Circulation Cardiovascular Case Series

An obese but otherwise healthy 53-year-old man was unloading a delivery van when he was struck from behind by a slow-moving garbage truck, pinning him between the 2 vehicles. The patient was lying supine on the ground when emergency medical services arrived. He was alert and oriented with a Glasgow Coma Scale score of 15. The patient was complaining of pain in his right upper extremity and numbness in his left foot. His initial vital signs were notable for a heart rate of 100 bpm; his blood pressure was 150/90 mm Hg; and his breathing was elevated at 22 breaths per minutes. The patient denied loss of consciousness and had no neck, back, or chest pain. Per emergency medical services, the patient’s midchest appeared erythematous and his left lung field was coarse on auscultation, and he had a small abrasion on his left knee. The rest of his in-the-field examination was unremarkable. A cervical collar was placed, and the patient was placed on a back-board for transport. The patient’s vital signs remained stable en route per the emergency medical services’ report, although he became increasingly anxious and repeatedly removed both his cervical collar and a nonrebreather mask that had been placed empirically. On arrival in our trauma bay, the patient was found to be in shock: pulse rate, 129 bpm; blood pressure, 69/51 mm Hg; respiratory rate, 20 breaths per minute; and O 2 saturation, 80% on room air. He remained awake with a Glasgow Coma Scale score of 15 but now was complaining of difficulty breathing and of right-sided chest and back pain. His primary survey was notable for rhonchorous breath sounds bilaterally and right-sided chest wall crepitus; his abdomen was soft and had no peritoneal signs. The patient remained tachycardic, but his blood pressure improved to 127/113 mm Hg as 2 L crystalloid and 1 U red blood cells were given in bolus. His O 2 saturation improved to 96% on a nonrebreather mask providing O2 at 15 L/min. His initial ECG demonstrated sinus tachycardia with questionable electric alternans in leads V1 and V5 (Figure 1). The patient’s focused assessment with sonography for trauma (FAST) examination was unremarkable. A chest radiograph revealed extensive right subcutaneous emphysema, multiple right lateral rib fractures, a small rightsided apical pneumothorax, and bilateral patchy opacities consistent with pulmonary contusion or hemorrhage. His cardiomediastinal silhouette was normal (Figure 2A). A pelvic radiograph was negative for injury. A right chest tube was inserted with minimal serosanguinous output (Figure 2B), and a Foley catheter was placed.