might be a dumb question... but since he used a traction splint, wouldn't you use the backboard to secure the splint? and if you're going to backboard someone, i'd give you funny looks if they weren't wearing a C-Collar. Besides, perhaps he'd like to cover all his bases, it's his license, if he doesn't want to take a risk, thats his prerogative...
soooo there we were.....
- Thread starter cookiexd40
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Well yeah but .... defensive medicine is the worst kind of all
I'm going to show my EMT-B ignorance here, but what are the downsides to administering a bolus?
adamjh3
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I remember reading or hearing somewhere, no, I can't provide a link, I don't remember where it was, that the body will naturally vasoconstrict and shunt blood to the vital organs when it detects significant blood loss. So wouldn't pumping fluid into a bleeding patient trick the body into thinking it has plenty of volume, and thus, worsen the bleeding?
I could be way wrong, or way off track. I'm not presenting this as fact, but as a question.
I could be way wrong, or way off track. I'm not presenting this as fact, but as a question.
Pretty much, look up permissive hypotension
ExpatMedic0
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I am just waiting for the "Because we can" guy to speak up
If I could just point out:
There is a difference between permissive hypotension in an uncontrolled hemorrhage and volume replacement in a low stage shock.
In an isolated femur fx, I don't think a small fluid bolus is going to detrimental. It might even provide some minor benefit (like stopping a cellular fluid shift) that is not going to be measured in a massive BP increase or suddenly mking the pt all better. I would bet that in the ED the pt probably received a total of a liter or more.
That is a far different event than uncontrolled truncal bleeding, or any uncontrolled bleed for that matter.
I don't think that this person needed to be boarded, but in the US, it seems the amount of people not put on a board is so minimal that the point isn't worth arguing anymore. If it is in the protocol, just follow the protocol. That has to be changed at the administrative level, not on the scene.
There is a difference between permissive hypotension in an uncontrolled hemorrhage and volume replacement in a low stage shock.
In an isolated femur fx, I don't think a small fluid bolus is going to detrimental. It might even provide some minor benefit (like stopping a cellular fluid shift) that is not going to be measured in a massive BP increase or suddenly mking the pt all better. I would bet that in the ED the pt probably received a total of a liter or more.
That is a far different event than uncontrolled truncal bleeding, or any uncontrolled bleed for that matter.
I don't think that this person needed to be boarded, but in the US, it seems the amount of people not put on a board is so minimal that the point isn't worth arguing anymore. If it is in the protocol, just follow the protocol. That has to be changed at the administrative level, not on the scene.
8jimi8
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This is the way I read it too. Cookie, you may just be playing it off like you are trying to be cool, or something, i can't quite tell, by the way that you write, but its sounds to me like you are reckless.
i understand that a femur fx has a potential for blood loss, Linuss, but I don't see why he administered a bolus. Did they not cover the concept of permissive hypotension in trauma. Sure have the bag READY. But arbitrarily administer a bolus because "you can," or "because it won't hurt" (when you don't know for sure that it won't hurt.)
What if all he needed was a little fluid bolus to knock loose a fat embolism?
you didn't say how fast you bolused him. let me guess... you squeezed the bag?
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(just a note.. I'm a little tired and might ramble a bit...)
The OP saw the MOI. Being thrown to the ground and then being stomped on very easily could cause a very distracting injury that masks perception of an injury that occurred by impact with the ground. Personally, I wouldn't have boarded the kid based on MOI alone. If I saw that there was zero potential for spinal injury, then he gets put on the board to stabilize the traction splint...
A closed femur Fx can result in a 1,000 - 1,500 mL blood loss. The traction splint can reduce some loss by putting the thigh muscles under a bit of tension, reduces some involuntary muscle tetany, and reduce some pain by not allowing the bone ends to grate against each other.
It's actually not a bad idea...
The bilat IV's... not a bad idea to have available. Would I have run in 250mL? I doubt it. In the grand scheme of things, that little amount of fluid probably won't matter. From what I recall in years past, most people are a little "dry" anyway. He's young, his body should be able to compensate pretty well for a while. At a SBP of 110, getting a good clot going to stop the bleeding wouldn't be all that easy for the body to do, though some local vasoconstriction will help get that started within the first 10 minutes or so. After that, you might see some vasodilation locally... and then the clots might just get blown off.
Permissive Hypotension is an interesting concept that works pretty well, from what I have read over the past few years. About all I'd do is just keep his SBP at around 90 at the worst...
OP
OP
cookiexd40
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no i did not squeeze the bag and no i dont do a damn thing in my life to be "cool"...this was posted as somethin to talk about and it has turned into a burn cookie thread cause everybody is always better than someone else...im sorry for everybody that have made good solid points and yet there are certain people on here that feel it is needed to constantly argue.
JPINFV
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Discussing cases is one way to learn and grow...
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OP
cookiexd40
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i agree but it isnt a disscusion anymore....when sh!tty comments like "let me guess you squeezed the bag" are said without knowing me, my experience and/or knowledge then now hes just being demeaning for no reason other than to be a :censored::censored::censored::censored::censored:
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firetender
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I am curious, since that's never anything I was taught or equipped to do in the field, How DID you give someone a 250 cc bolus of LR?
8jimi8
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my comments were a reflection of your attitude of "because I can"
the last thread that I criticized you on was because you callously dismissed the risk of infection.
you don't seem to represent a desire for evidence based practice, or retention of even the basics of the science you are practicing.
call me whatever name you want, i don't feel i'm better than you; however i feel compelled to correct you when i feel that you are espousing a dangerous or oblivious course of action.
the last thread that I criticized you on was because you callously dismissed the risk of infection.
you don't seem to represent a desire for evidence based practice, or retention of even the basics of the science you are practicing.
call me whatever name you want, i don't feel i'm better than you; however i feel compelled to correct you when i feel that you are espousing a dangerous or oblivious course of action.
reaper
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I asked the questions of why things were done. You cannot use the excuse of MOI for boarding this particular Pt. I can bet that there were at least 10 other young men that were thrown to the ground that night and some probably a lot harder.
I was asking for the reasoning behind the treatments. You post on a forum, expect it to be discussed.
Bolusing a pt "because you can" or "it won't hurt" is not the way to provide care. If you had said you did it because the leg had extensive swelling, which could be a sign of internal bleeding, then I would say go for it. We try to get you thinking of why you are doing a treatment or procedure. That will make you a better medic, when that time comes.
I was asking for the reasoning behind the treatments. You post on a forum, expect it to be discussed.
Bolusing a pt "because you can" or "it won't hurt" is not the way to provide care. If you had said you did it because the leg had extensive swelling, which could be a sign of internal bleeding, then I would say go for it. We try to get you thinking of why you are doing a treatment or procedure. That will make you a better medic, when that time comes.
ExpatMedic0
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Ok, I am sorry if I even mentioned the "because we can" guy. I know we all have seen or known "that guy, but I did not think the OP was him. Here I see an EMT-I following his local protocols in addition to the knowledge of common textbook information and his training (an NREMT test question actually) that a femur fracture can cause up to 1500ml of internal bleeding.
Why are you busting his balls if may ask about the fluid? I agree with giving fluid to this pt.
I would have looked into the long spine board a bit more myself though. I work a lot of contact sport stand by. I would judge the MOI, then consider his GCS, if the pt. lost consciousness at any point, if he had any neck or back pain and if he did if it was off to the side (muscular) then palpated every vertebra for painful stimuli, crepatis, and assessed, do a full DCAP-BTLS, checked BP and skin for signs of neurological shock and checked Pulse Motor Sensation in all 4 extremity's before reaching a decision to backboard him or not.
I think giving smart a$$ comments to this guy is kind of rude and if he comes here to reflect on a call and ask what we think, why not give him some polite professional feedback?
Why are you busting his balls if may ask about the fluid? I agree with giving fluid to this pt.
I would have looked into the long spine board a bit more myself though. I work a lot of contact sport stand by. I would judge the MOI, then consider his GCS, if the pt. lost consciousness at any point, if he had any neck or back pain and if he did if it was off to the side (muscular) then palpated every vertebra for painful stimuli, crepatis, and assessed, do a full DCAP-BTLS, checked BP and skin for signs of neurological shock and checked Pulse Motor Sensation in all 4 extremity's before reaching a decision to backboard him or not.
I think giving smart a$$ comments to this guy is kind of rude and if he comes here to reflect on a call and ask what we think, why not give him some polite professional feedback?
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MonkeySquasher
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Well many people beat me to my comments. But I want to post them anyway. =p
Echoing Epi-do... Human body tends to focus on the most painful stimulus presented. Which I would assume was the femur fracture. Kid COULD have had a neck/spine/pelvic injury and pain could have been masked by the femur fracture. Not to mention, being fully packaged makes movement easiler from ground-to-cot, and cot-to-ER bed. Top deck could be used to package too, but the Dr may yell if it wasn't a longboard for trauma. Not to mention, the mom's a nurse. Would have looked crappy if you HADNT backboarded her son, and she'd called you on it later because she wanted it done.
To be fair, I actually don't mind it, and usually play guinnea pig for the new EMT classes. Because I'll tell them if I can move, and if I'm not tied in tight enough, or if it's too tight.
I'm just curious, how old was the patient, and the estimated weight? You use the word "kids", and it's a high school, so I wonder if it was considered a pediatric or an adult. Because I thought pediatric fluid boluses were 20mL/kg.... Which would put this kid around 28lbs. lol
Does your protocol still say to bolus fluid even though the systolic was over 90-100mmHg?
Cookie, calm down. We aren't trying to attack you, we just want you to think about and explain your actions. You can do whatever you want in the field, so long as you truly believe its in your patient's best interests, and you can EXPLAIN your thought process to a Doc or, worse, to a lawyer/jury. "It wasn't going to hurt" will just have a Dr/Lawyer throw a number of complications into your face... Fluid overload, fat embolus, fluid infiltration at either the IV site, or the site of the break, even to suggest you CAUSED bleeding from the break by giving the bolus. A lawyer is in it to win it.. We're just trying to get an answer because we're curious. haha
Echoing Epi-do... Human body tends to focus on the most painful stimulus presented. Which I would assume was the femur fracture. Kid COULD have had a neck/spine/pelvic injury and pain could have been masked by the femur fracture. Not to mention, being fully packaged makes movement easiler from ground-to-cot, and cot-to-ER bed. Top deck could be used to package too, but the Dr may yell if it wasn't a longboard for trauma. Not to mention, the mom's a nurse. Would have looked crappy if you HADNT backboarded her son, and she'd called you on it later because she wanted it done.
To be fair, I actually don't mind it, and usually play guinnea pig for the new EMT classes. Because I'll tell them if I can move, and if I'm not tied in tight enough, or if it's too tight.
I'm just curious, how old was the patient, and the estimated weight? You use the word "kids", and it's a high school, so I wonder if it was considered a pediatric or an adult. Because I thought pediatric fluid boluses were 20mL/kg.... Which would put this kid around 28lbs. lol
Does your protocol still say to bolus fluid even though the systolic was over 90-100mmHg?
Cookie, calm down. We aren't trying to attack you, we just want you to think about and explain your actions. You can do whatever you want in the field, so long as you truly believe its in your patient's best interests, and you can EXPLAIN your thought process to a Doc or, worse, to a lawyer/jury. "It wasn't going to hurt" will just have a Dr/Lawyer throw a number of complications into your face... Fluid overload, fat embolus, fluid infiltration at either the IV site, or the site of the break, even to suggest you CAUSED bleeding from the break by giving the bolus. A lawyer is in it to win it.. We're just trying to get an answer because we're curious. haha
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because I can
I understand quite well permissive hypotension, but I think this is not a case where it would become a factor or benefit the pt.
The purpose of it is to aid in clotting until surgical repair can be used to stop a hemorrhage. The body doesn't require surgical intervention for most bleeds and certainly not with uncomplicated fx.
Once the active bleeding stops, there is fluid shift that can be dealt with. Are you going to see some major change in the pt? no. But is there really some terrible tragedy in adding isotonic fluid in an amount that is third spaced in order to prevent an extracellular volume shift? I doubt it very much. In fact, If you consider that much of the literature still advocates volume replacement. (PHTLS, ITLS, and ATLS, where permissive hypohypotension was just added for consideration in the latest edition.) For all intents and purposes, perhaps we could complain he didn't give enough fluid. (which I why I posted he would likely get more in the ED) Taking care of vascular volume until a patient's long term mechanisms take over is not wrong or bad. Infact, cellular level care is some of the best care. To quote a famous trauma surgeon, whos name I know but Can't spell, "Critical care isn't a place, it's a state of mind."
The medical community as a whole is not going to accept simply letting all wounds bleed. The kid is most likely going to surgery anyway which will cause a bit more bleeding. It is why you always let ortho fix their issues first in surgery, because the forces they use destroy everything you have done to that point. But it doesn't mean do nothing for a pt. untill ortho is finished.
The ACEP would be very proud of quoting 1500 ml coming out of a femur. Only 33% more than what ACS publishes. Just from my experiences, I think 1500 may be a little extreme.
I think it may be a little premature for crucifying somebody without looking at the total care of this patient.
Traction splinting:
The only way to stabilize a femur is externally, but I am not a fan of traction splints. Actually that is an understatement, I think the ones marketed to EMS are utter garbage. You know what happens to those when you get to the hospital? They come off. Because they mess up x-rays. Especially the lateral shots.
But I do like traction, I have found applying manual traction while the patient is sitting on the cot and then tying his foot in place with kling to the stretcher to maintain it works very well. They usually even brace themselves against the back because it helps the pain. (then I dose them with something, I am antipain) If you secure a pt to a board you can just as easily tie the kling to a handhold. Easy, cheap, and effective. Can't beat it with a stick. (A stick would be a better traction device, it doesn't mess up x-rays) Then when they get to the ED, you can just transfer where the kling is tied. Then you don't worry about coming back for your traction splint either. (ortho or your neighborhood ED tech will be holding manual traction for x-rays) Then the pt. can go right back to the bed and get tied into traction again while surgery is scheduled, and all the pregame that comes with that.
Now doing the proper treatment without knowing why is the whole basis of US EMS. It is not what I advocate for, but it is still a fact we have to live with.
I understand quite well permissive hypotension, but I think this is not a case where it would become a factor or benefit the pt.
The purpose of it is to aid in clotting until surgical repair can be used to stop a hemorrhage. The body doesn't require surgical intervention for most bleeds and certainly not with uncomplicated fx.
Once the active bleeding stops, there is fluid shift that can be dealt with. Are you going to see some major change in the pt? no. But is there really some terrible tragedy in adding isotonic fluid in an amount that is third spaced in order to prevent an extracellular volume shift? I doubt it very much. In fact, If you consider that much of the literature still advocates volume replacement. (PHTLS, ITLS, and ATLS, where permissive hypohypotension was just added for consideration in the latest edition.) For all intents and purposes, perhaps we could complain he didn't give enough fluid. (which I why I posted he would likely get more in the ED) Taking care of vascular volume until a patient's long term mechanisms take over is not wrong or bad. Infact, cellular level care is some of the best care. To quote a famous trauma surgeon, whos name I know but Can't spell, "Critical care isn't a place, it's a state of mind."
The medical community as a whole is not going to accept simply letting all wounds bleed. The kid is most likely going to surgery anyway which will cause a bit more bleeding. It is why you always let ortho fix their issues first in surgery, because the forces they use destroy everything you have done to that point. But it doesn't mean do nothing for a pt. untill ortho is finished.
The ACEP would be very proud of quoting 1500 ml coming out of a femur. Only 33% more than what ACS publishes. Just from my experiences, I think 1500 may be a little extreme.
I think it may be a little premature for crucifying somebody without looking at the total care of this patient.
Traction splinting:
The only way to stabilize a femur is externally, but I am not a fan of traction splints. Actually that is an understatement, I think the ones marketed to EMS are utter garbage. You know what happens to those when you get to the hospital? They come off. Because they mess up x-rays. Especially the lateral shots.
But I do like traction, I have found applying manual traction while the patient is sitting on the cot and then tying his foot in place with kling to the stretcher to maintain it works very well. They usually even brace themselves against the back because it helps the pain. (then I dose them with something, I am antipain) If you secure a pt to a board you can just as easily tie the kling to a handhold. Easy, cheap, and effective. Can't beat it with a stick. (A stick would be a better traction device, it doesn't mess up x-rays) Then when they get to the ED, you can just transfer where the kling is tied. Then you don't worry about coming back for your traction splint either. (ortho or your neighborhood ED tech will be holding manual traction for x-rays) Then the pt. can go right back to the bed and get tied into traction again while surgery is scheduled, and all the pregame that comes with that.
Now doing the proper treatment without knowing why is the whole basis of US EMS. It is not what I advocate for, but it is still a fact we have to live with.