Trauma make the diagnosis

[hammerpcp]

Can we get any medical history? How about events from earlier in the night? any drug use?

Side note: Do you needle decompress someone who is maintaining BP? Here we don't.

How are is vital signs?

Is his respiratory irregularity in any particular pattern? i.e. Cheyne stokes?

Is BP rising and is HR slowing?

Why is he covered in minor abrasions? Is there shattered glass present or is this form previous event?

So far my working diagnoses (assuming a BGL of 130 is normal???) is a head injury from the accident causing unconsciousness. Not exhibiting cushings triad, so not going to hyperventilate. Pneumo is secondary injury and is currently not life threatening. (Pt is maintaining sats, colour is improving and compliance with ventilations is good.)

[chbare]

Hammerpcp, no medical history on this patient. UDS is positive for meth and his ETOH level is 230mg/dl. I agree he is not presenting with signs of tension pneumothorax and I would consider holding off on immediate needle decompression, however, with your ultra progressive ambulance, you could always consider a chest tube. Current V/S; P-88 reg, RR-14 with PPV, B/P- 170/89, O2 sat-100%, Temp- 100.6 F. There was allot of broken glass inside the cab, and this may explains the abrasion and lacerations. Are there any tests or procedures you would like to perform?

Take care,

chbare.

[chbare]

I am sorry I overlooked this. ERDoc mentioned getting some scans and I did not give you guys that up date.

Here is a non contrast CT of his head. For the sake of simplicity lets assume that all of the other slices follow what you see on this slice.

Take care,

chbare.

[hammerpcp]

From my interpretation of the CT scan your pt is obviously pregnant.

[chbare]

Hammerpcp, I sure hope he's not pregnant. Then again you never know. I forgot that BGL's are in mmol/L where you live. A BGL of 130mg/dl is about 7.2 mmol/L. Lets say that you tuck your patient in for the night and in the morning he remains unresponsive and the repeat CT is negative. What do you think?

Take care,

chbare.

[AZCEP]

I'll throw it out there for grins, but I'm doubting it even as I type it.

Diffuse Axonal Injury.

Maybe it's the pessimist in me, but this doesn't sound like the run of the mill bump on the noodle.

[chbare]

AZCEP, you nailed it! History of an acceleration/decelleration MOI, sustained coma, and a normal CT scan. (many times DAI will present with a normal CT and MRI will be used to detect the lesions) This person will probably not recover. Here is a link if anybody would like more information on DAI.

http://www.emedicine.com/radio/topic216.htm

Take care,

chbare.

[AZCEP]

And the crowd goes wild!!!!!

[Asysin2leads]

Diffuse Axonal Injury? Sure, why not. Sounds good. Okay, now lets focus on things I actually care about. From the beginning:

Scene is secure. Assure proper PPE (turn out coat, helmet, adequate foot wear) and if possible, use appropriate tools to make entry, call for extrication. If possible, secure c-spine, see if patient can tolerate OPA and use BVM to hyperventilate. If possible, use a KED to secure the spine during extrication, then secure to long board and reassess, mental status, pupil reaction, additional injuries. EKG, prep with 1.5mg/kg lidocaine, sedation if necessary, perform intubation hyperventilate to reduce ICP enroute. I've hear around the watercooler some places are even starting to use Labetol to reduce BP in head injuries in the field. Transport to the Level II. Attempt to gain medical/demographic information enroute.

[Ridryder 911]

Actually, hyperventilation is contraindicated in ICP and THI cases for the past 5 years. Studies and research has found, that it actually did too good of job that cerebral arterial receptors respond so well that it causes too much vasoconstriction and ischemia and maybe necrosis can occur distal from the arterial bleed. Normal ventilation rates as well fluid therapy is suggested.

I will try to find the link, of CHI and Nuero ... that has all the updates for EMS.

R/r 911