# IV/Monitor?



## rjddvm (Jul 23, 2010)

Scenario:  Belted driver of car which missed a curve and hit a tree in the back passenger side at about 50 mph.  Airbag deployed and he did not hit windshield or steering wheel, and did not lose consciousness.  Belted passenger in back, where the actual impact occurred, being treated as a Level 1 trauma.

Driver is up and walking around but shaking and hyperventilating.  Is fully immobilized and transported.  No apparent injuries, A and O X 4, HR in the 130s, O2 98% RA, hyperventilating, CMS all normal, complaining of increasing numbness and tingling in extremities, but no pain. 

Question:  hook up to cardiac monitor and establish IV access on 25-minute trip to trauma center, or not?

I know what I would have done but am interested in what those of you with more knowledge and experience think, because what was done (or not done) was not what I thought.


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## Shishkabob (Jul 23, 2010)

Yes monitor and yes IV, as the hyperventilation can be more then just, well, hyperventilation, as there's no telling what happened inside the chest, such as a pulmonary contusion.


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## 18G (Jul 24, 2010)

If the airbag deployed that tells me there was prob some sort of frontal impact. It sounds like given the significance of the MOI and the condition of the backseat passenger, your patient needed cardiac monitoring and IV access. 

As for the hyperventilation, it could have been anxiety related from the whole situation or it could have been compensatory for something like Linuss suggested. Were you able to mitigate the hyperventilation by coaching the patient or did it persist? 

I would err on the side of caution and monitor w/ IV.


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## rjddvm (Jul 24, 2010)

I'm a medic student so was the "extra person" in back and not in charge of how this patient was handled.  I spent most of the trip chatting with the driver (17 y.o.), patting his shoulder, holding his hand, etc. to try to calm him down; his hyperventilation improved but his HR didn't drop. 

I'll let you all know what was done or not done after a few more people reply; if no one else replies, I'll post in a day or two.

Thanks for the input so far, I'm interested in all opinions!


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## Veneficus (Jul 24, 2010)

Why not?

figure that he is going to get a blood draw at the trauma center, so if you are drawing blood in the unit, it is going to be billed as ALS anyway. 

Might as well leave the IV in instead of just a butter fly draw. That way in the unlikely event something was wrong, he wouldn't have to be stuck again. 

Seeing a decrease in QRS amplitude is an excellent way of detecting a tamponade early and monitoring for it. In fact I have seen that successful more times than I have seen a dx on listening to heart tones or doing an ultrasound. (mostly because it doesn't take as long to hook up an EKG than it does to track down and operate the ultrasound)

Lateral forces also create a much higher index of suspicion that must be ruled out than frontal or rear impacts. I would be willing to bet, as such, at the trauma center both of these patients will be lookng at a full workup to include a surgical consult, labs, xray, and a CT of the head, chest, abd, and pelvis with spinal recons.

Defensive medicine at its finest.

I think it is more of a logistics issue than a clinical requirement.


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## MrBrown (Jul 24, 2010)

Veneficus said:


> Seeing a decrease in QRS amplitude is an excellent way of detecting a tamponade early and monitoring for it.



My thoughts exactly



Veneficus said:


> Lateral forces also create a much higher index of suspicion that must be ruled out than frontal or rear impacts. I would be willing to bet, as such, at the trauma center both of these patients will be lookng at a full workup to include a surgical consult, labs, xray, and a CT of the head, chest, abd, and pelvis with spinal recons.



We have a surgical registrar on the Trauma Team so that takes care of the consult.  It should be noted I dislike surgical registrars, they always want to cut people open, sheesh! Those anaesthesology registrars are even worse then always want to give people drugs, often before the surgical registrar cuts them open 

Would a cervical spine x-ray, a pelvic x-ray and an abdominopelvic ultrasound not suffice to rule out spinal or pelvic injury and bleeding in the abdomen or pelvis?

I am no expert on lab tests or values (heck don't ask me what a Chem-7 is) but I would be primarily interested in looking for ethanol and a blood typing.


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## abckidsmom (Jul 24, 2010)

Yep.  For all the reasons Vene spelled out.

I'm not one to blow off that kind of heart rate, too.  I give grace up through the 110s, above that, I'm looking for a reason beyond anxiety and hyperventilation.


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## Aidey (Jul 24, 2010)

I would probably chuck him on capnography with that long of a transport.


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## rjddvm (Jul 24, 2010)

Excellent thought about the QRS amplitude, I hadn't thought of that one!


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## MrBrown (Jul 24, 2010)

Oh lets order CBC, K, Cr, PTT, Utox, EtOH and an ABG too!

Wait I have a better idea!

*Thumbs to the end of his Trauma textbook

Hmm it doesn't say how the patient turned out, but it says the Consultant did it!


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## Veneficus (Jul 24, 2010)

MrBrown said:


> We have a surgical registrar on the Trauma Team so that takes care of the consult..



So do we, but they still bill it as a consult. Dependng on the seniority of the surgeon up to $5K to say "you don't need me." That is brilliant and much less work than surgery.



MrBrown said:


> It should be noted I dislike surgical registrars, they always want to cut people open, sheesh! Those anaesthesology registrars are even worse then always want to give people drugs, often before the surgical registrar cuts them open ..



I'll just pretend I didn't see this. B)



MrBrown said:


> Would a cervical spine x-ray, a pelvic x-ray and an abdominopelvic ultrasound not suffice to rule out spinal or pelvic injury and bleeding in the abdomen or pelvis?.



No. The c spine xrays have an unacceptably high false negative of injury. (if my memory serves me, between 20-30%)

US will suffice for abd and pelvic bleeding, but will not be useful for great vessles in the thorax. A ruptured aorta can take hours before any clinical findings appear. Plus you will get the whole spine recons. The renal shots with the contrast are also very good for finding damage to the renal vessles or contusions to the kidneys. (which manifests usually on donorcycle trauma)



MrBrown said:


> I am no expert on lab tests or values (heck don't ask me what a Chem-7 is) but I would be primarily interested in looking for ethanol and a blood typing.



I thought all trauma patients were + etoh? at least it seems that way.  

Typing is useful, but you can also find others markers of damage like CKMM, which when compared with urine protein can predict possible rhabdo. Also if you do find a bleed you will need all the blood findings and it is just easier to draw and do it all at once and not need it than it is do piece meal. Especially when you work in a busy center. There are also liver enzymes to look at.  all the other values are useful in the ICU if that is the eventual disposition.


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## MrBrown (Jul 24, 2010)

Veneficus said:


> So do we, but they still bill it as a consult. Dependng on the seniority of the surgeon up to $5K to say "you don't need me." That is brilliant and much less work than surgery.



Heck we have publically funded healthcare so don't ask me how the billing works, it all comes from that black hole called the Government.  

Now what *is* interesting is that although our trauma team has a critical care registrar, an EM reg, one of those pesky surgical registrars P), three nurses, probably a radiographer, and a Team Leader they don't have an anaesthetist.

... probably because he was alredy in the elevator on the way up to the roof of the hospital struggling to put on that funny jumpsuit on over his scrubs while the helicopter got warmed up


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## Veneficus (Jul 24, 2010)

MrBrown said:


> Now what *is* interesting is that although our trauma team has a critical care registrar, an EM reg, one of those pesky surgical registrars P), three nurses, probably a radiographer, and a Team Leader they don't have an anaesthetist.



You can always tell when somebody speaks English, there is always an extra "A" in anesthesia 

Actually I'd be the first to say that anaesthesia (the doctor, not the chemicals) is really a complete waste in the emergent setting. Not that they aren't useful, just more useful somewhere else, like the OR or ICU.


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## LondonMedic (Jul 24, 2010)

Veneficus said:


> Actually I'd be the first to say that anaesthesia (the doctor, not the chemicals) is really a complete waste in the emergent setting. Not that they aren't useful, just more useful somewhere else, like the OR or ICU.


(Before I start I shall declare a competing interest - anaesthetics and intensive care)

I have a fair experience of trauma care in various hospitals and with various specialities.

Many emergency medics can perform the functions of an anaesthetist - they can intubate, they can ventilate, they can get big lines in, they can even anaesthetise. However, anaesthetists can do all of this, specialise in doing all of this and bring to the party a thorough understanding of the physiology of trauma. What is more, they also provide continuity of care (at least as a department), so when three different surgical teams are queuing up to do sequential operations, it will be the same anaesthetists who will be with the patient throughout - from resus through to the unit.

So, whilst an anaesthetist is replaceable in a trauma call, I don't think that they are quite as disposable as you make out.


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## Veneficus (Jul 24, 2010)

LondonMedic said:


> (Before I start I shall declare a competing interest - anaesthetics and intensive care)
> 
> I have a fair experience of trauma care in various hospitals and with various specialities.
> 
> ...



My judgement of anaesthesia in the emergent setting isn't based on the ability of other providers to manage an airway. (In the US emergency physicians also intubate and they bring knowledge of trauma probably second only to a critical care surgeon, who will also be with the patient from door to discharge if they are severe enough, as the CC surgeons oversee the surgical intensive care unit as well)

What I am trying to point out is that anesthesia's abilities of managing complex patients in the medical ICUs or multiple surgeries is a better use of the resource then taking them out of those environments to oversee or perform the initial steps of resuscitation. Not because they lack the ability. ( I am actually quite fond of their abilities)

I have experienced that in the truly critical patients, they spend almost no time in the ED (which can be a bit sparce on equipment compared to an ICU) and are shipped as soon as possible to either surgery or to the ICU, where the expertise and equipment to manage them is already waiting.


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## Chimpie (Jul 24, 2010)

These are some great points, but let's keep this to the OP's topic please.  Or at least until he's replied with what happened.


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## rjddvm (Jul 24, 2010)

Well, since you asked... 

Neither an IV nor an EKG monitor were used on this patient.  I didn't (and still don't) understand why, so I asked the medic in charge after we had transferred the patient to the ED staff.

The medic's response was that he had found nothing significant on his trauma exam (neither did I) and the 2/10 lumbar pain the patient reported was from his chronic back issues, relating to a fracture of L5 several years ago, which according to the patient did not affect the cord itself.  (From what he described it sounded like he fractured one or both transverse processes playing football in middle school, with no cord involvement.)  The numbness and tingling were from hyperventilation.

I was concerned about possible neurogenic shock, spinal injury only manifesting itself as the patient's adrenaline wore off after the crash (especially since he'd been walking around for about 1/2 hour by the time we got there), some kind of chest injury that might have shown up as an EKG abnormality, and internal bleeding.  While the back pain might well have been from his old injury, I didn't think that could be determined without some kind of imaging. 

I was also concerned that if this guy suddenly went south on us, we'd be trying to get an IV started on someone with very low BP, and we'd also be scrambling to get the leads on him asap.  I just thought we should have erred on the side of caution and started an IV and EKG, especially with the MOI involved...but the medic did not agree.

So I'm glad to see that from all of your responses, I wasn't as off base as the medic made me feel I was...

The back seat passenger, the one who was thought initially to be a Level 1, turned out not to be as badly injured as first thought.  But of course we didn't know that at the time.

So here's my next question if anyone has read this far: at what point do you give IM epi to an anaphylaxis patient?  If there are no respiratory s/s but all-over hives, itching, and N/V, would you go ahead and give it, or wait to see if respiratory issues develop?  

Would your answer be the same if the patient had already received IV SoluMedrol 125 mg and Benadryl 50 mg, with no improvement in her body-wide hives, some improvement in her itching and nausea, and no change in her breathing (she was showing no signs of breathing issues and not complaining of any)?

Thanks for the opinions...I'm in the middle of the transition from academic to real-world and it's good to hear from people who've BTDT.


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## Shishkabob (Jul 24, 2010)

Wow, that anaphylaxis call is out of left field...

I don't give IM epi... IM epi is for the epi-pen (per protocols).  I give either SQ or IV, depending.   Than again, you gave solumedrol without respiratory compromise, so I have no clue what your protocols state.


Epi, as far as when I give it, is only for severe reactions, IE respiratory distress and/or very low BP.   





Now as for the first scenario, aren't you a medic student?  Were you doing school ride time on the rig?  I've always been able to make the call at what is done and when when I was a student, and the only time a preceptor could/should intervene is if it was dangerous care to the patient.  The whole point of ride time is to learn your style while still having a safety net, not learning someone elses style.


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## Aidey (Jul 24, 2010)

rjddvm said:


> I was concerned about possible neurogenic shock, spinal injury only manifesting itself as the patient's adrenaline wore off after the crash (especially since he'd been walking around for about 1/2 hour by the time we got there)



Why? A spinal cord injury (or sometimes brain injury) is the only thing that would cause neurogenic shock, and adrenalin is not going to mask that. The fact that he had been walking around for 1/2 and hour before you got there decreases the chance of neurogenic shock, not increases it. The fact that he was walking at all pretty much rules it out totally.


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## MrBrown (Jul 24, 2010)

rjddvm said:


> I was concerned about possible neurogenic shock, spinal injury only manifesting itself as the patient's adrenaline wore off after the crash (especially since he'd been walking around for about 1/2 hour by the time we got there), some kind of chest injury that might have shown up as an EKG abnormality, and internal bleeding.



If this dude has been walking around for a half hour, I don't think he's going to have or get neurogenic shock.

Exactly which chest injuries appear as an ECG abnormality? (excluding cardiac tamponade)

Yes I would be worried about internal bleeding (ruptured liver, perforated bowel etc) but an ECG monitor won't help there.



rjddvm said:


> I was also concerned that if this guy suddenly went south on us, we'd be trying to get an IV started on someone with very low BP, and we'd also be scrambling to get the leads on him asap.  I just thought we should have erred on the side of caution and started an IV and EKG, especially with the MOI involved...but the medic did not agree.



I'd probably stick in a lock with an 18g because it provides, as you say, ready access for pain relief and fluid if required.



rjddvm said:


> So here's my next question if anyone has read this far: at what point do you give IM epi to an anaphylaxis patient?  If there are no respiratory s/s but all-over hives, itching, and N/V, would you go ahead and give it, or wait to see if respiratory issues develop?
> 
> Would your answer be the same if the patient had already received IV SoluMedrol 125 mg and Benadryl 50 mg, with no improvement in her body-wide hives, some improvement in her itching and nausea, and no change in her breathing (she was showing no signs of breathing issues and not complaining of any)?



No, adrenaline is only for severe anaphylaxis i.e. very hypotensive, grey, sweaty, nauseous, ALOC.

Isolated hives or itching and nausea on thier own are not anaphylaxis.  Anaphylaxis here is defined as (from memory) a reaction that includes cardiovascular or respiratory compromise or collapse.  



Linuss said:


> I don't give IM epi... IM epi is for the epi-pen (per protocols).  I give either SQ or IV, depending.   Than again, you gave solumedrol without respiratory compromise, so I have no clue what your protocols state.
> 
> Epi, as far as when I give it, is only for severe reactions, IE respiratory distress and/or very low BP.



We give IM adrenaline first then if that doesn't work hang up a drip of 1mg adrenaline to one litre of fluid run at 2gtt/s titrated.


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## Veneficus (Jul 25, 2010)

MrBrown said:


> Exactly which chest injuries appear as an ECG abnormality? (excluding cardiac tamponade)



Blunt cardiac injuries can appear with EKG changes.



MrBrown said:


> Yes I would be worried about internal bleeding (ruptured liver, perforated bowel etc) but an ECG monitor won't help there.



I'll go with this.




MrBrown said:


> We give IM adrenaline first then if that doesn't work hang up a drip of 1mg adrenaline to one litre of fluid run at 2gtt/s titrated.



Sub Q injection of Epi is highly suspect. It has been used in surgery for ages to slow absorbtion by vasoconstriction.

As we all know in shock, circulation to the dermis is compromised as well.

IM is more than likely a superior administration route compared to Sub Q. All 3 of the academic medical centers i am affiliated with have replaced sub Q with IM. 

You guys down on the other side of the world sure do like your drips.

I would like to point out that when people are or report allergy to radiological dye and the test absolutely must be performed, or a medication with a reported allergy must be administered, prophylactic epi can be given. Certainly it is not ideal, nor should it be common, but sometimes the situation calls for extraordinary measures.


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## MrBrown (Jul 25, 2010)

Veneficus said:


> Blunt cardiac injuries can appear with EKG changes.



Thats what I kind of figured



Veneficus said:


> Sub Q injection of Epi is highly suspect. It has been used in surgery for ages to slow absorbtion by vasoconstriction.



Yes, well most of my practice is highly suspect to begin with .... 



Veneficus said:


> You guys down on the other side of the world sure do like your drips.



We have adrenaline infusions for anaphylaxis, severe asthma and bradycardia.

Although our previous guideline stated we were able to mix 1mg of adrenaline into ont litre of fluid and give 10cc boluses (0.01mg) the new guideline says that an infusion is preferred.

It is so much easier than dopamine


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## Veneficus (Jul 25, 2010)

MrBrown said:


> It is so much easier than dopamine



No Way

take weight in Kilos, drop last number, multiply by 4 and you have your dose ranges.

example:

86Kg pt. drop the ones column, you have 8 multiply by 4 = 32.

8gtts/min = 5mcg/kilo/min 

32gtts/min=20mcg/kilo/min

up or down they trade 1gtts/min for 1 mcg/kilo/min 

accurate up to 0.10 mcg damn fine precision.

second quick exmple:

120 kg patient, = 12 x 4 = 48 

12-48 gtts/min for 5-20 mcg/kilo/min respectively.


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## MrBrown (Jul 25, 2010)

Veneficus said:


> No Way
> 
> take weight in Kilos, drop last number, multiply by 4 and you have your dose ranges.
> 
> ...



1.  Take out vial of adrenaline
2.  Pull cap off medication port on IV bag
3.  Inject adrenaline into bag of fluid
4.  Shake well and slap on an "adrenaline" sticker

Heaps easier mate


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## Veneficus (Jul 25, 2010)

MrBrown said:


> 1.  Take out vial of adrenaline
> 2.  Pull cap off medication port on IV bag
> 3.  Inject adrenaline into bag of fluid
> 4.  Shake well and slap on an "adrenaline" sticker
> ...



we have premixed bags of dopamine.

spike bag with 60 gtts set, count the drops.


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## Shishkabob (Jul 25, 2010)

OR... Take weight in pounds,

If it's above 209, drop the last number and subtract 2 from it, and that's your 5mcg

If it's below 209, drop the last number and subtract 3, and that's your 5mcg.



IE, if they weigh 210, it becomes 21, then you subtract 2 so it's 19

19 gtts/min for 5mcg/kg


(Works for my concentration bags)




Wont help you much though Brown... you and your weird metric system


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## Aidey (Jul 25, 2010)

Veneficus said:


> No Way
> 
> take weight in Kilos, drop last number, multiply by 4 and you have your dose ranges.
> 
> ...



That. Is. Awesome. I'm assuming it is for the standard 1600mcg/ml concentration? 

Any other good ones?


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## 18G (Jul 25, 2010)

Myocardial contusion can show as PVC's on the monitor. 

Epinephrine in my opinion is a little easier than dopamine. 

Just add 1mg of Epi to a 250mL bag = 4mcg/mL.

Then just use the clock method:

1mcg/min = 15gtts
2mcg/min = 30gtts
3mcg/min = 45gtts
4mcg/min = 60gtts

Want a higher concentration per mL? Add 2mg of Epi to a 250mL bag which yields 8mcg/mL. 

Simple.


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## MrBrown (Jul 25, 2010)

I hear (and this is only what I hear) that we don't have dopamine because an adrenaline infusion is "better".

"Better" how I don't know but it seems that all of the Australasian services use adrenaline 1mg/1,000ml and North America uses dopamine.


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## Hellsbells (Jul 26, 2010)

...To the OP

The thought process of your preceptor seems to be a little suspect. The numbness and tingling are just from hyperventilation? Perhaps, but until spinal injuy is ruled out, it stays in the differential. 

One could argue for or against a cardiac monitor in this case, I'd put it on, there is a long transport time and its a simple method for continous monitoring of the pts heart rate. 

I think an IV would be a must for this pt. Even if you don't anticipate the need for fluid replacement or analgesics, the pt may need an antiemetic. THe last thing you want is the pt vomiting while strapped to a backboard.


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## i5adam8 (Jul 26, 2010)

I'm going to agree with everyone and say absolutely put him on the monitor and start an IV. Their are very few patients who I don't put on the monitor,and the anxious behavior could quite possibly be early signs of shock.


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## Veneficus (Jul 26, 2010)

Aidey said:


> That. Is. Awesome. I'm assuming it is for the standard 1600mcg/ml concentration?
> 
> Any other good ones?



You covered the epi. 

If I am not mistaken it is 800mcg in 500ml. But I would have to look and I am at home


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## Veneficus (Jul 26, 2010)

MrBrown said:


> I hear (and this is only what I hear) that we don't have dopamine because an adrenaline infusion is "better".
> 
> "Better" how I don't know but it seems that all of the Australasian services use adrenaline 1mg/1,000ml and North America uses dopamine.



"better" may be relative to the pathology being treated. They both work from different receptors.


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