Hot Seat #194: A Pedestrian Pickle

Posted on: August 29, 2022, by :

You receive a call from EMS, who is on-scene with a 13-year-old female who was a pedestrian struck by a car reportedly traveling at 15mph, requesting assistance with destination. She is amnestic to the event. EMS reports that she is currently ambulatory, alert, and oriented. She sustained lacerations to her face and is complaining of left shoulder pain. Vital signs are: HR 75, BP 120/73, RR 16, 98% on RA. IN fentanyl was given. They are 5 minutes from the community ED and 20 minutes from your trauma center.


You advise EMS to bring the patient to your institution as a basic trauma activation. On initial assessment:

HR 87, BP 114/76, RR 14, 100% on RA, T 36.9C

Primary survey:

  • Airway patent. Multiple teeth are missing, luxated, and fractured with bleeding in the mouth
  • Breathing spontaneously, not labored. CTAB with symmetric chest rise
  • Circulation: 2+ radial/DP pulses, skin is warm, no obvious external hemorrhage
  • Disability: Alert, GCS 15, PERRL, 3mm b/l

Secondary survey:

  • Gen: Crying appropriately, consolable/directable
  • HEENT: 10cm full thickness laceration to R side of face extending from forehead to jawline involving fascia/muscle. 4cm laceration to L side of forehead. Nasal bridge swelling with active bleeding from b/l nares. In addition to dental injuries, several buccal mucosal lacerations are present
  • Neck: C-collar in place
  • Chest: RRR w/o murmur/gallop. CTAB. No chest wall crepitus or TTP
  • Abd: s/nt/nd
  • GU/rectal: normal w/o blood at the meatus. Adequate rectal tone
  • MSK: focal swelling/TTP of the L shoulder. Spine well-aligned w/o focal midline TTP/stepoffs
  • Neuro: no deficits. Sensation intact

Basic trauma labs are ordered and normal. CT head shows no acute intracranial process. In addition to the dental injuries, CT max/face shows nondisplaced right maxillary fracture and multiple displaced comminuted fractures of the nasal bones. CT C-spine is normal. L humerus XR shows a displaced Salter-Harris type II fracture of the proximal humerus. Plastic surgery, dentistry, and orthopedics are consulted. They request a coordinated ketamine sedation in order to sequentially perform their respective repairs.

The decision is made to forego ketamine sedation in the ED. With morphine as needed, plastic surgery is able to perform facial repair, dentistry splints the remaining teeth, and orthopedics performs minimal reduction and applies hanging cast to the left arm. With nasal packing, epistaxis resolves and nasal repair is scheduled for later in the week.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Harrison Hayward
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1 thought on “Hot Seat #194: A Pedestrian Pickle


  1. For the question of destination, I would ask for the community ED physician to make a joint decision. As it turns out, this adolescent would have required transfer. But the extent of injuries wasn’t clear from the EMS report. Good call!
    For the question of sedation, the questions for our colleagues are how much pain and for how long? The answers guide the choice of sedation. The attendings seemed to move away from ketamine, or any sedation, because the facial fractures would make bagging and getting a good seal more challenging. It seems that the better choice was to not sedate but provide analgesia and local anesthetic.
    The injuries sound painful!

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