Motocross Mayhem

[Timmy]

G’Day Guys.

Just a little scenario we had happen here on the weekend, just after some different opinions on how you’d manage this patient.

You’re a single paramedic in a small country town, could be classified as a remote area.

Your called to the local motocross track (about 20 mins out of town) for a 16 year old male, unresponsive post high speed ejection from his motor bike during a race.

What would you like to know?

[DwayneEMTP]

What is the location of the body?

The position that you found him in?

Before touching him, what is you initial impression of the person and the scene?

Going slow so that many can participate...

Dwayne

[uglyEMT]

Let me take a crack at it (BLS here so bear with me if I stop beyond my SOP)

16yr Male. High Speed ejection. Unresponsive

First I would be looking for paralysis signs. Are his arms curled up to his chest? Are they bent away from him? This can be done while walking up to the patient. So no loss of time for interventions but can guide you in your next steps.

Check for pulse? If there is one proceed to next step. If not skip step and proceed to Airway.

Next chin thrust to open airway followed by a quick RTA for s&s of trauma. Helmet, note scratches, dents, deformity. Is it going to imped airway adjuncts or interventions. If so it will need to be removed. Quickly but carefully.

Secure airway if needed. Gag reflex? NPA or no gag then OPA. (like I said Im BLS so I stop at PAs if I was a medic tube him probably). By this time I would be assesing the need for medivac. I would at least have had the bird on standby due to MOI.

Once airway is secured is Pt breathing on his own? Yes but shallow bag him w/ BVM on 15lpm O2. If breathing on his own NRB w/ 15lpm O2.

Circulation. What color are the nail beds, lips, gums. Is he profusing OK or are we looking at a cardiopulminary issue? BP / Pulse?

OK now we have our ABCs out of the way time to go trauma naked here. Cut everything away to his skivies while taking note of scratches, tears, rips. All can lead to conclusions of internal injuries. Keep gear together including helmet for transport with Pt to ED for Docs to inspect as well. The helmet is especially important.

What kind of injuries are we looking at now that his gear is removed? Broken bones, chest injuries, head injuries? Concusion or closed head trauma? Bleeding from ears, nose, mouth? Any CSF leakage?

Full spinal procautions with this patient so collar and board as quickly as possible and prepare for transport. Depending on findings and mode of transportation is he being flown or driven.

I will stop here as depending on the answers will dictate my course of action. Right now his main priorities are ABC and immobilization. Findings will dictate future interventions.

If I was to hazard a guess, just a guess, might be looking at some sort of chest injury from impact with the bars of the bike or impact with the track. Depending on if he slide into anything or not possible broken bones in the arms, ribs, pelvis, legs. Could be looking at a closed head injury if he impacted from a fall of height or if his head impacted the track with force. Spinal injury is a high suspision in my book. Hopefully not showing signs of paralysis upon initial observation. If he is alot of what happens next will be dependant on where the SCI is and to what systems they will effect.

Good scenario, can't wait to hear some answers to get moving along with this patient. Even from a BLS level its a very good training scenario.

Edited November 8, 2010 by UGLyEMT

[fakingpatience]

After making sure he is breathing, or having someone assist him w/ respirations (including NPA/ OPA) if he is not, Vitals, including GCS. Is he posturing? Ask bystanders if he moved at all after crash, did he appear unconscious immediately, or was he initially conscious and lose consciousness slowly. What caused the crash? How did he fall, what did he hit first?

What do his pupils look like? Are they responsive, are they equal, or is one blown?

Full trauma assessment

[Timmy]

You arrive to find the St John crew (standby first responders) have a packaged patient with a GCS of 8 (initially a GCS of 3 but improved slightly with 100% 02), decorticate posturing, tachypneic/shallow respirations sitting around 52 breaths a minute, right pupil is dilated, failed OP airway insertion X 3 due to trismus, having trouble maintaining a patent airway due to trismus and increased production of secretions.

Just to make things interesting the fathers become aggressive over the first responders cutting his motocross gear and refuses to let you cut any more… You have the chest exposed and the helmet was removed by first responders with cervical support for airway management. The helmet is smashed.

The first responders have completed a secondary assessment which is NAD.

Vitals:

BP: 183/115

Pulse: 92

Resps: 52

SP02: 95% with 100% 02.

Nill past history or medications, a very fit and healthy 16 year old in a whole lot of trouble.

[uglyEMT]

The 8 GCS has me worried but glad he came back from a 3.

The posturing is a very bad sign, we have a spinal cord compromise. While he's breathing on his own lends me to believe it may be we are not dealing with a severed cord but one that may be in compression somewhere.

Dad well, get the kid in the rig and cut away. At a GCS of 8 you are now under infered concent, we dont need Dad to tell us anything. I am not transporting without trauma naked. This kd has multiple severe trauma injuries I want to see it all. Leave the skivies I can palpate the pelvis to check for destablization.

Helmet smashed, dialted pupil low GCS we have head trauma. Any CSF noted? Raccon eyes? Battles Signs? We have a head injury that needs immediate attention.

Do we have a bird available? I want this kid on a table quickly.

High BP and Pulse and shallow respirations we could be looking at a tension pnuemo. Do we have JVD? I would definatly keep an eye on the BP and Pulse as well as the breaths. This kid may need a chest tube placed.

Being I am BLS I appologize if I am missing something ALS that should be done.

[Timmy]

Nil CSF, raccon eyes.

Bilateral airway entry is good and equal.

Nill JVD

Chopper is on the way with a doc and intensive care paramedic, ETA one hour.

You’ve got the kid loaded, it’s not suitable to land chopper at the track. You can make it to the local hospital which has one ED bed, on call general doctor (who may or may not feel like tubing) within 20mins. The hospital has a chopper pad. Police are on scene and are happy to keep dad company for a bit.

[uglyEMT]

Glad to hear about the NIL makes me feel better.

PD taking care of Dad good. Less on me.

Lets get rolling to the hospital with the pad. At least a GP has more in a one bed ED then we have on a rig. Bird flying so looks like the next hour we will be assessing, reassessing, baggin and sweating.

[mobey]

Leave the skivies I can palpate the pelvis to check for destablization.

I'll wait a bit before I jump in and get all ALS (which I am excited to do), I just wanted to grab this quote and let UglyEMT know that one time, I had an Uncx pt from a rollover. I did exactly as you mentioned, and left her undies in place.

As it turns out, she had a small puncture wound in the crease between her leg and her... well.... you get the idea!

My point is, be thourough on Uncx trauma pt's. That was what I consider to be my biggest failure of a call so far.

[uglyEMT]

Thanks for the heads up Mobey. I will check crotch seams from now on. I always figured if there was a wound(s) blood would be visable on the undies and as such be treated.

But again thank you for the heads up