medic53226 Posted July 2, 2006 Posted July 2, 2006 50Y/O MALE PT THAT WAS MOWING A PASTURE IN THE MIDDLE OF NOWHERE IS THROWN FROM TRACTOR AS HE IS TRYING TO MOW A TREE LINE, PT IS FOUND ON HIS LEFT SIDE STATING THAT HIS LEFT LEG HURTS AND RIGHT SHOULDER HURTS PT IS AOX4 AND CAN ANSWER ALL QUESTIONS BUT, DOES HAVE A MENTAL HANDICAP, AND IS A LITTLE SLOW, NORMAL FOR THE PT, PT WHEN THROWN TO THE GROUND LANDS ON SOME BRUSH AND TREES AND A BARB WIRE FENCE. This what I will give you, now you tell me what you want to know.
ncmedic309 Posted July 2, 2006 Posted July 2, 2006 Well, to start, let's knock out quick, but important basics... Any scene hazards? How far was he thrown, height? How significant is the mechanism? How far are we from the trauma center? Do we need flight services? Is he trapped? Maintain C-Spine immobilization, he's going on a board... He's alert and oriented and airway appears patent. Lung sounds? Tidal Volume? Radial pulses? Any obvious signs of outward trauma, severe bleeding?
Cookie Posted July 2, 2006 Posted July 2, 2006 Scene Safety, any hazards. Since he was thrown from the tractor, it was an open tractor, what kind of mower, bar type, belly mower or pull behind? ABC's C spine. Loss of consciousness? Did the tractor roll over him? How long between the time of the incident and help arrives? These are a few of the things that I want to know and do first.
Acosell Posted July 2, 2006 Posted July 2, 2006 Where's the tractor now? Is it going to come back and run us over? Hold C-Spine Check Airway Check Breathing Check Circulation Quick full body check for further injuries/bleeding and then we'll go from there.
chbare Posted July 2, 2006 Posted July 2, 2006 -General impression of the patient and scene. -Identify any hazards. (Animals, the tractor, weather, etc.) -Ascertain the need for additional resources and make sure there is only one patient. (Is this guy so tangled up in a fence that we may need help cutting it away from him, or is he impaled and we need to do some cutting to free him from the object?) -Where is the closest trauma center and how far away is it by air and ground? -Do I have air evac resources? -What is the weather like? (Is this guy going to freeze or burn up?) Then the general primary assessment stuff. ABCDE's and the rapid trauma survey with c-spine precautions. Specific treatments based on the above findings. Take care, chbare.
medic53226 Posted July 2, 2006 Author Posted July 2, 2006 Scene is safe no animals, tractor has continued across the pasture and stuck on a fence, the height of the tractor is 6' from the ground, c-spine immobilized, no chopper a T Storm is moving overhead, and about to rain, pt in the field found by a passerby, unknown time frame from accident. Hot day 90's, pt very sweaty. No LOC, known prior to arrival and non after arrival. V/S BP 88/40 Resp 28 Pulse 128 Lungs clear Right/Clear upper left, diminished lower left Pupils PERL Cyanotic nail beds on hand and feet Obvious Fx to right tib/fib with deformity to right ankle, good pedal pulses in both feet no deformities noted to left leg. SPO2 90% RA Crepitis on left lower ribs Local hospital 10 mins Trauma 3 20 mins Local hospital is small and no specialty care just 3 bed er and ob with 50 some general beds What do you want to know now. I hope I answer alot of your questions, keep them coming.
chbare Posted July 2, 2006 Posted July 2, 2006 Medic53226, -Do we have air evac resources? -Does the local hospital have any surgical abilities? -Is the patient having notable dyspnea? -Belly soft and non tender? -Back exam findings? -Pelvic pain or instability? We need to get this patient on high flow oxygen and obtain vascular access. The lower left rib crepitus and hypotension is a very high index of suspicion for a splenic injury. If this is the case, dumping crystalloids into this guy will not help. We need to get him to a hospital with surgical capabilities. It also sounds like he has a left sided pneumothorax. Depending on what we are allowed to do, I would dart the chest. (Low o2 sat, low B/P, Tachycardia, and cyanosis along with the crepitus and diminished lung sounds-> tension pneumo until proven otherwise in my book) If there is no improvement with the dart, then I would think he has a significant vascular injury. Take care, chbare.
medic53226 Posted July 2, 2006 Author Posted July 2, 2006 Pelvis unstable on pelvic girdle test, abdomen very tender to the light touch, pt alert have to have MC and is refused by MC for the dart, no jvd, trachea mid line no shift, no back pain, no chopper bad weather, and yes the do have 1 surgeon, and they have to call him in, but not on hand. 2 large bore IV's bilateral Forearms, Monitor sinus tach left rib immobilized with dressing
chbare Posted July 2, 2006 Posted July 2, 2006 Medic53226, it looks like we may have a pelvic fracture in addition to all of his other injuries. The question now is, where to go. This guy needs trauma care and a trauma surgeon. I am leaning toward the level III. (unless I can get him to a trauma team faster by going to another hospital) Load the patient with spinal precautions and take measures to maintain a regular temp. Pelvic splint device if available. Is this ILS or an ALS unit. If I cannot take measures to manage the airway (if it comes to that), I would also call for an intercept. I would give some fluid as well. (500ml bolus and frequently assess. The last thing I want to do is raise the B/P and blow out clots. The whole Fick principle thing again.) Take care, chbare.
medic53226 Posted July 3, 2006 Author Posted July 3, 2006 als and the next county that has the trauma 3 hospital has the same protocols and it is its support hospital that said no to the dart, they as well as us don't have RSI, PT with the fluid did increase the BP. The hospital that we are going to has on had trauma surgeon and other areas of care and ortho surgeon on hand and has a 30 bed er, they can handle this pt and the trauma 1 hospital is 1hr 30 min drive. This a actual pt I had just 2 shifts ago, and was wondering what the emt city crew would have done different and might have followed what I had did. As for the pt ER reported that he had a adb bleed due to spleen, curshed pelvis, dilocated right shoulder, fx tib/fib and had a exit wound, fx right ankel, fx ribs 7-12, they found that the pt had been ran over by the tractor, from family members that had showed up at the ER. The pt had not been on the side of the mower or thing could have been alot worst.
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