Cases & Commentaries

Missing Trauma

Commentary By Gregory J. Jurkovich, MD

The Case

A 54-year-old woman collapsed behind the counter
of a small neighborhood market. She was discovered a few minutes
later by a customer, who immediately called 911. On arrival,
paramedics found the patient unresponsive, with poor respiratory
effort and a barely palpable pulse. Initial treatment included
fluid resuscitation and external pacing for a heart rate in the
40s. The patient was transported to the nearest emergency
department (ED), where an initial chest x-ray suggested congestive
heart failure. Rather acutely, the patient became pulseless, and
CPR was initiated as the patient's cardiac rhythm went from
bradycardia to ventricular fibrillation, and then asystole. The
patient was pronounced dead after an hour of failed resuscitative
efforts.

The transporting
paramedics later returned to the ED, which, of note, was not a
trauma center. The ED physician informed the paramedic team of the
patient's death and reported that the patient had a tiny amount of
blood on her left nipple, which he attributed to chest
compressions. Together, the paramedics and the ED physician
examined the patient's clothing and discovered a drop of blood
inside her bra and a small hole in the bra itself. Further review
of the admitting chest x-ray indicated the presence of a small
caliber bullet in the area of the left ventricle, which was
initially thought to be a cardiac monitoring electrode. The medical
examiner was notified of the possible homicide, and an autopsy
confirmed that a bullet likely lacerated the patient's left
ventricle.

The Commentary

Failure to recognize trauma as
the cause of a patient's dire clinical condition is unusual,
perhaps even rare. Most traumatic injury events are either
witnessed, recalled, or associated with compelling physical
evidence that gives responding EMS personnel a clue as to the
mechanism. However, as this case so dramatically presents, rare
events do indeed happen and we need to be alert to them. I'll
analyze this case by first focusing on the injury itself, and then
broaden the discussion to common errors in the care of patients
with trauma.

Trauma patients are those who have sustained a
physical injury. Clinicians, particularly surgeons, more often use
the term "trauma," whereas epidemiologists and public health
personnel prefer the term "injury." William Haddon, widely
recognized as the father of modern injury prevention strategies,
may be responsible for this distinction, in that he wanted to
distinguish the event (for example, a motor vehicle collision) from
the injury or damage to the body. In describing the mechanism of
injury, he evoked the concept of energy exceeding the body's
threshold for injury or damage.(1)
Stedman's Medical Dictionary defines injury as "damage;
wound; trauma" and likewise defines trauma as "wound; an
injury inflicted, usually more or less suddenly, by some physical
agent."(2)

Regardless of these definitions, the patient
depicted in this scenario sustained a penetrating injury to the
heart. Wounding mechanisms are typically placed in two major
categories: blunt or penetrating. Blunt injuries are the result of
falls, motor vehicle or motorcycle crashes, bicycle accidents,
pedestrians hit by cars, or blunt force assaults. Penetrating
mechanisms are knife or gunshot injuries, but would also include
impalement with such bizarre items as nail guns, tree limbs, or
virtually any imaginable object. Burns are usually regarded as a
distinct injury mechanism and are typically included in trauma
databases. Drowning, poisoning, hanging, and asphyxiation are other
types of injury that are more difficult to categorize and are
excluded from many, but not all, trauma databases.

The approach to any trauma patient, regardless
of mechanism of injury and locale (prehospital or ED) or providers
involved (EMT or physicians or nurses), has been well standardized
and widely accepted.(3)
This process is best known and promulgated by an educational course
sponsored by the American College of Surgeons (ACS) entitled
"Advanced Trauma Life Support" or ATLS.(4) The basics of this educational program have been
adopted worldwide (in over 40 countries) by virtually all specialty
physicians and EMS personnel who provide trauma care. More than 1
million physicians worldwide have taken an ATLS course. This course
had its beginning in 1978 with a pilot course conducted in Auburn,
Nebraska, and was formally adopted as an educational program by the
ACS in 1980. Of course, trauma care has its real roots in the
military conflicts that have required physicians to care for the
injured since the beginning of recorded medical history. Today, the
principles established by the ATLS course are good starting points
for the systematic evaluation and emergency treatment of any trauma
patient.

The ATLS approach to trauma care is often
referred to as the ABCs of trauma. The approach should
begin with the airway (A), to ensure an open, functioning airway.
Next in priority is assessment of breathing (B), or the exchange of
air. It is not enough to have an open and patent airway. The lungs
and mechanics of ventilation must be functional to exchange oxygen.
In the case presented, this was the first sign that something was
amiss: the patient was not moving air. Inspection of the chest wall
and listening for breath sounds should have indicated the lack of
air movement and need for intubation to secure the airway and
provide for mechanical ventilation. Bag-mask valve ventilation may
also be useful, but only as a temporizing step.

Third in line is circulation (C). This
includes assessing for blood pressure, heart rate, and capillary
refill, and establishing IV access and crystalloid infusion. The
response to resuscitation directs the urgency and likelihood of
blood loss as the cause of shock. Signs of hemorrhagic shock are
low blood pressure, tachycardia, flat neck veins (no central venous
filling pressure), and low capillary refill. Hemorrhagic shock is
by far the most common type of shock seen in trauma patients.
However, cardiogenic shock is not infrequent, either from cardiac
tamponade or direct cardiac injury. The major clinical features
that distinguish tamponade from hypovolemic shock are distended
neck veins or elevated venous filling pressure (seen in cardiogenic
shock). Beck's triad—muffled heart tones, jugular venous
distention, and hypotension—describe the classic presentation
of pericardial tamponade. Kussmaul's sign—jugular venous
distention upon inspiration—may also be seen in pericardial
tamponade but is frequently absent (sensitivity,
10%-20%).(5) It
is unclear if these findings were assessed or observed in our
patient's case. The fourth step in the initial assessment is a
brief neurological examination (D = disability) to determine level
of consciousness, pupillary response, and motor and sensory
strength. The primary purpose for this is to assess for head or
spinal cord injury.

The fifth and final step of the
initial assessment for every trauma patient would have been the key
to our patient's diagnosis, and that step was missed. The fifth
step is E for exposure and the environment. In the ED, this means
completely undressing the patient and log-rolling her onto her side
to examine both the back and the total body from head to toe, while
maintaining normothermia. In the prehospital setting, it means
being aware of the situation and circumstances and then looking
closely at the patient, her clothes, and the setting for hints
regarding the mechanism of injury. The presence of a penetrating
wound in the "cardiac box" (roughly defined as that area of the
anterior thorax bordered by the sternal notch superiorly, the
nipples laterally, and the xiphoid inferiorly) should have raised
the suspicion for cardiac tamponade as the primary cause of shock
in this patient.

Although cardiac tamponade was
described as universally fatal in the earliest medical writings (by
the likes of Hippocrates, Ovid, Celsus, and Aristotle) (6),
modern studies have found a reasonably high survival rate for
penetrating cardiac wounds treated aggressively and promptly with
volume resuscitation, pericardial decompression (needle aspiration
or formal pericardiotomy), and direct repair of the cardiac
wound—all without cardiopulmonary bypass. In fact, survival
rates in modern urban trauma centers for patients with stab wounds
to the heart who present in extremis or full arrest range from 30%
to 70%.(7)
Survival rates for patients with gunshot wounds are lower, and for
the rare patient with blunt trauma–induced cardiac rupture,
even lower (less than 5%). Nonetheless, patients with penetrating
cardiac wounds who have some sign of life at the time of EMS
arrival (pulse, respiration, blood pressure, organized cardiac
rhythm) and who can be transported to a trauma center expeditiously
should undergo resuscitative thoracotomy, as this heroic maneuver
can result in dramatic saves.(8)

The scenario depicted in this
case (missed penetrating cardiac wound) is so infrequent as not to
make a top-ten list of mistakes in trauma care. In fact, the
opposite scenario is more common: a patient who has
suffered a primary cardiac or neurologic event is mislabeled as a
trauma patient. But other errors in trauma care are even more
common. Missing an acute arrhythmia that leads to an automobile
crash probably tops this list, followed closely by missing a
transient neurologic event that precipitates a fall. These cases
often lead to full trauma alerts, accompanied by many mobilized
resources, followed by total body imaging and aggressive
resuscitation. Ultimately, caregivers realize that there are no
injuries and then move on to look for other, medical,
causes.

Other common errors in trauma
care involve missed injuries. For example, many injuries are
discovered in a delayed evaluation after 24-48 hours in the
hospital, during what has been called the "tertiary survey." Small
bone fractures, sprains, and ligamentous injuries dominate this
group. Hollow viscous (bowel) injuries following blunt torso trauma
occur in perhaps 1% of blunt trauma patients. In adults, failure to
diagnosis such injuries early carries dire clinical consequences
with significant morbidity and even mortality. In evaluating the
extent of injury after penetrating wounds, we continue to be guided
by an old saw, "there must be an even number of
holes"—meaning that an entry wound needs to be accompanied by
an exit wound. Tracking the offending agent from entry to exit or
termination is the best assurance of not missing any
injuries.

Take-Home
Points

The take-home messages from this rare care are
two:

  • A complete physical examination
    remains a key and fundamental component of the work-up for any
    patient in extremis. Systematically searching the entire body for
    signs of injury, infection, inflammation, foreign bodies, or other
    evidence of illness or injury is essential.
  • The "ABCs" of trauma assessment and
    resuscitation hold as true in the field as they do in the ED. If a
    patient is not responding as expected, go back to "A" and start
    over again looking for the reason.

Gregory J. Jurkovich, MD
Professor of Surgery, University of Washington
Chief of Trauma, Harborview Medical Center

References

1. Haddon W Jr. The changing approach to the
epidemiology, prevention, and amelioration of trauma: the
transition to approaches etiologically rather than descriptively
based. 1968. Inj Prev. 1999;5:231-235. [go to
PubMed]

2. Stedman's Medical Dictionary. 22nd ed.
Baltimore, MD: Williams & Wilkins; 1972.

3. Prehospital Trauma Life Support Committee
of the National Association of Emergency Medical Technicians.
PHTLS: Basic and Advanced Prehospital Trauma Life Support. 5th ed.
St Louis, MO: Mosby; 2003.

4. American College of Surgeons Committee on
Trauma. ATLS: Advanced Trauma Life Support for Doctors. 7th ed.
Chicago, IL; 2004.

5. Asensio JA, Garcia-Nunez LM, Petrone P.
Trauma to the heart. In: Feliciano DV, Mattox KL, Moore EE, eds.
Trauma. 6th ed. New York, NY: McGraw Hill; 2008.

6. Asensio JA, Petrone P, Pereira B, et al.
Penetrating cardiac injuries: a historic perspective and
fascinating trip through time. J Am Coll Surg. 2009;208:462-472.
[go to
PubMed]

7. Powell DW, Moore EE, Cothren CC, et al. Is
emergency department resuscitative thoracotomy futile care for the
critically injured patient requiring prehospital cardiopulmonary
resuscitation? J Am Coll Surg. 2004;199:211-215. [go to
PubMed]

8. Hopson LR, Hirsh E, Delgado
J, et al. Guidelines for withholding or termination of
resuscitation in prehospital traumatic cardiopulmonary arrest. J Am
Coll Surg. 2003;196:475-481. [go to
PubMed]