Disagreement on a scenario

[ironguy321]

since my friend and I have not been hired yet as EMT-B's (we're both in firefighter school) we always drill each other on different scenarios. We were drilling each other last night when we came up with a scenario we disagree on:

You have a 25 year old male who is unresponsive. No medical history, medication bottles., bystanders, bracelets, etc. around; just a dark alley and an unresponsive man. He has a stab wound to his upper right abdomen. Vitals are respirations 8 shallow, Blood pressure is 100/60, pulse is 126 rapid, skin is cool. What do you do?

My response: Get him onto the ambulance and use a BVM at 100% oxygen. Request ALS. Once they arrive, patch up the wound, have the medic start an IV, continue to use BVM.
Friends response: Have your partner use a BVM 100% oxygen while you patch up the wound on scene. Load and go. No need for ALS.

What would you do in this situation?

 

[Ridryder911]

First what is the response time of ALS, second what type of services are provided by the ED and the response time to the ED. The correct answer is dependent upon more information.

If there is a close ALS response, or the ED is delayed or not rated accordingly to Level II or I , then I would await for ALS. Since the patient has to be ventilated the patient needs secure airway, as well possible fluid and IV access, while enroute.

Another alternative answer is meet and rendezvous with the ALS unit, so both of you are correct.

p.s.. the patient does need ALS.


R/r 911

 

[Asclepius]

You need to implement shock protocol. Get the patient in a trendelenburg position. Initiate an ALS intercept. Begin transport immediately. Of course, you should have taken spinal precautions. What are the patients lung sounds? Is he moving air on the right side? Is the wound sucking? I know you said abdomen, but where at on the abdomen? What is skin condition? Is he perfusing with the amount of air he is moving? Definately assist his respirations. If the patient is unresponsive some kind of airway adjunct is appropriate.

There is no question that this is a load and go scenario. Treatment is supportive and should be focused on definitive care ASAP. Ask for the intercept if your transport time requires it. Can you do glucose monitoring or EKG on your BLS rig? If so, and you have time, those are always a plus.

 

[JPINFV]

You need to implement shock protocol. Get the patient in a trendelenburg position.

I would have to disagree with this treatment. There is very little to no evidence that the trendelenburg position actually increases blood pressure, while some studies points to the position increasing intracranial pressure as well as making breathing more difficult.

 

[Asclepius]

I would have to disagree with this treatment. There is very little to no evidence that the trendelenburg position actually increases blood pressure, while some studies points to the position increasing intracranial pressure as well as making breathing more difficult.

The BP is 100 which is where you want it to stay. You're BLS and so you have nothing to keep the BP at that level except the trendelenburg position. It isn't going to hurt this patient and it might buy you some time until you get the ALS intercept. The patient is already decompensating based on his level of consciousness and intercranial pressure does not seem to be an issue with this patient based on both the MOI and the systolic and diastolic bp.

Whether you do the TP or not, the answer to your question is he does indeed need ALS ASAP. Whether that is in the form of an intercept or a rapid transport to the ED based on distance and time.

 

[JPINFV]

The BP is 100 which is where you want it to stay. You're BLS and so you have nothing to keep the BP at that level except the trendelenburg position. It isn't going to hurt this patient and it might buy you some time until you get the ALS intercept. The patient is already decompensating based on his level of consciousness and intercranial pressure does not seem to be an issue with this patient based on both the MOI and the systolic and diastolic bp.

If it comes between treating my patient's with a technique with, at best, shoddy evidence that also shows harm or not treating a patient past a ride to the hospital or paramedic intercept, then I'll choose the latter. Now, if there are studies that can show that the trendelenburg does increase a patient's blood pressure, then I'm all for it. Until then, it is about time that EMS starts moving towards evidence based practices and away from the dark ages.

Conclusion

The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicine.

Johnson, S., Henderson, S. O. "Myth: The Trendelenburg position improves circulation in cases of shock." Can J Emerg Med 2004;6(1):48-9.

OBJECTIVE: To review the literature on use of the Trendelenburg position as a position for resuscitation of patients who are hypotensive. METHODS: PubMed online, cited bibliographies, critical care textbooks, and Advanced Cardiac Life Support guidelines were searched for information on the position used for resuscitation. Because of the heterogeneity of the data, only pertinent articles and chapters were summarized. RESULTS: Eight peer-reviewed publications on the position used for resuscitation were found. Pertinent information from 2 critical care textbooks and from the Advanced Cardiac Life Support guidelines was included in the review. Literature on the position was scarce, lacked strength, and seemed to be guided by "expert opinion." CONCLUSION: The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.

Bridges N, Jarquin-Valdivia AA. "Use of the Trendelenburg position as the resuscitation position: to T or not to T?" Am J Crit Care. 2005 Sep;14(5):364-8.

If wanted, I'll see if I have access to these journal articles at school and will post them later.

 

[enjoynz]

We were taught to place an unresponsive Pt in the recovery position in the ambulance.
Of course if you are assisting breathing with a BVM, they would be supine!
I agree with the load and go, meet the ALS in route, if you are a distance from hospital.
Also cover the wound before you take off!
Cheers Enjoynz

 

[Grady_emt]

Of course, you should have taken spinal precautions.

Why would you have to take C-Spine precautions. Its an isolated wound to the abdomen? You also have other issues to deal with (resp rate, potentailly becoming hypo-vol.) why waste the time C-spining when the pt needs rapid transport to an appropriate trauma facility with trauma surgeons. I could see possibly throwing him on a LBB for ease of movement from the ground scene and as a hard surface for compressions should he arrest.

Assist breathing, NPA/OPA or Combitube/ETT as tolerated and allowed by protocal
ALS Intercept (dont wait for them, meet them on the way)
Big IV's
Continuous monitoring enroute with rapid transport.

 

[VentMedic]

Why would you have to take C-Spine precautions.

Unwitnessed fall to the ground.

The stab wound may not have been the only injury, especially in a violent attack, but was the most obvious to distract.

Florida case in the 1980s set a precedent. Two private ambulance EMTs got a new career mowing lawns and the hospital had the deep pockets. Fire Rescue Paramedics, who released the patient to BLS transport, had limited liability by being an entity of the government. And, the patient was a quad.

There was also another famous case in NYC involving an intoxicated person falling and suffering a C-Spine fx.

Currently in California, there is a C-spine case involving an elderly person, who had fallen, arriving to the ER by EMS on a back board for a hip fx. No C-spine precautions. It was assumed his decrease in sensation and mobility was from the hip fx and/or old age. He had two C-spine vertebrae broken.

 

[MSDeltaFlt]

These guys are right. ALS unit or Level II/I ER; the closest wins. Package the pt. Leave flat. No Trendelenburg. Bandage the wound. Get an airway. Bag him. Not necessarily in that order.

 

[Asclepius]

Why would you have to take C-Spine precautions. Its an isolated wound to the abdomen? why waste the time C-spining when the pt needs rapid transport to an appropriate trauma facility with trauma surgeons. I could see possibly throwing him on a LBB for ease of movement from the ground scene and as a hard surface for compressions should he arrest.

An example of an isolated injury would be someone who slips off a curb twisting their ankle. That is an isolated injury. Someone found unresponsive in an alley with no other information and an obvious stab wound is a trauma patient. Trauma patients get spinal precautions, period. We have no way of knowing just how he was assaulted. We only know for sure that he has a puncture wound in his abdomen. This EMT basic stuff. You're walking a dangerous and potentially career ending line if you're so tunnel visioned on just the obvious injury.

The trendelenburg position is arguable, I guess. Until protocols start changing as an EMT basic who is dealing with hypovolemia this is your only option. You have to keep the organs perfusing and you do that with the only tools you have available.

 

[ironguy321]

you guys bring up a lot of interesting points. next time, ill try and be more specific about everything. we were taught in basic "the ABC's" so what i was trying to hit hard on was the fact that his breathing wasn't good but at the same time he was bleeding from his Abd. (was trying to see if he would suspect the liver). i can see how protocols play a major role in this.

this is a side question on it but if your partner is driving and your using a BVM, how do you notify the hospitial ?

 

[Asclepius]

Well, you can have your partner radio ahead or you can have your dispatcher notify the receiving hospital/ALS unit. Hopefully, you'll have some other help, like FD or PD that can help.

 

[medic001918]

Why would you have to take C-Spine precautions. Its an isolated wound to the abdomen?

Can you tell how deep that knife went? Or what it hit inside the abdominal cavity? If the answer is no (and in a stabbing that's more than likely the case), then you should immobilize this patient. Anything less isn't really acceptable.

Shane
NREMT-P

 

[Flight-LP]

Or take additional help with you to the ER. If you are bagging someone, you need more than one person in the back. One person ventilations with a BVM are ineffective, ideally you want three people..............

Apply SMR, give him a little O2, DO NOT place him in trendelenburg on the board, be happy with a 100 systolic BP as it is more than fine, bandage as necessary, go to an ALS unit or hospital as quickly as safely possible. This patient needs to be intubated and an NG tube placed, as simple BVM ventilation will possibly cause further issue due to over inflation of the gut.

 

[JPINFV]

be happy with a 100 systolic BP as it is more than fine,

Doh, I totally didn't see that and connect it with permissive hypotension.

 

[Asclepius]

DO NOT place him in trendelenburg on the board, be happy with a 100 systolic BP as it is more than fine

I should have specified myself. Yes, the 100 systolic is great. They're actually teaching now to keep it around 90. The TP was a suggestion meant more for if his pressure continued to fall.

 

[Flight-LP]

He could have a non-prefusing MAP and I still wouldn't put him in a trendelenberg position. For one, there is no evidence supporting it. Two, it will cause an increase in ICP. Three, it makes the LBB that you pt. is lying on and the stretcher less secure and unsafe for transport. No benefit and multiple risks, seems like a no brainer to me...................

 

[Ridryder911]

Before it became too deep (since it is on a basic level) I was going to suggest to perform a better assessment, while enroute. Pressure systolic of 100 and really a mild tachycardia of 120's, I would be looking for another underlying cause of unresponsiveness. Since it does not appear to be compensated, at the time.

I would personally leave well enough alone with a stab wound in the right upper quadrant. Laceration of liver and potential of laceration of portal artery, mesenteric artery, bowel and kidney. Personally, I would prefer not to raise the BP any higher, and would be concern of possible other injury of the < LOC. But, contributed the scenario to that a scenario..

Trendelenburg or not, really won't matter and waste of time, it does not work.. but it makes providers feel better that they did something. The body works best if you sometimes leave it alone, such as good ole supine, or even lateral. As discussed "permissive hypotension" and watch the MAP and Cerebral perfusion, and of course coronary perfusion, etc..

Let's not make it any more cloudy, to be able to see the trees past the forest.

R/r 911

 

[certguy]

Scenerio

In all cases of major trauma c - spine precautions should be taken not only because of the unwitnessed fall but also the length of the weapon used and the angle of entry as well as the amount of force used in the attack are all unknown . There could possibly be spinal cord damage . In our county , there's only 1 trauma center ( 60 miles out at least through a windy canyon road ) , so I would consider a medivac transport depending on weather conditions . I would , in addition to c - spine and getting ALS ( air and ground ) enroute , insert an NPA ( if no evidence of head trauma to contraindict it ) assist ventilations , dress the wound , monitor v/s closely , and haul booty for the LZ . As a BLS unit , unless protocol is changed , TP is the only real option I can use to increase b/p reguardless of controversy , so I would use it . Has anyone thought to check for exit wounds ? For all we know , the weapon could've been a machete . I would also grab a FF for extra manpower in case he codes ( c - spine would also put a coding pt. already on the board for a firm CPR surface )