64 yo M fall, not dangerous (per dispatch)

If I were actually on scene with this patient, no way would my index of suspicion of dissecting AAA be high enough to start an IO or call a trauma alert. Isn't he still basically asymptomatic with back pain and hypotension in the 80s?

Since you posted it on here, I'm assuming the right answer is "Trauma Alert and expeditous transport to the trauma center."
 
with a dropping BP in the 60s i see no problem. Another attempt was made by my partner but no luck. He is well know to EMS and surround hospitals for terrible access.
 
Brought him to the local hospital with fluid running through the IO and his pressure back up to 100s. Come to find out he had a small bilateral hemos with a T5 T6 shift. Our med control battled that this was a trauma pt and should have went to the trauma center and my company felt different. The case went to Rounds with good discussions but no resolution. So my question with this scenario is there a time limit on "traumatic events" and going to trauma centers? Example if a fall happened lets say 10 hours before would you still go to a trauma center?
 
Also where i work, if i were to not start an IO in this situation and just bring the pt to the hospital hypotensive, i would get a new one ripped reall quick
 
Burritomedic1127 said:
Brought him to the local hospital with fluid running through the IO and his pressure back up to 100s. Come to find out he had a small bilateral hemos with a T5 T6 shift. Our med control battled that this was a trauma pt and should have went to the trauma center and my company felt different. The case went to Rounds with good discussions but no resolution. So my question with this scenario is there a time limit on "traumatic events" and going to trauma centers? Example if a fall happened lets say 10 hours before would you still go to a trauma center?
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If a fall happened 5 minutes before I got there I still may not go to a trauma center. Trauma =\= trauma center
 
Burritomedic1127 said:
Agreed. Our med control felt different. Interested in people thoughts on trauma center or not with this pt
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I would not have transported to a trauma center based on your scenario. Unless they're using the magic of hindsight, they probably wouldn't have advocated it at the time before knowing the end diagnosis either.
 
Side note: If you transported 2 minutes to the local hospital, how did you have time for a missed IV, a 22G thumb IV with fluid running, and a numeral head IO with enough fluid bolused to increase his BP to 100 systolic?
 
Both went for IVs at the same time once in truck, IO with pressure bag until transferred pt to hospital bed. Their first BP was in the low 100s
 
chaz90 said:
Unless they're using the magic of hindsight, they probably wouldn't have advocated it at the time before knowing the end diagnosis either.
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Exactly. They had no complaints from the initial report but after the magic of x ray they were singing a different song.
 
I wouldn't have taken him to the trauma center based on what's here.
 
Burritomedic1127 said:
My bad slow response here

Pt walked to truck, no obvious signs of trauma, skin color WPD, no signs of respiratory distress. Pt started complaining of non radiating back pain between the shoulder blades. No head neck or back pain on palpation. Pt refused backboard because it makes his breathing worse but allowed for BP once in the truck. Pt was hypotensive in the 80s. Afib on the monitor in the 70s, 12 lead unremarkable, 98 on RA, NIBP 60/40

Local hosp 2 mins away
Trauma center 15 mins away
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Honest answer? depending on the local hospital (and what surgical options they have immediately available), I might head to the trauma center.

When I hear back pain between the shoulder blades, and really hypotensive (esp if old and/or a previous history of smoking), AAA bells start going off in my head. if he gets dizzy when he stands up or passes out, then they are really going off.

If it's a triple A, then he will need surgical intervention, and need it fast. if the local hospital can do it, go there. if not, go to the trauma center. no trauma alert

btw, you gave an IO to a conscious frequent flier with poor vascular access? ouch, he must have loved you after that.
 
DrParasite said:
btw, you gave an IO to a conscious frequent flier with poor vascular access? ouch, he must have loved you after that.
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Yeah he's well known through the city for having episodes of rapid Afib and poor access. He's no stranger to prehospital IOs. There's a perfect EJ but our medical director frowns on them and is in favor of IOs. We give 40mg of lido real slow initially through the IO if they're conscious to try and help with the pain of the rapid flush that follows. Still would rather have an unconscious pt for an IO but they do work well.
 
Do you have anywhere in protocols that has this addressed? Trauma or destination? I know we want to go to the most appropriate facility with our patients but everywhere I've worked if they're not specialty like trauma cva stemi they go to the closest.
 
Uclabruin103 said:
Do you have anywhere in protocols that has this addressed? Trauma or destination? I know we want to go to the most appropriate facility with our patients but everywhere I've worked if they're not specialty like trauma cva stemi they go to the closest.
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http://www.mass.gov/eohhs/docs/dph/emergency-services/trauma-hospital-destinations.pdf. Here's our state Trauma POE Plan. The medical control doc felt this Pt met the physiologic criteria of having a SBP < 90 (in the setting of a "trauma")." Myself and my company felt since his "traumatic event" happened greater than 12 hours prior, the closest hospital was fine. Nothing set on time limits of traumatic events. So I'm assuming somewhere in between the golden hour if your urban and the golden day if your in the wilderness would be the call haha
 
You just need a better retro-specto-scope for your ambulance.

Though this guy is rather hyotensive, but not knowing his baseline BP and with essentially no physical findings and not even a bit of tachycardia, I don't think many people would really say "SICK!" I doubt many would even go the IO route. I wouldn't (and even knowing the outcome don't) feel like that trauma protocol applies - it's supposed to identify patients who are dropping their blood pressure in a rapid and life threatening manner in the immediate aftermath of the trauma. Until the dx. was made, I don't see any evidence that his BP was related to his fall at all.

Sure rupturing aneurysms/dissections may be better served at the trauma center. I might have chosen a big hospital for that reason - but I'd probably make that decision independent of his trauma. I would not have predicted the actual diagnosis based on your findings.

I don't get all the flak you're getting. Was there a bad outcome due to the destination? Sounds like it didn't end up mattering in the end - pt. got what sounds like very good care, was diagnosed, and presumably treated just fine.
 
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