Trauma Medical

[Bieber]

You are the second paramedic on a dual paramedic 911 ambulance responding to a motor vehicle versus motor vehicle accident at a busy intersection in an urban setting with a posted speed limit of 40 MPH. Dispatch advises you are the second truck in and may respond non-emergency traffic.

Upon arrival at the scene the first truck advises you that your patient will be in the blue car that has pulled over in a nearby parking lot. You park your ambulance next to the patient's car, which you note to have moderate passenger side damage that is consistent with a T-bone strike, and you see that the other vehicle involved--a van--has moderate front end damage as well. There are no scene hazards present and fire personnel are by the driver's door immobilizing the patient with a C-collar and KED.

When you get out, a paramedic from the other ambulance advises you that the patient is an 80 year old male single-occupant driver of the car who was struck by the van while attempting to turn left in front of them at the intersection. He states that the patient was restrained, had no loss of consciousness nor any symptoms prior to the crash but following it began to complain of chest pain localized to his chest with no radiation and described as dull. There is no accompanying shortness of breath, nausea or weakness nor is the pain exacerbated by palpation or respiration and is not relieved by anything either. The first on scene crew advises they did a 12-lead EKG which was non-diagnostic and the rhythm lead showed a regular sinus rhythm with no ectopy.

The patient cannot recall hitting his chest against the steering column and there was no airbag deployment. Inside the vehicle, you also note no significant compartment intrusion or spidering of the windshield. The patient is alert and oriented x3 with no speech deficits and appears to be in no significant distress and has a patent airway, unlabored respirations, a strong and regular radial pulse and warm, dry skin consistent in color and has no visible injuries noted by exam.

Vital Signs

HR: 88

Resp: 16

B/P: 122/78

SpO2: 100% on room air

Blood Glucose: 128

Pain: 8/10

EKG: Regular sinus rhythm, no ectopy.

12-lead EKG: Non-diagnostic.

HEENT: Pupils are round and reactive to light bilaterally. Mucous membranes moist. No nasal flaring or perioral cyanosis. No soft tissue injury or deformity to the skull. No abnormal secretions from the nose/ears.

Neck: No JVD, retractions, tracheal deviation, subcutaneous emphysema, soft tissue injury or deformity/pain/tenderness to the cervical spine (however exam is limited due to the patient being immobilized with a C-collar and KED prior to your arrival).

Chest: Equal chest rise, adequate depth of respiration. No soft tissue injury or structural abnormality to the chest wall noted. No CABG scars or signs of an internal pacemaker/defibrillator noted.

Abdomen: Soft, no bruising, distention, pain/tenderness.

Pelvis: Stable. No pain/tenderness.

Posterior: Unable to assess due to the patient being immobilized with a KED prior to your arrival.

Extremities: Neurovascular function intact x4, no numbness or tingling.

Neurological: Alert and oriented x3, GCS 4, 5, 6.

Respiratory: Lung sounds clear and equal bilaterally.

Cardiovascular: Radial pulse strong and regular.

GI/GU: No nausea/vomiting.

Integumentary: Skin is warm, dry and consistent in color.

For the treatment of ACS, your system carries the usual aspirin and nitroglycerin as well as fentanyl but no thrombolytics. There are three hospitals that provide PCI in town, and two of them are also the certified trauma centers although the third one will take minor trauma patients. All of the hospitals are within twenty minutes of your location.

Go!

[Dustdevil]

Go!

I agree.

[Chief1C]

Had something similar. Minor crash, for the speed anyway. No complaints, we arrived. Driver got out when the ambo pulled up, walked about ten feet, collapsed. Ended up being the first CPR Save in a number of years. Crash caught [the patient] by surprise, had an MI. Flown to a cardiac center, living, breathing and walking today; same quality of life.. Just in a new car.

Then again, I've also had a patient with a dull chest pain after a 55mph vs Tree, head on. No other complaints. Crawled out of the car, walking around, talking, vitals then were probably better than mine today. Talked [the patient] out of refusing b/c of the other injuries in the car, had two choppers on the ground awaiting extrication. [the patient] was on a board, flight doc got in, did an EKG - suggested [the patient] be loaded into their ship "NOW". While doing that [the patient] became unconscious. Never lifted off, brought [the patient] back to the ambo, dead. Tamponade. Not a mark on [the patient].

The latter really shook me up, couldn't write the sheet for hours, my hands were shaking so bad. Had me in tears. It's the calls that leave you asking if you did all you could, and not being able to say yes, that will burn you out before you know what hit ya.

Edited May 3, 2011 by 2c4

[DartmouthDave]

Hello,

Nice post Bieber.

As you know, geriatric patients present differently. Perception of pain may be effected by DM as well as other health issues. Bones are more brittle. In general, a decline in muscle mass also afford a lesser degree of protection from trauma.

I would be leery of using an ACS protocol because of:

1) Significant MOI

2) Patient's age

3) No history of chest pain prior to smash up

4) Skin is warm and dry

5) VS stable

Some DDX could be:

1) Rib fracture(s)

2) Pulmonary Contusion

3) MSK pain

I would also like more of a medical history and medications the patient is on.

However, any actual dx in this setting would be difficult. So, transport to a trauma centre for a FAST/XRAY and a trauma work up would be the best option.

IMHO.

Cheers

Edited May 3, 2011 by DartmouthDave

[uglyEMT]

Taking from a BLS standpoint (hope you don't mind Beiber)

Sounds like a seatbelt injury.

Could be bruised sternum. Broken, fractured ribs.

Nothing we can do diagnosticaly in the field. Maintain C-spine, transfer to long board, transport. ED needs to run a chest xray.

Doesn't sound cardiac related due to the ECG strip, history, and presenting conditions.

[Just Plain Ruff]

When in doubt, take this old codger to the nearest trauma facility that can do cardiac procedures also.

Kill two birds with one hospital.

[fiznat]

Why is the 12 lead non diagnositc? Artifact or is the ECG itself borderline? If the problem is artifact, just do it again!

[ERDoc]

NEVER say it isn't cardiac just because the EKG is normal.

[Bieber]

Why is the 12 lead non diagnositc? Artifact or is the ECG itself borderline? If the problem is artifact, just do it again!

Non-diagnostic simply means that there's no signs of disease present. It doesn't exclude MI from the potential diagnosis, the EKG just isn't of diagnostic value (due to a lack of pathological changes) in that particular patient.

The patient's only history is mitral valve prolapse, and they take an unknown medication and have no allergies.

Let me change up the scenario just a little bit, though. Let's say the patient is now cool, pale, diaphoretic and has ST elevation in leads V3 and V4 and says the pain is radiating to his left arm and jaw. How does this alter your treatment?

Edited May 4, 2011 by Bieber

[Bernhard]

The heavy pain (8/10) alone tells, that there is some more than only a none or minor injured patient.

nor is the pain exacerbated by palpation or respiration and is not relieved by anything either.

This always is a good sign for non-trauma related pain and leads me to check for cardiac reasons. However, there is a chance for some arterial rupture, which also usually does not respond to palpation/respiration.

Our coronary syndrome standards include nitroglyzerine, but considering potential trauma, I would leave this for the moment. So here would be my next actions:

• O2 inhaler mask (6 l/min, if SpO2 reads >95%)
• at least one i.v. line
• considering pain medication: we have s-ketamine, which is contraindicated in coronary settings and aspirine, which is not trusted in trauma. So I would like some opioid, but for that I have to call an emergency physician to the scene -> do this. In the given setting, fentanyl already is available for me, which then would be my (only) choice here -> give it (analgesic dose).
• repeat the trauma check if possible (at least when in the ambulance, depends), close watch on thorax, lung sounds and abdomen.
• preparing transport: putting patient on a stretcher with upper part of the body elevated, calling dispatch to check with one of those PCI/trauma hospitals.
• very close monitoring and prepare to meet the following: cardiac arrest or heavy shock.
• start of transport

Since the patients conditions now get worse, I'm thankful that I kept a close eye on him.

Let's say the patient is now cool, pale, diaphoretic and has ST elevation in leads V3 and V4 and says the pain is radiating to his left arm and jaw. How does this alter your treatment?

Not very different from the above, the diagnosis of a coronary syndrome just gots the number 1. So, if the patients blood pressure is still stable >> 100 systolic and my repeated trauma check doesn't show anything, I probably now would try nitroglyzerine. Transport already is in progress, if traffic is stuck, with lights & sirens. Consider more O2 if SpO2 gets lower than 95%. Try to sufficient release pain (may be a bit more Fentanyl, depending on the situation). Monitor vitals and ECG closely. Calm him down verbally. Document. Know where my defibrillation and intubation equipment is - if veeeery suspicious, consider applying defib patches to be prepared.

Is there any evidence for a diabetic (history, medication and/or equipment found, i.d. card, shunt for dialysis, typical needle marks)? There are rare cases that the symptoms may lead to another solution then, however, this wouldn't affect my treatment anyway.

How does the patient now? Following options are in mind:

• still unhealthy but more or less stable -> continue the above and hand him over to the emergency room
• worse, more and more unstable, but alert -> additionally repeat trauma check (abdominal bleeding? pneumo-thorax? or still just the coronary problem?)
• losing consciousness -> additionally intubation
• cardiac arrest -> reanimation, full program