# 67 yo Fall from the roof



## LACoGurneyjockey (Jul 12, 2014)

You are dispatched to a fall, and arrive to find a 67 year old male sitting in a chair in the back bedroom. He is conscious, alert, and oriented, with a large laceration to the right forehead, a large abrasion to the right arm, and you note a strong smell of alcohol at 0900. He states he fell approximately 10 feet from the roof while trying to repair an air conditioning unit in 95 degree heat and landed on his right side on hard packed dirt. Unsure if he lost consciousness, and the fall was unwitnessed. Family heard him shouting, came out to find him on the ground and brought him inside. 

He is complaining of pain to his: head, neck, back, entire right side, and chest. BP is 146/80, pulse of 90, RR is 28 with an spo2 of 94% on room air. Pupils are PERRL, lungs are clear and equal bilaterally, skin is warm pale and moist. When you try to place this patient on a backboard he complains of acute exacerbation of his chest pain and sudden onset difficulty breathing. You place the patient in a position of comfort semi-fowlers with a C-collar which relieves his SOB and reduces the chest pain. He has a history of a cardiac stent, high cholesterol, HTN, and an MI about a month ago. He takes metorpolol, simvastatin, and NTG, and has no known drug allergies. 

Now at this point, you have a local community hospital 10 minutes away capable of CT, basic ortho, but no specialties and no trauma capabilities. Your nearest trauma center is 70 minutes away code 3, and you can have an airship    on the ground in just under 30 minutes. 
Anything else you'd want to do? Is this patient going local or to the trauma center 80 miles out. Anything else you'd want to do? Any further details you need?


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## Rialaigh (Jul 12, 2014)

LACoGurneyjockey said:


> You are dispatched to a fall, and arrive to find a 67 year old male sitting in a chair in the back bedroom. He is conscious, alert, and oriented, with a large laceration to the right forehead, a large abrasion to the right arm, and you note a strong smell of alcohol at 0900. He states he fell approximately 10 feet from the roof while trying to repair an air conditioning unit in 95 degree heat and landed on his right side on hard packed dirt. Unsure if he lost consciousness, and the fall was unwitnessed. Family heard him shouting, came out to find him on the ground and brought him inside.
> 
> He is complaining of pain to his: head, neck, back, entire right side, and chest. BP is 146/80, pulse of 90, RR is 28 with an spo2 of 94% on room air. Pupils are PERRL, lungs are clear and equal bilaterally, skin is warm pale and moist. When you try to place this patient on a backboard he complains of acute exacerbation of his chest pain and sudden onset difficulty breathing. You place the patient in a position of comfort semi-fowlers with a C-collar which relieves his SOB and reduces the chest pain. He has a history of a cardiac stent, high cholesterol, HTN, and an MI about a month ago. He takes metorpolol, simvastatin, and NTG, and has no known drug allergies.
> 
> ...



meh....system to system dependent I would guess. If he is complaining of pain of more then a 5/10 I would probably be calling for some orders for morphine. Really my only concern with this guy is a head bleed from a transport decision standpoint. Other then checking lung sounds fairly frequently and assessing for signs of a deterioration there is not much I am going to do for this guy. 

12 lead an a IV.

And really this transport decision would depend on the community hospital, how efficient are they are getting patients through, how are they with transfers, what are the ER docs there comfortable with. And also the service I am in, that's a long transport to take a truck out of service if the county or city only has a few, but if there is a lot of coverage then its different.

 In my area this guy is likely going to the community hospital, we only have 4 units in the county and our community hospital is pretty good about moving quickly.  he would get a full trauma ct within 20 minutes of rolling through the door and if anything serious popped up they would have a chopper in the air within another 10 minutes, but given the slim chance of that Im thinking I transport to community hospital. Really its so service to service dependent though.


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## captaindepth (Jul 12, 2014)

Initially I'm concerned about why he fell off the roof. Was there a syncopal event leading to the fall? Any chest pain/SOB prior to the fall? The head, neck,back and right sided pain all make sense from the MOI but the chest pain and SOB point me towards another reason for the fall. Also his respirations are a red flag IMO. Id try to find out what his normal BP is, and if he has been compliant with all medications. also investigate alcohol use (i.e. chronic, residual from previous night, and any drug use?) 

He gets 2 large bore IVs ( w/ moderate fluid bolus), O2(w/ ETCO2), and a 12 lead right away. Any nystagmus?, FPA, and like Rialaigh said frequent lung sounds. Id use caution when managing his pain with alcohol on board and possible difficulty breathing, maybe 0.5-1.0 mcg/kg Fentanyl. 

As far as transport decision id put the helicopter and standby and decide between the local community hospital and flight depending on the 12 lead findings.


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## DesertMedic66 (Jul 12, 2014)

captaindepth said:


> Initially I'm concerned about why he fell off the roof. Was there a syncopal event leading to the fall? Any chest pain/SOB prior to the fall? The head, neck,back and right sided pain all make sense from the MOI but the chest pain and SOB point me towards another reason for the fall. Also his respirations are a red flag IMO. Id try to find out what his normal BP is, and if he has been compliant with all medications. also investigate alcohol use (i.e. chronic, residual from previous night, and any drug use?)
> 
> He gets 2 large bore IVs ( w/ moderate fluid bolus), O2(w/ ETCO2), and a 12 lead right away. Any nystagmus?, FPA, and like Rialaigh said frequent lung sounds. Id use caution when managing his pain with alcohol on board and possible difficulty breathing, maybe 0.5-1.0 mcg/kg Fentanyl.
> 
> As far as transport decision id put the helicopter and standby and decide between the local community hospital and flight depending on the 12 lead findings.



Why a moderate fluid bolus? None of his vitals are showing any signs of hypovolemia and/or hypoperfusion. 

SOB and chest pain can easily be caused by Fx or bruised ribs (granted id still get a 12-lead).


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## Clare (Jul 12, 2014)

What is the motor score of his GCS? 
Peripheral motor strength? symmetry? sensation?
What does inspection of his chest and abdomen reveal?
Does his chest rise and fall symmetrically? 
What degree of air entry does he have?
When you percuss his chest what does it sound like?
Does palpation of his chest and ribcage reveal anything? 
Does he know what his BP is normally? 

I'd probably want to talk to the local hospital and see if they would be comfortable accepting this bloke.  While for sure he is going to need at least a  CT scan and some x-rays if they are not experienced in dealing with trauma then it might be just as well taking him to the major trauma centre.  

There is no role for taking him by helicopter at this point.  A total time saving of at least an hour would be needed and he'd need to be a more sicker than he is.

My main concerns are spine, haemo/pneumothorax, fractured ribs +/- flail chest, pelvic fracture and spleen.


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## captaindepth (Jul 12, 2014)

95 degrees outside and ETOH on board, im thinking there is some degree of dehydration which i believe warrants some fluids. As far as the CP being a result of trauma is absolutely possible but an MI one month prior really grabbed my attention.


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## LACoGurneyjockey (Jul 12, 2014)

Rialaigh said:


> In my area this guy is likely going to the community hospital, we only have 4 units in the county and our community hospital is pretty good about moving quickly.  he would get a full trauma ct within 20 minutes of rolling through the door and if anything serious popped up they would have a chopper in the air within another 10 minutes, but given the slim chance of that Im thinking I transport to community hospital. Really its so service to service dependent though.



You have 3 trucks in the area, and one additional unit can be post moved but is over an hour away. Local hospital is really hit and miss with trauma, at times they do a full workup and can have a transfer ready within 1-2 hours, other times it takes all day, other times they take vitals and send the patient back out without any CT, x ray, etc. Typically they are not at all comfortable handling trauma and often question why we bring them even if it's clearly within our protocol. 



captaindepth said:


> Initially I'm concerned about why he fell off the roof. Was there a syncopal event leading to the fall? Any chest pain/SOB prior to the fall? The head, neck,back and right sided pain all make sense from the MOI but the chest pain and SOB point me towards another reason for the fall. Also his respirations are a red flag IMO. Id try to find out what his normal BP is, and if he has been compliant with all medications. also investigate alcohol use (i.e. chronic, residual from previous night, and any drug use?)



He says he just missed the top step on the ladder and fell, and is unsure if he ever lost consciousness. Nothing out of the ordinary before he fell. Doesn't know his normal BP, but he states and family confirms he's been taking all his meds as directed. For the alcohol, patient denies any alcohol and family states "he had a problem a while ago but not anymore". 



Clare said:


> What is the motor score of his GCS?
> Peripheral motor strength? symmetry? sensation?
> What does inspection of his chest and abdomen reveal?
> Does his chest rise and fall symmetrically?
> ...



GCS of 15, distal CMS is intact in all 4 extremities, however he has significant weakness in his right arm and shoulder. Abdomen reveals nothing of note. You palpate the chest and its tender and painful to touch all down the right side but no paradoxical movement, no crepitus. He's moving air well but states it is painful to take a deep breath.

You get him in the truck and run a 12 lead which shows STEMI.
That trauma center 80 miles out is also your nearest STEMI receiving center.


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## captaindepth (Jul 12, 2014)

With the 12 lead showing STEMI, get ASA(with no signs of significant bleeding) and NTG on board, continue fluids and O2, monitor vitals and the EKG monitor and get the helicopter en route. Keep pt in position of comfort and monitor pain management while while waiting for the helicopter. Transport to the trauma/STEMI receiving center 80 miles away. 

Any changes in complaint or presentation during pt contact?


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## DesertMedic66 (Jul 13, 2014)

STEMI with elevation in which leads?

http://www.annals.in/article.asp?is...me=13;issue=1;spage=73;epage=74;aulast=Bhagat


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## LACoGurneyjockey (Jul 13, 2014)

Turns out he had a subdural bleed, Fx clavicle, and Fx of ribs 1-10 on the right. He also had a T1 fx of the transverse process, and a pneumothorax reported at 5% by the ER doc afterwards. Also had a BAC of .180 in the ER...
ST elevation in leads 2, 3, and aVF if I remember correctly.


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## DesertMedic66 (Jul 13, 2014)

LACoGurneyjockey said:


> Turns out he had a subdural bleed, Fx clavicle, and Fx of ribs 1-10 on the right. He also had a T1 fx of the transverse process, and a pneumothorax reported at 5% by the ER doc afterwards. Also had a BAC of .180 in the ER...
> ST elevation in leads 2, 3, and aVF if I remember correctly.



Most of those injuries were ones I would be looking for. SOB and chest pain most likely caused by the Fx ribs. Weakness in the right arm could be easily explained by the injuries to the right side of his body. 

ST elevation can be caused by brain bleeds (not just MIs). And a BAC double the legal driving limit means he likes to start his party early in the day. More than likely an alcoholic who went clean followed by a relapse.


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## LACoGurneyjockey (Jul 13, 2014)

DesertEMT66 said:


> Most of those injuries were ones I would be looking for. SOB and chest pain most likely caused by the Fx ribs. Weakness in the right arm could be easily explained by the injuries to the right side of his body.
> 
> ST elevation can be caused by brain bleeds (not just MIs). And a BAC double the legal driving limit means he likes to start his party early in the day. More than likely an alcoholic who went clean followed by a relapse.



Not because I'm doubting you, but because I've never heard it before and you peaked my interested, can you link anything further about brain bleeds and ST elevation?


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## DesertMedic66 (Jul 13, 2014)

LACoGurneyjockey said:


> Not because I'm doubting you, but because I've never heard it before and you peaked my interested, can you link anything further about brain bleeds and ST elevation?



I'll see if I can find anymore. Our ER doc and resident at our trauma center told me about it around a year ago (I think). I did some initial research on it then.

Edit: I couldn't figure out how to link to a google search for some reason but if you google "brain bleeds causing st elevation" you will get results and studies.


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## Chupathangy (Jul 16, 2014)

So in the case of ST elevation in a subdural bleed, ASA could potentially be more harmful than beneficial right?


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## LACoGurneyjockey (Jul 16, 2014)

I would imagine so, but I'd have a hard time taking a patient who fell down bumped their head with no major trauma and ST elevation, and skipping thru my chest pain protocol. Someone correct me if I'm wrong, but I don't believe there's any definitive way to rule out cardiac origin of ST elevation vs a bleed, certainly not in my mid 1990s era protocol.


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## Chupathangy (Jul 16, 2014)

No you're absolutely right. You'd have a pretty tough time explaining it to the ED.


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## jrm818 (Jul 16, 2014)

DesertEMT66 said:


> I'll see if I can find anymore. Our ER doc and resident at our trauma center told me about it around a year ago (I think). I did some initial research on it then.
> 
> Edit: I couldn't figure out how to link to a google search for some reason but if you google "brain bleeds causing st elevation" you will get results and studies.



Here's a nice summary: http://lifeinthefastlane.com/ecg-library/raised-intracranial-pressure/


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## Handsome Robb (Jul 16, 2014)

Are you guys talking about cerebral T waves?


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## Handsome Robb (Jul 16, 2014)

I guess I should look at the links before I open my mouth.


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