He he, yeah a bread and butter call so to speak. Let me give the case. Sorry, I was putting it all together last night and had to actually do some work. Funny how these EMS type jobs work.
Here you go:
You arrive on scene and police have secured it. They report that a male patient attempted to evade police during a routine speeding stop and the chase ended when the patient ran head on into a side rail on the interstate travelling at a "high" rate of speed.
Your general impression:
You find a prone and unresponsive male of about 30 years lying in the dirt approximately 20 feet from where his motorcycle hit the guard rail. He is not wearing a helmet and it looks like he took an up and over ejection pattern. The rather obvious mid femur deformities also suggest an up and over over ejection.
Upon initial contact, you log roll the patient supine with spinal precautions and continue to note unresponsiveness. The patient is breathing shallow and irregular, a rapid, thready radial pulse is noted, and a 5 cm profusely bleeding laceration is noted to the left temporal area of the cranium. The patient is essentially covered in abrasions, has a left sided neck haematoma with slight tracheal deviation and appears cyanotic. The rest of the rapid trauma survey is essentially unremarkable.
You manage him initially as a crash airway and are able to successfully utilise adjuncts and good bag mask technique. The cyanosis resolves and you have good compliance with the bag. Direct pressure controls the bleeding from the head laceration.
VS: P-120, BP- 92/50, SPO2-100%, Temp- 35 Celsius. BGL= 128 mg/dl.
You opt to intubate the patient and easily pass a 7.5 ETT and note a Cormack and Lehane grade I view upon passing the tube. Placement is verified with sounds, chest rise and fall, lack of epigastric sounds and waveform capnography with a good plateau shaped waveform. The depth of insertion is appropriate for the tube and patient size.
However, you notice asymmetrical chest expansion. You notice that the right chest wall begins to expand first, followed shortly by left chest wall expansion. The lung sounds are clear and good compliance with bagging is noted.
What could be going on?
