Stabilizing a Trauma Patient Beyond the "Golden Hour"

VentMedic

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These are for those of you who have asked questions about CCT, Flight, MAP, ABGs, terms Rid and I have used or who don't know what all goes into stabilizing a patient for a transport from a smaller hospital to a trauma center:



Stabilizing a Trauma Patient Beyond the "Golden Hour"

By Paul Mazurek

http://www.ems1.com/Columnists/paul...izing-a-Trauma-Patient-Beyond-the-Golden-Hour

An air medical transport team is called to the intensive care unit of a local referring center for a 27-year-old male brought to the emergency department after a high-speed rollover motor vehicle crash. The patient sustained a closed head injury and an open-book pelvic fracture. The crash occurred two hours prior to the team’s arrival at the referring center. He is still in spinal precautions, intubated, and has a pelvic binder in place.

Prior to the crew’s arrival on the unit, the patient had received four units of type-specific packed red blood cells (PRBCs) and six liters of crystalloid. He is restless and fighting mechanical ventilation. Blood pressure is 100/56. The monitor is showing a sinus rhythm at 104 beats per minute. Peripheral pulses are palpable and the patient’s skin is warm, dry and pale. His oxygen saturation is 96 percent on 1.0 fiO2. There is approximately 100 ml of amber urine in the patient’s urimeter.

While serum potassium level is slightly elevated at 5.5 mEq/liter, electrolytes are relatively normal. Hemoglobin and hematocrit are 12 gm/dl and 35 percent, respectively. Serum and urine toxicology screens are negative and the most recent arterial blood gas (ABG) includes a pH of 7.21, a PCO2 of 38 mmHg, a PO2 of 120 mmHg, and bicarbonate of 16 mEq/liter.

With a mean arterial pressure (MAP) of 71mmHg and an oxygen saturation of 96 percent, the patient appears to be stable from a hemodynamic perspective. Is this an accurate assessment? Is further resuscitation required? How do we know?

For the answers to the questions and explanations:
http://www.ems1.com/Columnists/paul...izing-a-Trauma-Patient-Beyond-the-Golden-Hour

Keep in mind that the above is just an overview of things to consider for transport.

Another good article by this author:
Transport Management for the Sepsis Patient

Your transport team is called to the intensive care unit of a 68-bed community hospital 30 nautical miles away for a 64 year-old male admitted three days ago with “flu-like” symptoms. The patient had been admitted to the hospital by his primary care provider for general malaise, a temperature of 100.9F and a high white blood cell count.

Sputum cultures were positive for gram-negative rods and appropriate oral antimicrobial coverage had been initiated. Early this morning, the patient experienced increased dyspnea, weakness and confusion. He was transferred to the ICU for further work up.

Upon your arrival, the patient’s condition appears to have declined significantly. He is intubated and mechanically ventilated, appears quite anxious and is repeatedly triggering the ventilator high-pressure alarm. A dopamine drip is infusing through a recently-inserted, right subclavian triple-lumen central venous catheter. The dopamine is currently running at a dose of 15 micrograms per kilo per minute. He received 40 milligrams of Lasix intravenously for low urine output. Current vital signs include a heart rate of 124 bpm, blood pressure of 82/48 (MAP of 59 mmHg), respiratory rate of 22 breaths/minute and an oxygen saturation of 91 percent on 100 percent oxygen fiO2. Central venous pressure measured at the distal lumen of the central venous catheter is three mmHg and cardiac output as measured by an esophageal doppler was 9.4 liters/minute.

How would you explain these assessment findings? Is the patient receiving appropriate management in the ICU based on best practices? How would you and your team proceed with management and transport?

Read more for answers and explanations at:
http://www.ems1.com/columnists/paul...2-Transport-Management-for-the-Sepsis-Patient

An Emergency of the Aortic Kind

http://www.ems1.com/columnists/paul-mazurek/articles/400977-An-Emergency-of-the-Aortic-Kind
Air Transport Case of the Month

You are called to the emergency room of a community hospital to transport a 57-year-old male with a 12-hour history of chest pain. The patient is to be delivered directly to the cardiac catheterization lab of an academic medical center 50 miles away.

He has received a 12-lead EKG and portable chest x-ray. Initial laboratory studies have been drawn and sent. The bedside nurse reports that the patient has received chewable aspirin, three sublingual nitroglycerin tablets with minimal relief, a total of 5mg of morphine sulfate IV and the first of three 5mg IV metoprolol doses. Heparin and nitroglycerin infusions have been prepared but not yet started. A dose Retavase (Reteplase), 10 units IV have also been ordered but not yet administered.

Upon your arrival, the patient is in obvious distress. He has 7/10 chest pain and pale, cool skin. He is also complaining of tearing back pain radiating to the left side of his neck. Vital signs include a heart rate of 94 beats/minute, a respiratory rate of 20 breaths/minute (regular and non-labored), a blood pressure of 154/96, and an oxygen saturation of 97 percent on two liters/minute of oxygen by nasal cannula. The 12-lead EKG shows ST-segment elevation in leads I, aVL, V5 and V6. Chest x-ray shows a widened mediastinum and a blunted aortic knob.

What are your treatment priorities? Are there any differential diagnoses to consider at this time? Should the nitroglycerin and heparin drips be initiated? When would you start the ordered thrombolytic therapy?

Read more for answers and explanations at:
http://www.ems1.com/columnists/paul-mazurek/articles/400977-An-Emergency-of-the-Aortic-Kind

These scenarios are just to get one to think about how important it is to have a solid foundation established in your education and to continue to advance your knowledge. Somethings shouldn't be memorized but rather they should be understood. The scenarios are also to introduce one into the vast world of critical care medicine.
 

Airwaygoddess

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To understand and learn.....

These are very great posts Vent!!:):):)
 

Ridryder911

EMS Guru
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EEEK ... I am having flash backs of the CFRN and FP-C tests questions!...........


R/r 911
 

fma08

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Can't thank you enough for this post, very insightful.
 

rhan101277

Forum Deputy Chief
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These are tough, out of my skill range. Let me go back under my rock.

I didn't realize that some transports can be this complicated.
 
OP
OP
V

VentMedic

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It gives you a different insight on transport medicine and why some of us are big advocates of EDUCATION and not just meeting the minimum amount of "training hours" as required by your state.
 

mycrofft

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Thanks, it's always good to read stuff over my depth.

Yes, we always need to press on, and it's incumbent upon the younger folks to press ever further as they amass a body of practical experience.
 
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