74 yo Male MVC

[pbruss]

74 yo male comes in by EMS as a level 1 trauma after MVC. Driver, not restrained, airbag deployment, moderate damage to car, no LOC, complanes of CP and feeling lightheaded.

AAOx3 no distress on backboard and c-collar, complaining of "a little bit of pain in my chest". BP- 90/60, P-50's and irregular, R-14, T-98.6

Exam - moderatly tender contusion to sternum that reproduces his chest pain, no other signs of trauma. lungs and heart both sound normal. everything else is normal.

Trauma  gets CT from head to toe that shows a non-displaced sternal fracture. NO pneumo/hemothorax or pericardial efusion or other traumatic injuries of the brain , spince, chest, abd, pelvis or exts.

pt remains hypotensive and bradycardic - surgeon wants a pressor started. you get more historu form pt and family who say he has "an abnormal heart beat" and low ejection fraction for which he recently had a pacemaker placed. attached is his chest x-ray. and ekg. (i appoligise about the quality, they are form Lima's computersystem)

Is there anything you can do at the bedside that would be diagnostic and theraputic?

Attachments:

[Bjs04f]

So pretty concerned based on trauma, with sternal fracture showing significant thoracic trauma. In addition EKG is showing slurred S wave which can be seen in RBBB as well as cardiac rupture with tamponade. looking at CXR there is widening of the mediastinum with displacement of the pacemaker lead leads me to worry he has R ventricular injury with tamponade. CT is pretty sensitive for pneumo and hemothorax, so less worried about that. Id go ahead and bedside echo, or if hes really in trouble do a pericardiocentesis ( mainly because I want to do one).

[pbruss]

good thought process. however, echo shows no effusion, no tamponade, no collapse of right ventricle durring diasystole, no focal abnormalities in wall motion. does show reduced EF and global hypokensis which is from his underlying heart disease not an acute injury.

he remains brady and hypotensive but stable. there is something else to do that could increase the effency with which his heart is beating.

[Bjs04f]

So then the decision now is this cardiogenic or hypovolemic. WE did the echo, how did the IVC look? We could add dobutamine if the MAP can tolerate it, if not begin fluid resuscitation.

[pbruss]

your on the right track but your thinkg to hard. IVC was fine - no collapse. things are pointing to cardiogenic. you could do dobutamine which the trauma surgeon was pushing for biut there is something else a lot simpler to do. Take another look at the EGK namely the P waves. How do they look to you

[Bjs04f]

in lead II I think Im seeing a lot of non conducted P waves. Could try pacing him, see if this is complete heart block which would explain the need for pacemaker. Do some overdrive pacing see what happens.

[pbruss]

close enough. the ekg shows his pacer is not working, the CXR leads me to believe it waqs damaged in the accident. we could place a transvenous pacer or transcutaneously pace. but there is something a lot simpler to do. put a magnet over the pacer which tells it to overdrive pace at a set rate without sencing. thats what we didi and it worked great. see attached EKG with the magnet on

Attachments:

[Bjs04f]

Close enough works for me, interesting case. The CXR looks awful

[kemple]

Good case. Can't say I would have thought to use the magnet there.