Blast Injuries Case 3

You are on duty in the ED one evening when the fire brigade declare a major incident.

There has been an explosion in a new nightclub and you are assigned to the resuscitation room.

A 22-year-old man is brought in to the department. He is conscious and talking in short sentences. He tells you that he was standing very close to the stage when something under the stage appeared to explode.

He was thrown backwards by an estimated 20 feet, landing heavily on his side. He has trouble hearing your questions but appears fully orientated…

You perform your primary survey:

A: The patient is talking to you with three-point cervical spine control in place and he is receiving high-flow oxygen via a reservoir bag.

B: His oxygen saturations are 96% and the respiratory rate is 22 breaths per minute (bpm). His chest is quiet throughout and you cannot hear any added sounds. There is no external evidence of injury to the thorax.

C: He is warm and well-perfused with a blood pressure of 110/86. His abdomen is soft but minimally tender around the umbilicus. Bowel sounds are present. There is no evidence of long-bone fracture.

D: He is GCS 15/15 with equal and reactive pupils and on log-roll has no external evidence of injury to the occiput, no step or deformity to the spine and a normal PR examination.

E: There are multiple wounds to the limbs, none of which appear to be bleeding profusely.

What should you do next?

The pelvic x-ray is normal.

The chest x-ray reveals bilateral opacification in a perihilar distribution (butterfly distribution).

Click on the x-ray to enlarge.

Which of the following statements is correct?

The patient now complains that he is feeling very breathless. His respiratory rate has increased to 36 bpm and his oxygen saturations have fallen to 93% on high-flow oxygen via a reservoir bag.

He looks grey and is very distressed. Re-evaluation of his chest again reveals quiet breath sounds bilaterally but you can now hear bilateral coarse crepitations.

Arterial blood gases are as follows:

• pH 7.34
• pO² 7.6
• pCO² 3.7
• HCO³ 21.6
• BE -5.2

Should you prepare to intubate the patient or not, and why?

After explaining to the patient what is about to happen, you intubate him with no immediate complications.

You observe bilateral chest wall movement, can hear breath sounds both sides and the patient has a normal end-tidal CO2 trace. You have established ongoing sedation and paralysis. You are adjusting the settings on the ventilator.

As he was hypoxic, should you ensure he receives a high PEEP and 10 ml/kg via volume-controlled ventilation, or not, and why?

You have stabilised the patient on the ventilator and have organised a CT scan of the thorax, abdomen and pelvis.

You are on the telephone referring your patient to the ITU receiving doctor when the resuscitation room nurse calls you over to your patient. She says the ventilator is starting to alarm "high airway pressure".

Should you alter the alarm settings on the ventilator or not, and why?

You review your patient. The endotracheal tube remains secured at 24 cm at the teeth. There is misting of the tube with each breath. There is no obstruction of the ventilator tubing.

On examination of the patient, the oxygen saturations are 91% on 100% oxygen. The right hemithorax appears to move less with each breath than the left and is quieter on auscultation.

The patient feels cool peripherally and the non-invasive blood pressure reads 92/48.

What is your next course of action?

On review, your patient's trachea is deviated to the left with hyperresonance on the right.

You perform a needle decompression and hear a satisfying hiss of air. The oxygen saturations return to 97% on 100% oxygen and the right hemithorax moves with respiration. The blood pressure improves to 103/62.

You perform a right-sided large-bore tube thoracostomy with no immediate complications.

Which of the following would you like to happen prior to transfer to ITU?