Kiwiology Posted February 29, 2012 Posted February 29, 2012 Patient is status 1 (critical, life threatening problem) Everything besides time to reach an appropriate hospital pales into insignificance and need not be done if it delays us getting him to hospital Get him in the ambulance, either grab a bunch of cops and carry him there or have somebody very quickly get us the stretcher. If we can get a drip into him, something big like a 14g in his AC, then let's do that, if not, I am not worried about it Get going towards hospital with much early notification, the radiologist and consultant surgeon may be on call at home you never know, or they might need to clear CT or open up another theatre
DesertEMT Posted February 29, 2012 Author Posted February 29, 2012 Nearest level 1 trauma hospital is 19 minutes away. In the time between you loading the patient and reaching the hospital what interventions would you/could you do?
DFIB Posted February 29, 2012 Posted February 29, 2012 As a Basic with expanded protocols I would: 1. Three way occlusive dressing to sucking chest wound. 2. Bleeding Control in other wounds 3. Large bore IV with Ringers Lactate 4. O2 titrated to maintain SSPO2 around 96 5. Positive pressure ventilation to help pneumothorax 6. Notify hospital 7. Waste no time in transport
runswithneedles Posted February 29, 2012 Posted February 29, 2012 Open up the lines and titrate to keep bp @ 90 systolic. Initiate MFI to secure airway Needle decompression on the affected side (3rd intercostal space if memory should serve me right) Place the combo pads on in route and be ready for cardiac arrest Call into the level 1 trauma center and alert them to have a surgical team ready Be ready for vomiting of blood put on safety googles/ glasses do I have an engine onscene where I can take rescue crew with me to handle ventilations? if not ill steal a cop and have him do it also I didnt see if anyone else asked this but....Has this guy been searched for weapons himself.
DesertEMT Posted February 29, 2012 Author Posted February 29, 2012 The patient was searched, no weapons found and an engine is on scene
Kiwiology Posted February 29, 2012 Posted February 29, 2012 Trachea is beginning to show slight deviation to the right side Abdomen is rigid & distended with diffuse tenderness Chest wound is a sucking chest wound (sorry I forgot to mention that) patient admits to being nauseous and urinating himself, you note hematuria patient had lost almost 30% of his blood volume when you first arrived on scene and when you begin to load the patient onto the gurney his BP begins to drop, while his heart rate begins to increase, as does his respiration's. His mental status also begins to deteriorate, the patient shows a marked increase in anxiety and confusion A sucking chest wound gets a defibrillation pad placed over it; three way dressings are a waste of time Give him one litre of fluid as a bolus through a big bore drip; we want to give him just enough fluid to perfuse his brain Initiate MFI to secure airway Whatchoo talkin bout? Needle decompression on the affected side (3rd intercostal space if memory should serve me right) He most likely has a left sided haemothorax; decompressing "just in case" carries a high risk of piercing the lung as haemothorax will push the lung anteriorally Place the combo pads on in route and be ready for cardiac arrest If this bloke does have a cardiac arrest, the most likely rhythm will be PEA or asystole so I wouldn't bother do I have an engine onscene where I can take rescue crew with me to handle ventilations? if not ill steal a cop and have him do it One thing I've never understood is the American phenomonia of "assisting ventilation" it's not something we do here if the patient is spontaneously breathing unless oxygenation is very, very poor and such patients are excellent candidates for RSI. If his oxygenation is OK then you should avoid the temptation to do this, remember this bloke may indeed have a lowered SpO2 because he has lot a considerable amount of his blood volume and haemoglobin (so reduced oxygen carrying capacity); cramming more oxygen down his gob is not going to help because if it can't be carried then it's really no good.
runswithneedles Posted February 29, 2012 Posted February 29, 2012 MFI (Medicine Facilitated Intubation) Its same principles as RSI however it does not use a paralytic. It just uses versed and a long lasting sedative (cant remember the one our protocols use but Ill be glad to check once I'm done with clinicals)
Kiwiology Posted February 29, 2012 Posted February 29, 2012 MFI (Medicine Facilitated Intubation) Its same principles as RSI however it does not use a paralytic. It just uses versed and a long lasting sedative (cant remember the one our protocols use but Ill be glad to check once I'm done with clinicals) I would be extremely hesitant to go near this patient with RSI and even less inclined to go near him with gangsta old school butcher shop style "medication facilitated intubation". Such practice was banned here 10 years ago because it kills people. Nothing against you personally mate but both of these are big no-no's. For a patient with haemmorhage the only thing midazolam (versed) is going to do is drop his blood pressure even more, which really is not a good thing. Ketamine is appropriate as an induction agent because it has a low cardiovascular risk profile and is very safe for shocked patients. Should you want to intubate somebody you absolutely must use a paralytic agent, be it most commonly suxamethonium or something longer acting. To not do this is extremely poor practice and requires that you use larger dosages of sedation (especially midazolam). My anaesthesia texts and discussions with several anaesthetists has lead me to understand that in-hospital these patients are likely to concurrently receive several units of red blood cells and plasma as well as an ED ultrasound to identify the source of bleeding and once they are bit more stable they will be anaesthetised and moved to theatre. One of my more basic anaesthesia textbooks (written for the anaesthetist working in a developing country) talks of the "cascade" anaesthesia technique of fluid (or blood) resuscitation paralysis, intubation, induction and analgesia in that order. Apparently it's an actual thing.
DFIB Posted February 29, 2012 Posted February 29, 2012 Kiwi Quote A sucking chest wound gets a defibrillation pad placed over it; three way dressings are a waste of time Would you be so kind as to offer an explanation?
Kiwiology Posted February 29, 2012 Posted February 29, 2012 Would you be so kind as to offer an explanation? Absolutely not, you must accept everything I say as Gospel and never question it! In a recent clinical circular, our Clinical Management Group stated If there is a penetrating chest or upper abdominal injury then it should be sealed with an occlusive dressing. We recommend a defibrillation pad placed over the wound. We do not recommend attempting to create a one way valve by taping a dressing on three sides over the wound. The reason for this is threefold; first - it is rare for a tension pneumothorax to develop in this situation, secondly – it can be very tricky and time consuming to do and thirdly – such dressings rarely work.
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