# My final Trauma Assessment of Class



## firemedic0227 (Nov 17, 2011)

Today was my final Practical exam of Paramedic class. I have a question for a little insight into a Trauma assessment I had. I was dispatched to an adult male that had fallen from a tree about 20 feet up. He was showing signs of Cushings Triad and had a blown right pupil which means a high suspicion of Increased ICP. His B/P was 210/130 his Pulse was 56 and showing sinus brady on the monitor. I treated all the patients wounds which were a broken lower leg and thats it. I decided to give atropine .5mg IVP for the bradycardia because my book said that Atropine had no contra-indications when given in the field. I was told that I failed because I gave a medication that had and adverse effect on the patient. After giving the patient the Atropine all his vitals remained the same and didn't change. Anyone have any insight into why it was contra-indicated in this case even though everything I have read has said there is not contra-indications to giving atropine in the field.


----------



## fast65 (Nov 17, 2011)

I think they may have failed you because the underlying condition was NOT cardiac related. Atropine is indicated for symptomatic bradycarida, this most certainly was not a case of symptomatic bradycardia. You said it yourself, this gentleman was displaying Cushing's Triad, which is what? Hypertension, bradycardia, and irregular respirations. The bradycardia in this case is being caused by increased vagal stimulation after the baroreceptors detect the hypertension, so it's due to the head trauma, not an actual cardiac issue. That's kind of a quick explanation, but I'm sure others here would be willing to go further into it, and correct any mistakes I made.

So in a sense, you failed becase you gave atropine when it was not indicated. Did you RSI this guy?


----------



## Handsome Robb (Nov 17, 2011)

Not necessarily contraindicated but inappropriate in the scenario you presented. 

The patient is hypertensive already there's no reason to increase his HR. BP is directly correlated with cardiac output. Cardiac output = stroke volume x heart rate. By increasing his rate you very well could boost his pressure which would increase his ICP and make the cerebral herniation worse. That's why you failed, or at least my take on it. 

Also did you administer it on scene or enroute? Did you treat the leg on scene? With this patient there is absolutely no reason you should be playing around on scene, fix immediate life threats, package and get moving, the only thing that's going to save this patient is a neurosurgeon. As long as there's not a life threatening bleed from the leg the LSB will stabilize it just fine, even if there was severe bleeding TQ the leg and be done with it, you absolutely can justify that, now NREMT testing verbalize direct pressure then TQ.

Cushing's triad is indicative of cerebral herniation which would indicate mild hyperventilation preferably with continuous ETCO2 monitoring, I'd aim for ~35 mmHg.

I don't want to sound mean but honestly your treatment was inappropriate and very well could have been detrimental to a live patient.


----------



## fast65 (Nov 17, 2011)

NVRob said:


> Not necessarily contraindicated but inappropriate in the scenario you presented.
> 
> The patient is hypertensive already there's no reason to increase his HR. BP is directly correlated with cardiac output. Cardiac output = stroke volume x heart rate. By increasing his rate you very well could boost his pressure which would increase his ICP and make the cerebral herniation worse. That's why you failed, or at least my take on it.
> 
> ...



I'm glad someone actually took the time to type out a clear explanation


----------



## Handsome Robb (Nov 17, 2011)

fast65 said:


> I'm glad someone actually took the time to type out a clear explanation



I'm just hoping it made sense and wasn't totally wrong haha.


----------



## socalmedic (Nov 17, 2011)

what they said^^. atropine is not for bradicardia, it is for hypotension caused by bradycardia. the most important part of making pt care scenarios is to test you critical thinking. a kushings scenario was probably used to see if you would give atropine, and my guess is that you are not the only one who did that. also scene time longer that 10 min should be a failure, and treating the leg on scene would have been a failure with me unless the leg was FUBAR, LSB is enough of a spline for me. he needs a ventriculostomy/crainonomity stat. mannitol or 3% saline would have been indicated and most likely what they wanted to hear.


----------



## Shishkabob (Nov 17, 2011)

Atropine is indicated for SYMPTOMATIC bradycardia, ie bradycardia that's causing issues, mainly due to low mean arterial pressure not perfusing the brain and causing altered mental status.  This patients AMS isn't caused by a bradycardia related issue, but instead the bradycardia is a symptom of the underlying issue.  I have a resting heartrate of 54 witha  BP of 120/80.  Would you give me atropine?



You giving atropine, and thereby increasing his heartrate, without a doubt increased his blood pressure, causing even more issues, and potentially (most likely) killing the patient.






The proper thing would have been trying to maintain a reasonable EtCO2 level, NOT increasing the heartrate for a non-cardiac related issue.




NVRob said:


> I'd aim for ~35 mmHg.


All the ones I've seen prefer 30mmHg.  35, while at the lower end, is still normal.  Normal isn't going to help the patient... especially if you have people bagging at 100% fiO2.


----------



## firemedic0227 (Nov 17, 2011)

Thanks for all the insight guys, that is why I thought I was failed. It was just a brain fart on my part.


----------



## bigdogems (Nov 17, 2011)

Just a little bit of stuff to help your with your registry. On your trauma pt station: C Spine as soon as you make pt contact, Hi flow O2, After clearing airway make sure to ask for respiration rate and if its adequate. If not, OPA and BVM. Outside of a fluid bolus you shouldn't be giving meds in your major trauma station. If your vitals get worse it usually means you missed treating a major life threat


----------



## firetender (Nov 17, 2011)

*This is what concerns me...*

When you are tested on a scenario you are being asked to go through the same thought process you would in an actual situation. Here's what you said after reporting the signs, symptoms and vitals:



arharris83 said:


> I decided to give atropine .5mg IVP for the bradycardia because my book said that Atropine had no contra-indications when given in the field.


 
Big Red Flag, not on the choice, but on the reasoning.

You choose to administer a drug based on its actions in a given situation because the book said it had "no contraindications in the field"?

Here, I have to ask what book and what field? 

None of the drugs in your toolbox are without contraindications. As already established, speeding up the heart would contrbute to increased BP, therefore potentially increasing ICP. The guy needed a hole bored into his head but they would have flunked you on that as well!

Please, understand this is a friendly slam, but I'm harping on this because of your insistence:



arharris83 said:


> Anyone have any insight into why it was contra-indicated in this case even though everything I have read has said there is not contra-indications to giving atropine in the field.


 
Yes...your choice was based on potentially fatal tunnel-vision. You only considered Atropine in relation to it speeding up a bradycardic heart without consideration of the bigger picture.

Please don't continue missing the Big Picture. That means you really need to know your drugs (refer to threads on NS and O2), especially the fact that NONE of them are absent contraindications. In this case, working off a little bit of knowledge could have had fatal ramifications.


----------



## Handsome Robb (Nov 17, 2011)

Hey if it makes you feel any better I killed a "patient" in class yesterday when I gave NTG to an Inferior MI before doing a right sided 12-lead.


----------



## Shishkabob (Nov 17, 2011)

NVRob said:


> Hey if it makes you feel any better I killed a "patient" in class yesterday when I gave NTG to an Inferior MI before doing a right sided 12-lead.



In your defense,  a right sided 12 lead doesn't keep someones vessels from dilating ^_^


----------



## Handsome Robb (Nov 17, 2011)

Linuss said:


> In your defense,  a right sided 12 lead doesn't keep someones vessels from dilating ^_^



True haha. I wouldn't have given it after he showed me the rV-4 after the fact though h34r:


----------



## Shishkabob (Nov 17, 2011)

NVRob said:


> True haha. I wouldn't have given it after he showed me the rV-4 after the fact though h34r:



Why?

I would have.


----------



## Chief Complaint (Nov 17, 2011)

NVRob said:


> Hey if it makes you feel any better I killed a "patient" in class yesterday when I gave NTG to an Inferior MI before doing a right sided 12-lead.



Not to thread jack, but this is something that i wasnt taught in school.  No 12 leads at all for that matter.  I had to hear it for the first time on an internship shift.  Pretty crazy how terrible my program is eh?


----------



## Melclin (Nov 17, 2011)

To add just a little to what others have said...

There is a difference between a lack of indications and contraindications.

For example, you turn up to a pt with nausea and vomiting after having read a so called paramedic text. Are there any contraindications to adrenaline? To narcan? How about Morphine? Sux? Most probably not. But would you give any of these drugs to this person who rightly nauseated over this travesty of a textbook? Of course not. There are no *contraindications*, but there are no *indications*.

Firetender is absolutely right to say it is a little disturbing that the rationale for any drug should be "because it said in my book". If you're going to give a drug, you need to have a idea of what outcome you hope to achieve with your pt and why that drug with achieve that.


----------



## firemedic0227 (Nov 17, 2011)

Thanks for all the help guys, I got tunnel vision when usually I don't have a problem with Trauma Assessment but today I did. It's better to make the mistake in class and no in the field. I will not make this mistake on a live person after today that is for sure. There is a lot of things that I need to get better at and study more on this would be one topic. Once again thanks guys!

As far as the NTG in an Inferior MI, I was quizzed by a Paramedic while doing a ride along on an inferior MI call. He asked me if we could have given NTG with it and I said yes (Because I was never taught not to). He informed me that you don't want to give it with an Inferior MI, we took this pt. to the hospital and the Cardiac DR asked if we gave NTG we said know and he was like Good Call.


----------



## Shishkabob (Nov 17, 2011)

ARGH!!!


It's perfectly fine to give NTG to an inferior MI, so long as it's done smartly.


----------



## Handsome Robb (Nov 17, 2011)

Linuss said:


> Why?
> 
> I would have.



The risk of killing their preload with a RVI has been *preached* to us. "If you give someone with a RVI nitro you can kill them". Also in the scenario my transport time was <10 minutes to a capable facility.

Regular 12 showed 2mm elevation in II, III and aVF and no reciprocal changes. The V-4R had 1-2mm depending on who's measuring.

Chief you didn't have 12 leads in your program?? Didn't you just finish recently?

Wow sorry for the thread jack. /off topic.


----------



## Shishkabob (Nov 17, 2011)

NVRob said:


> The risk of killing their preload with a RVI has been *preached* to us. "If you give someone with a RVI nitro you can kill them". Also in the scenario my transport time was <10 minutes to a capable facility.



Just a quick note, RVI =/= inferior MI.  Inferior MIs include the RV in only about 30-50% of the time, and it isn't always significant enough to  be pre-load dependent.  



> Regular 12 showed 2mm elevation in II, III and aVF and no reciprocal changes. The V-4R had 1-2mm depending on who's measuring.


  No reciprical changes... so how sure were you that it was a STEMI as opposed to say, injury, benign early repol, or something else?





Starlings law, people.


----------



## Dwindlin (Nov 17, 2011)

Linuss said:


> ARGH!!!
> 
> 
> It's perfectly fine to give NTG to an inferior MI, so long as it's done smartly.



This.


----------



## Handsome Robb (Nov 17, 2011)

I'm starting a new thread, standby.


----------



## Chief Complaint (Nov 18, 2011)

Removed


----------



## Handsome Robb (Nov 18, 2011)

Chief Complaint said:


> Leaving me hanging with all this talk about a new thread!  Couldnt wait.



http://emtlife.com/showthread.php?t=26860 

Sorry, I got distracted.


----------



## HMartinho (Nov 18, 2011)

Just one question:

this patient does not need to be intubated? In some situations, not all, our doctors and nurses often do a rapid induced intubation...


----------



## Nervegas (Nov 18, 2011)

NVRob said:


> I don't want to sound mean but honestly your treatment was inappropriate and very well could have been detrimental to a live patient.



Wasn't mean, and if this was a patient of mine in the field, there would be a helicopter in this persons future if we were more then 10 min from a lvl 1 trauma center, or during rush hour etc. Like Linuss said, the only thing that is going to save this patient is a neurosurgeon to relieve the ICP.



HMartinho said:


> Just one question:
> 
> this patient does not need to be intubated? In some situations, not all, our doctors and nurses often do a rapid induced intubation...



Not necessarily, but could be yes, a BIAD might also be an appropriate choice to reduce on scene time.


----------



## STXmedic (Nov 18, 2011)

You realize it takes damn near 10min just to LAUNCH the helicopter....


----------



## Nervegas (Nov 19, 2011)

PoeticInjustice said:


> You realize it takes damn near 10min just to LAUNCH the helicopter....



I would have had them launched right after I did a quick assessment, and it doesn't take quite that long, it might take 10 minutes to aos. Plus its one of our SOP's, > 15 min from definitive care for a priority 1 pt and we are supposed to fly them.


----------

