This is the third case in a series looking at critical care medicine. Patients under the care of the critical care team may develop delayed complications of their illness or injuries. These cases can help individuals and teams prepare to identify and manage these patients who become newly, and sometimes unexpectedly, unstable.
This case comes from Dr. Dominique Piquette, academic Intensivist at Sunnybrook Hospital in Toronto, Ontario with updates from Dr. Sameer Sharif (Hamilton Health Sciences, Hamilton, Ontario) and Dr. Sophie Ramsden (Emergency Medicine Resident, McMaster University, Hamilton, Ontario)
Why it Matters
Major trauma patients sometimes decompensate after initial resuscitation. A detailed re-examination is important as the decline can be caused by an injury that was identified or missed in the initial stabilization phase. Delayed (but still early) development of shock in a trauma patient has the same differential differential diagnosis as during the primary survey but the treating clinician needs to be vigilant to avoid early diagnostic closure based on lab and imaging results that have been completed.
Clinical Vignette
A 46-year-old woman pinned between truck and car has been resuscitated in ED and multiple injuries were identified, including bilateral rib fractures with flail chest, liver laceration and unstable T5-6 fractures with reduction of canal diameter. ICU has admitted the patient while she awaits OR later today to stabilize the spine.
Case Summary
A 46-yearold female pedestrian struck by a truck is admitted to ICU with multiple injuries, including a thoracic spinal cord injury, a right flail chest and pneumothorax, and a liver laceration. While awaiting OR for spinal stabilization, she decompensates into mixed respiratory failure and hemodynamic instability. She will require ventilatory support, escalation of vasopressors, and will develop a tension pneumothorax post-intubation.
EM Sim Cases 