# First Trauma Code



## RocketMedic (Dec 3, 2011)

65 yo m rolled his truck and was ejected. Lafort two fractured cranial vault with csf, drainage massive bleeding pulseless apnic on arrival. Attempted ett due to massive oral bleeding, missed, good combitube, transport. Not surviveable but great practice.. Learned a lot to improve on.


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## Shishkabob (Dec 3, 2011)

Your agency won't let you call a blunt traumatic arrest that was unwitnessed?


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## Dwindlin (Dec 3, 2011)

Linuss said:


> Your agency won't let you call a blunt traumatic arrest that was unwitnessed?



Beat me to the question!


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## Smash (Dec 3, 2011)

Rocketmedic said:


> 65 yo m rolled his truck and was ejected. Lafort two fractured cranial vault with csf, drainage massive bleeding pulseless apnic on arrival. Attempted ett due to massive oral bleeding, missed, good combitube, transport. Not surviveable but great practice.. Learned a lot to improve on.



:blink:

I don't think that even counts as a traumatic arrest.  That's just a good old fashioned corpse.  I'm pretty sure it's illegal in most places to interfere with a corpse.


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## AlphaButch (Dec 3, 2011)

At least you gained something out of the experience.

As for protocols (at least in TX) some are backwards, some are progressive - and alot of them are seldom reviewed or changed once they're written.


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## fast65 (Dec 3, 2011)

Linuss said:


> Your agency won't let you call a blunt traumatic arrest that was unwitnessed?



That's what I was wondering as well.


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## Akulahawk (Dec 3, 2011)

In the two counties that I'm familiar with out here, if that patient is in a PEA < 40 or in asystole, the patient is determined dead right on the spot. If that patient is in any other rhythm, or the rate is greater than 40, full resuscitation measures must be done.


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## NomadicMedic (Dec 3, 2011)

This would fit the "head trauma" portion of my "withholding resuscitation" protocol.


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## Akulahawk (Dec 3, 2011)

In any event, a traumatic injury like that usually results in resuscitation practice...


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## tydek07 (Dec 4, 2011)

If I would come up to that today, would I work it? No
If I would have come up to that 3 years ago, would have I worked it? Probably

When I first started working as a paramedic I was in the mindset that I could save everyone and everything. I soon realized that this is not so. I have worked a couple traumatic arrests over the years and not one has survived.  I now believe our protocol on traumatic arrests  If they meet the criteria for withholding resuscitation, I withhold it. You have to remember that there are always those "weird ones". If your gut says to start CPR, start CPR. Did I, or will I, ever get in trouble for starting CPR... heck no. Would I get in trouble for not starting CPR when I should have? You know it! And like you and others have said, it was practice.


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## Doczilla (Dec 4, 2011)

We recently had a case like that here in Afghanistan. It was a mid-20's local male who was PLOWED by a up-armored humvee while checking culverts.  He had the whole nine yards- open skull fracture with all the fixin's, long bone fractures, and in what seemed like a peri-arrest bradycardia with agonal respirations. Not a true trauma arrest, but similar mechanism. 

Some might consider him not survivable had they found him pulseless and apneic, but every case is different. Of course, in a mud hut in a third-world country vs. a stringent EMS agency with "mother may I?" guidelines, the choice to resuscitate may not be so clear. 

After an RSI [with atropine included in the premedication phase], F.A.S.T exam,and all the immobilization mumjo-jumbo, and a mack-truck of broad-spectrum antibiotics, he was flown out to a CASH with neurosurgical capabilities. Two days later, he was awake and talking in his bed. This was approximately two hours after the point of injury. 

If anyone wants more information on the drugs used, or discuss the R.S.I choice on someone with a GCS of 3, let me know. 

V/R, 

John


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## RocketMedic (Dec 4, 2011)

What unit are you in that lets you RSI? We cant even give otc nsaids in 1AD.
i worked the code for practice mostly but an off duty emt from my organization had made initial contact periarrest and we had some Texans helping. I know he cant be saved, but I did want to try.


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## usafmedic45 (Dec 4, 2011)

Rocketmedic said:


> What unit are you in that lets you RSI? We cant even give otc nsaids in 1AD.
> i worked the code for practice mostly but an off duty emt from my organization had made initial contact periarrest and we had some Texans helping. I know he cant be saved, but I did want to try.



Two words: organ donor.


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## DPM (Dec 4, 2011)

Doczilla, do you ever think about the standard of living with these guys? Not having a dig at you, it sounds like a nasty call that you've done well with, but what happens when that L/N survives?

Case in point: One of our ANA callsigns takes x3 casualties from an IED strike. 2 Cat B and the poor bugger that detonated it was Cat A. R leg amputated at the knee, L Leg barely hanging on mid thigh and a badly smashed up right arm. He was extracted, MERT got him back to our Hospital at BASTION and he survived... As a triple amputee. In a country as poor as that, with little or no healthcare available, he's now a huge burden on his family. We had a chat with the ANA commander and the consensus was they could just about manage with one leg, but anything more than that and they'd want to be left to die... A payout for a dead son would help their families a lot more than a disability pension and having to care for him for the rest of his life. 

Obviously in the real world we don't have to make these decisions, and as callous as it sounds, in Afghan I've had times when I felt relived that they've died.


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## Doczilla (Dec 4, 2011)

Well, yeah you're right. This is one success story intermixed with several sad ones, as well. This one just happpened to turn out favorably, which may or may not have had to do with the care rendered. [Probably more thanks to the neurosurgeon who drilled the burr holes in his head.] This guy was ABP, so partner force enjoys some type of priority over regular L/N's. [As you probably are aware] 

Not all of our encounters ended happily. The biggest victims here seem to be the kids, because the parents just don't give a crap. They let a kid "fall" into a bread oven and finally decide to take he/she to you when eschars develop; leaving you to deal with not only the primary life-threats, but also the secondary and tertiary effects as well [rhabdomyolysis, hyperkalemia, renal failure, hypoglycemia, airway swelling, etc]

To address the previous question, I can't exactly tell you the unit I'm in, but I will tell you that in our little "mud hut" of a little aid station we have quite the array of drugs and capabilities. For RSI, we have much to choose from, including Etomidate, Ketamine, Fentanyl, Versed, Propofol, Vecuronium, and Succynlcholine. 

V/R, 

John


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## DPM (Dec 4, 2011)

I dealt with more of the 'door kicking' side of things, in the upper Gereshk area.  We had PEDRO / MERT from Bastion within about 20 mins and a fairly decent Med Centre at MOB Robinson, even KAF was about 40 mins... but not a whole lot on the ground. We could deal with the trauma but for nearly everything else it was Aeromed to some where that could cope. And based on the types of casualties we had it worked well. Most of the L/N had left the area so leaving the PB was pretty much an advance to contact! Good times...


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## RocketMedic (Dec 4, 2011)

Way crazier than Iraq.


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## Brandon O (Dec 5, 2011)

usafmedic45 said:


> Two words: organ donor.



What are the procurement regulations in your region? Around here live organs can't be used unless the donor is perfusing at time of recovery.


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## RocketMedic (Dec 5, 2011)

This patient was not a donor possibility.


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## 18G (Dec 6, 2011)

Head trauma that severe as to cause cardiac arrest = DRT (dead right there).


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## usafmedic45 (Dec 6, 2011)

You know that they can still recover kidneys, heart valves, tendon, ligaments, bone, skin, corneas even after cardiac death right?.   The criteria are nationally standardized for the most part.


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## usafmedic45 (Dec 6, 2011)

Rocketmedic40 said:


> This patient was not a donor possibility.



What makes you say that?


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## Dwindlin (Dec 6, 2011)

usafmedic45 said:


> You know that they can still recover kidneys, heart valves, tendon, ligaments, bone, skin, corneas even after cardiac death right?.   The criteria are nationally standardized for the most part.



We don't code people in this region just because they are donors, is this a common practice else where?


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## usafmedic45 (Dec 6, 2011)

Nope....it's not a standard protocol.  It's just something of a joke around here that if you work a trauma and they arrest at any point, you're effectively transporting and treating a donor.  However, that said, it was a valid defense if our medical director asked why you worked someone:  "His license says he's an organ and tissue donor".  It may not be in the protocols but it was done at least by myself and several others that I have worked with.


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## RocketMedic (Dec 6, 2011)

usafmedic45 said:


> What makes you say that?



Diabetic, cardiac history, and lack of nearby/reasonable harvest team ability.


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## usafmedic45 (Dec 6, 2011)

Rocketmedic40 said:


> Diabetic, cardiac history, and lack of nearby/reasonable harvest team ability.


Ah.....good point.  They could have still harvested tissues probably.  

By the way, you do realize that most organ transplant procurements aren't done at places with a dedicated team right?


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## Brandon O (Dec 7, 2011)

usafmedic45 said:


> You know that they can still recover kidneys, heart valves, tendon, ligaments, bone, skin, corneas even after cardiac death right?.   The criteria are nationally standardized for the most part.



This is not my field, but as I understand it most tissues (which are non-living items) are not super time-sensitive as far as viability, and can be recovered within a day or two of death. And I believe even kidneys can only be taken if bypass is underway.

I used to have this same understanding (CPR to help maintain organ viability) but recently sat through a very good talk at the Western Mass EMS Conference and was disabused of this. Good stuff like hearts come from those on life support or neurologically dead, not someone who dies in the field with no ROSC.

Interesting topic. Folks who work in procurement are very passionate and understandably so; they help an amazing number of people.


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## usafmedic45 (Dec 7, 2011)

> And I believe even kidneys can only be taken if bypass is underway



You can procure cadaveric kidneys within a couple hours of cardiac death as I understand it.  It's preferable to get them from a "living donor" but you can (and they used to do it heavily in the past) recover them from the "freshly dead" so to speak.

Why would they bypass a patient to recover organs? Do you mean they have to still have perfusion?  What about donation after cardiac death (where they withdraw support from someone in the OR and allow them to progress to clinical death prior to recovery of the organs, such as is done if someone is not technically brain dead but the otherwise non-recoverable clinically)? 



> Good stuff like hearts come from those on life support or neurologically dead, not someone who dies in the field with no ROSC.



Right...but my point being if we can get ROSC from these folks- and we do in a significant number of cases who are later realized to be nothing more than ventilated corpses- why not give them the chance to be donors?  Also, you can still get a lot of stuff out of a person who is clinically dead and its much easier to convince most coroners and ME (speaking as a former deputy coroner and my experiences with a lot of my colleagues) to allow procurement if the patient is in the hospital than sitting in the morgue.


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## Sasha (Dec 7, 2011)

usafmedic45 said:


> You can procure cadaveric kidneys within a couple hours of cardiac death as I understand it.  It's preferable to get them from a "living donor" but you can (and they used to do it heavily in the past) recover them from the "freshly dead" so to speak.



You can procure one of my kidneys right now for the right price.



Sent from LuLu using Tapatalk


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## usafmedic45 (Dec 7, 2011)

Sasha said:


> You can procure one of my kidneys right now for the right price.
> 
> 
> 
> Sent from LuLu using Tapatalk


No comment.....just, no comment. LOL


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## medic417 (Dec 7, 2011)

Sasha said:


> You can procure one of my kidneys right now for the right price.
> 
> 
> 
> Sent from LuLu using Tapatalk





usafmedic45 said:


> No comment.....just, no comment. LOL



Isn't there a word for someone that sells herself for money?h34r::unsure:


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## Brandon O (Dec 7, 2011)

usafmedic45 said:


> Why would they bypass a patient to recover organs? Do you mean they have to still have perfusion?  What about donation after cardiac death (where they withdraw support from someone in the OR and allow them to progress to clinical death prior to recovery of the organs, such as is done if someone is not technically brain dead but the otherwise non-recoverable clinically)?



Okay, ya made me dig up my notes.

Here's what I have: ideally we have a brain-dead patient who is on life support. We have lots of time to bring in the transplant guys, set everything up, then pull organs and rush them over to the recipients.

Alternately, there's the possibility of donation after cardiac death by planned extubation. You have a patient who is NOT brain-dead, but surely will not survive without our ongoing life support (the classic DNR pull-the-plug scenario), and the family or proxies support withdrawing care. You extubate; if the heart stops within 50 minutes (why 50? I may have this down wrong), you can go ahead and take live organs. Ideally, if you're in a major tertiary center (we have a couple in Boston that'll do this), you park them on cardiac bypass, keeping the patient perfused, and we can have it all -- otherwise, we get a "just died, hurry and grab some stuff" situation, and all you get is the relatively robust kidneys and liver.

You can also have an unplanned arrest, but usually you won't get much but tissue from that.

I am far from an expert here and there may be regional variation, so find a real expert if you want good advice; YMMV.



> Right...but my point being if we can get ROSC from these folks- and we do in a significant number of cases who are later realized to be nothing more than ventilated corpses- why not give them the chance to be donors?  Also, you can still get a lot of stuff out of a person who is clinically dead and its much easier to convince most coroners and ME (speaking as a former deputy coroner and my experiences with a lot of my colleagues) to allow procurement if the patient is in the hospital than sitting in the morgue.



Fair enough. I gather than any ROSC, even for a moment, will be used as the last time known alive, which can affect donation significantly. So you may be onto something.


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## usafmedic45 (Dec 8, 2011)

> Fair enough. I gather than any ROSC, even for a moment, will be used as the last time known alive, which can affect donation significantly. So you may be onto something.



That was my point all along.  You get practice out of them even if they can't be procured from.  

BTW, as someone who has benefited from tissue donation, I would argue that getting those items out of a body is quite a big deal.  It's not as glamorous as a heart or set of lungs, but it's still just as useful only in different scenarios.


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## usafmedic45 (Dec 8, 2011)

> Ideally, if you're in a major tertiary center (we have a couple in Boston that'll do this), you park them on cardiac bypass, keeping the patient perfused, and we can have it all -- otherwise, we get a "just died, hurry and grab some stuff" situation, and all you get is the relatively robust kidneys and liver.



Usually, the way DCD is done with the procurement teams already present. I mean, you said it yourself: it's a planned extubation.    That negates the "need" for bypass.  I've worked quite a few hospitals (including a major transplant center) and been in on more procurements than I can count and I have never seen anyone put on bypass for it.  Maybe Boston's OPO is in bed with the local perfusionists and does it differently, but I've not seen that done anywhere I have worked.


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## Brandon O (Dec 8, 2011)

usafmedic45 said:


> Maybe Boston's OPO is in bed with the local perfusionists



:lol:


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## medicdan (Dec 8, 2011)

usafmedic45 said:


> Maybe Boston's OPO is in bed with the local perfusionists and does it differently, but I've not seen that done anywhere I have worked.



You said it, not me. I have seen the same thing as Brandon-- an obsession with bypass post extubation while procurement teams get in place. I'll ask a friend at NEOB and see what their policy is.


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## usafmedic45 (Dec 8, 2011)

That's just :censored::censored::censored::censored:ing stupid.  Why not just hold off on a planned extubation for DCD until after the teams arrive?


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