# Trauma Patient



## Cawolf86 (Jul 22, 2010)

Hey there,

this "mini scenario" is based off of something I was thinking about while studying today - I have never come across it personally. Thanks!

Patient is a 40 y/o male who was part of a bar fight. Initial impression is that there is one patient (the male listed) laying on the sidewalk outside a local bar at 0130. Police are on scene and have determined it is safe.

The patient is on the sidewalk in a "heap" but generally in the prone position with his hips slightly flexed. Initial assessment shows that he is responsive to painful stimuli with a GCS of 8 (E1, V2, M5). He currently has a patent airway and his respirations appear adequate but borderline shallow. Upon examination of the skin you find he has poor cap refill (environmental) -  pale, cool, and slightly diaphoretic skin skins.

A rapid scan shows no sign of a skull fracture, contusions/abrasions to the right lateral aspect of the neck around C6 with no crepitus. There is a penetrating wound to the anterior right arm with no exit wound that is bleeding venously. There are multiple minor lacerations and abrasions on the abdomen. The most alarming find is a knife currently in the patient on the dorsal flank on his left side. It appears to be about 5-7 inches long and is penetrating completely in the left upper flank of the patient with only 1 inch not inserted.

Vital signs are taken and show BP 110/70, P 100 rapid and slightly thready, RR 24 with low tidal volume.

My question is how would you manage this trauma patient?


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## MrBrown (Jul 22, 2010)

Breath sounds?
JVD?
Is the abdomen distended, tender etc?
Tracheal deviation?
Pupils?

Quite simply this dude probably has some sort of nasty internal injury (perforated bowel, punctured liver, cardiac tamponade .....) as a result of being shanked and probably has a brain injury from being lumped over the noggin.  I would want to exclude a tension pneumo or a haemopeunothorax.

Speed is the buzz word at the moment.

IV/IO access
Fentanyl, ketamine and suxamethonium
Intubate and ventilate
Compress and stop the bleeding
Bulky dressing and stabilise/pack around the knife
Hard collar and scoop
Drive to a high level trauma centre with much of the fastness

Taking a bit of a poke in the dark with these but lets play EM Reg:

CBC/Tox screen
Several units of non-type specific blood on hand until we cross-match then some units of type specific
Ultrasound and CT scan to find out extent of internal/neuro bleed (if any)
Surgical consult


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## Cawolf86 (Jul 23, 2010)

My apologies for such a scattered post - my true intent was to gain insight into the proper positioning of a patient with a penetrating trauma in the back where the object may be in a vital organ. This MOI along with requiring spinal axis immobilization is my true question.

Sorry for such a scattered post! I won't let it happen again.

-Andrew


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## LondonMedic (Jul 23, 2010)

Cawolf86 said:


> My apologies for such a scattered post - my true intent was to gain insight into the proper positioning of a patient with a penetrating trauma in the back where the object may be in a vital organ. This MOI along with requiring spinal axis immobilization is my true question.


Justify immobilisation?


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## MrBrown (Jul 23, 2010)

LondonMedic said:


> Justify immobilisation?



Because protocol says, havent you learnt a thing about how the Americans operate yet? 

If we have to we can position the patient supine or at an angle no problem might take some inventive scooping.

I would be primarily worried about lung (tension or haemopueumothorax) or spinal injury and/or a wound to the heart (tamponade).

Now, I know its patchy and hardly guarenteed (from the horses mouth) but can we have one of those handy fellows in funny orange getup pop along for a look? .... what, what the bloody hell are you looking at me like that for, I just bought this outfit online for eight hundred pounds


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## Veneficus (Jul 23, 2010)

I think in this case, trying to "iimobilize" isn't so much of a spinal cord issue, but trying to immoblize the knife.

If the blade already transected the cord, nothing immobilization is going to do to help that. Even if you didn't have primary cord injury local inflammatory response could cause the secondary if it is close enough along with a tamponde of spinal arteries from a bleed somewhere in the chest or abd.

I would just try to immobilize the knife, and use a scoop to lift him to the cot, probably best to lay him as best you can on the side so you can do some work.

I would definately not suggest removing an impaled object to put somebody on a spine board, that is crazy. Equal to pushing the object in further.


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## boingo (Jul 23, 2010)

[





MrBrown said:


> IV/IO access
> Fentanyl, ketamine and suxamethonium
> Intubate and ventilate
> Compress and stop the bleeding
> ...



New Zealand protocol or care to justify?


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## jjesusfreak01 (Jul 23, 2010)

MrBrown said:


> Speed is the buzz word at the moment.
> 
> IV/IO access
> Fentanyl, ketamine and suxamethonium
> ...



Do you use Ketamine as an anesthetic for RSI?


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## Cawolf86 (Jul 23, 2010)

LondonMedic said:


> Justify immobilisation?



Not that it is correct, as my county tends to be behind in protocol updates - but an unwitnessed MOI, evidence of trauma to the spine, and unconsciousness would 100% qualify a patient for spinal axis immobilization.


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## Cawolf86 (Jul 23, 2010)

Veneficus said:


> I think in this case, trying to "iimobilize" isn't so much of a spinal cord issue, but trying to immoblize the knife.
> 
> If the blade already transected the cord, nothing immobilization is going to do to help that. Even if you didn't have primary cord injury local inflammatory response could cause the secondary if it is close enough along with a tamponde of spinal arteries from a bleed somewhere in the chest or abd.
> 
> ...



I definitely would stabilize a penetrating object - especially one presenting like this.

I would also definitely be required to LSB this person.

In this case would a medical director in your area request patient positioning other than supine to stabilize the knife? Is there liability IF there actually is partial cord damage?


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## Veneficus (Jul 23, 2010)

Cawolf86 said:


> I definitely would stabilize a penetrating object - especially one presenting like this.
> 
> I would also definitely be required to LSB this person.
> 
> In this case would a medical director in your area request patient positioning other than supine to stabilize the knife? Is there liability IF there actually is partial cord damage?



I can only imagine how poor the system in your area is that you "must" carry out opposing directives that may actually result in more harm to a patient.

Having said that, let me answer the question.

I have never met a medical director who would require a spineboard when an object is sticking out of the patient's back. (as you stipulated dorsal flank) It just defies logic.

In any protocol I ever worked under, there was usually something on the first or second page that stated the protocols were guidlines and shouldn't be substituted for sound clinical judgement or some similar phrase that basically gives a provider permission to think and not blindly follow orders.

In one system I worked for it was pointed out to me by an FTO that we can only provide treatment we have orders for. I then asked him to point out the protocol for control of bleeding. (there wasn't one) So I suggested we must be practicing without a license and until such a protocol is put in place nobody should attempt to control bleeding. (a bleeding control protocol stll does not exist in that service, the med director made mention it is impossible to write a protocol for every conceivable situation and a few for situations that aren't)

It is the paramedic that initiates contact of medical control. I never had a doc call me up randomly or monitor calls and ask me how things are going. A paramedic should difinitively ask for the orders they feel they need, provide a concise and reasonable communication detailing why they are asking for them, and mention anything that is pertinent to a potential negative clinical outcome of the request. It might sound something like this because in reality I wouldn't bother to call in this scenario, i'd just do it:

"Good evening this is veneficus calling to speak with a physician.

Dr. So and So, what's up? 

Morning Doc, I have a 40/yo trauma patient with an impaled object protruding from his rear flank. With your permission sir, I am going to immobilize him in his current position as best I can in order to transport him. If I put him on a board it might drive the knife farther into him. He also has a host of other life threatening injuries secondary to the assault, which may include spinal cord damage. I'll see you guys as soon as I can get him there (eta given)

Sounds good Vene, the trauma team and I will see you when you get here."

I know in CA you guys might or will get a nurse on the phone, as long as you are operating under the license of a physician, you have the right to ask for a physician. If I actually need orders for something, I am going to need to discuss it with somebody who practices medicine, not a nurse who practices nursing and answers a phone.

As for liability you are always liable for any decision you make. Including the decisions to follow orders without thinking or deciding to do nothing.

Calling a medical control doc gets affirmation from a higher level provider it is probably a good judgement call. 

I would much rather make a plantiff prove that I caused the spinal damage and not the original insult than have to prove I did not make the injury worse after I knowingly placed him on a board that potentially would have impaled the object further or caused so much movement to get him on the board a reasonable person could conclude there was increased level of injury from the knife.

(I will never be tried by a jury of my peers, only a jury of people who couldn't get out of jury duty) I would prefer a bench trial but in my home state every award over $20K must be decided by a jury.


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## Cawolf86 (Jul 23, 2010)

I definitely agree on the fact that our protocols are guidelines and not laws to blindly follow. I was just intrigued because the collection of injuries this patient has sustained have conflicting treatments (if LSB is even helpful) in regards to patient positioning. Say the object is in the left-rear flank - would you place him on a LSB in right-lateral? Or just transport on the gurney in the best position to keep the object stable?


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## Veneficus (Jul 23, 2010)

Cawolf86 said:


> I definitely agree on the fact that our protocols are guidelines and not laws to blindly follow. I was just intrigued because the collection of injuries this patient has sustained have conflicting treatments (if LSB is even helpful) in regards to patient positioning. Say the object is in the left-rear flank - would you place him on a LSB in right-lateral? Or just transport on the gurney in the best position to keep the object stable?



On the gurney.

The soft matress will pad him and create less distortion than the board will. 

Many treatments in medicine cause opposition. That is where the art comes in.


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## MrBrown (Jul 26, 2010)

boingo said:


> [
> 
> New Zealand protocol or care to justify?



Actually now that I think about I wouldn't put a collar on this guy, he's gonna be unconscious and paralysed pretty soon anyway!



jjesusfreak01 said:


> Do you use Ketamine as an anesthetic for RSI?



Yes we use fentanyl and either midazolam if the patient has neurogenic cause for coma with GCS < 10 or ketamine for everybody else.

Once he is nicely intubated, scooped and in the ambulance lets drive to a major level trauma centre with much of the fastness.

So ... a surgical registrar, an EM reg, a neuro consultant and a Brown are in resus when an anaesthestist walks in ...


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## Melclin (Jul 26, 2010)

I don't even really see this as being an issue. In what world would anyone think that spinal immobilization in a patient for whom there were questionable (at best) indications was more important than the stabilizing the knife. It seems like a pretty obvious choice...you're hardly going to pull the knife. 

I would manage the pt on their opposite side and load and go with supplemental oxygen. I would rendezvous with MICA (ALS), but I certainly wouldn't be sitting around on my hands waiting for them or delaying for anything for that matter (even cannulation).

Do we think his GCS is from neuro insult? I don't think this pt is indicated for _prehospital_ RSI. Penetrating truncal trauma, can't fluid load which is required for RSI in our system as far as I know. Midaz and fent are no going to help with any hypovolaemia. Unless he is ridiculously combative, and given his injuries, I think rapid transport would be more prudent. I think if we load and go he could be in a trauma bay with a surgical team being activated with a tube faster than waiting on scene for ALS and going through the whole business of tubing there.


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## MrBrown (Jul 26, 2010)

Melclin said:


> Do we think his GCS is from neuro insult? I don't think this pt is indicated for _prehospital_ RSI. Penetrating truncal trauma, can't fluid load which is required for RSI in our system as far as I know. Midaz and fent are no going to help with any hypovolaemia. Unless he is ridiculously combative, and given his injuries, I think rapid transport would be more prudent. I think if we load and go he could be in a trauma bay with a surgical team being activated with a tube faster than waiting on scene for ALS and going through the whole business of tubing there.



I suppose it could be.  The five minutes its going to take to intubate this chap I think are well worth it; it'll give us definitive control of his airway, prevent him from becoming combative or aggrivating injuries any further, provide a more stable platform for the hospital team to work with, stop the anaesthetist from having to come down (dragging a large pile of equipment and a Technician to hold his hand) and (now this might sound bad) it's going to be the expected standard in-hospital before he goes to CT or the OR so why not do thier work for them?

Now, it could also be that Brown has become a rogue practitioner wanting to dish out sux to everybody and fly off into the sunset in his large red and yellow helicopter?

Kind of sounds like my last acid trip


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## Melclin (Jul 26, 2010)

MrBrown said:


> I suppose it could be.  The five minutes its going to take to intubate this chap I think are well worth it; it'll give us definitive control of his airway, prevent him from becoming combative or aggrivating injuries any further, provide a more stable platform for the hospital team to work with, stop the anaesthetist from having to come down (dragging a large pile of equipment and a Technician to hold his hand) and (now this might sound bad) it's going to be the expected standard in-hospital before he goes to CT or the OR so why not do thier work for them?
> 
> Now, it could also be that Brown has become a rogue practitioner wanting to dish out sux to everybody and fly off into the sunset in his large red and yellow helicopter?
> 
> Kind of sounds like my last acid trip



He'll probably get tubed in hospital. But I think though its a matter of prioritizing their needs. If we could do all the same things as a hospital can simultaneous to tubing, then I would definitely go for it. But we can't simultaneously activate the surgical team, overhead x rays, book a CT, a theatre, get various consultations, hassle ICU for a bed, group & cross match & Hb, FBE, Coags, flirt with the nurses, etc. Despite the possible risk to his airway, I think the bigger risk is to wait 10 minutes on scene, hand over to MICA and have them assess him (5mins), setup for and perform RSI (obviously I've never done one but I reckon you might be pushing it to setup for and do one, essentially by yourself, in under 5 mins). I reckon we can roll him straight into the warm waiting arms of a trauma team in that time. 

I suppose its sort of pointless to read into it too deeply given its a hypothetical scenario, but it still seems an interesting dilema. I know its one that MICA have a bit in multitrauma - "Is the coma from haemorrhage or head injury". The person's pulse and BP don't seem bad enough to lead to a GCS of 8 (but of course everyone is different), then neither does it really seem like a head injury - no obvious head trauma, weird GCS :wacko:

The question here is whether his coma is due to haemorrhage or neuro insult (could it be from something else..drugs..or did he skull a bottle before he got stabbed?). Coma due to haemorrhage is generally a contraindication in our system specifically because they don't want medics spending an age tubing when the pt really needs blood and a surgeon, but there might be some wiggle room. I think I'll ask someone from MICA about this scenario, hypothetical though it may be.


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## mycrofft (Jul 26, 2010)

*Cut to the chase (pun intended)*

Problems:
#1: impaled object, length unknown, pt holding his own.
#2: potential blunt force trauma to abdomen and/or neck.

OBSERVATION: If I go playing Twister with this guy to board him, the board may become rapidly superfluous as he dies.
QUESTION: What is the receiving MD going to notice with approval, that you essentially twisted the knife in the pt's gut to board him, or  took a basiclly if momentarily stable condition and held it until surgical support was on hand for the old "One, two three, NOW!", with two large bore blood IV's hanging?
SUGGESTION: make every effort to maintain position without unnecessary realignment of neck/spine, stabilize object with bulk and tape and maybe elastic self-adhere bandage, secure IV placement in each antecube, and _didi mau_ to hospital.


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## boingo (Jul 27, 2010)

You might not want to rush to intubating this guy, he's in a tough position for airway management, and you quite likely have significant internal hemmorhage that you can't control.  The drugs used for induction, and then for on-going sedation may lead to hemodynamic collapse, a problem that would be easier to manage if the procedure were to take place while a surgeon was on scene and prepped.  I'm not saying he wouldn't end up with a tube in my truck, but I think a good degree of risk/benefit analysis needs to occur.


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## FFDrury (Jul 27, 2010)

I agree with you Boingo  Risk/ Benefit analysis is need with this case. My question is if patient has a patent airway, lets worry about the trauma such as the knife in the patients back which to me would be a major concern. I am thinking possible Hemothorax or Hemopneumothorax may be even a pericardial Tamponade. Either case it be I dont want to spend much time on scene. And Back Boarding on this one is out of the question because of the location of the knife. I place on the cot and go to the nearest trauma center and monitoring the patients airway. If it then becomes an issue then lets deal with it. I think basic here ABC's since he has a patent airway OPA wouldnt hurt but spending the time on scene to ET is it really worth the chance of losing this patient 
Remember "minium time on scene Maxium care enroute "


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## Sassafras (Jul 28, 2010)

I'm just thinking I'd like to see Brown try to intubate in this position.


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