Timmy Posted November 8, 2010 Author Posted November 8, 2010 I have no problem with getting ALS involved. There is an ALS paramedic on scene and a first responder is an ED nurse in there day job. Are we going to stay and play or scoop and run? Only down side, the ALS paramedic can not RIS single officer. Still having some airway troubles.
uglyEMT Posted November 8, 2010 Posted November 8, 2010 Load and go. Patient is already packaged. Lets get to difinitive care. Especially with no intubation allowed (RSI) get the GP involved due to airway comprimise still being a factor
Just Plain Ruff Posted November 8, 2010 Posted November 8, 2010 All signs point to a very very bad outcome for this kid. Posturing, pupil problems. 1 hour for a helicopter and then who knows how long to definitive neurosurgical intervention BAD MOJO I would say that we will eventually need to discuss if his organ donation card is up to date and signed. As a medic I'll try ot get him paralyzed and intubated. Maybe the ER has a ct scan? too much to ask for a 1 bed ER. Smashed helmet - what does his skull feel like? This kids in major trouble and probably no matter what we do for him in the field, there are just some people who we cannot help. I've ran nearly this exact scenario before but we had a 30 minute ETA of helo and a 10 bed ER plus a good Nurse anesthatist to intubate this kid. (this was prior to us being able to use paralytics to facilitate intubation). The kid I ran ended up helping 15 other people with his organs and skin.
Timmy Posted November 8, 2010 Author Posted November 8, 2010 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 Sorry Dwayne, I completely missed your post! The mechanism is the rider went over the tabletop jump, became air born at high speed, landing on the back of his head (head took all the impact), patient was found supine, was log rolled by first responders who removed the chest armour and helmet, onto scoop with collar and packaged, the patient has been moved onto a stretcher but remains track side. First impression, the dude looks really sick. The rapid, swallow and noisy respirations are noted at first as well as decorticate posturing. Apart from dad being a little ansy about cutting the gear the scene is clam, everything is in control and running as smoothly as possible. The race is stopped and there are no dangers.
Timmy Posted November 8, 2010 Author Posted November 8, 2010 There’s actually a positive outcome to this case. You have a 14g insitu on the right CF NACI running 10mg metoclopramide IV NSR on a 3 lead Still have tristmus, NPA not recommended due MOI and trauma to head. In the car he projectile vomits about 1.5 litres of content You stop the car to maintain airway with suction and pop the patient into lateral position, IVC in and to recheck BP You attempt to get another 14g in, in response to a painful stimuli the patient then sits up with eyes closed, no verbal response, still has decorticate posturing (noted flection in both arms and hands) then lye’s back down. The straps on the board have been removed in response to the patients airway needs, risk of aspiration and the patient has been placed in the lateral position, collar still insitu with cervical support as best as we can. Patient is unresponsive to sternum rub but responses to peripheral stimuli. Will give him a GCS of 5. BP: 164/73 – P: 52 – R: 47 – SP02: 96% with intermittent 100% 02. Right pupil is still dilated.
fakingpatience Posted November 9, 2010 Posted November 9, 2010 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. Don't mean to derail the train of thought on this tread, but I have a quick question. Posturing is a sign of head trauma, not necessarily related to spinal compromise, right? Honestly, I wouldn't worry about getting another 14G in, don't think I would have even tried with the first one. A 16 should be all the hospital needs to give bloods I believe, and everything we want to give would be fine with an 18. Does the pt still have a gag reflex? Oh, and what does IVC stand for? If we can't establish an airway in the field, I would pick the quickest option to get him to the closest place that can RSI or establish another airway (cric if necessary due to facial trauma). Probably would end up going to the ER, and having the helicopter there ready to transport this kid to a trauma center once he has an airway. (sorry this is so jumbled)
DwayneEMTP Posted November 9, 2010 Posted November 9, 2010 Sorry Dwayne, I completely missed your post! The mechanism is the rider went over the tabletop jump, became air born at high speed, landing on the back of his head (head took all the impact), patient was found supine, was log rolled by first responders who removed the chest armour and helmet, onto scoop with collar and packaged, the patient has been moved onto a stretcher but remains track side. First impression, the dude looks really sick. The rapid, swallow and noisy respirations are noted at first as well as decorticate posturing. Apart from dad being a little ansy about cutting the gear the scene is clam, everything is in control and running as smoothly as possible. The race is stopped and there are no dangers. No worries brother... Yeah, coon eyes, posturing, unresponsive, hypertensive, tachypneic, blown pupil, local ER is not going to do anything necessary for this kid I don't think unless he gets lucky and you ER docs Neuro brother is visiting... Dwayne
Timmy Posted November 9, 2010 Author Posted November 9, 2010 The posturing can indeed indicate a head injury (just depends on what his ICP is up to and were the bleed is) as well as a spinal injury. Unknown gag reflex, tristmus is preventing us getting to his airway. IVC is intravenous cannular. You’ve got him to the local ER, old doc is a little hesitant to RSI and will wait for the chopper (can hear them approaching). Now for the ALS guys… You’re in the ER, with the chopper gear… Go for it.
mobey Posted November 9, 2010 Posted November 9, 2010 Initial assessment will has been covered satisfactory for me. 1st things 1st. BGL, 12 lead, ETC02. RSI with Fentanyl and Succ to pass the tube, then Rocuronium for long term paralysis. I am not using Versed at this time because I believe Fentanyl will do the trick, and I would hate to drop his BP, then find out he is bleeding internally and not get the pressure back. Ketamine is out since it causes a transient increase in ICP. Once the tube is confirmed, I will drop the suction down it to clean up any aspiration from the vomit earlier. Make sure those I.V.s are at TKO rate for now. I would like a pt weight to set my vent.
Timmy Posted November 9, 2010 Author Posted November 9, 2010 BGL: 6.4mmol ECG: NAD ETC02: 37mmhg Its estimates he weighs 70kg. RSI as follows: Fent 100mcg Midaz 7mg Sux 105mg I can give you his ICP if you wish to dabble with the associated pharmacology.
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