Unresponsive

[ERDoc]

You are an ALS crew who is called to a house that is 5-10 min away from a small community hospital that is the equivalent of a level 3 trauma center. The call comes in as an 88y/o female, unresponsive. En route, FD on the scene tells you that they have a female with a depressed skull fx who is unresponsive and fell last night. You contact the local hospital to see if you should bring the pt there, go to the level 1 trauma center that is 45 min by ground or call for the helicopter. You are told to get to the scene and assess the pt, then make the decision from there.

You arrive on scene and find an unresponsive female who is breathing with a scalp that looks like this (only the injury was over the left parietal scalp):

Discuss.

[DartmouthDave]

Hello,

Thank you for posting.

Lets start with our initial assessment.

GCS?

ABC?

Get her on the monitor and see what happens next.

David

[systemet]

First thoughts:

* This person is very old. Do they have any documentation limiting what care we can provide?

* That looks like a hematoma, not a clear depressed skull fracture.

* I like that my fire department uses words like "depressed skull fracture", and am impressed that they're not hitting on the patient's granddaughter.

(1) I would like more information about the patient's history, and events surrounding the injury, e.g. fall vs syncope, prodrome, seizure-like activiity, pacemaker / AICD,. anticoagulation (riding the old dagatrabin train?), etc. Are there any bystanders, or obvious findings on scene?

(2) ABCDE -- Are they moving all four limbs (particularly the ride side), is there a hx of ambulation since the injury? Aniscoria? We may have to c-spine this person if our history is limited/unreliable and they're comatose. I really don't want to have to do this, especially in an octagenarian I may have to intubate.

(3) I have to ask, is it really a depressed skull fracture? Do they smell toast when I push down on it? We should probably avoid the "depressed-skull-fracture by committee" where six different providers push down on the same swollen mass and eventually decide there is a solid structure underneath that seems to be moving.

(4) I guess we should do an H&P?

(5) I'm not up on what makes a level 3 trauma center. Is this EM stafffed? Does it have a CT scanner? Presumably no neurosurg / neuroICU?

[Edit: needed a question mark, probably a couple more beer. And had questions about trauma center designations]

Edited March 13, 2015 by systemet

[island emt]

is she breathing normally and supporting her airway ?

what is her pulse rate & rhythm ?

what do her pupils look like?

Any signs that this might be other than the results of a simple fall?

did anyone else witness the fall?

Unresponsive with head hemotoma gets full spinal package as they can not answer questions that would allow us to use spinal protocol to not collar & board.

a level 3 most likely does not have neuro available and may or may not have a CT or MRI available , thus she need to go to higher level facility unless she has advanced lifecare directives that state DNR or other wishes for medical care.

[ERDoc]

Hello,

Thank you for posting.

Lets start with our initial assessment.

GCS?

ABC?

Get her on the monitor and see what happens next.

David

GCS 3, 1, 6

Airway patent and pt is breathing. Palpable pulse with a rate in the 90s.

Monitor shows a sinus rhythm.

First thoughts:

* This person is very old. Do they have any documentation limiting what care we can provide?

* That looks like a hematoma, not a clear depressed skull fracture.

* I like that my fire department uses words like "depressed skull fracture", and am impressed that they're not hitting on the patient's granddaughter.

(1) I would like more information about the patient's history, and events surrounding the injury, e.g. fall vs syncope, prodrome, seizure-like activiity, pacemaker / AICD,. anticoagulation (riding the old dagatrabin train?), etc. Are there any bystanders, or obvious findings on scene?

(2) ABCDE -- Are they moving all four limbs (particularly the ride side), is there a hx of ambulation since the injury? Aniscoria? We may have to c-spine this person if our history is limited/unreliable and they're comatose. I really don't want to have to do this, especially in an octagenarian I may have to intubate.

(3) I have to ask, is it really a depressed skull fracture? Do they smell toast when I push down on it? We should probably avoid the "depressed-skull-fracture by committee" where six different providers push down on the same swollen mass and eventually decide there is a solid structure underneath that seems to be moving.

(4) I guess we should do an H&P?

(5) I'm not up on what makes a level 3 trauma center. Is this EM stafffed? Does it have a CT scanner? Presumably no neurosurg / neuroICU?

[Edit: needed a question mark, probably a couple more beer. And had questions about trauma center designations]

She is full code.

The husband reports that the pt got her feet caught on a rug around 9pm. She has a pubic rami fx from a fall 3 months ago and has times where she has a shuffling gait. Hit her head on the door but not the ground. No loss of consciousness. She went to bed at 11pm not complaining of anything. Her husband went to wake her up the next morning and she wouldn't respond. Only other history is hypertension for which she takes atenolol. Nothing unusual found on the scene other than too many FFs standing around doing nothing.

ABC as previously stated. D-no collar applied, E-no other injuries noted. She was walking around after the fall last night. Currently she will squeeze weakly with her right hand. No movement in right leg or left leg/arm. Questionable unequal pupils. FFs state the left pupil was constricted as does one of the medics on the ambulance. Other medic thinks they look equal. Palpation of the scalp demonstrates the firm swollen area, it is difficult to say with certainty if there is any underlying abnormality.

H&P normal, except for what is stated. The ER is staffed with a board certified ERDoc and a CT scanner. No seurosurg services.

is she breathing normally and supporting her airway ?

what is her pulse rate & rhythm ?

what do her pupils look like?

Any signs that this might be other than the results of a simple fall?

did anyone else witness the fall?

Unresponsive with head hemotoma gets full spinal package as they can not answer questions that would allow us to use spinal protocol to not collar & board.

a level 3 most likely does not have neuro available and may or may not have a CT or MRI available , thus she need to go to higher level facility unless she has advanced lifecare directives that state DNR or other wishes for medical care.

She is breathing and supporting her airway.

Pulse is 90s and regular

The husband and 2 other family members witnessed the fall

[systemet]

Well, it's beginning to sound like maybe she should have got a CT last night.

It sounds like the family has a pretty good explanation for the fall, it's probably a simple trip and fall. This may be partly a result of all the infirmities of age, a prior ortho' injury, and possibly a bit of Parkinson's developing ("shuffling gate"). I think for confounders, any suspicion of elder abuse? Any recent med changes? Any suspicion of sepsis? While we may have other more pressing issues to deal with, it would be nice to point out to the ER if there are any issues in the home to be aware of, e.g. other trip hazards, need for handrails, walking aids, home care, etc. This is beginning to have the smell of a one-way trip.

Unfortunately, I think even with this good history, we have to c-spine her. If she was 40 years old with this history I wouldn't. This is going to increase her ICP, decrease her respiratory reserve, increase her risk of aspiration, and make intubation more difficult. But, I can't see the ER being too happy if I don't.

ITLS would make this a critical trauma, and we'd be tearing out of there like it's the end of the world. Reality, this has developed over night. Let's get an IV, bG and a set of vitals, and run a 3-lead, and make a decision about where we're going. The 12-lead can probably get done during transport, or as it takes all of two minutes, on scene. I'd pull some blood for an iSTAT en route. It seems unlikely that she's hypoglycemic (although she is old and beta-blocked, which could mask some symptomology) or that this is some sort of atypical seizure activity, but those possibilities should be respected.

It's tough here. She's old, probably has a subdural, but may not, probably isn't a good neurosurgical candidate, and has been sympomatic for an unknown period of time. Palliation is a likely pathway. However, it's not really appropriate to speculate on that until a physician has reviewed a CT. On one hand, the local ED with a CT can do this, ease some burden on the trauma center, and rule out some ddx. On the other, if she does have a significant subdural, we're just wasting time, waiting for secondary transfer.

In an ideal world, I'd call a physican, respect that they have greater knowledge of this area, and ask their preference. This also avoids me having to take responsibility for a decision where there's good reasons to go both ways. Forced to make the decision myself, I would lean towards transporting to the trauma center.

Edited March 13, 2015 by systemet

[island emt]

^^^ What he said ^^^ I agree in that while it appears to be a simple fall down go boom , which she has a history of.

However their id significant reason to believe in a bleed going on and my money would be a trauma center with neuro available.

But I agree on the phone call to the local Doc and see how they want to proceed.

Around here they would most likely say go south to the level 1 an hour & a half down the road that has 24 hour neuro availability.

[ERDoc]

Well, it's beginning to sound like maybe she should have got a CT last night.

It sounds like the family has a pretty good explanation for the fall, it's probably a simple trip and fall. This may be partly a result of all the infirmities of age, a prior ortho' injury, and possibly a bit of Parkinson's developing ("shuffling gate"). I think for confounders, any suspicion of elder abuse? Any recent med changes? Any suspicion of sepsis? While we may have other more pressing issues to deal with, it would be nice to point out to the ER if there are any issues in the home to be aware of, e.g. other trip hazards, need for handrails, walking aids, home care, etc. This is beginning to have the smell of a one-way trip.

Unfortunately, I think even with this good history, we have to c-spine her. If she was 40 years old with this history I wouldn't. This is going to increase her ICP, decrease her respiratory reserve, increase her risk of aspiration, and make intubation more difficult. But, I can't see the ER being too happy if I don't.

ITLS would make this a critical trauma, and we'd be tearing out of there like it's the end of the world. Reality, this has developed over night. Let's get an IV, bG and a set of vitals, and run a 3-lead, and make a decision about where we're going. The 12-lead can probably get done during transport, or as it takes all of two minutes, on scene. I'd pull some blood for an iSTAT en route. It seems unlikely that she's hypoglycemic (although she is old and beta-blocked, which could mask some symptomology) or that this is some sort of atypical seizure activity, but those possibilities should be respected.

It's tough here. She's old, probably has a subdural, but may not, probably isn't a good neurosurgical candidate, and has been sympomatic for an unknown period of time. Palliation is a likely pathway. However, it's not really appropriate to speculate on that until a physician has reviewed a CT. On one hand, the local ED with a CT can do this, ease some burden on the trauma center, and rule out some ddx. On the other, if she does have a significant subdural, we're just wasting time, waiting for secondary transfer.

In an ideal world, I'd call a physican, respect that they have greater knowledge of this area, and ask their preference. This also avoids me having to take responsibility for a decision where there's good reasons to go both ways. Forced to make the decision myself, I would lean towards transporting to the trauma center.

No recent med changes. There is nothing at the scene or with the family that concerns you for elder abuse. Rectal temp is 35.8, other vitals and EKG as previously stated. Finger stick is 23. The family reports no seizure like activity and you do not see anything that you would call seizure like activity. The local ER says they can handle her and transfer her if needed.

[island emt]

Of course the local ER wants her.

Then they can bill for a ER workup and CAT scan then determine they need to ship to an appropriate level of higher care.

We had the same thing here for a while with our STEMI protocol . At first they wanted up going direct to a hospital with interventional Cath lab capabilities 24/7.

then they realized how much revenue was bypassing them and going down the road. So they changed it so that we needed to stop at the level 3 with no interventional Cath lab so they could assess and possibly start running clot busters then ship from there down the road to a facility where they could actually do something to fix the occlusion.

It's all about the $$$$

[systemet]

No recent med changes. There is nothing at the scene or with the family that concerns you for elder abuse. Rectal temp is 35.8, other vitals and EKG as previously stated. Finger stick is 23. The family reports no seizure like activity and you do not see anything that you would call seizure like activity. The local ER says they can handle her and transfer her if needed.

Thanks for posting the scenario, by the way.

Sorry, 23 mg/dl (US units - hypoglycemic) or 23 mmol/L (International units - hyperglycemic)? If she is hypoglycemic, we should give 12.5 g of dextrose and reassess (a lower dose, d/t the association with badness in neurological injury, and likeliness of intracranial ungoodness). . If she is hypoglycemic, this might explain the right-sided neuro deficits (is there a fancy medical name for this? I know Todd's paresis is focal deficit following seizure? I like to advertise this as much as possible so that I can pretend to be more intelligent than i am).

We've got the description earlier that her airway is "patent", even though she's obtunded (GCS 10). Can we get a saturation on her? I assume she's moving good air, and her lungs sounds are ok? No right lower lobe aspiration crackles? The previously fractured pelvis is not obviously fractured again on physical exam? (I appreciate it's a ramus, so it may be difficult to tell). I think from the information I have, I'd be comfortable holding off on advanced airway management, especially if we're going to the community ED 5 minutes away (which in all likelihood would be a good plan if we were going to meet a helicopter or for stabilisation prior to driving 45 minutes).

If an emergency medicine staffed ER is willing to take this patient, then I think I'm willing to defer to their greater experience, education and judgment.

It would be nice to have a blood pressure.

Regarding the ECG, the description we were given is "sinus rhythm". So, the 12-lead shows NSR as well?

Thanks!

It's all about the $$$$

I'm lucky this isn't an issue locally (non-US). The only health economics issue I remember running into is when we first started thrombolysing people, we were run municipally, and the city was losing a couple of thousand dollars on every eligible STEMI for the cost of the tenecteplase. Ultimately the hospitals starting supplying us for free. Now we've changed governance models, and this is no longer an issue.

With public medicine though, comes a sort of chronic under-funding and under-staffing. So it's not always a win.