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trauma assessment scenario

Discussion in 'Scenarios' started by 8jimi8, Mar 8, 2010.

  1. 8jimi8

    8jimi8 Active Member

    Location:
    Northern Arizona
    called to scene of 1 vehicle vs tree.

    Initial impression: no skid marks, moderate frontal damage, no air bag, steering wheel intact, 1 patient, driver restrained - flaccid in drivers seat, driver door won't open due to impact, no entrapment of patient beyond the damaged door. Fire and LE on scene.

    initial assessment:
    no witnesses
    Your partner takes c-spine
    driver moans weakly to loud verbal stimuli, does not open eyes.
    breathing is shallow and rapid 38/min breathe sounds are wet rales in all fields
    circulation is weak and thready at 133 b/min
    nrb 15l/min
    high priority - rapid transport patient
    medic alert bracelet: Cardiac history, allergy to HCTZ.

    no sample or opqrst available
    rapid trauma assessment reveals pms + (withdraws to painful) in all extremeties, eyes perrl, no signs of basilar skull fracture, no signs of dcapbtls or any obvious trauma (rapid trauma assessment is essentially negative except for a minor oozing laceration to the left cheek)
    baseline vitals 90/50, hr 155, breathing 35 o2 sat 80
    extricate with a KED and long backboard.

    once the patient is loaded in the ambulance 2 large bore IVs
    place the patient on the monitor reveals ...

    multifocal pvcs and runs of paroxysmal vtach 8, 10 , 12
    Oxygen saturation reads 75, patient is breathing 28 /min

    what do you do.


    call out your interventions once the ambulance starts moving. 15-20 minutes until the hospital. you can have 1 MFR/firefighter in the patient compartment with you.
  2. 8jimi8

    8jimi8 Active Member

    Location:
    Northern Arizona
    oops glucose is 136 and 4 mm st-depression in AVf
  3. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    Seems like LVF, or maybe a cardiac contusion (but you did say there was no obvious signs of trauma). Either way, I would think this patient is probably pretty stuffed.

    My job in this situation would be simply to call MICA. Could try some suction.

    From a MICA perspective, this patient would want intubating and an adrenaline infusion with some fluid boluses I suppose.
  4. 8jimi8

    8jimi8 Active Member

    Location:
    Northern Arizona
    are you sure you want to bolus?
  5. 8jimi8

    8jimi8 Active Member

    Location:
    Northern Arizona
    oh pt is 67 years old
  6. MrBrown

    MrBrown New Member

    I would say this patient is pretty buggered myself.

    1. Remove Firefighter from ambulance, this is not a fire truck
    2. Fluid bolus
    3. Suction and laryngeal mask airway
    4. Intensive Care Paramedic

    My guess is myocardial injury.

    Any sign of a haemopneumothorax, unstable pelvis or internal bleeding?
  7. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    I'm fairly certain the MICA deal in this kind of scenario is a fluid bolus once/if the chest clears up, with the adrenaline, yes.
  8. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    I'm not sure he'd take an LMA. Whats his motor response, so we can complte a GCS, 8jimi8.

    Whats your rationale for fluid before inotropes? Surely that'd drown him further.


    If he was really going down s**t creek, you could try some manual PEEP, I'm not personally of that persuasion, but some here are.
  9. are you sure this is a trauma scenario?

    It sounds like a cardiac scenario uncleverly disguised as trauma.

    There are a lot of findingss here, but what does the pt. look like? I would guess cyanotic, perhaps pale. Skinny? Fat? Is his spine abnormally kyphotic? What are the angle of his femurs? Dependant Edema? internal Pacemaker/defibrilator? Surgical scars? Urinated on himself?

    For clarification there was no airbag or the airbag was not deployed?

    That will make a difference on index of suspicion. Damage to the vehicle is an outdated measurement.

    Is there a "seatbelt" sign?

    No eye opening: 1
    Moans: 2
    withdraws to pain: 4

    with a GCS of 7, I have no idea why you would waste time with a KED unless you were going to not use a backboard to protect his breathing.

    With the exception of a minor laceration, this seems to be a cardiac problem so far. His BP, while low and definately a concern with his EKG doesn't seem overly low if he is on an ACE inhibitor or non thiazide diuretic. It doesn't seem like there is significant beta blockade with a rate of 155 either, but still possible. Wet lung sounds also point to a cardiogenic shock type scenario from left sided failure. I think this was included specifically to rule out a fluid bolus.

    Dobutamine or dopamine sounds like a good idea. I think would start with that.

    An aggressive approach would be to wait for a v-tach and cardiovert him, but I am not predisposed/condoning doing that. Just keeping options open.

    Positive pressure ventilation may help as well.

    The backboard will not help his respiratory efforts, you may have to forgo it in this case, or incline the head as much as safely possible.
  10. EMTinNEPA

    EMTinNEPA Guess who's back...

    Any drainage or bleeding from the ears, nose, or mouth? Any jugular venous distension? Are the heart sounds clear and crisp or muffled? Any pitting edema in the lower extremities? How are the pupils? Is the pelvis stable and firm? Any signs of possible femur fractures? Is the abdomen soft and nontender without masses, distension, rigidity, or guarding? Does he have a pacemaker? What is the baseline rhythm of his EKG? Sinus tachycardia with multifocal PVCs and paroxysmal ventricular tachycardia, or atrial fibrillation with multifocal PVCs and paroxysmal ventricular tachycardia, or something else?

    While awaiting answers to these questions...

    Treatment: 15lpm NRB, extrication straight to a long back board (no KED, this patient is in too poor a condition to waste that time), IV access, 12-lead EKG, definitely a candidate for intubation. Am I working in a system that allows paramedics to RSI? I wouldn't worry about the hypotension too much, maybe give a small fluid bolus to get his systolic pressure above 100. As for the PVCs and runs of V-tach, I would treat him with lidocaine once I got his pressure up, depending on the frequency of PVCs and runs.

    The big question here is did he crash because he's having an MI and the PVCs and V-tach made him hypotensive and he blacked out, or are the PVCs and V-tach a symptom of cardiac contusion?

    Very good scenario!
  11. I would guess with the lack of skid marks and his medical bracelet his event supposedly happened prior to.

    it also mentioned the rapid trauma assessment to be negative.

    Pupils were listed as equal and reactive to light.

    the underlying rhythm question is a good point though.
  12. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    Oh, didn't see that. Well with a GCS of 7 and if he's truly moaning, I think we safely say he won't take an LMA.

    You don't think this pt is a candidate for intubation?
  13. boingo

    boingo New Member

    This is a hypoxic patient, first priority is to fix that. The irritable rhythm is unlikely to improve without addressing oxygenation. Skip the non rebreather and assist ventilation w/BVM. Where does that get us? I don't want to get too far ahead with drugs, fluids, etc...just yet.
  14. EMTinNEPA

    EMTinNEPA Guess who's back...

    I'm leaning that way too. However, at 67 his reflexes may not be the best or he simply didn't have time to react.

    The reason I ask about the underlying rhythm is because his medic alert bracelet simply says "cardiac history", which isn't very specific. Did he have an MI in the past? Is he being treated for atrial fibrillation? Does he have congestive heart failure? The answer to this question combined with assessment findings may sway me to one way or the other in terms of which treatment modalities I may use.

    Also, I don't know if I would go for dopamine to increase his pressure. In order to get the pressor dose I would have to deal with the beta 1 effects of the inotropic dose as well, which may not be the best thing since he's already showing signs of hypoperfusion and his heart-rate is in the 130s. Correct me if I'm wrong, but increasing heart-rate would increase workload which would increase myocardial oxygen demand, and it's already obvious that there isn't enough oxygen to go around.
  15. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    Perhaps, I'm no expert. My thinking is that the idea with dopamine or dobutamine wouldn't be to get to a pressor dose, but used specifically because of the inotropic effects (inotrope refers to a drug that increases contractile force, not rate, although inotropes are often also chronotropes). This would increase the cardiac output which would in turn reduce the pressure behind the left ventricle that was causing the oedema, in turn fixing the problems with oxgenation. Although I'm not sure how fast that would work, if indeed it does work, so I feel directly addressing the oxygenation simultaneously is the best course of action.

    I'm thinking intubation, but vene, you are appear to be against this? Whats your thinking? How quickly do inotropes work to fix a problem like this?
    Last edited by a moderator: Mar 8, 2010
  16. EMTinNEPA

    EMTinNEPA Guess who's back...

    From 5mcg/kg/min to 10mcg/kg/min, dopamine stimulates the Beta-1 adrenergic receptors, which do cause increased contractility, but also increases automaticity, including increased sinoatrial node conduction, which means increased heart-rate. My impression was that the dopamine would be used to remedy the hypotension as an alternative to a fluid bolus so that no more fluid would be added to an already (from the sounds of it) fluid overloaded patient. The problem is to get the Alpha effect of vasoconstriction (and ergo blood pressure), you have to increase the dose to 10mcg/kg/min to 20mcg/kg/min, meaning you still have to deal with the Beta-1 effects. Dobutamine is also a primarily Beta-1 agent with selective Alpha-1 effects.
  17. 8jimi8

    8jimi8 Active Member

    Location:
    Northern Arizona
    Today 05:00 AM
    Veneficus
    are you sure this is a trauma scenario?

    There are a lot of findingss here, but what does the pt. look like? I would guess cyanotic, perhaps pale. Skinny?Dependant Edema? internal Pacemaker/defibrilator? Surgical scars? Urinated on himself?

    For clarification there was no airbag or the airbag was not deployed?

    Today 05:31 AM
    EMTinNEPA Any drainage or bleeding from the ears, nose, or mouth? Any jugular venous distension? Are the heart sounds clear and crisp or muffled? Any pitting edema in the lower extremities? Is the abdomen soft and nontender without masses, distension, rigidity, or guarding? Does he have a pacemaker? What is the baseline rhythm of his EKG? Sinus tachycardia with multifocal PVCs and paroxysmal ventricular tachycardia, or atrial fibrillation with multifocal PVCs and paroxysmal ventricular tachycardia, or something else?

    Today 06:15 AM
    boingo This is a hypoxic patient, first priority is to fix that. The irritable rhythm is unlikely to improve without addressing oxygenation. Skip the non rebreather and assist ventilation w/BVM. Where does that get us? I don't want to get too far ahead with drugs, fluids, etc...just yet.


    Your protocol limitations are limited only by your training / con-ed , your medical control has personally told you that she would back you as long as you can justify your treatment plan. (if you are a student you may intervene with any skill you have been checked off on and in that case your partner is not the firefighter/MFR, it will be your paramedic preceptor- but you are leading the call)

    Car is an older model, no airbag to deploy.

    Pt has circumoral cyanosis, No rhinorrhea / otorrhea, approx 5'11, 130lbs estimated, No kyphosis, Thorax is not appreciably barrelled. Trachea is midline, JVD is positive. Breath sounds are diminished in the bases, but still very wet bilaterally with coarse ronchi and rales in all fields. Heart sounds are present, muffled by the loud respiratory sounds. You think you hear an S3. Generalized edema 1+/4

    An old scar from the angle of louis, midline descending to the epigastrium, Nothing palpable under the skin that would indicate and ICD/Pacemaker, No seatbelt sign, abdominal palpation reveals a reducible mass in the luq - no thrill, no guarding. Pelvis is stable, no appreciable MOI to lower extremities, except some bruising to bilateral knees. There are 2 non-contiguous, faint, linear scars on the medial aspect of the pt's left lower extremity beginning superior to the patients knee, the second inferior and medial from the knee pt's pants / undergarments are CDI, bilateral lower extremity pitting edema 2+/4,


    Baseline rhythm was Sinus Tach but now the runs of vtach are the predominant feature on the monitor, hr is intermittently 130-175

    Pts o2 sat rises from 70 to 84 with BVM ventilations. Pt will not accept an oral adjunct.

    You find a tattered stained medication list in the wallet... all you can make out is colace 100mg, "diltzam" (cannot read the dosage), 4 medications you cannot read except for the dosages: 5mg, 75 mg and 12.5mg and 5mg

    still >15 minutes left to hospital, you can hear the driver cursing traffic.


    Yah, Vene.... poorly disguised! Rather, not disguised at all, just undiscovered in the initial assessment.


    From what I understand, people are considering drugs, but have not actually administered any, correct?

    Call out your interventions and i will try to respond with tx response. In all fairness this was (not a National Registry psychomotor exam) my final psychomotor trauma assessment scenario. All of the initial interventions are what I did up to loading the patient in the ambulance. If you would skip the KED or backboard, just state that you would have omitted that, as some have already.
  18. EMTinNEPA

    EMTinNEPA Guess who's back...

    From the "Crazy Ideas" file, what about CPAP? Perhaps if we used CPAP we could push all the fluid in the patient's lungs back into the intravascular space, simultaneously increasing oxygenation and blood pressure while eliminating the pulmonary edema.

    EDIT: In light of 8jimi8's last post, CPAP might not be such a crazy idea after all.
    Last edited by a moderator: Mar 8, 2010
  19. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    Fairly certain the idea with an inotrope like dopamine or dobutamine would be to increase cardiac output. That after all that is the problem in the first place. If the idea was solely to cause vasoconstriction then the effect would be the same as adding fluids - it would further overload an already overloaded system. You wouldn't be using a norad infusion in a patient like this.
  20. 8jimi8

    8jimi8 Active Member

    Location:
    Northern Arizona
    let me know if i skipped your intervention.

    I'm no expert, so i can really only give you the details that were given to me. I'll try to keep from embellishing this scenario way out of control :)

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