# Car accident.



## Jondruby (Nov 16, 2015)

Called out to a car accident 15 yof PT with gash in head. We got there pupils sluggish, drainage out left ear. 1st BP 90/77 2nd 101/80 kept trending and getting better. various scrapes, PT kept alert and talking although not orientated. Called ALS. We had 4X4s on the gash, checked it, this wasnt a skinflap laceration. Head split open like a melon, no skull showing. PT stated pain in head 10/10. She was shockey, kept her warm and trending her vitals, everything hanging good. Paramedics got in. I rode in their ambulance, got to ER nurses asks Paramedic should they call the flight? He says no, its just a laceration with a skin flap. My partner who was with him in our rig, said he didnt even look at the gash on her head. We gave the nurses and Doc our reports of PT status and what happend. Got an update later about our PT, life flighted her because of a skull fracture.


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## Martyn (Nov 16, 2015)

And no one else noticed the left ear drainage? Thats a BIG clue...


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## Jim37F (Nov 16, 2015)

Martyn said:


> And no one else noticed the left ear drainage? Thats a BIG clue...


as soon as I read that I was asking if the halo test showed CSF or not.....this patient meets multiple trauma center criteria for me based on this description


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## Jondruby (Nov 16, 2015)

Right our first responder checked right away when she got on scene, there was none then. I checked when we got on scene with the rig, there was drainage of CSF, clear. I am glad for the ALS meeting us, but other than starting an IV lock they didnt do anything that we hadnt already done. I checked pupils in the rig and they were equally responsive, maybe a little sluggish, but the drainage was very noticable. I feel like my crew did an great job with everything, everyone worked together well; but I was a little disappointed about the quality of care the Medics showed, I realize they are human and do work rigorous hours like we all do, but when the us as EMTs are catching obvious clues the medics aren't, its not good. The one guy just walked in with this hot-shot attitude, he came off like this was no big deal and had everything under control, then misses something like that. We are working with human lives, better be safe than sorry.


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## Jim37F (Nov 16, 2015)

Skills wise I don't think there's much else for ALS to do on top of BLS for this call beyond starting an IV and being prepared for advanced airway measures/fluids should the patient need it......Otherwise the best thing ALS could do is the exact same thing BLS could do, speed to definitive care (which in my mind is still a trauma center over even over the closer ED that's just going to have to transport the patient out towards one anyway)


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## Jondruby (Nov 16, 2015)

Yea we trasported to the closest trauma center, they sent her on to the big hospitals for some surgery I believe.


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## Jondruby (Nov 16, 2015)

So I apologize apparently I got some mis-information we are unsure of the skull fracture, but she did complain about pressure in her head  and had ear drainage. The Paramedic did push morphine, which I think in contra-indicted for traumatic head injuries, isn't it? She should be getting out today or tomarrow is the info thru the grapevine which is great. Thanks guys


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## chaz90 (Nov 16, 2015)

So what are we working with here?

The patient has a head laceration, which we all know bleed a lot and are initially impressive and "scary" for bystanders. Evidently there is a flap of skin hanging too. Patient is said to be "shocky," which is a meaningless medical term when used generically and out of context. I'm guessing you mean she is tachycardic and tachypneic since you advised her BP wasn't terrible. 

You advised the patient was alert but not oriented. Did this improve at all during transport? Can you clarify what you mean by disoriented? Many traumatic head injuries result in at least a short time of confusion and disorientation. This could be relatively minor, or of course could be an ominous sign of a significant intracranial issue. 

Now you mention the ear drainage. The halo test is not very sensitive or specific. The draining blood may or may not have contained CSF. In the scheme of pre-hospital treatment, you simply can't diagnose the presence of CSF in blood or not. Either way, the patient clearly needs transport and further evaluation. 

What would you have preferred the medics do in addition to what they did? A stable patient with improving mentation and a head laceration can easily be evaluated at the local trauma center. If something more sinister shows up on imaging or evaluation, transport can be arranged at that point.  It sounds like you're working off of a lot of rumors and misconceptions here.


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## Doczilla (Nov 16, 2015)

Jondruby said:


> 1st BP 90/77 2nd 101/80 kept trending and getting better



For an adolescent female, the pressure climbing isn't necessarily "better". The first consideration is that adolescent females have a dump of estrogen during puberty--- and as a smooth muscle relaxer, estrogen plays a role in why women have "lower baselines" than men. 

While we're on that topic, you can actually hear an extra heart sound (s3) in adolescent females because the estrogen can also make the ventricular wall floppy. Is it clinically relevant? No, but as rare as hearing an s3 is, hearing it in otherwise healthy people is pretty cool, and will help you catch it when you need to (heart failure, shock states) 

So, why is a climbing pressure ominous in a head injury? Remember Cushing's triad: narrowing pulse pressure/hypertension, bradycardia, and ataxic respirations.  

The blood pressure is climbing to oppose the increase in ICP, as the body can detect these changes through the chemo receptors and baroreceptors. So while everyone is tunnel visioning on the "blood coming from the ear" on that call, I would be concerned about the pressure trending upwards.  A pressure of 120/90 may be well above her baseline.


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## Jondruby (Nov 17, 2015)

Ok Doczilla, I wasn't aware of that, although it makes sense. PT was cold, and B/P was rising not dramatically, but steady. The drainage coming out the ear was not blood, but clear fluid, which is CSF, right? Her memory was not improving and she did not know what day, where she was going, or what we were doing when she was in the rig. There was not much more the Paramedic could've done really, although Morphine and Fentanyl are not recommended for traumatic hear injuries, right? I would rather have had the medics help intercept, than have gone on without them and had our PT condition get worse.


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## Tigger (Nov 17, 2015)

I do not understand the point of the post here. Do you have a problem with the medic's care? What exactly would you like done instead? When you gave your handoff report did you mention that you suspected CSF drainage? That would be an important part of the handoff.

Pain management is not necessarily contraindicated for head injuries (at least not here). Generally we wouldn't be giving a significantly altered patient pain medication, perhaps she was not as altered as you thought? 

I think above all that it's important to actually fact-check yourself before calling someone else. There is nothing wrong with asking why the medic chose to treat the way he did, just ask after the call.


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## Jondruby (Nov 18, 2015)

No, really the medic didn't really do anything that we hadn't already done, besides start IV lock. I didn't mean it to sound that way that he didn't do his job. I was a little concerned with the extent of the head injury and when we arrived at the ED he told the nurse that it was just a laceration (which technically was true), and said no penetration injuries etc. We handed off our report and did describe that there was suspected CFS drainage. And as far as the pain management goes I was just reading about the Morphine and Fentanyl contradictions in cases of head injuries with inter-cranial swelling. I never did get a chance to ask him after the call. Personally I thought he did a good job for what he had to do which wasn't much. My partners were a little twerked at his attitude, when he was on board. I am new, but I guess if I was in the medics boots, I would've told the nurse to go ahead and call the flight (which they did anyway) and taken her condition more seriously until she had been thoroughly  evaluated. That's all. I did not intend that to sound like I was bashing him, just had my questions. And I do re-run calls thru what we've done and see what we could've done better, and personally I think my crew did  a good job on that call, the others on that one thought the same.


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## Doczilla (Nov 19, 2015)

Well, and (this is only to play devils advocate), sometimes cases like that just need diesel more than anything else. Even the saline lock is more a "just in case" thing for: 
- Seizures
- RSI drugs if she goes downhill
- Preventing hypotension (DEVASTATING in head injuries) 

Other than that, there is literally nothing to do other than carefully control scalp bleeds and perform serial neuro assessments.

 I think what we have here is a case of how poor people skills and composure can be translated into "bad provider"; which unfortunately can come from our patients, the public, and even coworkers.


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## hogwiley (Dec 22, 2015)

If the nurse asked the paramedics if she should be life flighted and they really did say no its just a scalp laceration, despite clear drainage from the ear, sluggish pupils, aloc and rising bp, then that was sounds pretty stupid to me.

How can they say they suspected csf drainage from the ear and yet say it's just a scalp laceration i don understand. The two do not compute unless they simply meant to relay they didn't SEE or FEEL an obvious fracture at the site of the Lac, and we're under the impression the rn understood the implications of the other findings.

The extent of damage to the vehicle and how the patient was found are also important.


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## hogwiley (Dec 22, 2015)

I should add that you aren't really going to SEE a fracture, or attempt to feel for a skull fracture, nor is a fracture necessarily going to be at the site of a gash on someones head if they suffered blunt trauma. Which is why I'm puzzled they would tell the Nurse she just has a scalp laceration. If they suspected CSF is draining from her ear she obviously has more going on than just the scalp laceration, as CSF doesn't just flow out of peoples ears for no reason.


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## redundantbassist (Dec 23, 2015)

Sp02? Pupils? Given the information provided, this patient should be transported to a trauma center as soon as possible.


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## GloriousGabe (Dec 24, 2015)

hogwiley said:


> CSF doesn't just flow out of peoples ears for no reason.


I've heard of people say this does happen from their nose but I'm not sure about ears.


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## redundantbassist (Dec 24, 2015)

GloriousGabe said:


> I've heard of people say this does happen from their nose but I'm not sure about ears.


CSF can leak from the nose due to sinonasal trauma but it is more common coming from the ears.


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## GloriousGabe (Dec 24, 2015)

redundantbassist said:


> CSF can leak from the nose due to sinonasal trauma but it is more common coming from the ears.



I knew a guy who could fill up an entire cup full of CSF through his nose. He got surgery to have that leak fixed.


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## jwk (Dec 25, 2015)

GloriousGabe said:


> I've heard of people say this does happen from their nose but I'm not sure about ears.


A CSF leak anywhere can be a very big deal, whether post-trauma, post-surgery, or post spinal/epidural anesthetics.  With trauma, besides being a sign of a significant head injury/skull fracture, there can be a very high risk of infection.  With post-op or post-anesthesia CSF leaks that persist, patients get very bad headaches.


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## GloriousGabe (Dec 27, 2015)

jwk said:


> A CSF leak anywhere can be a very big deal, whether post-trauma, post-surgery, or post spinal/epidural anesthetics.  With trauma, besides being a sign of a significant head injury/skull fracture, there can be a very high risk of infection.  With post-op or post-anesthesia CSF leaks that persist, patients get very bad headaches.


Yeah the guy I know who used to have his spinal fluid drip out of his nose had the worst headache anyone ever had. He had no trauma- it just happened on its own.


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