# Where to take this patient?



## Melclin (Nov 20, 2010)

15:30 on a nice sunny day and you are drawn away from watching Australia demolishing the English in the first test for a...

*CODE:1 - 82 yrs female - Traumatic injuries (Possible dangerous body area).*

*O/A:* You are directed to a smiling older woman sitting on the ground in the garage of an expensive looking house with a bloody towel wrapped around her ankle. She says that she tripped after having caught her leg on something, and fell hitting her head on the edge of the car bonnet on the way down. She is quite sorry to be such a bother, and if you could just help her up, her son will take her to the doctor. 
*
O/E:*

-a small lac above her right eye with a mid sized developing haematoma. 
-a 10cm lac on her left calf of medium depth, no spontaneously bleeding.
-estimated blood loss of about 20-40mls. 

Nil LOC.
Nil C-Spine tenderness or back pain (spontaneously and on palpation).
Nil apparent neuromuscular deficit. 
No dizziness before falling (she is quite adamant that she fell because she caught her leg on what turns out to be a pretty nasty jagged piece of metal protruding from the hot water service). 
No chest pain, SOB, current dizziness, diaphoresis.
No headache or blurred vision. 
No allergies.

3/10 pain for the lac on her leg. 1/10 pain for lac on her head.

*Vitals*
Her skin is warm and pink. BP: 200/100, Pulse: 48 (strong, regular), RR: 18 (regular, no distress), Temp: 36.9 (98.4), GCS:15, Pupils : Left pupil is 3mm larger than the right pupil (it is unclear if that is normal for her). 

*Meds*
Warfarin, Candesartan. 

*Hx*
Hypertension, cataract surgery, osteoarthritis, stroke (two years previous, is unclear about any lasting deficits). 

She is generally in good health and is relatively fit. 

Pt is unhappy about going to hospital and is insistent on going to the toilet first and collecting a few bits and pieces from her dresser.

So, a few questions:
-What are you concerned about, why, and what are you going to do about it?
-Spinal precautions?
-Can she go to the toilet and potter about?
-Transport choice (just your thoughts in general about what kind of hospital you think she needs)?
-Level of transport urgency?
-Any medications?


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## SoCal (Nov 20, 2010)

Melclin said:


> 15:30 on a nice sunny day and you are drawn away from watching Australia demolishing the English in the first test for a...
> 
> *CODE:1 - 82 yrs female - Traumatic injuries (Possible dangerous body area).*
> 
> ...



So, a few questions:
-What are you concerned about, why, and what are you going to do about it?
#1, Head Bleed, especially with the lac to the head, warfarin, unequal pupils, high BP, and decreased pulse.

-Spinal precautions?
Absolutely.... Old with fragile bones and obvious strike to the head.

-Can she go to the toilet and potter about?
No! C-Spined and transported.

-Transport choice (just your thoughts in general about what kind of hospital you think she needs)?
One with a CT scanner. Preferably a trauma canter with a neurosurgeon and trauma team.

-Level of transport urgency?
An easy code 3, URGENT.


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## Akulahawk (Nov 20, 2010)

I'll bite... some. Some responses in the quote, some after.


Melclin said:


> 15:30 on a nice sunny day and you are drawn away from watching Australia demolishing the English in the first test for a...
> 
> *CODE:1 - 82 yrs female - Traumatic injuries (Possible dangerous body area).*
> 
> ...


If you haven't noticed, my main concern is that she's got a rising ICP and it hasn't gotten to the point of causing a headache that she's noticed. Right now, she's probably attributing the HA to the forehead lac. I suspect that she has enough of an ICP rise to cause her body to start compensating for it via usual HTN and Bradycardia. Given that she's 82, She probably has more room in the cranial vault due to brain shrinkage that she's able to "hide" the injury far better than I, and that has also has likely contributed to her getting as severe an injury as I think she's got... where that likely wouldn't bother me.


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## SanDiegoEmt7 (Nov 20, 2010)

Any head trauma while on warfarin would be a trauma center candidate.  The elevated BP and pupils increase this concern.  Seems like a simple decision.


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## JPINFV (Nov 20, 2010)

Melclin said:


> So, a few questions:
> -What are you concerned about, why, and what are you going to do about it?
> -Spinal precautions?
> -Can she go to the toilet and potter about?
> ...



1. Elderly? Check
Positive head trauma? Check.
Pupils not equal? Check.
Anticoagulants? Check.

Hello possible sub-arachnoid hemorrhage, which can take hours to develop. 

2. Nope, not indicated based on physical exam. 

3. Nope, however I am more than willing to go retrieve something from her room if she wants something. 

4/5. Non-emergent transport to trauma or stroke center, but be prepared to upgrade. 

6. Not at this time, and the potential ones I'm thinking of to control bleeding (vitamin K and fresh frozen plasma) aren't available prehospital anyways.


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## Akulahawk (Nov 20, 2010)

SanDiegoEmt7 said:


> Any head trauma while on warfarin would be a trauma center candidate.  The *elevated BP and pupils* increase this concern.  Seems like a simple decision.


Not just the BP and Pupils... Bradycardia is also part of this puzzle and nearly completes a certain triad...

I'd want serial BP's with this patient... Because she's heading towards a path towards completing Cushing's Triad... she's just not presenting with abnormal respiratory patterns yet. If she does, it's not good...


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## usalsfyre (Nov 20, 2010)

Agree mostly with the others.

Very high suspicion for a bleed somewhere in the cranial vault with a resultant increased ICP. No c-spine precautions, as I don't indications for it based in exam. Once we get her loaded we're going to take a nice, easy, non-emergent for now ride to a tertiary center while we monitor her VERY closely. Treat pain and agitation PRN, if she deteriorates enroute consider RSI.


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## MrBrown (Nov 20, 2010)

*Brown struggles into his "DOCTOR" jumpsuit and slings the Thomas Pack over his shoulder ... its a go, something about a fall, possibly from height, theres an ambulance on scene already.  

She needs to go to a trauma centre by ground ambulance, no spinal precautions or specific treatment right now.


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## boingo (Nov 20, 2010)

It would be very unlikely that this patients unequal pupils, HTN and bradycardia are secondary to ICP while she is sitting there chatting with you with minimal complaints.  I certainly have concern, especially with her being anticoagulated, however someone with enough ICP to alter pupils and VS are not going to be carrying on a lucid conversation.


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## Veneficus (Nov 20, 2010)

*Lolfdgb*



Melclin said:


> 15:30 on a nice sunny day and you are drawn away from watching Australia demolishing the English in the first test for a...



No worries, cricket goes on forever, you'll not miss anything. It sounds pretty one sided anyway.



Melclin said:


> *CODE:1 - 82 yrs female - Traumatic injuries (Possible dangerous body area).*



Is there a such thing as not a dangerous body area on an 82 y/o?




Melclin said:


> You are directed to a smiling older woman sitting on the ground in the garage of an expensive looking house with a bloody towel wrapped around her ankle.



No need to get upset and use vulgarity  Now if it were a rugby match we were missing that would be different. 



Melclin said:


> She says that she tripped after having caught her leg on something, and fell hitting her head on the edge of the car bonnet on the way down.



Is that like a trunk?

Amnesia? 
Is the car damaged? 



Melclin said:


> She is quite sorry to be such a bother, and if you could just help her up, her son will take her to the doctor.



I think I would talk her into going with us instead. We'll have Brown tear off his velcro fastened jump suit and do a little dance in his bowtie and thong, and maybe she will follow him right to the truck.




Melclin said:


> a small lac above her right eye with a mid sized developing haematoma.



How big is it exactly and how fast is it developing?



Melclin said:


> -a 10cm lac on her left calf of medium depth, no spontaneously bleeding.
> -estimated blood loss of about 20-40mls.



Of no worry, if it needs sewing, it will be done at the hospital. A good idea to check for signs of a fx though. 



Melclin said:


> Nil LOC.
> Nil C-Spine tenderness or back pain (spontaneously and on palpation).
> Nil apparent neuromuscular deficit.
> No dizziness before falling (she is quite adamant that she fell because she caught her leg on what turns out to be a pretty nasty jagged piece of metal protruding from the hot water service).
> ...



Lots of nothing, a findings are looking good.




Melclin said:


> 3/10 pain for the lac on her leg. 1/10 pain for lac on her head.



distracting injury, makes the pain scale less reliable.



Melclin said:


> Her skin is warm and pink. BP: 200/100, Pulse: 48 (strong, regular), RR: 18 (regular, no distress), Temp: 36.9 (98.4), GCS:15, Pupils : Left pupil is 3mm larger than the right pupil (it is unclear if that is normal for her).



She had a stroke in the past, what was the baseline after that? With the location of the hit I am thinking it is a focal deficit. 



Melclin said:


> Warfarin, Candesartan.



What else is she supposed to be taking? Apparently that is not controlling her BP, there has to be a reason she was only on an angiotension receptor blocker for her HTN. With bp numbers that high I am thinking there is an issue with the BP control or a renal component. 



Melclin said:


> Hypertension, cataract surgery, osteoarthritis, stroke (two years previous, is unclear about any lasting deficits).



With the uncontrolled HTN and previous CVA, and 48 hr I think I would start a cardiac workup. I have a high suspecion of a some kind of renal artery patho or kidney failure. I also think the warfarin isn't very good with a 10 cm lack and 20-40 ml of blood loss. How deep is it? Did it penetrate fascia or is it still in the dermis? When was the last time she had her warfarin adjusted or INR measured? 



Melclin said:


> She is generally in good health and is relatively fit.



Maybe for an 82 y/o, but I don't like it.



Melclin said:


> Pt is unhappy about going to hospital and is insistent on going to the toilet first and collecting a few bits and pieces from her dresser.



Perhaps better done by the family.

So, a few questions:


Melclin said:


> -What are you concerned about, why, and what are you going to do about it?



Renal failure, uncontrolled HTN, low output cardiac failure/cardiogenic shock. She may have a subarach or subdural, but I am leaning agaisnt it. 

I am going to do a 12 lead, look for current or prior signs of infarction. Listen to heart tones, percuss the boarders of the heart, and if transport time allows, do an ankle/brachial index. I would also start on some cranial nerve tests other than the pupil reflex and some more neuro eval if nothing more than for a baseline.

She'll get all the normal care, IV w/o fluid, monitor, maybe 2L o2 on cannula.  



Melclin said:


> --Spinal precautions?



I wouldn't put her on a spineboard but I would encourage her to sit on the cot and not be overly spunky. If she is kyphotic the board will cause more issues. I am not liking the idea of laying her flat.



Melclin said:


> Can she go to the toilet and potter about?



Absolutely not, she can have a bed pan. 



Melclin said:


> -Transport choice (just your thoughts in general about what kind of hospital you think she needs)?



An academic hospital that has cardiac, neurosurg, trauma, pulmonary, and renal available all on site. With her history and presentation, with a lack of medications and explanations why, she is going to have multisystem issues.




Melclin said:


> --Level of transport urgency?



I do not advocate the use of lights and sirens ever.



Melclin said:


> ---Any medications?



Depends on what I see on the 12 lead and the rest of my findings. 

She is going to need a head CT to rule out any bleeds, that is a given. She might not have passed out, but perhaps her coordination was affected at some level.  I agree she is too lucid to be presenting with cushings triad. The BP and heart rate are not adding up and in the absence of a gross head injury, I think it must be caused by something else.

My current differentials in absence of other findings:

TIA
CVA
head bleed
PE
MI
CHF
Thrombolic/Embolic event (especially in the renals)
Spinal injury possible, but I cannot explain the high BP and low HR with damage in the cervical area. Perhaps a focal herniation, but again, her mental status is too good. Any repetative movements?  
Since the renal bifurcation is one of the most likely sites of a AAA  better add that in too. (prerupture)
Pseudoaneursim in the Aorta starting at the aortic arch as well. 

At this point, the list is going to be very long until we get some more data.

What was her Blood sugar while we are at it? (might as well be complete)


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## Veneficus (Nov 20, 2010)

this blood pressure issue is getting to me. 

Maybe it's a tumor.

With a paraneoplastic syndrome like SIADH


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## mikie (Nov 21, 2010)

*Fyi...*

I love how thorough Veneficus is.  Why the jump to the tumor though?  A new neoplasm of somesort?  since she's had a stroke before, I'd imagine a comprehensive neuro assessment was done (including imaging), which probably ruled out a tumor.  

But your the doc !


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## Melclin (Nov 21, 2010)

*Vene:*
No amnesia.
No car damage.
There was almost no swelling on the head lac when we arrived. 15 mins later is was maybe... 4-5cm wide, 2-3 above the normal skin level.
No indications of a fracture in physical or mechanism. Happily stands on it. 

She wasn't too sure about what was normal for her after her stroke. She was pretty uninterested in her medical history and didn't know much about it. I never thought of a focal deficit :wacko: 

With some significant prompting, there was some suggestion that the pupils were entirely normal for her after the cataract surgery. 

Issues with BP control. I think so too. Her normal blood pressure is "quite high". The listed medications are all that were there. 

No BSL (see my later comments).


*To everyone:*

Interesting tx decisions. Now lets say, there is: 
-an ED with CT, no neuro and no ICU: 15 mins.
-a metro trauma centre (I suppose you would call it a level 2 centre in the US) with general, ortho & plastics surg, ICU. No reliable neuro: 20 mins.
-a true level one trauma centre: 35 mins L/S. 

Which one are we happy with?



I thought this case was interesting because I think it would have been easy to have a panic about cushing's triad, forgetting that its a _late sign_ and as far as I've known, almost impossible to have with a GCS of 15. Interesting to see who is immobilizing and who isn't. 

That said I don't believe the attending paramedics were worried enough. I wholly believe she was a lay still on the stretcher candidate so I was happy with them not collaring. However, no BSL, not interested in the monitor, until I put it on later in the truck (I had to put my foot down a little in that regard) and not at all happy with their letting her go to the toilet by herself and their tx decision. 

I'm don't think she had an ICP problem from a bleed, but I certainly feel something untoward was going on and I wanted to go to a trauma centre to be safe. At the very least she'll want observation for a few days and some investigations into the BP issue. Most of all, I was not confident enough in saying "no bleed" to bet her life on it and I'm still happy with my position about the trauma centre. Especially given...

*20mins after arrival*, having just left the scene, I found her BP to be 250/120 and her pulse was now 40. Still completely asymptomatic and no different in any regard to the information provided in the first assessment. By the time we arrived at hospital, 20 mins later, her BP was down to 160/90 and her pulse up around 50. She went straight to CT and I was very disappointed in not being able to follow up on the job.


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## JPINFV (Nov 21, 2010)

I'd go with metro trauma. If it's a SAH, then you don't need reliable neuro surg, just neuro surg. since SAH isn't a fast bleed with a ton of space to bleed into.


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## Veneficus (Nov 21, 2010)

*To everyone:*



Melclin said:


> Interesting tx decisions. Now lets say, there is:
> -an ED with CT, no neuro and no ICU: 15 mins.
> -a metro trauma centre (I suppose you would call it a level 2 centre in the US) with general, ortho & plastics surg, ICU. No reliable neuro: 20 mins.
> -a true level one trauma centre: 35 mins L/S.
> ...



I agree with JP, metro trauma.

This lady does not have the multisystem trauma that requires the level I. 

I do think she needs a right and proper IM hospitalist to put her conditions and meds back in order. It doesn't look like she is being properly managed from you description. 

History of CVA, hypertension and the best they could do was an angiotension receptor blocker for it? Better than nothing, but not by much.



Melclin said:


> Interesting to see who is immobilizing and who isn't.



The same level of immobilization she would have gotten in the hospital only she would have gotten a Miami J c-collar.  



Melclin said:


> That said I don't believe the attending paramedics were worried enough. I wholly believe she was a lay still on the stretcher candidate so I was happy with them not collaring. However, no BSL, not interested in the monitor, until I put it on later in the truck (I had to put my foot down a little in that regard) and not at all happy with their letting her go to the toilet by herself and their tx decision..



It happens, but many people seem to focus in on the artificial seperation between trauma and medical. It was a memory aid that got out of control. 



Melclin said:


> I'm don't think she had an ICP problem from a bleed, but I certainly feel something untoward was going on and I wanted to go to a trauma centre to be safe. At the very least she'll want observation for a few days and some investigations into the BP issue. Most of all, I was not confident enough in saying "no bleed" to bet her life on it and I'm still happy with my position about the trauma centre. Especially given.....



I don't think anyone would definitively say "no bleed" until they saw a CT. It was indicated without doubt. I think it would be outright negligent not to scan her head. But like all geriatrics, their other issues, especially since it looks like they are not managed well for whatever reason, make the whole situation more complicated. (I like complicated, anything with less than 3 system pathologies is not really challenging enough in my mind.)



Melclin said:


> having just left the scene, I found her BP to be 250/120 and her pulse was now 40. Still completely asymptomatic and no different in any regard to the information provided in the first assessment. By the time we arrived at hospital, 20 mins later, her BP was down to 160/90 and her pulse up around 50. She went straight to CT and I was very disappointed in not being able to follow up on the job.



I really think they are going to find the BP is an issue outside of the injuries.


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