# How would you handle the care for these Pts



## 1badassEMT-I (Jun 22, 2010)

You have arrived at the scene of a MVC involving a car and an SUV. You recognize a side impact on the drivers side of the car with about 12 inches of intrusion into the passenger compartment and very little damage to the SUV. All other passengers have left the vichiles without injury except the driver of the car, a 20y/o male slumped over the steering wheel with obvious contact of the steering wheel to his anterior chest.

The pt. is awake, anxious, diaphoretic, and breathing rapidly (rr30). He has a weak, thready, rapid radial pulse. There is tenderness and bursing over the left upper  quadrant of his ABD.


What injuries do you expect in this Pt.?

How would you manage this Pt.? 

You are 30 minutes away from the nearest trauma center. How does this alter your plan of action?

PLEASE ANSWER ALL THE QUESTIONS::::: And have fun with your answers!


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## MrBrown (Jun 23, 2010)

I would suspect any of the following

Cervical spine injury
Perforated bowel
Ruptured spleen
Lacerated liver
Cardiac tamponade, 
Fractured ribs or sternum,
Pneumothorax,
Haemopneumothorax,
Flail chest
Pelvic or leg fractures

Plan of action

Hard collar and KED
Move to ambo
Vital signs survey
Expose and examine in partic looking for chest/abdominopelvic injuries and shock
IV access (does not mean 14ga. in the AC!)

Time factor does not change my plan at this stage, the time to hospital is probably significantly less than the time it would take for HEMS to come to me.


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## Dominion (Jun 23, 2010)

I'd expect internal damage/bleeding (spleen rupture, pneumo, hemopneumo, tamponade), look out for any obvious fractures, assess for head injury, spine injury, and be suspect for any chest trauma as well.

Initial treatment would involve immobilizing and extricating, IV's for potential fluid needs to keep BP no less than 100 systolic.  Supportive care currently with no further information.  Note: After reading Browns reply I would like to specify the same, if the BP is stable/> 100 systolic, 18g saline lock with fluids on standby if needed.  

If no signs of head injury, vitals remain stable and we can coach the breathing down we'd go ahead and transport to the local trauma center by ground.

If any of the following conditions are met; prolonged response time, prolonged extrication, unstable vitals, respiratory status worsens, or signs of significant head injury then I would go ahead and attempt air transport.


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## thatJeffguy (Jun 23, 2010)

Dominion said:


> I'd expect internal damage/bleeding (spleen rupture, pneumo, hemopneumo, tamponade), look out for any obvious fractures, assess for head injury, spine injury, and be suspect for any chest trauma as well.
> 
> Initial treatment would involve immobilizing and extricating, IV's for potential fluid needs to keep BP no less than 100 systolic.  Supportive care currently with no further information.  Note: After reading Browns reply I would like to specify the same, if the BP is stable/> 100 systolic, 18g saline lock with fluids on standby if needed.
> 
> ...


Air?  When a trauma center is 30m away?  

Other than that, I agree with everything you've said.  If this guy has a decent BP, (>80mmHg) he's getting a fast ride.  If he's lower than that, I'd try to get a bird to meet us somewhere nice and safe.


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## Dominion (Jun 23, 2010)

That is our own local protocol that if any of those conditions are met Air transport is started by dispatch not us.  Also for us atleast in some extremes of the county air transport is 5-10 minutes and ground is 30-50 depending on traffic.  Usually we can have air transport on scene before or right as a med unit is arriving.

Now with that said, if I beat the helicopter on scene, I'm going to transport ground, not going to wait for a helicopter to land.


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## Simusid (Jun 23, 2010)

Already covered by "Doc Brown" above but I want to highlight again, just as much for myself.   If I approached this scene and found a diaphoretic patient, probably my first thought would be shock management and I would get a BP ASAP.


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## 1badassEMT-I (Jun 23, 2010)

Simusid said:


> Already covered by "Doc Brown" above but I want to highlight again, just as much for myself.   If I approached this scene and found a diaphoretic patient, probably my first thought would be shock management and I would get a BP ASAP.



I give you a A plus for the SHOCK so far!!!!


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## 1badassEMT-I (Jun 23, 2010)

MrBrown said:


> I would suspect any of the following
> 
> Cervical spine injury
> Perforated bowel
> ...



Nice Brown A plus


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## 1badassEMT-I (Jun 23, 2010)

*Answer to this scenerio!*

Based on the high mechcanism of injury, you should have a high suspiscion for thoriacic and ABD injuries leading to hemorrhagic shock, as well the possiblity of nonhemorrhagic shock. Because this patient is in shock, rapid extrication is required with spinal control. High o2 concentration should be delivered to the most appropiate airway device based on the level of consciousness and the ability to main a secured airway. External sources of hemorrhage should be sought and controlled. The status of the neck viens would help differentiate hemorrhagic from nonhemorrhagic causes of the shock.

Transport should be RAPID, and establishing two or more large bore IV lines for fuild administration should be done en route. Transport should not be delayed to establish IV access. If you supect intraabdominal bleeding, and the patients status is deteriorating in the absence of penterating thoriac injury, consider PASG use in routeif available (CANT REMEMBER THE LAST TIME I USED THEM).

The major focus of management is rapid extrication and transport to the trauma canter, where definitive control of hemorrhage would prevent progression through the various stages of shock, leading to death or compilcations of hypoperfusion, such as renal failure, respiratory failure, and multiorgan dysfunction syndrome.


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## 1badassEMT-I (Jun 23, 2010)

Dominion said:


> I'd expect internal damage/bleeding (spleen rupture, pneumo, hemopneumo, tamponade), look out for any obvious fractures, assess for head injury, spine injury, and be suspect for any chest trauma as well.
> 
> Initial treatment would involve immobilizing and extricating, IV's for potential fluid needs to keep BP no less than 100 systolic.  Supportive care currently with no further information.  Note: After reading Browns reply I would like to specify the same, if the BP is stable/> 100 systolic, 18g saline lock with fluids on standby if needed.
> 
> ...



Why just a lock?  Base on you information you were given that this person is in SHOCK and fuilds should be given. Just wondering why the lock? And thanks for wieghing in on this.


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## 1badassEMT-I (Jun 23, 2010)

thatJeffguy said:


> Air?  When a trauma center is 30m away?
> 
> Other than that, I agree with everything you've said.  If this guy has a decent BP, (>80mmHg) he's getting a fast ride.  If he's lower than that, I'd try to get a bird to meet us somewhere nice and safe.



What about IV and all the other good stuff?


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## Sasha (Jun 23, 2010)

1badassEMT-I said:


> Why just a lock?  Base on you information you were given that this person is in SHOCK and fuilds should be given. Just wondering why the lock? And thanks for wieghing in on this.



Google permissive hypotension. The administration of fluids can be more harmful than good, as long as the patient is perfusing vital organs (with blood, not koolaid) like the brain and kidneys, they probably don't need fluids


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## Sasha (Jun 23, 2010)

http://emtlife.com/showthread.php?t=10970&highlight=permissive+hypotension

A thread that talks a little about it


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## 1badassEMT-I (Jun 23, 2010)

Sasha said:


> Google permissive hypotension. The administration of fluids can be more harmful than good, as long as the patient is perfusing vital organs (with blood, not koolaid) like the brain and kidneys, they probably don't need fluids



I gave the answer to this scenario:

Based on the high mechcanism of injury, you should have a high suspiscion for thoriacic and ABD injuries leading to hemorrhagic shock, as well the possiblity of nonhemorrhagic shock. Because this patient is in shock, rapid extrication is required with spinal control. High o2 concentration should be delivered to the most appropiate airway device based on the level of consciousness and the ability to main a secured airway. External sources of hemorrhage should be sought and controlled. The status of the neck viens would help differentiate hemorrhagic from nonhemorrhagic causes of the shock.

Transport should be RAPID, and establishing two or more large bore IV lines for fuild administration should be done en route. Transport should not be delayed to establish IV access. If you supect intraabdominal bleeding, and the patients status is deteriorating in the absence of penterating thoriac injury, consider PASG use in routeif available (CANT REMEMBER THE LAST TIME I USED THEM).

The major focus of management is rapid extrication and transport to the trauma canter, where definitive control of hemorrhage would prevent progression through the various stages of shock, leading to death or compilcations of hypoperfusion, such as renal failure, respiratory failure, and multiorgan dysfunction syndrome.


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## 1badassEMT-I (Jun 24, 2010)

1badassEMT-I said:


> I gave the answer to this scenario:
> 
> Based on the high mechcanism of injury, you should have a high suspiscion for thoriacic and ABD injuries leading to hemorrhagic shock, as well the possiblity of nonhemorrhagic shock. Because this patient is in shock, rapid extrication is required with spinal control. High o2 concentration should be delivered to the most appropiate airway device based on the level of consciousness and the ability to main a secured airway. External sources of hemorrhage should be sought and controlled. The status of the neck viens would help differentiate hemorrhagic from nonhemorrhagic causes of the shock.
> 
> ...




I liked the article BTW!!!!!!!!!


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## Sasha (Jun 24, 2010)

1badassEMT-I said:


> I gave the answer to this scenario:
> 
> Based on the high mechcanism of injury, you should have a high suspiscion for thoriacic and ABD injuries leading to hemorrhagic shock, as well the possiblity of nonhemorrhagic shock. Because this patient is in shock, rapid extrication is required with spinal control. High o2 concentration should be delivered to the most appropiate airway device based on the level of consciousness and the ability to main a secured airway. External sources of hemorrhage should be sought and controlled. The status of the neck viens would help differentiate hemorrhagic from nonhemorrhagic causes of the shock.
> 
> ...



Your posts are sometimes hard to read, so I find myself skipping over most of them, my comment was directly related to your quoted statement reprimanding a poster for saying they would establish an IV lock, not just the scenario at hand. Sorry, I may have only been a medic for less than a year but I do like to read up on evidence based medicine and share my limited wealth of knowledge. Just because they're a trauma patient does not mean they require fluids.


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## 1badassEMT-I (Jun 24, 2010)

1badassEMT-I said:


> I gave the answer to this scenario:
> 
> Based on the high mechcanism of injury, you should have a high suspiscion for thoriacic and ABD injuries leading to hemorrhagic shock, as well the possiblity of nonhemorrhagic shock. Because this patient is in shock, rapid extrication is required with spinal control. High o2 concentration should be delivered to the most appropiate airway device based on the level of consciousness and the ability to main a secured airway. External sources of hemorrhage should be sought and controlled. The status of the neck viens would help differentiate hemorrhagic from nonhemorrhagic causes of the shock.
> 
> ...



I said for fluild administration didnt say DROWN THEM!


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## 1badassEMT-I (Jun 24, 2010)

Sasha said:


> Your posts are sometimes hard to read, so I find myself skipping over most of them, my comment was directly related to your quoted statement reprimanding a poster for saying they would establish an IV lock, not just the scenario at hand. Sorry, I may have only been a medic for less than a year but I do like to read up on evidence based medicine and share my limited wealth of knowledge. Just because they're a trauma patient does not mean they require fluids.



I didnt reprimand nobody just ask why. just a lock...see thats the problem people seem to skip over stuff. And this post wasnt hard to follow at all....and it came directly from PHTLS the sixth edition almost word for word! I suggest the next time learn what is a question is and a reprimanding is...I asked a QUESTION!


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## Sasha (Jun 24, 2010)

1badassEMT-I said:


> I didnt reprimand nobody just ask why. just a lock...see thats the problem people seem to skip over stuff. And this post wasnt hard to follow at all....and it came directly from PHTLS the sixth edition almost word for word! I suggest the next time learn what is a question is and a reprimanding is...I asked a QUESTION!



It's hard to follow due to poor sentence structure and horrid spelling.

P.S: My spelling is nowhere near perfect, but not tragically bad either, and my ideas are normally understood.


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## 1badassEMT-I (Jun 24, 2010)

Sasha said:


> It's hard to follow due to poor sentence structure and horrid spelling.
> 
> P.S: My spelling is nowhere near perfect, but not tragically bad either, and my ideas are normally understood.



Well dont be so quick to JUDGE me. That senario was perfectly written. However you just jump on my question that I was reprimanding a poster over. THAT IS WRONG OF YOU! admit it! When in fact it was a legit question I asked the poster.


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## Sasha (Jun 24, 2010)

I didn't jump on you, there was no hostility in my first post, it was a simple informative post.


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## MrBrown (Jun 24, 2010)

Without getting personal here, the treatment modalities you discuss are horrendously outdated and have long been proven ineffective *or* shown to increase M&M

IV fluids should be restricted in the context of hypovolaemic shock from uncontrolled bleeding (e.g. an RTA patient with lacerated liver who is bleeding internally) prior to operative control of the bleeding.  Our blood pressure target here is ... mm, I think 80mmHg.  Somebody else can explain the CPP/MAP thing better than I can.

PASG (MAST) pants autotransfuse about what, maybe a couple hundred CC of blood? We threw them out a decade ago in the face of absolutely no evidence they work and evidence they increase mortality.

There is nothing magic about oxygen, most patients only require 2-3 litres on a nasal cannula.  Patients often recieve oxygen that is not clinically indicated nor beneficial and/or in concentrations above what is required.  If this patient where acutely hypoxaemic then yes, some oxygen is definately indicated ... I would probably go with 8-10 litres.  We rarely (read: never) go above 10lpm here.

With the hospital being 30 minutes away it's still going to be faster to go by land ambulance than a helicopter; HEMS will take 5-10 minutes to depart, say 5-7 minutes flying time each way and say 8-10 minutes to do handover, load and prepare for departure.  That's 23 minutes at the least, faster to go by road.


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## reaper (Jun 24, 2010)

This is why I do not like scenarios from a badly written text book!

You can't expect people to answer full questions on this scenario, as there is not a full assessment or vitals given.

 The pt is diaphoretic? Is it 100 degrees out or is it from shock? 

RR of 30? Is this from shock or because a 20 yo was just in an accident?

Rapid Thready pulse? What is the Pt's normal pulse rate and quality?

We would need a full set of vitals. Most specifically a BP. Whether I start a lock or a line, does not matter. I need an assessment and vitals, before any fluids are given. A lock is fine to start. I can hook a line at any time, as needed. Scenarios are great to do on here, but you have to have all the info for people when they ask. That is how people learn to make the right decisions.


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## 1badassEMT-I (Jun 24, 2010)

reaper said:


> This is why I do not like scenarios from a badly written text book!
> 
> You can't expect people to answer full questions on this scenario, as there is not a full assessment or vitals given.
> 
> ...



You are right! But there again this text book is being used to this day.... I used this for a reason because I wanted to see if anybody would pick this up.... and you did Reaper OUTDATED! However still being taught.


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## 1badassEMT-I (Jun 24, 2010)

MrBrown said:


> Without getting personal here, the treatment modalities you discuss are horrendously outdated and have long been proven ineffective *or* shown to increase M&M
> 
> IV fluids should be restricted in the context of hypovolaemic shock from uncontrolled bleeding (e.g. an RTA patient with lacerated liver who is bleeding internally) prior to operative control of the bleeding.  Our blood pressure target here is ... mm, I think 80mmHg.  Somebody else can explain the CPP/MAP thing better than I can.
> 
> ...



WOW never over 10lpm that interesting! PASG is never used here either just came from the book that is still being used here is all. However I still have them on my truck.


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## 1badassEMT-I (Jun 24, 2010)

reaper said:


> This is why I do not like scenarios from a badly written text book!
> 
> You can't expect people to answer full questions on this scenario, as there is not a full assessment or vitals given.
> 
> ...



Nobody ask so we didnt play long!


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## Veneficus (Jun 24, 2010)

MrBrown said:


> PASG (MAST) pants autotransfuse about what, maybe a couple hundred CC of blood?



They autotransfuse nothing of consequence.

They can be used to pneumatically cross clamp an abd aorta.


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## MrBrown (Jun 24, 2010)

Veneficus said:


> They autotransfuse nothing of consequence.
> 
> They can be used to pneumatically cross clamp an abd aorta.



Aw but its funererer if you do it right there at the roadside!


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## reaper (Jun 24, 2010)

That is a main reason i do not like PHTLS. But, you have to also realize that the instructor books will have more to the scenarios in them. They want the Pt's to ask for that info and then they supply it.

Problem with a lot of text books are they are outdated, even when new. It is up to us to learn more and keep up to date on medicine. EMT books still preach 15lpm by NRB. Anyone with an education knows that is not always needed. These alphabet courses are there just to pick up a little info. They are not the last word or definite treatment for all Pt's.


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## Sasha (Jun 24, 2010)

> Anyone with an education knows that is not always needed.



Correction, almost NEVER needed


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## Veneficus (Jun 24, 2010)

MrBrown said:


> Aw but its funererer if you do it right there at the roadside!



Roadside open laparotomy?

I am going to adopt Brown.


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## Sasha (Jun 24, 2010)

Veneficus said:


> Roadside open laparotomy?
> 
> I am going to adopt Brown.



Sounds dirty, but what's a little sepsis gonna hurt?


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## lightsandsirens5 (Jun 24, 2010)

Sasha said:


> Sounds dirty, but what's a little sepsis gonna hurt?



Ha ha ha! Great Sasha!


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## 1badassEMT-I (Jun 24, 2010)

reaper said:


> That is a main reason i do not like PHTLS. But, you have to also realize that the instructor books will have more to the scenarios in them. They want the Pt's to ask for that info and then they supply it.
> 
> Problem with a lot of text books are they are outdated, even when new. It is up to us to learn more and keep up to date on medicine. EMT books still preach 15lpm by NRB. Anyone with an education knows that is not always needed. These alphabet courses are there just to pick up a little info. They are not the last word or definite treatment for all Pt's.



You are correct!


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## 1badassEMT-I (Jun 24, 2010)

Sasha said:


> Correction, almost NEVER needed



You are correct also!


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## 1badassEMT-I (Jun 24, 2010)

We need to get the OUTDATED books out. Reaper with what you said about books being outdated  when they come out so true. How can we bridge that. Because it is still being taught.


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## Akulahawk (Jun 24, 2010)

*Late to this one, but...*



1badassEMT-I said:


> You have arrived at the scene of a MVC involving a car and an SUV. You recognize a side impact on the drivers side of the car with about 12 inches of intrusion into the passenger compartment and very little damage to the SUV. All other passengers have left the vichiles without injury except the driver of the car, a 20y/o male slumped over the steering wheel with obvious contact of the steering wheel to his anterior chest.
> 
> The pt. is awake, anxious, diaphoretic, and breathing rapidly (rr30). He has a weak, thready, rapid radial pulse. There is tenderness and bursing over the left upper  quadrant of his ABD.
> 
> ...


Injuries? Well, from the steering wheel marks, I would suspect that he may have sternal/rib fractures, punctured lungs, contused or punctured heart, or (since he's still alive) even an aortic tear that hasn't completely ruptured... the LUQ abdominal pain could mean that any of the internal organs (stomach, spleen, kidney, lots of intestine) could also be damaged in some manner. Since the guy managed to whack the steering wheel so hard, he might have TBI or cervical spine issues... Oh the list is long, and none of which I can definitively treat in the field.

Treatment? Darned near "textbook". Keep him "dry" unless he needs fluid to maintain a SBP of 100. 

If I'm 30 minutes from a trauma center, it makes no difference in what I do. An hour? Perhaps. Helicopters are usually a specifically requested resource, and would almost definitely be one within a 30 minute drive time. Unless the helicopter is already on scene, I'm driving the patient in.


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## Dominion (Jun 24, 2010)

1badassEMT-I said:


> Well dont be so quick to JUDGE me. That senario was perfectly written. However you just jump on my question that I was reprimanding a poster over. THAT IS WRONG OF YOU! admit it! When in fact it was a legit question I asked the poster.



It's been said several times but I'll repeat it again.  Permissive Hypotension, which I was also taught in my most recent PHTLS course.  I dont remember if it was in the book or not but I distinctly remember the instructor telling us to focus on keeping the BP > 85-90 systolic with small boluses IE 250cc - 500cc at the max.  A single large bore 16-18 or two 18g IV's are sufficient to achieve this goal.  

You gave me no information in the scenario to indicate WHAT the BP or MAP of this patient was so I had no idea what the perfusion status could be in that arena, in my first post I mentioned something about I had no further information to base an appropriate answer on.  My bad I didn't directly ask you "What are the other vital signs", then again the scenario asked what I would look for, what my treatment plan was, and how would I manage an extended transport time.  

As far as PASG in PHTLS it may be in the book but any educator with a brain is going to make sure the class knows that PASG is not used anymore at all.


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## 1badassEMT-I (Jun 24, 2010)

Dominion said:


> It's been said several times but I'll repeat it again.  Permissive Hypotension, which I was also taught in my most recent PHTLS course.  I dont remember if it was in the book or not but I distinctly remember the instructor telling us to focus on keeping the BP > 85-90 systolic with small boluses IE 250cc - 500cc at the max.  A single large bore 16-18 or two 18g IV's are sufficient to achieve this goal.
> 
> You gave me no information in the scenario to indicate WHAT the BP or MAP of this patient was so I had no idea what the perfusion status could be in that arena, in my first post I mentioned something about I had no further information to base an appropriate answer on.  My bad I didn't directly ask you "What are the other vital signs", then again the scenario asked what I would look for, what my treatment plan was, and how would I manage an extended transport time.
> 
> As far as PASG in PHTLS it may be in the book but any educator with a brain is going to make sure the class knows that PASG is not used anymore at all.



It was directly as it was in the book......we all know PASG are not used anymore last time I used them were late early 90s.... Not saying you are wrong about anything else I did this to see if anybody would notice the outdated PHTLS book that is still being used daily.


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## jjesusfreak01 (Jun 24, 2010)

It's not completely awful if the textbooks are slightly outdated, so long as they stay away from medical statements that are fundamentally wrong. Information about MAST systems is tempered by the fact that many systems don't carry them anymore. Also, protocols should serve to keep everyone on track.

That said, my class is using an older version (8th ed) of the Brady textbook, and it is obvious that a good amount of the information is either outdated or plain inapplicable. Almost everything that they teach us about PCRs is inapplicable to our county's system. Also, stuff like use of the PASGs is talked about like it's still in use.


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## Smash (Jun 25, 2010)

Veneficus said:


> Roadside open laparotomy?
> 
> I am going to adopt Brown.



Why stop at an open lap?  Go the full crack I say: "Brown, the rib spreaders please..."


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## MrBrown (Jun 25, 2010)

Smash said:


> Why stop at an open lap?  Go the full crack I say: "Brown, the rib spreaders please..."



Hang on, we'd better tell the patient 

"Now look here mate, this is going to hurt pretty bad I'm not going to lie and there is no other way to put it but we have to do it to keep you alive.  Try to think of something nice and just go with that man"

Somebody get me 2mls of ketamine to start and dilute it up to 20, thats 200mg, what, maybe give the whole 200, should knock them out you think?


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## 1badassEMT-I (Jun 25, 2010)

jjesusfreak01 said:


> It's not completely awful if the textbooks are slightly outdated, so long as they stay away from medical statements that are fundamentally wrong. Information about MAST systems is tempered by the fact that many systems don't carry them anymore. Also, protocols should serve to keep everyone on track.
> 
> That said, my class is using an older version (8th ed) of the Brady textbook, and it is obvious that a good amount of the information is either outdated or plain inapplicable. Almost everything that they teach us about PCRs is inapplicable to our county's system. Also, stuff like use of the PASGs is talked about like it's still in use.



Hey we got PASG on our trucks.....they take up space and collect dust.


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## usafmedic45 (Jun 26, 2010)

> I said for fluild administration didnt say DROWN THEM!



LOL ...and they just wanted to make sure you weren't saying that.  Don't be so defensive.  Sasha doesn't bite...unless asked.  Even then, you have to ask nicely. 



> Somebody get me 2mls of ketamine to start and dilute it up to 20, thats 200mg, what, maybe give the whole 200, should knock them out you think?



Worked in Viet Nam. 



> WOW never over 10lpm that interesting!



Not really.  If they are not oxygenating adequately with an FiO2 of >60 or so, there is something pretty wrong and chances are good that throwing more oxygen alone at the problem is not going to solve it.  



> Also for us atleast in some extremes of the county air transport is 5-10 minutes and ground is 30-50 depending on traffic



Yeah, but by the time you factor in all the issues already mentioned beyond the simple scene to hospital flight time, even with a 30-40+ minute ground transport chances are good that a patient sent by ground would be at the hospital 5 to ten minutes ahead of the helicopter transported patient.   This is assuming that the ground crew transporting the patient did not sit on scene and screw around. 

As for transport decision making, no call for the helicopter indicated in this situation.  Unless you're close to an hour out, there is no justifiable reason to call for the helicopter.  A properly equipped and trained ALS ground unit can do most of the things this patient will need and can deliver them faster and easier while delivering the patient to the things that they can't.  

When it comes to vascular acess, I would probably put a single 16-18 gauge in and would either do a saline lock or at most a TKO drip.


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## mycrofft (Jun 26, 2010)

*I think "Scenarios" are an aquired taste.*

The best one can do is give one's working hypothesis on approach and initial response, then it degrades into a jungle of "What about/Yes, but", "NIGYYSOB", and flowcharting.

So much of the art of medicine, even as a nurse or a tech, is WATCHING the pt and adapting tx to s/s. The science is know which measure or insult is causing the bad things to happen..or the good things.

The field worker's art specifically is know what to treat before transport, during transport, and the best way to transport.

Oh, and billing info collection!


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## irish_handgrenade (Jun 26, 2010)

Look for obvious fractures, spinal injuries, head injuries, internal bleeding from organs or long bone fractures, and possible tamponade/pnuemos. 
Assess mental status -> rapid trauma assessment -> extricate -> full spine immobilization -> reassess-> assess vitals -> O2/monitor -> I agree with 2x IVs, but I would saline lock one, and put fluids to the other, if BP is above 90 systolic I KVO unless trends in BP show the pt does need a fluid bolus-> rapid transport, If the local ER (30 minutes away) is not a higher level trauma center I would either have a flight crew meet us enroute at the ER or enroute to a higher level facility. There is no reason delaying definitive care if the closest ER is not a high enough level trauma center. 

And as for your little tif with sasha, dude you kinda flipped off the deep end, there is no absolutely correct answer to any scenario and if you are going to make it in this business you need to understand that EMS is 95% gray area, and 5% black and white. Also you should not wear your feelings on you sleeve cuz they will get blood, poop, and vomit on them...


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## Sasha (Jun 26, 2010)

> Don't be so defensive. Sasha doesn't bite...unless asked. Even then, you have to ask nicely.



Or talk dirty to me. 



> Yeah, but by the time you factor in all the issues already mentioned beyond the simple scene to hospital flight time, even with a 30-40+ minute ground transport chances are good that a patient sent by ground would be at the hospital 5 to ten minutes ahead of the helicopter transported patient. This is assuming that the ground crew transporting the patient did not sit on scene and screw around.



I think a lot of people forget that a helicopter is not always better, and you have to think ahead and do the math and make sure there is actually a benefit to the patient for HEMS transport, and that it's not just something you can go back to your buds and tell them about the "cool trauma call" that you worked that was so bad you sent them out by helicopter. Even if they can get them to the hospital faster, it may not always be in the best interest of the patient.


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## usafmedic45 (Jun 26, 2010)

> Or talk dirty to me.



Duly noted but my fiancee would never go for that. 



> Even if they can get them to the hospital faster, it may not always be in the best interest of the patient


Yeah, medical care in the back of a helicopter is extremely limited.  Aeromedical operations may have a lot of "cooler toys" but several of them it's damn tough to use in flight, which is one reason why scene times for truly critical patients being flown out are much longer than we should be comfortable with.  Intubations in a lot of helicopters is much harder than doing it in the back of an ambulance or on scene.


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## Veneficus (Jun 26, 2010)

mycrofft said:


> The best one can do is give one's working hypothesis on approach and initial response, then it degrades into a jungle of "What about/Yes, but", "NIGYYSOB", and flowcharting.
> 
> So much of the art of medicine, even as a nurse or a tech, is WATCHING the pt and adapting tx to s/s. The science is know which measure or insult is causing the bad things to happen..or the good things.
> 
> ...



I think a scenario should be instructive and present information for the purpose of critical thinking or debate. 

It should not simply be a "war story" or a "guess what I am thinking" excercise.

It also really bugs me when a complete physical and history is not presented and the author wants somebody to ask about every detail. Some findings are grossly apparent and just my brief looking over of a patient can yield considerable information before I touch them, which is absolutely certain to be next.


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## Melclin (Jun 26, 2010)

Sasha said:


> Or talk dirty to me.



*spits coffee over keyboard and desk in surprise*

You gotta be careful throwing talk like that around. You're likely to kill a bloke. 

*God dammit Brown*, you gotta give me some warning if your choppers going to start tubing small horses, or the Prescribing Authority is ganna start thinking you're nicking some ketamine on the side and selling it to glassy eyed ravers.  

Whenever I think of "extending to a clamshell" when cracking chests, I can't help but think of that talking hamburger that flogs McDonalds. Odd.


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## usafmedic45 (Jun 26, 2010)

> I can't help but think of that talking hamburger that flogs McDonalds


In the quiet words of the Virgin Mary: Come again?


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## MrBrown (Jun 27, 2010)

Melclin said:


> *God dammit Brown*, you gotta give me some warning if your choppers going to start tubing small horses, or the Prescribing Authority is ganna start thinking you're nicking some ketamine on the side and selling it to glassy eyed ravers.



Not likely, we carry 200mg in 2ml and inject the whole thing into a pack of 5% dextrose to make 10mg/ml. 

The max dose we can give is 150mg ... now I have never seen anybody get 150mg of ketamine but I immagine they would be quite nicely "disassociated"


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## jjesusfreak01 (Jun 27, 2010)

Would 200mg put them at the borderline for losing spontaneous breathing control?


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## MrBrown (Jun 27, 2010)

jjesusfreak01 said:


> Would 200mg put them at the borderline for losing spontaneous breathing control?



I am not sure, I am not an anaesthetist 

Ketamine's main mechanisim of action is not on the opiod or respiratory centres so does not depress respiratory drive.  If anything it has a pro-respiratory and some bronchodialatory effects which make it great for asthmatics.

For prehospital RSI we give 1.5mg/kg, up to 150mg in combination with 1mcg/kg of fentanyl.

I have been meaning to pinch one of the anaesthetic reg's or consultants and have a chat about ketamine.


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## jjesusfreak01 (Jun 27, 2010)

Right, but enough of a dissociative will cause complete dissociation wherein the patients body will stop breathing because it no longer realizes that it needs to (or something like that). I am specifically thinking dxm overdose, but I would imagine ketamine would have a similar effect at high doses.


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## MrBrown (Jun 27, 2010)

I am not sure to be honest mate, I'll have a look after work.

You know I just bought this "DOCTOR" jumpsuit for seven hundred pound online right?


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## LondonMedic (Jun 27, 2010)

MrBrown said:


> Ketamine's main mechanisim of action is not on the opiod or respiratory centres so does not depress respiratory drive.  If anything it has a pro-respiratory and some bronchodialatory effects which make it great for asthmatics.


It can cause apnoea in overdose or overly rapid administration and does cause decrease in minute volume in paeds.


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## usafmedic45 (Jun 27, 2010)

> For prehospital RSI we give 1.5mg/kg, up to 150mg in combination with 1mcg/kg of fentanyl.



Why benzos?  Why fentanyl?  Adding an analgesic to anaesthetic seems kind of redundant and if you are working on an adult there is that spectre of an emergence reaction if you for some reason forget to keep the patient under.  When we use it- both in hospital and out of hospital- it's usually paired with lorazepam or midazolam. 

Personally, it's one of my favorite drugs for RSI, especially in asthmatics or hypovolemia.  I am glad to see that some progress is being made in reversing the long held bias against giving it in patients with head trauma now that it has been shown not to cause increases in ICP (and God only knows whenever they put out a new album it will be too soon.   ) and that it may have clinically significant neuroprotective effects.


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## MrBrown (Jun 28, 2010)

Honestly I do not know, I think fentanyl has some sedative / amnestic / sympathetic tone agonist features but I am not sure.  

Mind you how many anaesthestists give a pre-med? Lots.  

I hear ketamine will only produce anaesthesia for about ten minutes, much the same as etomidate and propofol.  I dno tho, last time I got hit with propofol several hours went by, although I do remember a tank of sevroflurane being present 

We follow up the ketamne and fentanyl with some midaz, not really to play anaesthetist but to keep the patient sedated enough where they dont remember.


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## Melclin (Jun 28, 2010)

usafmedic45 said:


> In the quiet words of the Virgin Mary: Come again?



Flog = sell

There used to be a big talking hamburger that bounced around on the teli (TV) flogging (selling) maccas (McD's) to kids. But they banned him because parents are too stupid to realise/to lazy to take responsibility for the fact that a regular diet of lolies (candy), maccas and coke would make their children fat.


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