trauma assessment scenario

[Veneficus]

I missed where the patient went from having runs of vtach to just vtach?

 

[MrBrown]

Apparently I did too.

 

[8jimi8]

I don't ever think i said just vtach,

I believe we went from stach with runs of vtach @ 8, 10 , 12 beats to

stach with runs of vtach 20 beats.

after intervention we went to

stach with bigeminal runs.

The reason that I increased the intensity of the vtach is because no one was moving beyond bagging in the airway portion of the exercise, my instructor kept making his O2 sat get worse (refractory to bagging with npa and 100 o2), until I intubated him. At that point his focus shifted to the runs of vtach.

I understand that everyone is frustrated with the timeline of moving the truck before intubating.

I apologize, that is my fault, I gave you the scenario "half way into" the scenario, if that makes sense. My bad y'all, like i said i was going to try and keep it from spiraling into infinite silliness!

 

[Veneficus]

I thought you were implying

because of the Vtach you were going to cardiovert them?

Our guideline for APO/CPE says to particulary look for, and exclude, VT and yet I did not, whoops

My primary concern is to fix his oxygenation problem. If he will not take an LMA and we cannot get his O2 up with a bag mask then all I can do is call for an Intensive Care Paramedic able to perform rapid sequence intubation.

As for CPAP hmm .... not sure to be honest. I know the M&M goes up in patients if you intubate them but I think it may be prudent to intubate this patient before he gets any worse which he may do with or w/o CPAP.

my primary concern about intubating was the scenario starting in a moving vehicle with a patient in c-spine precautions. That is not conducive to intubation. I agree it would be better to intubate the pt before wheels start turning.

controlling the airway should not be the difficult part of this scenario.

Now my bet from physiology 101 is that the VT is causing his circulatory and oxygenation problem. Could try amiodarone or we could cardiovert, I would be more inclined to cardiovert first then and hang up some amiodarone.

I'm going to stay away from lasix.

I was trying to get to the cause of the VT.

 

[8jimi8]

according to my instructor hypoxia was the primary culprit; however in the scenario, taking control of the airway did not lesson the degree of arrythmia. I guess he was going to see how far I would go.

That is the scary thing about scenarios... lots of slack to tie a noose and then put it on....

 

[mycrofft]

I wonder what the ER take on this would be?

Are there interventions they would rather were not field started (like inadequate IV's) because it muddles the diagnostic, or buggers theirn Rx regimens?

 

[Veneficus]

Are there interventions they would rather were not field started (like inadequate IV's) because it muddles the diagnostic, or buggers theirn Rx regimens?

In my ieal world, there is no seperation of care. If you do not posess the ability to definitively care for a pt. the goal should be to best prepare them for the next step.

Sometimes that means a treatment to make sure they live that long.
Sometimes it is a happy medium.
Sometimes it means doing nothing at all.

In a scenario (especially incomplete or unrealistic ones) we can really only say what we would do and why or what the current practices are.

I try to answer from a personal perspective as I think (and desperately want to believe) everyone who posts a scenario has at least an idea of what the standards of care are.

 

[rhan101277]

called to scene of 1 vehicle vs tree.

Initial impression: no skid marks, moderate frontal damage, no air bag, steering wheel intact, 1 patient, driver restrained - flaccid in drivers seat, driver door won't open due to impact, no entrapment of patient beyond the damaged door. Fire and LE on scene.

initial assessment:
no witnesses
Your partner takes c-spine
driver moans weakly to loud verbal stimuli, does not open eyes.
breathing is shallow and rapid 38/min breathe sounds are wet rales in all fields
circulation is weak and thready at 133 b/min
nrb 15l/min
high priority - rapid transport patient
medic alert bracelet: Cardiac history, allergy to HCTZ.

no sample or opqrst available
rapid trauma assessment reveals pms + (withdraws to painful) in all extremeties, eyes perrl, no signs of basilar skull fracture, no signs of dcapbtls or any obvious trauma (rapid trauma assessment is essentially negative except for a minor oozing laceration to the left cheek)
baseline vitals 90/50, hr 155, breathing 35 o2 sat 80
extricate with a KED and long backboard.

once the patient is loaded in the ambulance 2 large bore IVs
place the patient on the monitor reveals ...

multifocal pvcs and runs of paroxysmal vtach 8, 10 , 12
Oxygen saturation reads 75, patient is breathing 28 /min

what do you do.


call out your interventions once the ambulance starts moving. 15-20 minutes until the hospital. you can have 1 MFR/firefighter in the patient compartment with you.

Continue NRB at 15L

Lidocaine 1mg/kg - tach still present? shock 200J

1000cc fluid bolus re-assess B/P and bolus again

12 lead assessment, treat what you can

ETC02

Take o2 sat with a grain of salt BP low.

Continuous monitor in route