island emt Posted March 14, 2011 Posted March 14, 2011 A zot here. What is ZOT? Perhaps I know of this in a different wording. Pleasae advise. a bear hugger is a heating system in a blanket that circulates warmed air through channels in the unit wrapped around the pt. Very common in the more rural areas.
DartmouthDave Posted March 15, 2011 Author Posted March 15, 2011 Hello, The local trauma centre has been contacted and medevac is currently being arranged. Here is a summary of the treatment suggested so far by various posters: 1. CXR 2. FAST (The Focused Assessment with Sonography for Trauma...aka...F.A.S.T) 3. Reduce the midshaft femur fracture 4. Provide pain control 5. Give fluids/blood 6. Stabalize the pelvis 7. Warm the patient The results of these interventions are as follows: 1. CXR shows no pneumothorax. However, multiple rib fractures on the left and right side. There are also pulmonary contusions as well. 2. FAST shows a reptured bladder and some free air in the abd as well. A grade I splenic laceration (not too bad) and a liver lacerations as well. The heart looks fine: no contusion or effusion. 3. Traction is applied to the fractured femur and pulses return to the foot 4. The patient is given some Fentanyl IV but dose not help much. 5. The patient is give 1L of warmed NS 6. The pelvis is stabalized with a pelvic binder 7. The temp is now 36 and the patient has stopped shivering Despite this VS decline somewhat: GCS 14/15 Confused BP 100/80 HR 130-140 AF with PVC++ Resp 30+ SpO2 90-91% on NRB Cheers Have to run
Paramagic Posted March 15, 2011 Posted March 15, 2011 Nasty stuff. I presume he has a ruptured diaphragm as well as his flail segments and contusions. He needs intubated and ventilated now. Agents of your choice for RSI: I like ketamine with some more fentanyl given his tenuous BP and falling MAP (are you sure there is nothing wrong with his heart? That's a very narrow pulse pressure). Long term paralysis is indicated with adequate ongoing sedation to reduce O2 demand, and to enable adequate ventilation given his very high (and inadequate) respirations which would very much get in the way of a SIMV setting I think. More fluids are in order, but we need to replace red stuff with red stuff, not water. Now he really needs to be somewhere where they can fix him. Get him out!
DartmouthDave Posted March 15, 2011 Author Posted March 15, 2011 Nasty stuff. I presume he has a ruptured diaphragm as well as his flail segments and contusions. He needs intubated and ventilated now. Agents of your choice for RSI: I like ketamine with some more fentanyl given his tenuous BP and falling MAP (are you sure there is nothing wrong with his heart? That's a very narrow pulse pressure). Long term paralysis is indicated with adequate ongoing sedation to reduce O2 demand, and to enable adequate ventilation given his very high (and inadequate) respirations which would very much get in the way of a SIMV setting I think. More fluids are in order, but we need to replace red stuff with red stuff, not water. Now he really needs to be somewhere where they can fix him. Get him out! Hello Paramagic, Looking back, I may have been over the top, but I was trying to demostrate a decreasing pulse pressure due to hypovolemic shock (stage II leaning towards stage III). Here is a site that I think is interesting: http://www.stagesofshock.com/ Also, good point on the blood as well. This patient is a 'non-responder' to fluids. A unit of blood arrives from the blood bank started to infuse via a pressure infuser. The RT is preparing the intubation equipment and the RN is preparing the intubation medications (Etomidate/Sux)while the Dr preforms an airway assessment. Cheers
usalsfyre Posted March 15, 2011 Posted March 15, 2011 (edited) I agree with everything Paramagic said except for this... Long term paralysis is indicated with adequate ongoing sedation to reduce O2 demand, and to enable adequate ventilation given his very high (and inadequate) respirations which would very much get in the way of a SIMV setting I think. The primary reason to my mind he's got a 30+ bpm RR is the fractured ribs and the resultant pain interfering with good respiratory effort. Which means he does indeed need to be intubated and have mechanical ventilation initiated. But not with long-term paralysis and not on SIMV. Controlling pain and meeting O2 demand will reduce his respiratory rate. The first will be accomplished via LARGE doses of sedation and analgesics. The second mechanical ventilation will take care of. SIMV was (and still is) a weaning mode as developed. Weaning is not something we do much of in EMS, the reason it's a popular mode of transport ventilation is it's perceived as "safer" than A/C. However, SIMV (especially with pressure support) can deliver somewhat erratic ventilations to the point of becoming uncomfortable for the patient. In addition it may increase work of breathing, if the initial mandatory MV is inadequate the patient will now be trying to meet his O2 demands by breathing through the circuit. A/C is a better choice to reduce WOB, however requires closer monitoring, which shouldn't be an issue as your at bedside 100% of the time. Long-term paralysis has been shown to worsen outcomes (I'll dig up the references today). It also hampers assessment. Usually the only time you see long-term paralysis indicated is with your more exotic vent modes (HFOV, inverse ratio). Asynchronous interface with the vent is usually a sign of inadequate sedation. Edited March 15, 2011 by usalsfyre
HERBIE1 Posted March 15, 2011 Posted March 15, 2011 A zot here. What is ZOT? Perhaps I know of this in a different wording. Pleasae advise. A bear hugger is a warming device for hypothermia patients. It's basically a blanket filled with tubes of warm air that wraps around the patient. I'm sure there are plenty of similar devices with the same idea.
MetalMedic Posted March 15, 2011 Posted March 15, 2011 So far spot on Metalmedic The fact the leg is shortened and rotated already tells you that the femur is injured. Nothing penetrating tells of closed fracture. Thanks! Driving home I also thought about a puncture and realized that I was relying to heavy on a pneumo, but I didn't rule it out. Any paradoxical motion in the chest at all? -MetalMedic
promedEMT Posted March 16, 2011 Posted March 16, 2011 New EMT so also be gentle with me. (Also a basic so there is little I can do.) With his body temperature at 95 F he needs those wet clothes off and needs to be warmed up. High con O2 via non rebreather mask should be applied. Based on a shortened leg that is twisted and considering MOI it could be a fractured femur. If this not an open fracture it should be safe to try and apply gentle traction to regain a pulse to the extremity. and to alleviate some of the pain he might be in use a traction splint to straighten the leg out. nothing I can do for his EKG unless he goes into V-FIB or cardiac arrest. Also if pain is in his abdomen and blood in his urine it would also be nice to use an ultrasound to determine if he has any abdominal bleeding and where it is coming from. My thinking is he could possibly have a lacerated spleen which in that case he would need blood transfusions and a operating table. Also in regards to his breathing x-ray would be great to check for pneuo-hemo thorax and have a chest decompression done (although I cant do it)
MetalMedic Posted March 16, 2011 Posted March 16, 2011 Driving home I also thought about a puncture and realized that I was relying to heavy on a pneumo, but I didn't rule it out. Any paradoxical motion in the chest at all? -MetalMedic I shouldn't have been too eager last night, I didn't read the updated stats on the thread. Grrr to me. LOL. Anything major I'm missing? (Please feel free to PM me) -MetalMedic
DartmouthDave Posted March 23, 2011 Author Posted March 23, 2011 New EMT so also be gentle with me. (Also a basic so there is little I can do.) With his body temperature at 95 F he needs those wet clothes off and needs to be warmed up. High con O2 via non rebreather mask should be applied. Based on a shortened leg that is twisted and considering MOI it could be a fractured femur. If this not an open fracture it should be safe to try and apply gentle traction to regain a pulse to the extremity. and to alleviate some of the pain he might be in use a traction splint to straighten the leg out. nothing I can do for his EKG unless he goes into V-FIB or cardiac arrest. Also if pain is in his abdomen and blood in his urine it would also be nice to use an ultrasound to determine if he has any abdominal bleeding and where it is coming from. My thinking is he could possibly have a lacerated spleen which in that case he would need blood transfusions and a operating table. Also in regards to his breathing x-ray would be great to check for pneuo-hemo thorax and have a chest decompression done (although I cant do it) Hello, Sorry for the slow response. It seems I always get slammed at work when I try a case study. Excellent post. It is not what you can do but 'understanding' what is going on and what needs to be done the most important. You are bang on with: (1) Preventing hypothermia which is a killer in trauma patients (2) Reducing the fracture is good as well for pain control...like you said...also, to control bleeding which can be substantial and poorly tolerated by a older hypothermic patient (3) Recognizing the need for U/S, XRay and the OR......key concepts found in ATLS/BTLA....nice Here is a question for you: What do you think is causing the ugly looking EKG? Cheers
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