Unconscious kid lying in a room
- Thread starter EMT1A
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I agree with you and the cop side of me always looks at what evidence I have to tell me what likely happend.
However, here in WA (at least in Seattle) they backboard any unresponsive / unwitnessed fall.
I don't have much experience at Harborview, but when I have been there patients on backboards have been taken off within 15 minutes of arrival.
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Basically they're treating the "what if" patient who is being cared for by the lowest-capable provider when they direct a provider to backboard unwitnessed/unresponsive fall victims. And I'm not at all surprised to hear that many of those patients are taken off the board within 15 minutes of arrival. Why? The backboard's job is done at that point, even if it was necessary during extrication from the scene and transport.
If you are assuming c-spine precautions then you shouldn't be doing a head-tilt chin lift. You need to use a jaw thrust manuever. Right?
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ever done one on a person before?
If the person is not breathing you do what you have to to get the airway.
I understand you need to get the airway open above all else, so you're right but I am assuming this question was asked for testing purposes.
What movie is your picture from?
NomadicMedic
I know a guy who knows a guy.
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100% false. Patients on backboards at HMC are only taken off backboards when cleared by the trauma doc. It sometimes takes hours. Spend a busy Friday or Saturday there. Youll find MVC patients in Resus 2 and 4 that have been on boards for several hours. In fact, there have been several instances that I've witnessed at HMC where patients that arrived via ambulance, non boarded that were placed on backboards that were fetched from outside in the ambulance bay. Often the poorly fitting C-collar applied by EMS is removed and a plastic Philly style collar is applied by the ED staff as well.
The docs at Harborview practice CYA just like everyone else. If the PT can't be cleared, they wait on imaging.
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Bringing Out the Dead
on scene, simple as
BSI Scene safety.
ABC's for treatment.
intervene as needed
for assessment
as far as C-spine if it was witnessed and there are signs of possible MOI then without a doubt instant spinal precautions.
but look at the scene if the roommate is there ask what happened. if they called 911 and stuck around for you to arrive chances are they are concerned enough to tell you everything they know (i have been on some sketchy AMS or LOC calls where the roommates have seemed to hold info back but never have they not told me enough to get a clue of what they know), if pt fell, if pt had taken any drugs, if pt had simply drunk them selves into a LOC, dont forget that this person lives with the pt, there is your link to past medical Hx, medications, allergies to potential "shifty" activity out side of the norm recently. maybe this kids chick just dumped him and hes now a potential behavioral patient. may have taken something other than the alcohol.
use your senses.
look around what does the rest of the house look like. was this a party or is this guy the only guy drinking. (could key you in on how much alcohol this guy has had.) if a party happened and this guy got sick or hurt (everyone else bailed) theres signs of alcohol everywhere, whos to say this guy even had a drop?
assuming this guy has a patent airway (managed or not) and is breathing (assisted or not) and is not actively bleeding and is adequately perfusing, pack him up (assuming nothing on scene indicated spinal immobilization then) position lateral recumbent. full set of vitals to include spO2, BGL, pupils, and skin condition. monitor if you've got it. reassess enroute ABC. vitals every 5. transport code 2 (routine).
my battalion doc is an emergency medicine physician I guarantee she would agree with this statement 100%.
ABOVE EMS's level of care but her protocol for clearing a neck before removing full spinal immobilization is
1. no distracting injuries
2. sober
3. no neurological deficits
4. GCS of 15
5. no midline tenderness
all 5 criteria met = spineboard removed.
the other may call for imagery
BSI Scene safety.
ABC's for treatment.
intervene as needed
for assessment
as far as C-spine if it was witnessed and there are signs of possible MOI then without a doubt instant spinal precautions.
but look at the scene if the roommate is there ask what happened. if they called 911 and stuck around for you to arrive chances are they are concerned enough to tell you everything they know (i have been on some sketchy AMS or LOC calls where the roommates have seemed to hold info back but never have they not told me enough to get a clue of what they know), if pt fell, if pt had taken any drugs, if pt had simply drunk them selves into a LOC, dont forget that this person lives with the pt, there is your link to past medical Hx, medications, allergies to potential "shifty" activity out side of the norm recently. maybe this kids chick just dumped him and hes now a potential behavioral patient. may have taken something other than the alcohol.
use your senses.
look around what does the rest of the house look like. was this a party or is this guy the only guy drinking. (could key you in on how much alcohol this guy has had.) if a party happened and this guy got sick or hurt (everyone else bailed) theres signs of alcohol everywhere, whos to say this guy even had a drop?
assuming this guy has a patent airway (managed or not) and is breathing (assisted or not) and is not actively bleeding and is adequately perfusing, pack him up (assuming nothing on scene indicated spinal immobilization then) position lateral recumbent. full set of vitals to include spO2, BGL, pupils, and skin condition. monitor if you've got it. reassess enroute ABC. vitals every 5. transport code 2 (routine).
my battalion doc is an emergency medicine physician I guarantee she would agree with this statement 100%.
ABOVE EMS's level of care but her protocol for clearing a neck before removing full spinal immobilization is
1. no distracting injuries
2. sober
3. no neurological deficits
4. GCS of 15
5. no midline tenderness
all 5 criteria met = spineboard removed.
the other may call for imagery
Might as well quit wasting time and just send them to CT for their total body scan with spinal recons.
All joking aside, I strongly suspect this criteria came from consensus and a legal department.
Remember this is her criteria for removing immobilization for pt's who have suffered from or come from scenes that indicated significant MOI.
1. Distracting injury indicated from MOI. That's not talking about a c-collar that is too long for the pt.
2. Sober. This guy was injured to the point where a responder on scene decided he needs a back board. Not just any etoh pt. what's the difference between CNS depression to etoh or CNS depression to spinal injury. Priapism/ lack of? Not all spinal injuries will result in priapism.
3. Neurological deficits such as paralysis, paresthesia, priapism.
4. If you don't like GCS how about AMS? If they aren't A+O then they may need imagery.
5. Sure spine boards are uncomfortable. She also said this is one of the first things she does when she receives a patient. So if there is point tenderness on bony structures when they arrive they may need imagery.
PHTLS also follows this criteria for prehospital spinal clearance with the added part of significant MOI presence.
If they fail any one of those most likely they would go to imagery as soon as possible.
There isn't much if any time wasted in 1,3,4,5 all of which are part of your detailed physical exam anyway. Number 2 is the only one that may take a while.
Despite MOI being unreliable?
???
What is the difference between a brain injury and a spinal cord injury?
There are some rather key differences.
Just off the top of my head you could have herniation and its sequele which presents far different from neuro-sensory impairment.
Even on an unconscious patient vegatative functions vs reflexes are a big difference.
I'm just going to leave this alone.
I do not think you understand. It has nothing to do with choosing one scoring system over another.
the GCS scoring system is scientifically validated for prognosing recovery.
It is not scientifically validated on kids, it is not scientifically validated for intubation, nor determinging imaging.
It is clinicians who choose to use GCS scoring outside of its intended and proven purpose as a memory aid or treatment guidline.
My rather sarcastic point is, since being transported on a board or laying on one for the better part of an hour or two can cause this tenderness, physicians might wat to quit wasting time and just send them for imaging anyway. In modern times, that means a CT.
Who cares?
PHTLS is a watered down version of ATLS based on what is believed is safest practice for the least common denominator of field provider.
If a physician is making decisions based on PHTLS, they might want to get a thicker book.
Which is most patients. My point again, rather than trying to clear them, might as well just send them to CT.
Seems to me like range of motion deficit should probably be added to this list?
Anyway, you cannot summarize best practice from the personal choices of one clinician second hand. I would wager there is probably considerably more to the thought process behind who gets imaging and who doesn't that she is leaving unsaid.
Melclin
Forum Deputy Chief
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For certain, the non-specific compliants in the elderly create a lot of headaches due to the increased diagnostic requirements.
As well, the high compensatory ability of kids can also give a false sense of security.
I have seen in person kids "stabilized" by numbers code moments later on a trauma table while everyone was congratulating themselves.