TraumaBlast InjuryCardiologyPOCUSShockProcedures

History of Present Illness

Patient is a 34-year-old male who was packing class B fireworks launch tubes into a van when an explosion occurred. He was launched 10-15 feet across a garage, striking a rolled-down garage door frame. He presents with a large bleeding scalp laceration, chest pain, and tinnitus.

Patient Presentation — Dante arriving in the ED with a large, actively bleeding scalp laceration. A large scalp laceration can cause significant blood loss, but in the context of a blast injury, the external bleeding is secondary to evaluating potential internal injuries from the blast overpressure wave.

Emergency Department Course

Initial Assessment & Stabilization

00:15:35S02E12Trauma Bay

BP: 130/85, HR: 108…Dr. Robinavitch, Dr. Santos +2 more

Trauma arrival following blast injury.

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Medical Decision Making

Blast injuries can cause primary (overpressure wave), secondary (shrapnel), tertiary (thrown into objects), and quaternary (burns) injuries. The team must rapidly rule out internal bleeding and air-filled organ rupture. Brisk bleeding from the scalp requires rapid hemostasis to safely transport the patient to CT.

DDx

Traumatic Brain InjuryPneumothoraxCardiac ContusionInternal Hemorrhage

Diagnostics & Findings

Primary Survey
E-FAST Exam (Negative for pericardial effusion or free fluid in belly)

Findings:

Airway and breathing intact
Good lung sliding bilaterally
Tenderness over sternum (suspected fracture)
Deep scalp laceration through the galea

Interventions

Administered 50mcg Fentanyl
Raney clips applied to scalp for rapid hemostasis
Sent to CT scan

⮑ Outcome & Reassessment

Bleeding temporarily controlled; hemodynamically stable for CT transport.

Clinical Media

**Initial bedside E-FAST exam.**A negative initial E-FAST suggests no immediate, life-threatening internal hemorrhage or pericardial effusion upon arrival, establishing a baseline.

**Anatomical diagram of the 6 standard ultrasound probe placements used during an E-FAST exam.**The E-FAST systematically evaluates for life-threatening free fluid (blood) and air in the trauma patient. Positions 1-4 (Pericardium, RUQ, LUQ, Suprapubic) assess for cardiac tamponade and intra-abdominal hemorrhage. Positions 5-6 (Right and Left anterior thoracic) are the 'Extended' views evaluating for pneumothorax (lack of lung sliding) or hemothorax.

Post-CT Review & Procedure

00:24:00S02E12Treatment Room

StableDr. Robinavitch, Dr. Yolanda Garcia +2 more

Patient returns from CT for definitive wound closure.

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Medical Decision Making

CT confirmed an isolated sternal fracture without intracranial hemorrhage. The deep scalp laceration can now be closed definitively. Given the mechanism of blunt cardiac trauma, the patient requires overnight observation for delayed dysrhythmias or complications.

DDx

Myocardial ContusionDelayed Intracranial Hemorrhage

Diagnostics & Findings

CT Abdomen/Pelvis/Head/Chest

Findings:

Isolated sternal fracture
No skull fracture
No intracranial hemorrhage

Interventions

Administered 4mg Morphine
Local anesthesia (1% Lidocaine with Epinephrine)
Three-layer scalp closure (galea, sub-Q, skin staples)

⮑ Outcome & Reassessment

Patient is conversational, complains of chest pain with movement, but remains hemodynamically stable.

Clinical Media

**Three-layer closure of the scalp laceration.**The galea aponeurotica must be repaired in deep scalp lacerations to prevent subgaleal hematomas and ensure proper cosmetic and functional healing.

**Schematic diagram of the SCALP layers illustrating the anatomy relevant to a deep laceration repair.**A deep scalp laceration extending through the epicranial aponeurosis (the 'A' in SCALP, or galea) requires a layered closure. Suturing the galea relieves tension on the skin, prevents the wound edges from retracting widely, and limits the spread of infection or formation of a subgaleal hematoma within the loose areolar connective tissue.

Clinical Deterioration & Resuscitation

00:36:19S02E12Treatment Room

BP: 78 systolic (dropping to 64 systolic)Dr. Robinavitch, Dr. Yolanda Garcia +2 more

Patient complains of severe chest pain and rapidly becomes hypotensive.

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Medical Decision Making

Sudden profound hypotension with JVD and clear lungs strongly suggests obstructive shock (Cardiac Tamponade or Tension Pneumothorax). An immediate bedside echo is required. Once tamponade is confirmed, emergent pericardiocentesis is life-saving. Ketamine is chosen for sedation to preserve sympathetic drive and avoid further cardiovascular collapse. An apical approach is selected for the needle to minimize distance to the fluid collection under direct ultrasound visualization.

DDx

Cardiac TamponadeTension PneumothoraxMassive Hemorrhage

Diagnostics & Findings

Bedside Echocardiogram

Findings:

Jugular Venous Distension (JVD)
Pericardial effusion with Right Ventricular (RV) diastolic collapse
Systolic BP dropped to 64 mmHg

Interventions

500cc IV fluid bolus
100% O2 via Non-Rebreather mask
0.5 mg/kg Ketamine IV for procedural sedation
Ultrasound-guided pericardiocentesis (apical approach)
Placement of J-wire and indwelling pericardial catheter with 3-way stopcock

⮑ Outcome & Reassessment

Removal of 40cc of blood resulted in immediate hemodynamic improvement. Systolic BP rose to 90 mmHg, and carotid pulse strengthened. Patient stabilized for transport to the OR.

Clinical Media

**Ultrasound showing a pericardial effusion with RV collapse.**Right ventricular free wall diastolic collapse is a highly specific echocardiographic sign of cardiac tamponade, necessitating immediate decompression.

**Dr. Santos performing an ultrasound-guided apical pericardiocentesis under supervision of Dr. Robinavitch.**Using real-time point-of-care ultrasound (POCUS) allows for direct visualization of the needle tip entering the pericardial effusion. This dramatically reduces the risk of iatrogenic complications such as myocardial puncture, pneumothorax, or coronary vessel laceration compared to blind landmark techniques.

**Diagram illustrating the three common approaches to pericardiocentesis: Parasternal (A), Substernal/Subcostal (B), and Apical (C).**While the subcostal (substernal) approach is traditionally taught for blind or landmark-guided pericardiocentesis, point-of-care ultrasound allows physicians to utilize the apical approach safely. As Dr. Santos notes, the apical approach often provides a shorter distance with fewer intervening structures. If the fluid pocket is visualized directly lateral to the probe at the apex, the needle path is direct, minimizing the risk of inadvertent myocardial or hepatic injury.

**Placement of an indwelling pericardial catheter with a three-way stopcock following the initial aspiration.**Because the patient has an active myocardial tear (right atrium) secondary to the blunt trauma, the pericardial space will quickly refill with blood. Advancing a catheter over a J-wire and leaving it in place allows the team to continuously or repeatedly drain re-accumulating blood, preventing recurrent tamponade while bridging the patient to definitive surgical repair in the OR.

Diagnoses & Disposition

Evolving Diagnoses

[Trauma Bay]Deep Scalp Laceration
[Post-CT Review]Isolated Sternal Fracture
[Crash Assessment]Cardiac Tamponade secondary to traumatic Right Atrial tear

Current Disposition

Admitted to Operating Room (Cardiothoracic Surgery) for definitive repair of right atrial tear.

Casebook Analysis

Episode Context

Dante serves as the high-stakes, end-of-shift 'crash' patient. His sudden deterioration delays Dr. Robby from leaving the hospital on time and provides a high-stress teaching moment for Trinity Santos, who successfully performs an apical pericardiocentesis under pressure.

Attending's Review

Medical Accuracy

The presentation of delayed cardiac tamponade from a blunt sternal fracture (causing a slow right atrial tear) is medically accurate and a known pitfall in trauma. Using Ketamine for procedural sedation in a hemodynamically unstable patient is a smart choice, as it relies on catecholamine release to support blood pressure, unlike Propofol which would cause a lethal drop. The apical approach for pericardiocentesis, while less standard than the subxiphoid approach, is acceptable and sometimes preferred when using direct ultrasound guidance if the fluid collection is closest to the apex.

Complications & Errors

The initial assessment correctly cleared the patient based on a negative FAST and CT, but blunt cardiac injury can have delayed manifestations. The team properly decided to observe him rather than discharge him, which ultimately saved his life.

Clinical Pearls

Beck's Triad (Hypotension, JVD, and Muffled Heart Sounds) is the classic presentation for Cardiac Tamponade. In the ED, ultrasound is faster and more reliable than listening for muffled heart sounds.

A negative FAST exam on arrival does not rule out evolving hemorrhage. Serial examinations are crucial, especially in high-energy mechanisms like blast injuries.

Ketamine is the induction agent of choice in hypotensive/shocked patients requiring sedation, as it generally preserves or elevates blood pressure through sympathetic stimulation, though extreme caution must still be used in severe cardiogenic or obstructive shock where catecholamines are already maxed out.

Deep scalp lacerations that violate the galea aponeurotica will gape widely due to the antagonistic pull of the frontalis and occipitalis muscles. Suturing the galea is essential to relieve tension on the skin and allow for proper wound approximation.

A proper multi-layer closure of the scalp prevents the formation of a subgaleal hematoma. It also seals off the 'danger zone' of the scalp (the loose areolar connective tissue layer), preventing superficial infections from spreading via emissary veins into the intracranial dural venous sinuses.

Using staples for the outermost skin layer of the scalp is often preferred in the ED because it is faster than suturing, causes less damage to hair follicles, and reduces the risk of localized tissue ischemia.

In acute traumatic cardiac tamponade, the pericardial sac is stiff and does not have time to stretch. Removing even a small volume of fluid (as little as 20-50 cc) can dramatically decrease intrapericardial pressure and restore cardiac output.

When performing emergency pericardiocentesis for a suspected active bleed (e.g., atrial or ventricular tear), placing an indwelling catheter with a three-way stopcock is critical. This allows for repeated drainage of re-accumulating blood to bridge the patient to definitive surgical repair.

POCUS has revolutionized pericardiocentesis. Instead of relying solely on the traditional blind subxiphoid landmark approach, clinicians can now scan to identify the largest fluid pocket closest to the chest wall, frequently making an apical or parasternal approach safer and more direct.