# scenario



## EMR06 (Jul 6, 2006)

You are called to a car vs pole accident. You get there determine the scene is safe. Moderate damage to the front of the car and you notice the windshield has quite the crack in it.  Airway is clear patent, breathing is deep and respirations are 34. The pt seems to be alert and orientated.Skin is warm and moist. Capil refil is 2 seconds He does have a small laceration above his right eye that is bleeding. You notice a small stream of oozing blood for the pt's right ear as well. You start your  assesment. Head and neck are tender to touch you notice a bruising behind not one but both ears (battle's signs). The rest of the exam goes remarkable aside from the head and beck tenderness. As you begin your re-assesing the pt, the pt says there is a throbbing in his head and he feels very nauseous. About a minute later the pt  losses conciousness 





what now?
what is happening?
what do you want to know?


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## c-spine (Jul 6, 2006)

My first thought is how far out is ALS or a bird? 

Cap refill and respirations are nice, but what about blood pressure? Blood sugar (?)

Next - are there any other people in the car? Any further injuries? Can anyone tell me what happened and how the patient hit the pole? Can anyone give me a SAMLPLE history? Was the patient restrained? 

I want this patient out of the car, onto a board and I'd haul arse to the hospital. I want to make sure the airway is established and patent. If not patent, and the patient has no gag reflex, I'd want him tubed to protect said airway.

My thoughts would be he's got a head injury resulting in the swelling of the brain, and hence the losing consciousness; that or he's got internal bleeding that was not noted. With the crack in the windshield, however, I'd think more along the lines of head injury. Check responsiveness of pupils, keep airway and breathing monitored. Keep checking vital signs every 5 minutes. Keep ALS en route or intercept, and head to hospital.

(ok... what did I miss?)


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## MMiz (Jul 6, 2006)

*What now?

*Call for an ALS intercept but don't delay transport.  This person needs a trauma room.  Quick c-spine, backboard, and in the rig.  New full patient assessment in the rig.

*What is happening?

*I don't know, but I'll happily make a few educated guesses.  MOI and scene size-up point to blunt head             trauma with likely skull base fracture.  Patient in compensated shock stopped compensating... it's bound to happen.   

*What do I want to know
*
Far too much  Why did the patient impact the pole?  Bullet wound anywhere?  Any other cars involved?  Any witnesses?  What's "quite the crack?"  Medic-alert band?  Any meds on scene?  Any significant findings in the car or surroundings?  You telling me what you did is like someone asking me the meaning of life and I say "Rainbows are pretty".


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## EMR06 (Jul 6, 2006)

bp is 180/100 heart rate is 110. blood glucose is normal. you cant do a sample your pt blacked out. what now?what could be the problem?


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## EMR06 (Jul 6, 2006)

MMiz said:
			
		

> *What now?
> 
> *Call for an ALS intercept but don't delay transport.  This person needs a trauma room.  Quick c-spine, backboard, and in the rig.  New full patient assessment in the rig.
> 
> ...





no other cars involved. one person collision. dark country road.  Pt did not have a medic-a-lert.


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## MMiz (Jul 6, 2006)

Hmm.  I was always the kid that asked "What happens next" at the movies.


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## EMR06 (Jul 6, 2006)

MMiz said:
			
		

> Hmm.  I was always the kid that asked "What happens next" at the movies.




Can't do human generated scenarios can we?HMMM?LOL


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## rescuecpt (Jul 7, 2006)

MMiz said:
			
		

> You telling me what you did is like someone asking me the meaning of life and I say "Rainbows are pretty".



Best. Line. Ever.

HA!


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## c-spine (Jul 7, 2006)

EMR06 said:
			
		

> you cant do a sample your pt blacked out.




I know the patient blacked out, that's why I asked if there were any other people that could give me a sample history.    (that wasn't meant to sound b****y)

Any spinal injuries, before backboarding?


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## KEVD18 (Jul 7, 2006)

i want an intercept and if the nearest TRAUMA CENTER, not local doc in the box is more than 20min by ground, i want a helo. with the info youve given, i'm going with closed head injury with compensating shock poss secondary to an internal bleed or the h i . 

things i want to know:

what was the response time between crash and pt contact? battls sign is usually a late sign of a head injury which could be explaind if its was a vollie call out at 3am but interesting if there was an immediate response

throbbing in the head... where? front, back, top, base. was there trauma noted at that location? radiation? 

csm's: positive/negative, strong/weak etc

previously mentioned details that i gather werent avail( SAMPLE, loc etc)

sounds like a doosey of a call.


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## disassociative (Jul 7, 2006)

Can i get a  DCAP-BTLS? SAMPLE would be nice as well.
Vitals: Blood Pressure, Respiration, Pulse(Cushing Reflex?)

+ PMS Arms and legs?

Based on what I have seen; one of my first actions(after ABC and C-Spine) would be:

LifeFlight Standby

After LOC & battles sign; probably launch recommendation.

Does the pt vomit? If so, is there projectile vomiting?


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## Flight-LP (Jul 7, 2006)

Helicopter, quickly!!!!! Your patient is about to die and needs a neurosurgeon like yesterday..........

The pt. has a basilar skull fracture with temporal bone involvement, probably a combination of transverse and longitudinal, hence the bleeding from the ear, the complaint of nausea and the "throbbing" sensation. Since otorrhea of CSF and blood is present, your patient has probably tore a suture or venous sinus groove and now also has an epidural bleed. A period of lucidity followed by a loss of consciousness is the classic epidural bleed finding. This guy is gonna die quickly if you don't get him to a neuro-trauma center rapidly. 

Some good answers and thoughts, but most of the responses are items that just aren't needed until this guy gets stabilized. These delays can and will kill your neuro-trauma patients..................


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## MMiz (Jul 8, 2006)

Flight-LP said:
			
		

> Helicopter, quickly!!!!! Your patient is about to die and needs a neurosurgeon like yesterday..........
> 
> The pt. has a basilar skull fracture with temporal bone involvement, probably a combination of transverse and longitudinal, hence the bleeding from the ear, the complaint of nausea and the "throbbing" sensation. Since otorrhea of CSF and blood is present, your patient has probably tore a suture or venous sinus groove and now also has an epidural bleed. A period of lucidity followed by a loss of consciousness is the classic epidural bleed finding. This guy is gonna die quickly if you don't get him to a neuro-trauma center rapidly.
> 
> Some good answers and thoughts, but most of the responses are items that just aren't needed until this guy gets stabilized. These delays can and will kill your neuro-trauma patients..................


Do you mind if I change your username to "Doc"?


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## disassociative (Jul 8, 2006)

Try this:

http://www.trauma.org/resus/moulagetwo/moulagetwo.html

The responses are actually quite entertaining. This moulage is based
on Prehospital care.


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## Rangat (Jul 8, 2006)

Flight LP said all i want to say.

Life over limb, try to keep him stable, but get him on a board, 2x IV's, OP tubes & ET's if you can, but he is very priority 1, so respond with an escourt to the nearest trauma centre with a neuro surgeon. And it's just polite to phone them beforehand...


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## HFD EMS (Jul 12, 2006)

Flight-LP said:
			
		

> Helicopter, quickly!!!!! Your patient is about to die and needs a neurosurgeon like yesterday..........
> 
> The pt. has a basilar skull fracture with temporal bone involvement, probably a combination of transverse and longitudinal, hence the bleeding from the ear, the complaint of nausea and the "throbbing" sensation. Since otorrhea of CSF and blood is present, your patient has probably tore a suture or venous sinus groove and now also has an epidural bleed. A period of lucidity followed by a loss of consciousness is the classic epidural bleed finding. This guy is gonna die quickly if you don't get him to a neuro-trauma center rapidly.
> 
> Some good answers and thoughts, but most of the responses are items that just aren't needed until this guy gets stabilized. These delays can and will kill your neuro-trauma patients..................



ummmm if i am ever in a wreck i am going to have them call you!!!! VERY IMPRESSED!!!!!!


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## Jon (Jul 13, 2006)

Flight-LP said:
			
		

> Helicopter, quickly!!!!! Your patient is about to die and needs a neurosurgeon like yesterday..........
> 
> The pt. has a basilar skull fracture with temporal bone involvement, probably a combination of transverse and longitudinal, hence the bleeding from the ear, the complaint of nausea and the "throbbing" sensation. Since otorrhea of CSF and blood is present, your patient has probably tore a suture or venous sinus groove and now also has an epidural bleed. A period of lucidity followed by a loss of consciousness is the classic epidural bleed finding. This guy is gonna die quickly if you don't get him to a neuro-trauma center rapidly.
> 
> Some good answers and thoughts, but most of the responses are items that just aren't needed until this guy gets stabilized. These delays can and will kill your neuro-trauma patients..................


Gee... I just saw this.

Flight-LP said what I would say - the pt has an obvious closed head injury with elevated Intercranial pressure... The "lucid interval" is something that happens, and the sudden loss of consciousness combined with Battle's sign would make me get the patient to a Level-1 Trauma center.

*If I didn't have a medic handy, I'd check with command, then fly the bird... get the patient to the trauma center YESTERDAY.

Monitor the airway, the next step after going unconscious will probably be an altered pattern of respirations, probably Cheynne-Stokes respiration. The patient will probably need advanced airway management as well as assistance in respirations.


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## FF894 (Aug 27, 2006)

KEVD18 said:
			
		

> i want an intercept and if the nearest TRAUMA CENTER, not local doc in the box is more than 20min by ground, i want a helo. with the info youve given, i'm going with closed head injury with compensating shock poss secondary to an internal bleed or the h i .



Yep, get that boy on a board and get going :excl:


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## Ridryder911 (Aug 27, 2006)

what now? Cancel Christmas, happen to have a Black & Decker Drill available?
what is happening? He's dying...
what do you want to know? Catholic, protestant, etc...


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## MedicPrincess (Aug 27, 2006)

What now?  You hope that helicopter gets there and you get him on the bird before he dies on scene with you.

What next?  Get him intubated so you have a chance to protect his airway.  And hope that helo isn't to far away.

Whats happening?  He's having a very bad day.  And I'm willing to bet nothing is going right in the back of your truck.  Crap has been flung everywhere.  Who ever you have bagging him is probably doing it about 50 times a minute.  Your portable suction will probably choose this precise moment to stop working, only to mysteriously start working again once you've transferred him to the helo.  And I don't care if its 10 degrees below, your sweating  your butt off..

What do you want to know?  How far out is that helo.


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## Kendall (Aug 28, 2006)

I wish I was ALS... **sniff**

Best I could do w/ pt is ABC's, patent the airway w/ opa, highflow o2, KED & board, monitor vitals and hope to god that ALS is down the road and STARS is on the ball w/ a less than 8 minute in the air time. I'd also be praying that a generous MD/neurosurgeon is onboard (Often, STARS has a EMT-P, RN and an MD/surgeon onboard their flights... I'm suprised the whole crew makes it out alive...)

So... what's the end result?


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## FF894 (Aug 28, 2006)

Ridryder911 said:


> what now? Cancel Christmas, happen to have a Black & Decker Drill available?
> what is happening? He's dying...
> what do you want to know? Catholic, protestant, etc...





LMAO - true though


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## PArescueEMT (Aug 28, 2006)

EMTPrincess said:


> What now?  You hope that helicopter gets there and you get him on the bird before he dies on scene with you.
> 
> What next?  Get him intubated so you have a chance to protect his airway.  And hope that helo isn't to far away.
> 
> ...



you forgot about the pouring rain and thunder that started about 30 seconds after the bird was launched...


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## bunkerhillfire (Sep 24, 2006)

I would suspect TBI with the scenario especially with the Mastoid Process bruising and LOC.  Respirations 34 is rapid and Capillary refill of 2 seconds is borderline.  Do not delay transport and if extrication time is going to be lengthy, aeromedical should be utilized.  This is just my opinion.


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## FF894 (Oct 1, 2006)

Flight-LP said:


> Helicopter, quickly!!!!! Your patient is about to die and needs a neurosurgeon like yesterday..........
> 
> The pt. has a basilar skull fracture with temporal bone involvement, probably a combination of transverse and longitudinal, hence the bleeding from the ear, the complaint of nausea and the "throbbing" sensation. Since otorrhea of CSF and blood is present, your patient has probably tore a suture or venous sinus groove and now also has an epidural bleed. A period of lucidity followed by a loss of consciousness is the classic epidural bleed finding. This guy is gonna die quickly if you don't get him to a neuro-trauma center rapidly.
> 
> Some good answers and thoughts, but most of the responses are items that just aren't needed until this guy gets stabilized. These delays can and will kill your neuro-trauma patients..................



Yup - direct to OR baby


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## FF894 (Oct 1, 2006)

Jon said:


> *If I didn't have a medic handy, I'd check with command, then fly the bird...



Do your birds have stretchers?  We gotta get some of those....


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