Trauma Medical

[DwayneEMTP]

Did you remove the KED to do your assessment? Or was it left in place? Was it placed by career hosemonkeys or 5 calls/month vollies? -1 if you chose to assess around it without a significant reason for leaving it in place (flail chest segment, etc) as it's simply not possible to do even a EMT-basic assessment with it on. Also, if you DID leave it on then you were dishonest in many of your reported values above as it's also not possible to get good palp findings/lung sounds/abd assessment with it in place. (Heh...I get that this is a scenario my friend, having a little fun with you, but if it's more than a made up scenario....well, just sayin...)

Where exactly is the pain in his chest? What is his personal cardiac/medical history. What kind of things is he saying? What kinds of questions is he asking? What was his reaction when you stuck him with the IV? Does it appear that the accident was his fault?

You might try 'unremarkable' for your 'non diagnostic' ECGs. It seems to be less confusing, plus, to me, non diagnostic implies (Haven't looked it up) that it played no part in the diagnosis, and in this case I'm guessing that it gave you at least a heart rate, rhythm, and SPO2, right?

For me, this patient is cardiac for now for a couple of reasons. First, his age, next, the location of the pain and that it is not effected by resps/palp, and third, it's not uncommon, or so I've heard in JEMS or something, that single passenger, single vehicle accidents that cross a line of traffic have a wickedly high incidence of cardiac involvement.

If I can't fine a contraindication, and I'm 30mins out from the hospital (boarding, transport time) then I'm going to give him some ASA. For now I will hold off on the Nitro, but the ASA can possibly make a significant difference in this patients outcome.

Excellent scenario. We've not had many good ones in a really long time...since chbare got too busy to do them... Just sayin'...not to anyone in particular mind you...just sayin' in a general, non finger pointing way...

Dwayne

Edited to change Ked to KED, no other changes.

Edited May 4, 2011 by DwayneEMTP

[DartmouthDave]

Hello,

O2, IV and transport. No ASA or NTG.

Could be a STEMI only.

Could be a STEMI with a tramatic injury.

Could be a STEMI with an occult injury.

Could be a cardiac contusion.

So, IMHO, a work up by a trauma team at a hospital with angio. What if this patient needs a laparotomy?

With a short transport time in my mind the risk/benefit isn't there for more agressive ACS management.

Thnak you

PS.... Hmmm...since the only scenarios as of late have been posted by me it is hard not to feel a finger drifting in my direction. Just saying.

[1EMT-P]

At this point I am going to be wanting to head to one of the two trauma centers, reason being is that this is an 80 year old man who has just been in an MVA & who is experiencing chest pain that is 8/10. The patient appears to be " stable" maybe a bit too stable. I would start him on 02 4 LPM via N/C, I would start 2 IV's, I would also consider getting a second 12 Lead if there was time, maybe even a right sided EKG. I would also consider giving him some fentanyl for his pain.

[Kiwiology]

Extricate old bloke on scoop, put in ambulance, if he is in that much pain give him some entonox

Take patient to hospital

[Bieber]

Sorry it's taken me a while to respond to this thread a little more thoroughly. I'll try to address everyone's responses in this post.

Dustdevil - Good plan!

2c4 - What do you think you could have/should have done in that scenario?

Ugly - Thanks for the reply! Just remember that it's very difficult (see, impossible) to rule out cardiac involvement in the field. Still, you make a good point, not all chest pain is cardiac.

Bernhard - I really, really liked your treatment plan. The patient has no other visible signs of past medical history not previously disclosed. Consider your treatments in both scenarios to be successful in relieving the patient's pain. Only one question, though, why the oxygen if the patient's SpO2 > 95%?

Dwayne - I was hoping to hear your thoughts on this scenario, and you didn't disappoint. There's a little bit of truth and a little bit of fiction in this scenario. I removed the KED to do a proper assessment, you'll be happy to know.

Where exactly is the pain in his chest? What is his personal cardiac/medical history. What kind of things is he saying? What kinds of questions is he asking? What was his reaction when you stuck him with the IV? Does it appear that the accident was his fault?

In the initial scenario, the pain is described in the first scenario as being localized to the sternum. Only history is mitral valve prolapse, for which they take an unknown medication (it sounds like an antihypertensive) and no allergies. The patient is mostly quiet unless you speak to them, but is appropriate and consistent with an alert and oriented x3 person who is competent and of sound mind, and denies any weakness/dizziness, nausea/vomiting. Assessment of the chest reveals no structural deformity, CABG scars, or signs of an internal pacemaker/defibrillator. No reaction to the IV, and the accident does appear to be the driver's fault.

I want to ask you, Dwayne, what made you give the aspirin? Are you concerned about possible adverse sequelae resulting from it? Why didn't you give the nitro?

Dartmouth - Thanks for sharing!

1EMT-P - Likewise! But I demand a decision out of you. Fentanyl or no fentanyl?

And now, for everyone, a challenge question. How do the anticoagulant effects of aspirin compare to other blood-thinning agents (specifically thrombolytics) in terms to short and long term mortality in trauma patients? What about patients who take aspirin versus those who don't?

[Richard B the EMT]

Using my local protocols, extrication would be Long Spine Board, and O2 would be 8-10 LPM via Non Rebreather, but otherwise, I'm with ya.

[DwayneEMTP]

...I want to ask you, Dwayne, what made you give the aspirin?

Simply the possibility of this being a cardiac event. This doesn't appear to be a significant trauma at this point but but we won't really know for sure until we have serial assessment values. The ASA can help, and i"m not convinced based on the pts presentation at this point that it will be a significant detriment, though, of course I could get caught with my pants down here.

... Are you concerned about possible adverse sequelae resulting from it?

In this context I believe that you use sequelae incorrectly, I think that you're looking for 'adverse effect', as well 'adverse sequelae' is redundant. Not busting your balls here brother, I just know that you would not be happy with that going uncorrected.

And yeah, I am, though 324 of ASA shouldn't be disastrous if I've given it needlessly, but may give him a decrease in morbidity if I haven't. I can't recommend this course of treatment. Though it is what I believe I would do, it may be difficult to defend should you find the need to do so later. If your boss wants to kick your ass and call this a straight trauma then you are defenseless when this treatment is compared to your trauma protocol.

...Why didn't you give the nitro?

Here, though Nitro may be the correct treatment, I'm not a good enough provider to be able to reliably assess around it. Know what I mean? Though I'm relatively confident that I'm not going to find any traumatic boogie men hiding in this patient I don't want to create any significant hemodynamic changes until I have a chance to track his vitals for a bit. If I give the nitro and his pressure drops by 20 points, his heart rate increases, and he complains of blurred vision and a headache in the next 3-5 mins is that the nitro or is he compensating for something that I haven't yet discovered? 80% says it's all a Nitro effect, but the 20% is going to kick his, and my, ass.

Great scenario brother.

Dwayne

[Bernhard]

Bernhard - I really, really liked your treatment plan. The patient has no other visible signs of past medical history not previously disclosed. Consider your treatments in both scenarios to be successful in relieving the patient's pain.

That's indeed my main concern here, since pain is causing a lot more stress to the body with unhappy side effects - if released, then we (and not to forget the patient) usually have far less future problems. 8/10 is a lot, especially wtih elderly males usually understating.

But I agree with all others on a fast transport indication despite some quick i.v. & basic medication as described in my post. This patient has the potential for several bad surprises, better let them happen in the emergency room than in my ambulance...

Only one question, though, why the oxygen if the patient's SpO2 > 95%?

It's common here to give a minimum oxygenation to patients >95%, the minimum is dictated by the masks and is 6l/min (less flow would not make it to the patient). Target is not to increase the 95%, but to hold it. Sloppy speaking, the O2 need for brain & heart may be higher than the SpO2 tells for the fingertip. So, we give O2 for almost all patients with more than minor trauma/illness (exceptions apply).

If SpO2 falls, then O2 flow would be higher, usually the next step would be 10-12l/min if SpO2 decreases.

And now, for everyone, a challenge question. How do the anticoagulant effects of aspirin compare to other blood-thinning agents (specifically thrombolytics) in terms to short and long term mortality in trauma patients? What about patients who take aspirin versus those who don't?

I don't recall the exact scientific papers, but as far as I remember one recently read, especially with elder patients, ASA increases head trauma bleeding and has a significant mortal outcome. The drug information sheet on our ASA talks about general amplifying with other thrombolytics (no surprise).

I simply wouldn't recommend ASA on bleeding traumas, since one of the two effects is contraindicated (thrombolytic), the other (pain control) can be reached by other (& better) drugs.

Why my plan uses Nitro:

Nitro (we use isosorbiddinitrate=ISDN) enhances the O2 reception on the heart, and decreases O2 need of the heart - if there's a heart problem, that's what we want. Dilatation effect of larger/distal vessels (and therefore possible enhanced bleeding) is not the main issue with ISDN, allthough a risk. So it has to be used very carefully in this scenario, even if the probability of a STEMI is high, there still may be other trauma hidden - but this is rather unlikely (from what I read in the scenario). I would make sure to have a stable blood pressure >> 100 systolic, a running i.v.-line and a close monitoring. Ruling out contraindications as acute headache, high probability of bleeding and such. Then in the given scenario I would give it rather late in the process (after detecting the ST elevation and some plus time to get a feeling for the stability of the patient) and initially only 50% of regular volume to see whats happening. All in all, the nitro effects are exactly what a heart needs in developing STEMI (see ECG) beside calming the patient with pain relief and a quick hospital access.

[Chief1C]

2c4 - What do you think you could have/should have done in that scenario?

You know those speeches (for any other instructors, or former instructors) that we give about the one call that will blow your world apart? Open your eyes to the unpredictability of EMS? Cause you to lose sleep, possibly wanna curl up in the fetal position? The call came in at the worst time, there are five ambulances available for our area, four were on calls. The next closest are nearly an hour by road, and it felt like the bastards took their sweet old time to get there. I had three helicopters on the ground, before I had extra ambulances. I asked for "three additional ALS ambulances, ground or air, quickly, please". I had myself and an Ambulance Attendant (driver), which is a fancy word for someone that has CPR and Advanced First Aid training.

Four patients, three heavily entrapped; one self extricated. The only one that dies, is the only one that was properly restrained, conscious and alert. There were horrible facial injuries that were bleeding profusely, spraying, open fractures, multiple fractures on both ppl in the back b/c the seat broke loose. The front passenger went out the windshield, then slid back in, that person had an impalement on the side of their head. Still not sure to this day, but it looked like that thing between the windshield and rear view mirror, that black peg. It was bad, our truck was totally trashed, we used pretty much everything except the OB kits. If I had time to open them, I'd probably have used the OB pads for bleeding control on my facial injury patients. I think I did everything I could do, and some things I probably wasn't supposed to do in my scope. But they told me, maybe to make me feel better, that even if it happened outside the ER, it probably would have been fatal. Please let me keep believing that.