trauma call, head and facial assault

[knxemt1983]

So here's a scenario I ran into today and I would like some opinions on it.

Responded to a 29 year old female, assault victim. Once there the pt is ambulatory, but with numerous abrasions and lac's on her head, face, and upper extremities. She does not remember the occurence, only that she was knocked down and when she came to she was on the ground with head and face pain. Bystanders said she was repeatedly punched, and kicked on the head. No neck or back pain. Obvious broken jaw and nose.
Pmh: asthma
Nkda
Only med is proventil prn, rarely used
V/s: 130/80, pulse 100, spo2 96%, rr 16
Alert and oriented appropriately
Immobilize or not?

My partner disagreed with my decision. I immobilized with the thinking that if enough force was transferred to the head to break her jaw and nose, with loss of consciousness then spinal immobilization was needed. I wouldn't second guess it except the physician at the ed immediately pulled it all off when we got there. By our protocol for immobilization I was right, but is there something I'm missing? Would you have immobilized or not? I know the usual lessons about following protocol, and I have read up on current research on how immobilization is not completely effective etc etc etc, but wonder what the "standard" would be

 

[DesertMedic66]

For that call I would have immobilized also. Broken jaw + LOC + numerous hits to the face + hitting the ground = C-spine IMO.

And for alot of people you immobilize as soon as you get to the ER/ED they will remove then from C-spine (from what I have seen.)

 

[truetiger]

You did right by your protocol. Just because an ED doc pulled it off immediately doesn't mean he was right. I would make a note of this to whoever does your training/QA/education so that they can follow up with the hospital and find out why. If immobilization was not indicated for this patient you'll get an answer why and if it was, the hospital can follow up with the doc for improperly removing it.

 

[Melclin]

Doctors can pull all the c-collars off that they want, doesn't mean you shouldn't have put it on in the first place.

Take a job I went to a little while back. Assault, complaining of c-spine pain on palpation, altered numbness and tingling down the left side. I was pretty sure he didn't have a spinal injury and that the numbness and tingling was because he'd been laying on he left side on cold concrete for the past 25 mins. Still immobilised the kid. You have to. When we got to the ED all of a sudden the c-spine tenderness is gone and no more altered sensation. Doesn't mean it wasn't indicated half an hour ago.

I'm the last person to immobilise people every idiot I come across and I hate immobilising people when I do, but the fact remains that it is still a standard of care with certain indications. Multiple kicks to the head with LOC and a distracting injury. How can you write that on your PCR and not have immobilised the person? I would have immobilised in the sense that I would have put a collar on and asked her to lay still and flat on the bed.

 

[knxemt1983]

You did right by your protocol. Just because an ED doc pulled it off immediately doesn't mean he was right. I would make a note of this to whoever does your training/QA/education so that they can follow up with the hospital and find out why. If immobilization was not indicated for this patient you'll get an answer why and if it was, the hospital can follow up with the doc for improperly removing it.

Yeah I filled out an incident report to our qa department and medical director as well as sent the epcr to them for review. I don't regret doing it but wanted to make sure I wasn't out of touch, the fire dept agreed with my partner so I was totally outnumbered. I nformed the pt of the risks of notdoing it and she agreed it was best. As for the doc, idk if he was right or wronghe did some neuro tests and cleared it, if he wants to take it off that's on him and he's not bouncing down the road in a work truck lol

 

[truetiger]

Did he take her off the board or both the collar and the board?

 

[knxemt1983]

Doctors can pull all the c-collars off that they want, doesn't mean you shouldn't have put it on in the first place.

Take a job I went to a little while back. Assault, complaining of c-spine pain on palpation, altered numbness and tingling down the left side. I was pretty sure he didn't have a spinal injury and that the numbness and tingling was because he'd been laying on he left side on cold concrete for the past 25 mins. Still immobilised the kid. You have to. When we got to the ED all of a sudden the c-spine tenderness is gone and no more altered sensation. Doesn't mean it wasn't indicated half an hour ago.

I'm the last person to immobilise people every idiot I come across and I hate immobilising people when I do, but the fact remains that it is still a standard of care with certain indications. Multiple kicks to the head with LOC and a distracting injury. How can you write that on your PCR and not have immobilised the person? I would have immobilised in the sense that I would have put a collar on and asked her to lay still and flat on the bed.

That would be an option I would be open to, however our protocols are basically all or none. I mean we could document a refusal of lsb if that was the case, but likely would be in the "principles office" to 'splain ourselves for it. Not that we would be in trouble but it would just be a very extraordinary scenario. That's not likely to change either since even as times change rapidly its rare for our protocols to change other than with acls/pals

 

[shfd739]

I'd agree and say you were right. Our protocols stipulate any injuries above the clavicle get immobilized so I would have and could have justified it to the FD. I dislike having to immobilize and can usually rule out alot of folks but my sucspision would be high for this patient.

The ER docs can pull all the collars they want. Their initials mean more than mine.


---
- Sent from my electronic overbearing life controller

 

[knxemt1983]

Did he take her off the board or both the collar and the board?

The whole shebang.... he said just try not to move around much until we get some xrays and a ct. I wasn't exactly comfortable with it but he signed my pcr and I was leaving by then so it was outta my control and on his license, and livelyhood not mine

 

[knxemt1983]

I'd agree and say you were right. Our protocols stipulate any injuries above the clavicle get immobilized so I would have and could have justified it to the FD. I dislike having to immobilize and can usually rule out alot of folks but my sucspision would be high for this patient.

The ER docs can pull all the collars they want. Their initials mean more than mine.


---
- Sent from my electronic overbearing life controller

Yeah I justified it to them but they never wanna listen, they just wanted to hurry outta there and get back to the recliner. They actually wanted to walk the pt to the truck and said "just leave the cot in and we'll bring the pt out to ya". The call even came out as assault with positive loc

 

[truetiger]

Great job of advocating for your patient and not going with the group. Who cares what the fire dept thought. This is a good example of taking control of your patient's care.

 

[knxemt1983]

Great job of advocating for your patient and not going with the group. Who cares what the fire dept thought. This is a good example of taking control of your patient's care.

Thanls for the compliment. Its beenone of those nights of second guessing everything I do and I needed some reassurance.

 

[truetiger]

That collar should of stayed on until she was cleared by the radiologist. You shouldn't of had to justify your decision to anyone. Unlike the other thread, this was your patient whom you were transporting and writing the pcr on. They didn't like your answer, tough luck.

 

[Melclin]

The whole shebang.... he said just try not to move around much until we get some xrays and a ct. I wasn't exactly comfortable with it but he signed my pcr and I was leaving by then so it was outta my control and on his license, and livelyhood not mine

Sounds like he might have been in the c-spine precautions do nothing camp. Its a good camp. I think there is a lot to be said for pain relief plus "lay still"

There also may have been risk stratification algorithms in play that weren't immediately obvious to you. He/the hospital may feel that pt's in her demographic with her mechanism, with a normal neuro exam have a low enough likelihood of injury that they don't need to stay immobilised. Some institutions really don't like to leave c-spine precautions in place for too long. You should have had a chat to the doc about why. I know you work in a different system, but I've always found docs more than happy to chat if you ask nicely.

I wouldn't fret too much about what the hospital ended up doing vs what you did. There are many different factors in play. Pts report different things at different times, different institutions are willing to except different levels of risk and hospitals have ideal environments and plenty of time in which to do assessments.

Taking a pt sitting on the side of road upset, crying, cold, covered in blood and in pain, making quick decision about transport and treatment and getting it done with only one other person to help often involves challenges and compromises that hospitals often don't have to deal with. Its much easier to take a pt who has had time to calm down, has some pain relief on board, had been cleaned up warmed up and reassured, and thoroughly assessed then wander over and do a 5 minute neuro exam.

You shouldn't take what the hospital did later, to be the gold standard of what you should have done. Sometimes its because they have more time, more help, greater scope, more equipment, etc and other times they're just wrong. Take what they have to say into account, but ultimately its only ever expert opinion and hopefully you know where that sits on the hierarchy of evidence.

 

[knxemt1983]

Sounds like he might have been in the c-spine precautions do nothing camp. Its a good camp. I think there is a lot to be said for pain relief plus "lay still"

There also may have been risk stratification algorithms in play that weren't immediately obvious to you. He/the hospital may feel that pt's in her demographic with her mechanism, with a normal neuro exam have a low enough likelihood of injury that they don't need to stay immobilised. Some institutions really don't like to leave c-spine precautions in place for too long. You should have had a chat to the doc about why. I know you work in a different system, but I've always found docs more than happy to chat if you ask nicely.

I wouldn't fret too much about what the hospital ended up doing vs what you did. There are many different factors in play. Pts report different things at different times, different institutions are willing to except different levels of risk and hospitals have ideal environments and plenty of time in which to do assessments.

Taking a pt sitting on the side of road upset, crying, cold, covered in blood and in pain, making quick decision about transport and treatment and getting it done with only one other person to help often involves challenges and compromises that hospitals often don't have to deal with. Its much easier to take a pt who has had time to calm down, has some pain relief on board, had been cleaned up warmed up and reassured, and thoroughly assessed then wander over and do a 5 minute neuro exam.

You shouldn't take what the hospital did later, to be the gold standard of what you should have done. Sometimes its because they have more time, more help, greater scope, more equipment, etc and other times they're just wrong. Take what they have to say into account, but ultimately its only ever expert opinion and hopefully you know where that sits on the hierarchy of evidence.

All that sounds true, I plan to talk it over with our medical director (who happens to be this hospitals director also) tomorrow. We got sucked out of there for another call before I could chat with him, and he was new so idk who he was or if I'll even run into him again. We have a lot of team health docs move in and out all the time

 

[Handsome Robb]

For that call I would have immobilized also. Broken jaw + LOC + numerous hits to the face + hitting the ground = C-spine IMO.
/QUOTE]

I'll second this. The one question I have and I may have missed it is how were was her neuro exam? The way we are taught is that the mechanism is there and she has a distracting injury. Even if her CSM was intact I would still have put her in full spinal restriction unless she refused after being properly informed of the risks. We don't have imaging in the field to rule out a possible cervical injury. Sure you could go with the opinion of everyone else on scene but when it comes down to it, it's YOUR *** on the line.

This seems like a CYA case, did she have a cervical injury? Who knows in the prehospital environment, but why risk your certification and the pt's health? We don't have the tools to rule out c-spine precautions in the field in this case. A lot of people we see that are put in C-spine precautions don't need it but with the mechanism plus the LOC this pt experienced I'd say your correct. I'm interested in what you QA/QI department says about it.

 

[usalsfyre]

To play devil's advocate....

Did she have a distracting injury? Unless a patient is unable to calmly participate in my exam due to pain from another injury, I don't automatically assume "distracting" injury. Meaning just because she had a broken jaw doesn't mean it was "distracting" from a neck injury.

I don't know whether I would have c-spined or not. My hunch is no, but without seeing her I can't say. You didn't do wrong by doing so though, it's one of those grey areas in medicine.

 

[Smash]

Further to usalsfyre's comments, the incidence of spinal cord injury as a result of assault and blunt trauma is actually very low. Can't remember exact numbers off top of my head, but not much at all.

 

[8jimi8]

follow your protocols.

here's some food for thought. Not the article i was looking for but pretty sure the article i was looking for is referenced here.

http://www.scahec.net/prepares/summit/ppt/c_spinal.pdf

 

[HMartinho]

Obviously you should immobilize the victim. Here in Portugal is also very common in the triage nurses remove the immobilization equipment from patients, but it is their responsibility. From the moment that we deliver the patient in triage nurse, it is no longer our responsibility, but if we do not the immobilize the patient and follow the protocols, and the patient develops some complication, then it will be our responsibility, and we will have to answer for it!

BTW, I apologize for any mistake, I still have to improve my English