My wife and I got to spend time with friends we haven’t seen in a long time, and we even got some rock climbing in too! So, now that I’m relaxed and refreshed, we can spend some time talking about the scenario I gave you last week.
Last week, I posted a video showing a pretty brutal injury–a wrangler taking a horse kick right to the chest. If you haven’t had a chance to watch the video and think about it, I’ll wait! It’s a short video, and won’t take you much time at all. You can access it here.
Again, special thanks to Katey Duffey (@UnciaKate), who contributed some ideas of what was going on here, and what to look out for:
I agree! She got the big one!
So, what about you? What injuries are you worried about? What are you looking for? These are my thoughts.
I’ll stick to rock climbing. Not that I have anything against those who enjoy recreating with horses, but they aren’t my cup of tea. Primarily for this reason. A wise outdoor programing specialist used to tell me, “horse programs are the only programs I can think of where a 180 pound body tries to exert its influence on a 1500 pound body.”
Location, location, location. I watched a lot of videos of horse-related injuries before I found this one (incidentally; ouch!). I worry about this situation in particular due to the density of important organs and structures in the chest, as well as the large volume of blood in the major organs and vessels.
Chest wall problems: First and foremost, a kick with that amount of force to the chest could cause structural damage to the chest, such as broken or separated ribs, or a broken sternum. If two or more ribs are broken in two or more places, our patient could have a flail segment, or a segment of chest wall that is not connected to the rest of the ribcage. We breathe in by contracting our diaphragm and expanding the volume of our thoracic cavity, which creates negative pressure inside the chest and draws air in. If the chest isn’t structurally sound and can’t expand due to part of the chest collapsing, negative pressure isn’t created efficiently and breathing doesn’t happen efficiently. At very least it will hurt to take a breath, which may cause a feeling of shortness of breath.
Lung problems: Lungs are my biggest concern. Lungs are hollow, air-filled organs. As such, they are sensitive to changes in the pressure of the air that fills them. If our patient had full lungs when he was kicked, the sudden increase in pressure from the kick could cause barotrauma (pressure related injuries), such as lung overstretch and punctures. Lungs could also be punctured by the sharp end of a fractured rib. Punctures in the lungs put our patient at risk for a pneumothorax, or collection of air in the pleural space between the visceral and parietal pleura. As air collects, it causes the lung to collapse, which is really bad news for gas exchange. If too much air collects, intrathoracic pressure can increase to the point that a tension pneumothorax develops, and the mediastinum, heart, and lungs shift towards the unaffected size.
Cardiac bad stuff: I also worry about trauma to the heart; lots of possibilities here! Our patient could suffer a myocardial contusion, or bruising of the muscular wall of the heart. Signs of this would include chest pain and discomfort following direct trauma to the chest, that is not affected by level of activity. Our patient could also suffer a myocardial rupture, in which the wall of the heart bursts under pressure or due to weakness. Patients with myocardial rupture typically present with excruciating chest pain, rapidly dropping blood pressure, rapid onset altered mental status, coma, and death. A condition with a similarly rapid onset and outcome is aortic dissection, in which the aorta shears, causing massive internal hemorrhage. Individuals who experience significant trauma to the chest are at risk of aortic dissection due to rapid deceleration forces; because the aorta is fixed to the back of the rib cage and cannot stretch but so far, it may tear if stretched. If a blood vessel in the myocardium bursts, such as may happen in this case, the blood could become trapped in the pericardial sack which surrounds
the heart, and begin to put pressure on the heart. This is called a pericardial
tamponade. Symptoms would include muffled heart tones, and shortness of breath and other symptoms of shock (since the heart isn’t able to pump blood effectively to the body, leading to reduced perfusion). An EKG may also show electrical alternans, in which the patient’s QRS complexes (ventricular impulses) alternate between higher and lower magnitude. Finally, I also worry about the possibility of lethal cardiac arrhythmias. Commotio cordis is a condition in which a direct blow to the chest over the heart disrupts the electrical pacemakers of the heart, causing ventricular fibrillation. In this case, the patient is in cardiac arrest, and needs CPR and defibrillation, as well as ALS resuscitation.
Head, neck, and spine: Ok, I’m adding this primarily to cover my butt. It is a concern, due to the mechanism of injury and the forces involved. Is it my primary concern? No! Will I take control of the head, neck, and spine and consider further immobilization as needed and indicated by my exam? Yes!
Internal hemorrhage and shock: I touched on this a bit while talking about cardiac badness, but it bears mentioning again. With all the important stuff in the torso, and the large volume of blood found there, I would want to be very alert for symptoms of shock. This is especially important considering how easy it is for the body to hide thoracic and abdominal hemorrhage without external signs.
So, how will we treat this patient? Here are my thoughts.
Secure the scene: I’m sure horses are nice and all, but we need to get control of this horse, and move it somewhere else. I’ve watched far too many videos of horses kicking people in the head to feel comfortable doing patient care around those hooves.
Control the head, LOC/ABCs: Primary assessment stuff. Let’s take c-spine, and let’s assess level of responsiveness and ABCs. I may have a patient in cardiac arrest. If I note lack of responsiveness and pulse, I’ll have my people initiate CPR. If the patient is dealing with a commotio cordis situation and is in ventricular fibrillation, I’ll use a defibrillator if I have one and shock at whatever charge my protocols and manufacturer recommends. If I do have a pulse, I’ll check airway for blood, fluids, and missing teeth, then proceed accordingly.
Check the chest: This is part of my primary assessment, but it’s super important so
I’m giving it its own heading. I want to use several senses to assess the chest. I’ll want to directly visualize the chest, so I’ll go to skin. I’m looking for deformity, bruising, open and sucking wounds, and evidence of flail segments (like paradoxical breathing). I’m going to palpate the chest; I’m feeling for uneven movement, crepitus (the grinding feeling of bone ends), other deformity or instability, and pain. I also want to auscultate lung sounds with a stethoscope; I’m listening for absent or diminished lung sounds, wheezing, etc. I’ll treat what I see. If I see open wounds, I’ll seal them with an occlusive chest seal. Flail chest segments used to be treated with sandbags, or bulky dressings. The evidence is coming back now, and suggesting that positive pressure ventilation (PPV) with a BVM or CPAP/BiPAP system is more effective, and that the bulky dressings don’t work. I may consider slinging/swathing the arm of the affected size of the chest to provide some stability. As I’m a paramedic, if I find evidence of tension pneumothorax (crashing blood pressure, absent lung sounds on one side, crashing SPO2, signs of shock), I’ll decompress the chest using a needle thoracostomy. Just a reminder for my medic/MD/PA friends; the sites are the second intercostal space at the mid-clavicular line, and the 4th intercostal space at the mid-axillary line.
Manage shock: I want to anticipate shock if possible. I’ll get IV access as quickly as possible so I can provide fluids and medications as needed. If I start seeing evidence of shock, I’ll provide fluids to replace volume, with the goal of maintaining systolic BP of 90-110 mmHg and MAP (mean arterial pressure) around 65 mmHg.
Transport: This patient needs evacuation and transport, and soon. The injuries he has the potential for are serious, and he needs diagnostic capabilities, such as chest x-rays and CT scans, that we can’t provide. I’d be thinking helicopter medevac, especially if I’m treating chest injuries or seeing signs of shock.
That’s what I have for this week. I’ll have another one for you this Wednesday–if you have ideas for what you’d like to think about, let me know, either here in the comments or on twitter using #wwydwednesday.