A 23-year-old male is found at an outdoor skate park after calling 911 because he was concerned that he broke his arm after falling on an outstretched hand while inline skating. The patient complains of severe pain of the wrist with visible deformity of the distal right forearm. He was wearing a helmet but no wrist guards. He denies striking his head and has no neck nor back pain. He denies previous injury and explains that a pebble on the sidewalk caused him to fall. Subsequent to the fall, the patient states that he became very lightheaded and nauseated. His vision became fuzzy, which he described as “tunnel vision,” and states that his ears began to ring before he passed out. He thinks he lost consciousness because of the severe pain. The feeling of lightheadedness and “fainting” has happened to him before, even with minor injuries and once when donating blood. Bystanders state that the patient’s whole body shook about 4 or 5 times when he passed out, and he was unconscious for only a few seconds. He was not confused upon awakening.
He has no significant past medical history.
He does not smoke.
Vital signs: HR 65, BP 90/72, RR 16, SpO2 99% on room air.
Examination reveals a young, age-appropriate male in significant distress. He is awake and alert, without confusion. He appears pale and mildly diaphoretic. Examination of the head reveals no abrasions, lacerations, edema, or ecchymosis. A bicycle helmet is still in place and appears undamaged. The pupils are equal and 4 mm. There is no ear or nasal discharge, no loose or missing teeth, and no bite marks on the tongue. Neck reveals no cervical spinal tenderness, step-off, or deformity. The patient has no apparent range of motion limitation of the neck. Lungs are clear. Cardiac exam reveals a regular rate and rhythm. Abdomen is soft, nontender, and without ecchymosis. His back reveals no midline tenderness, step-off, or deformity. There is no ecchymosis of the flank. Pelvis is not tender. Examination of the right arm reveals a dorsal deformity of the distal forearm with associated tenderness. Distal pulses are full and capillary refill is brisk. Sensory function is grossly intact. The remainder of his extremities have full range of motion and are without evidence of injury.
1. Fractured arm with subsequent vasovagal syncope
2. Cardiac arrhythmia causing a syncopal episode leading to fall and subsequent fractured arm
3. Mechanical fall with closed head injury leading to a brief loss of consciousness
4. Seizure leading to fall and subsequent fracture
The patient’s right forearm was immobilized in a commercial splint. Voids were padded, and the hand was placed in a position of function. Neurovascular integrity was assessed both before and after splint placement and was intact. An ice pack was placed. The patient reported significant pain relief at that point. No other injury was identified on examination. The patient was placed in a supine position and reported significant improvement of his lightheadedness. His pallor and diaphoresis resolved. His vital signs were reassessed, and his blood pressure was 122/76 with a heart rate of 82 and respirations of 16. Advanced life support (ALS) was initially considered for pain management and for syncope; however, the patient reported adequate pain control after immobilization and the syncope was felt to be vasovagal in nature. The patient was transported to the emergency department without incident where his fracture was subsequently reduced and splinted, and he was discharged for outpatient orthopedic follow-up.
Key Management Steps
1. Assess for neurovascular integrity before and after splint placement.
2. Maximize basic life support (BLS) pain management with optimal immobilization and cold packs.
3. Look for evidence of other trauma, not just what is initially obvious.
4. Consider all causes of syncope and do not prematurely assume a vasovagal etiology.
The importance of prehospital BLS is often minimized or completely overlooked, but these interventions may have a significant effect on the patient’s course. Knowing the basics and implementing them well is applicable whether you are a first responder in the field or an attending physician in a tertiary care center. In this case, the patient had a very painful angulated forearm fracture.
Often, a cursory splint is applied, and the patient is given opioid pain medication. In this case, the responding ambulance crew was trained and equipped at the BLS level. Calling an ALS unit for a rendezvous is a valid consideration for patients with uncontrolled severe pain. Even in cases of relatively short transport times, there can be a significant delay before the patient receives analgesia after arrival in the emergency department. Pain medication administered by emergency medical services can greatly reduce time to adequate analgesia even if the medication is given in close proximity to the hospital. Adequate pain management, however, does not necessarily require parenteral opioids. Proper immobilization and the placement of a cold pack can have a significant effect on the level of pain. Even small movements of the sharp bone fragments can be excruciating. Don’t overlook these simple steps, especially in the field environment or any other time when it is necessary to move the patient.
In this case, this BLS crew utilized a commercial splint. Depending on the particular splint used, one may presume that the splint simply has to be applied and secured without any other intervention. Figure 12.1 depicts a simulated angulated fracture with a commercial splint. If the device was simply secured with the hook and loop fasteners, optimal immobilization would not be achieved. Figure 12.2 illustrates that sufficient padding and placing the hand in the position of function is necessary to provide the proper support to achieve maximal effect of the splint. Note that the hook and loop fasteners in this case had to be reinforced with tape because the padding rendered the native fasteners too short (Figure 12.3).
The patient also presented with a brief episode of unconsciousness. Syncope has many worrisome etiologies, and in any acute care situation, it is always crucial to consider the worrisome potential causes of the patients’ presentation rather than hastily settling on what might be the most likely cause. It is a common pitfall in acute care to misinterpret the patient’s findings as something benign when there is a more serious underlying process. Like uncontrolled severe pain, syncope is also a valid reason for a BLS crew to consider calling an ALS unit. Excluding worrisome etiologies does not always require advanced tests, but it does require careful history taking and decision-making.
In this case, the patient is a young, healthy male without a significant past medical history, such as an arrhythmia (like Wolf-Parkinson-White syndrome) or diabetes (suggesting the possibility of hypoglycemia). Furthermore, the symptoms followed the classic pattern of vasovagal syncope: a severe pain trigger with a prodrome of lightheadedness, nausea, “tunnel vision,” and tinnitus prior to losing consciousness. There was no evidence of head trauma on examination, and the history clearly indicates a mechanical etiology of the fall that is spontaneously recalled by the patient.
As vasovagal syncope is mediated by inappropriate vagal or autonomic tone, it is often associated with bradycardia and hypotension (secondary to vasodilation). Even though the patient appeared to be in significant pain, his initial heart rate was not tachycardic. This is consistent with his persistent vagal signs of mild hypotension, pallor, and diaphoresis. As with any instance of hypotension, the patient should be positioned appropriately. Simply having the patient lie flat will facilitate cerebral blood flow and decrease symptoms of presyncope. In this case, on reassessment after positioning the patient supine, his heart rate and blood pressure improved and his vagal symptoms resolved. If a patient is unresponsive, placing the patient in the recovery (lateral recumbent) position has the added benefits of reducing the potential of aspiration of fluid into the lungs and keeping the airway open. In at least 1 study, the simple act of placing an unresponsive child in the recovery position was associated with a reduced rate of hospital admission.1
Besides syncope, other etiologies such as seizure must be considered. Bystanders noted that the patient’s whole body shook 4 or 5 times after he passed out. These myoclonic jerks are common with syncope and are often misinterpreted as seizure activity, especially by laypersons.2 Other clues of generalized seizure activity, such as tongue biting and a postictal period of confusion, are also absent.
1. Julliand S, Desmarest M, Gonzalez L, et al. Recovery position significantly associated with a reduced admission rate of children with loss of consciousness. Arch Dis Child. 2016;101:521–526.Find this resource:
2. Josephson Syncope Convulsions (web video). YouTube. December 30, 2014. https://youtu.be/YaktxCXiUyY
Costantino G, Sun BC, Barbic F, et al. Syncope Clinical Management in the Emergency Department: A Consensus From the First International Workshop on Syncope Risk Stratification in the Emergency Department. Eur Heart J. 2016;37(19):1493–1498.Find this resource:
Limmer D, O’Keefe MF. Musculoskeletal injuries. In: Limmer D, O’Keefe MF, eds. Emergency Care. 11th ed. Upper Saddle River, NJ: Pearson Education; 2009: 700–713.Find this resource:
Qiunn J. Syncope. In: Tintinalli JE, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011: 360–365.Find this resource: