# Environmental Scenario



## Noctis Lucis Caelum (Dec 27, 2008)

A 60-year-old male went to get the newspaper and fell in his driveway between high snow banks. He lay there for nearly an hour before being discovered. He is alert, cold, wet, and appears to have a severely deformed open fracture of his ankle. The steps in management of this patient include:

 A. move him out of the cold, splint the ankle, administer high flow oxygen, and transport rapidly

 B. check ABCs, splint the ankle, move the patient into the ambulance, remove his wet clothing, and provide warmth

 C. check ABCs, remove the wet clothing, splint the ankle and control any bleeding, and move the patient out of the cold and provide warmth

 D. control any bleeding, splint the ankle and elevate the leg, administer high flow oxygen, move the patient into the ambulance, and transport

My original answer is C
The _correct_ answer is B, you don't control bleeding..why?


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## firecoins (Dec 27, 2008)

C is the wrong answer because you would not remove wet clothing outside. There is no mention of any extensive bleeding that needs to be controlled despite being an open fracture.  Answer what is there not and what you infer.


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## traumateam1 (Dec 27, 2008)

B.

Here is why:
A - You wouldn't move a pt with a broken leg, arm, or neck before splinting right? Why move a obvious broken ankle before splinting. Put blankets under and over him to help him warm up while splinting.
B - According to my protocols, that is the right order.
C - Unless you were going to cover him with warm blankets to keep help him, I don't see why removing the clothes would help. Get the ankle splinted and get him OUT of the cold.
D - Elevate the leg? Yeah... lets do that


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## Noctis Lucis Caelum (Dec 27, 2008)

thank you for the wonderful answers ^_^


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## mycrofft (Dec 27, 2008)

*Oh, I so LOVE multiple-choice questions! (rant rant)*

They are sometimes our best attempt to mechanize the imparting of fine decision making. They rarely have all the pertinent information and when it involves a chain of decisons/actions it ignores the fact that often you can do something so quickly, or simultaneously, that
 A-B-C-D can and often is ACB-D, or event CBA-D. Learn the test, know the material, and then act as closely to them as you can but still make sense.

If the pt is expiring from hypothermia, support the ankle and get him in; you aren't going to do much in the cold. One person starts O2 while the other rapidly splints the ankle in place, then the first one done (it is a race) starts rewarming per your protocols, maybe by revving up heaters and then removing clothing. The second one done gets on those VS, and might get ready for an IV attempt. Hie thee to the emergency department and call ahead.

By the way, hope your blankets were not ice cold from sitting in a unit parked outside?

And watch those VS, you may see a drop in BP from "peripheral rewarming syndrome" (peripheral vascular bed expands when rewarmed, increasing circulatory system volume without increasing circulating fluid).

Oh, and if he regains consciousness get his medical history and meds first, then what happened, before he LOC's again.


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## WuLabsWuTecH (Dec 27, 2008)

mycrofft said:


> They are sometimes our best attempt to mechanize the imparting of fine decision making. They rarely have all the pertinent information and when it involves a chain of decisons/actions it ignores the fact that often you can do something so quickly, or simultaneously, that
> A-B-C-D can and often is ACB-D, or event CBA-D. Learn the test, know the material, and then act as closely to them as you can but still make sense.
> 
> If the pt is expiring from hypothermia, support the ankle and get him in; you aren't going to do much in the cold. One person starts O2 while the other rapidly splints the ankle in place, then the first one done (it is a race) starts rewarming per your protocols, maybe by revving up heaters and then removing clothing. The second one done gets on those VS, and might get ready for an IV attempt. Hie thee to the emergency department and call ahead.
> ...


That's why you rewarm starting at the core first right?  Axilla, femoral arteries etc...


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## mycrofft (Dec 27, 2008)

*Ideally, core first, but a lot of that is clinical/theoretical, not field/pragmat*

I can imagine that the "core heating" gentle routine may feel better to someone who is truly COLD, but is it going to do the job quickly enough?

It can be argued you are "warming the core" (or "cooling the core") when you thermally address axilla, inguinum, and throat. However, if you are worried about getting that person warm or cool NOW,  the scalp, extremities, and entire dermis present a much larger surface to affect the circulating temp at, which will initially (and if you lie them down with their legs slightly elevated, continuedly) use that as a big heat exchanger from which the warmed juices go to the heart, then to the lungs (another huge temperature exchange surface) or corpus, round and round. Hospitals use warmer blankerts not armpit heaters. I think the inguinum/axillae/throat deal is how to best concentrate your warming resources if they are finite, and to allow prompt transport.

Try this experiment: lie on the frozen ground changing the slave cylinder on your hydraulic clutch in 12deg F weather working without gloves. Work for twenty minutes at a time, then go for a break and take a hot shower. Or, you can stand on the porch with a hot washcloth in each pocket. See whch gets your body up to temp faster, but I'd suggest you sit down after the BRIEF shower and suck down a hot cup of coffee or cocoa. (What a great experience, especially after that final work period and the dang thing WORKS!).

By the way, I read a silly thing but one which would support overall warming; that is the "you will force cold blood to the heart and stop it" theory. When they stop hearts intraoperatively they use _iced_ solution, but in the world circulation stops at about 85 deg F core temp, so to "shock the heart" thermally the unwarmed extremity blood would have to be far below the critical temp at which organ shutdown was already occurring. If you are warming the extremities, that would be obviated, no? I think your greater fear, if peripherally hypothermic for any _great_ length, would be lactic acidosis, and/or rhambdomyolysis. 

Well, why not go and try the second part of the experiment without the first? Have a good day, be safe and warm, and consider our sisters and brothers, and patients, out in the elements.

PS:
http://www.springerlink.com/content/p41x44n0412328k3/fulltext.pdf


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## BossyCow (Dec 29, 2008)

warming the extremeties first can cause the cold blood in the extremeties to chill the core temp further. There's a reason that the circulation to the extremeties has decreased. If you warm the core first the arterial blood will gradually rewarm the extremeties. Of course this is for extreme hypothermia, not just someone who's a bit cold.


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## mycrofft (Dec 30, 2008)

*In hospital core temp is raised through heated abd. lavage.*

I don't mean to sound irrascible, but if I "_warm_ the extremities", then how does that cause them to have _cold_ blood to circulate, versus "warming the core", which is done by warming areas where blood is flowing both directions but still not the "core" (neck and the base of extremities?). Also, if it causes vasodilation, shouldn't the warmed extremities hold more "extremity blood" "away from the core?
In real life, having been hypothermic and reheated, I did not experience any "cold rush" when I got back into the heat. I got all warm and fuzzy and pleasantly faint for a few minutes, but no cardiac flutters etc.
 I think it's like the experience we had in the 1980 heat wave in Nebraska, where putting hyperthermic pts in rubber rafts full of chilled water did a better and faster job getting these people to a safe temp than the usual practice of gradual cooling. No theory, just practice and observation of results.


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## BossyCow (Dec 30, 2008)

http://www.umcsn.com/Health_Info/article.asp?Category=All&ArticleID=388

or these.. 

Giesbrecht GG. Cold stress, near drowning and accidental hypothermia: a review. Aviat Space Environ Med. 2000; 71: 733-752.

Hiles JM, Schriver JP, et al. A new method of continuous venovenous rewarming. Curr Surg. 2002; 59: 186-189.

Immersion hypothermia. Accessed at mmember.melpc.org.au

Neufer PD, Young AJ, et al. Influence of skeletal muscle glycogen on passive rewarming after hypothermia. J Applied Physiol. 1988; 65: 805-810.

United States Search and Rescue Task Force. Cold water survival. www.ussartf.org.


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## mycrofft (Jan 1, 2009)

*I like the part about  warming extremities AND trunk*

because it is a closed system, unless you put arterial TK's on the extremities. As long as the heart's pumping you are getting that extremity blood, and as our physics teachers knew, any radiator is also a good collector.Warm em all over! Get an IV in, maybe a a urinary catheter to watch for myoglobin, dunno. Gotta follow protocols.

I think that what's holding back a unified reasonable effective treatment set is the in hospital/out of hospital aspect (medical establishment dumbing it down) along with the absolutely necessary ethical inability to torture humans for this data like the Nazi's did.


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## Outbac1 (Jan 2, 2009)

Of the options given I would have to go with "B". In reality it would likely be a quick ABC, confirm that the ankle is my problem, a pillow with some tape around the ankle, on the stretcher and into the truck. Once in the back you can work on clothes/vitals, Hx  and do a better job of splinting/pain mgnt. etc. enroute to the hospital.


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