# Chest pain an low spo2 after crash



## nymedic9999 (Oct 19, 2013)

Hi all I have a little scenario I want to run by you guys.  For the sake of the scenario assume you are on a BLS rig with a ALS fly car available.  How would you handle this call?  AND NO ITS NOT HOMEWORK

MOI-  The patient was the passenger in a vehicle when it was t-boned on the passenger side probably at around 40 mph.  About 4 inches intrusion to  the passenger side.  Passenger was restrained and no airbag deployment.  No other injuries in vehicle.

So you get dispatched for the mva with entrapment and no injuries.  You arrive on-scene to find a 80 year old male trapped in his vehicle due to his door being jammed. The patient initially only complains of neck pain and is extricated with Collar and LBB following fire taking the door off.  Patient is loaded into the ambulance  and vitals are taken. Patient is hemodynamically stable. SPo2 is slightly low at 90 so patient is placed on a nasal canula at 2 lpm.  This bumps his spo2 up to 98.  Full head to toe is conducted and no complaints are noted.  About 20 minutes out from the hospital thought the patient begins to complain of pain in his lower right chest over his lower ribs.  The pain is reproducible upon palpation and is believed to have been caused by the seatbelt/impact(impact was on the patients right side).  My question is as a basic truck would you continue on to the hospital or call for an ALS intercept due to his original low spo2 and the possibility of a underlying chest injury?


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## EMT B (Oct 19, 2013)

How long did extrication take? What is his medical history? Is he on any medications? Pain scale? GCS? Nausea? Vomiting? How far away is ALS? 

What does the area where the pain is look like? Is there bruising? Swelling? How did it feel? Was it rigid? Was it hot? Cold? How hard did you palpate it to reproduce the pain? Was he wearing the seatbelt properly? 

Just for giggles and grins what was his BP and, Pulse Rate and Respiratory Rate? Were they Regularly regular? Regularly irregular? Irregularly irregular? Strong pulse? Weak? Lung sounds? Difficulty breathing with the new pain?

If he was wearing his seatbelt correctly, I would think that you would more likely see pain below the *LEFT* side of the chest as opposed to the right side (see image below).


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## nymedic9999 (Oct 19, 2013)

Extrication took about 10 minutes.

Medical history

S- lower right chest pain, neck pain --> chest pain 8/10 (no facial grimace or whincing)
A- Coedine
M- only vitamins
P- Nothing that stood out --> very healthy for his age
L- Lunch
E- T boned

GCS-15, no nausea, no vomiting, ALS is 5 minutes out

Little bump over the area of pain.  No real bruise.  Light palpation causes pain. Area is soft.  No real DCAP-BTLS.  Normal temp

BP 160/90, hr 77 strong and regular, rr 16, spo2 98 on 2 lpm
Lung sounds clear in all fields, no trouble breathing.

And yes I was mistaken on the seat-belt.


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## EMT B (Oct 19, 2013)

Can you do a 12 lead? I might do one and call ALS for pain management, but nothing really scares me just yet. MAP is a little above normal, but I would rather have that, then a low map and no perfusion. Airway is patent and they have adequate ventilations. So they aren't on any meds like blood thinners etc for things like afib or htn?


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## nymedic9999 (Oct 19, 2013)

Basics in NY cant do 12 leads. He does have HTN but doesnt take any medication for it.  His history was clean.


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## Aidey (Oct 19, 2013)

nymedic9999 said:


> MOI-  The patient was the* passenger in a vehicle when it was t-boned on the passenger side* probably at around 40 mph.





EMT B said:


> If he was wearing his seatbelt correctly, I would think that you would more likely see pain below the *LEFT* side of the chest as opposed to the right side (see image below).




Passenger. Right sided impact. Right sided chest pain makes perfect sense.




To the OP. Let the poor guy sit up and see what that does to his SpO2. $5 says he develops bruising on the R side, and another $5 says the x-ray shows a broken rib or two.


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## EMT B (Oct 19, 2013)

forgot about that part Aidey. I got tunnel visioned on the seat-belt part.

@OP- Regardless of 12 lead i would still only call ALS for pain management due to being 20 mins out from the hospital


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## nymedic9999 (Oct 19, 2013)

Yeah he was boarded and collared as per our protocol.  I didnt think about the possibility that the board was causing his low spo2.  That is probably very likely.  So in this case ALS probably could be deferred.  I was concerned of a possible pneumothorax.


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## Akulahawk (Oct 19, 2013)

Let me see: Passenger in a car that was T-boned on the right side at about 40 mph, complaining of lower right chest pain that's reproducible with palpation... I would imagine that chest pain would be right about where either the car impacted or where the arm rest of the door impacted him when he hit it. 

Since he's on a LSB, he can't be sat up. I would imagine that he's probably now feeling a busted rib or two because the immediate fight/flight response is subsiding. Giving him some O2 is a good idea, but also remember that he's likely hypoventilating (and starting to retain CO2) because of the pain, so while his SpO2 numbers will look good, his EtCO2 won't.  What he's going to need is some pain control so that he can actually breathe without too much discomfort. As a Basic Provider or a Medic that isn't allowed to provide pain control to a patient like this, I'm going to watch him very carefully and make it pretty clear that he's going to need some pain control upon arrival at the ED. 

As to additional assessment, I'd also be almost willing to bet that a couple of his ribs will have positive crepitus upon palpation as well...

Oh, and it took me a little while to completely type this because work was a little distracting.


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## EMT B (Oct 20, 2013)

Is there any reason that this patient would not get pain meds prehospitally?


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## STXmedic (Oct 20, 2013)

EMT B said:


> Is there any reason that this patient would not get pain meds prehospitally?



BLS rig. Depending on transfer time versus ALS intercept time, it may be better for the patient to just get a smooth drive in.

If ALS is on scene, there's no reason pain management should be withheld. I may not start my Fent as high since the patient is in his 80s, but he'd still get it if necessary.


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## Handsome Robb (Oct 20, 2013)

STXmedic said:


> BLS rig. Depending on transfer time versus ALS intercept time, it may be better for the patient to just get a smooth drive in.
> 
> If ALS is on scene, there's no reason pain management should be withheld. I may not start my Fent as high since the patient is in his 80s, but he'd still get it if necessary.



Agreed.

I'm surprised a T bone accident with extrication didn't have ALS dispatched to it originally.


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## DesertMedic66 (Oct 20, 2013)

EMT B said:


> Is there any reason that this patient would not get pain meds prehospitally?



Welcome to crappy protocols. Only allowed to give pain meds for extremity injuries.


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## Akulahawk (Oct 20, 2013)

DesertEMT66 said:


> Welcome to crappy protocols. Only allowed to give pain meds for extremity injuries.


Agreed. I don't like it but we have similar protocols here. Pain control only for extremity trauma. Ribs aren't considered an extremity. If I could, I'd be happy to give enough to make him comfy and breathe OK without blotting out all of his pain. I'd be doing some very careful titration to a tolerable level of pain... He needs to feel some pain but just enough to know something's wrong and can localize the injury and allow him to breathe easier and therefore ventilate better. 

At least that would be my pain control plan for him. 

On a BLS rig, the best pain control stuff I have onboard is an ice pack... and a nice, smooth trip to the ED with a little supplemental O2 and some breathing coaching.


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## Carlos Danger (Oct 20, 2013)

nymedic9999 said:


> My question is as a basic truck would you continue on to the hospital or call for an ALS intercept due to his original low spo2 and the possibility of a underlying chest injury?



A room-air Sp02 in the low 90's is probably a normal finding in a supine 80 y/o. As long as there is no respiratory distress or other signs of a ventilatory problem, I would not be concerned with it at all.  

Likewise, having some pain after being hit by a car is expected and not necessarily a sign of anything that needs to be attended by ALS.

As for pain management, if you are only 20 minutes from the hospital, I would only call for an intercept if the pain is severe.


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## Medic Tim (Oct 20, 2013)

Where I volley in the US, per protocol we can only give pain medication to isolated extremity trauma and ACS pts. We usually call the hospital and get orders though.

If I had this guy where I am in Canada. He would have gotten a ride in position of least discomfort(no board) and pain medication if needed.


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## Rialaigh (Oct 20, 2013)

20 minutes to hospital, I'm not sure anything would keep me on scene period (Assuming ALS is over 10 minutes out).


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## EMT B (Oct 20, 2013)

he said earlier that the ALS zip car is 5 out.


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## STXmedic (Oct 20, 2013)

EMT B said:


> he said earlier that the ALS zip car is 5 out.



Umm... Where?


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## Carlos Danger (Oct 20, 2013)

EMT B said:


> he said earlier that the ALS zip car is 5 out.





STXmedic said:


> Umm... Where?



Here:



nymedic9999 said:


> Extrication took about 10 minutes.
> 
> Medical history
> 
> ...


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## STXmedic (Oct 20, 2013)

Halothane said:


> Here:



Lol thanks. I'm blind apparently :lol:


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## Christopher (Oct 22, 2013)

nymedic9999 said:


> Yeah he was boarded and collared as per our protocol.  I didnt think about the possibility that the board was causing his low spo2.  That is probably very likely.  So in this case ALS probably could be deferred.  I was concerned of a possible pneumothorax.



The supine position and his age/comorbidities almost assuredly are responsible for the lower SpO2. Even healthy people suffer a measurable degree of respiratory insufficiency while boarded/collared.

Without crazy anxiety or other vital sign changes, the likelihood of a PTX is low. Err, let me restate that, the likelihood of a clinically significant PTX is low.


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## mycrofft (Oct 22, 2013)

Eighty years old, fifteen minutes to get ALS (ten for extrication plus remaining five if all goes as planned) plus time to hospital...

Oxygen, spinal precautions with care to not compromise respiratory efforts, get to hospital. Continuous reassessment. Prepare for good handoff at receiving facility.

Think, what's in the right lower chest? Depending upon how low it is, it can be diaphragm, rib, liver, bowel, kidney, lower right lobe of lung, or even insult of a spinal nerve root serving that region. DEVELOPMENT of it may just be initial shock and adrenaline wearing off, or a worsening of general condition.

What I'd want is to pull over on the way to the hospital, with a potentially worsening post-MVA 80 y/o male, to get him pain relief...yeah, uh-huh.


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