Approach to Improving Safety
Setting of Care
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 CommentaryFailure 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.
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
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.
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.
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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]
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