DartmouthDave Posted September 19, 2010 Share Posted September 19, 2010 Hello, You are an ALS crew in a small town. The local hospital needs you to transfer a patient to the local university hospital for a surgery consult. The patient is a 22 year-old women that was struck by a car going 30km/h. She suffered a fractured left tib/fin, pulmonary contusion and a fractured right wrist. The patient has a five year history of ETOH abuse. In addition, she is a 1-2 pack a day smoker for the past 5 years as well. The patient is on no medications. Upon arrival the patient is pain free. But feels nauseated and anxious. She is fidgiting with her IV sites. She has been given Morphine for pain. C-spine is clear. Her VS are: GCS 15 BP 150/90 HR 110 EKG Sinus Tachycardia Temp 37.5 Spo2 92% on room air Lungs: fine crackles and a smokers cough Ok.....the road trip is three hours. Anything before you hit the road? Cheers A slab is on the leg and arm. Link to comment Share on other sites More sharing options...
lpndj6 Posted September 19, 2010 Share Posted September 19, 2010 Yeah I got a couple questions and this based on my previous experiences to include working ER (as a tech) and Cardiac Stepdown (as a nurse). 1st did they draw blood to see if she had ETOH on board? If not Id also like to know when her last intake was.. Alchohol DTs aint no joke. Ive had patients on CIWA scale when I was working the hospital on our floor simply due to the possible withdrawal issues. Based on the answers Id have to potentially ask for some S.Os to include benzos to treat possible severe anxiety. It seems if shes already aggitated in the ER shes probably already showing issues so thats gotta be addressed I dont need a patient going bonkers in the back of my truck or worse having a Grand Mal due to withdrawal. If they've given her morphine for pain Im not too worried bout a head injury at this point obviously and of course some SO's for pain control would be nice given its a 3hr ride and lets be honest even in a perfect world shes not going to be comfortable. Ok Ive said my peice anybodyelse wanna tackle this? Link to comment Share on other sites More sharing options...
Lone Star Posted September 19, 2010 Share Posted September 19, 2010 What is the condition of the pupils and their response to light? Is grip strength equal bilaterally? Range of motion? Slurred speech? Any pain on palpation of the abdomen? Guarding? Respiration rate? Equal chest expansion bilaterally? Link to comment Share on other sites More sharing options...
DartmouthDave Posted September 19, 2010 Author Share Posted September 19, 2010 What is the condition of the pupils and their response to light? PEARL @ 4mm Is grip strength equal bilaterally? Strong grips in the left and right arm Range of motion? Full ROM Slurred speech? No Any pain on palpation of the abdomen? Guarding? No...not an acute abdomen..FAST was clear Respiration rate? 24 to 28 Equal chest expansion bilaterally? Yes...shallow depth due to pain Cheers............. Yeah I got a couple questions and this based on my previous experiences to include working ER (as a tech) and Cardiac Stepdown (as a nurse). 1st did they draw blood to see if she had ETOH on board? If not Id also like to know when her last intake was.. Alchohol DTs aint no joke. Ive had patients on CIWA scale when I was working the hospital on our floor simply due to the possible withdrawal issues. Based on the answers Id have to potentially ask for some S.Os to include benzos to treat possible severe anxiety. It seems if shes already aggitated in the ER shes probably already showing issues so thats gotta be addressed I dont need a patient going bonkers in the back of my truck or worse having a Grand Mal due to withdrawal. If they've given her morphine for pain Im not too worried bout a head injury at this point obviously and of course some SO's for pain control would be nice given its a 3hr ride and lets be honest even in a perfect world shes not going to be comfortable. Ok Ive said my peice anybodyelse wanna tackle this? Hello, Dead on. This lady states that her last drink has been almost 48 hours ago. She states that she was trying to quit drinking because it has been destroying her life. She dose not think she is DT because she is too young. Old old drunks get that!!! She is tachy, diaphoretic, anxious and has faint tremors in her hands. Occasionally she picks at the Iv lines, ekg leads and foley. So, what would be choice in managing this? Cheers Link to comment Share on other sites More sharing options...
HERBIE1 Posted September 19, 2010 Share Posted September 19, 2010 I'd be worried about internal bleeding- long time alcoholics have clotting issues. Any of her injuries are worrisome and have the potential to cause bleeding- head and extremities, abdomen, as well as liver issues etc. I would also be concerned about potential seizures- it seems she's on the verge already. Any cerebral atrophy from the ETOH abuse-which would mean further concern about a head bleed. Electrolyte imbalances- due to probable poor nutrition could create cardiac issues. I'd also be worried about ARDS or other respiratory problems so I would closely watch her breathing. Someone like this- chronic alcoholic, PLUS high energy impact injuries- has the potential for being a train wreck. Link to comment Share on other sites More sharing options...
mobey Posted September 19, 2010 Share Posted September 19, 2010 Usually I would be worried about internal bleeds, subdural hematoma's etc etc as commonly seen in alcoholics, but this girl IS only 22. Not saying it can't happen.... I would just put those concerns on idle unless I get some indication something is going down a bad road. First thing she needs is some pain control. I would probably use morphine for the long lasting analgesic effects. Maxeran will ward off vomiting without sedating her, leaving lots of room for benzo's for withdrawl symptoms. She can have a thiamine injection, and I would start with 1mg SL Ativan. If we start seeing tremors or delerium I will be gratious with my benzo's. Link to comment Share on other sites More sharing options...
DartmouthDave Posted September 19, 2010 Author Share Posted September 19, 2010 (edited) I'd be worried about internal bleeding- long time alcoholics have clotting issues. Any of her injuries are worrisome and have the potential to cause bleeding- head and extremities, abdomen, as well as liver issues etc. I would also be concerned about potential seizures- it seems she's on the verge already. Any cerebral atrophy from the ETOH abuse-which would mean further concern about a head bleed. Electrolyte imbalances- due to probable poor nutrition could create cardiac issues. I'd also be worried about ARDS or other respiratory problems so I would closely watch her breathing. Someone like this- chronic alcoholic, PLUS high energy impact injuries- has the potential for being a train wreck. Hello, Good points. Here are some labs that are available currently: CBC: WBC 12 Hgb 92 Coags: INR 1.5 PTT 40 Platelets 250 Lytes: K 3.0 Na 145 Mg .97 Cr + BUN is slightly elevated.....can't think of the scale right now So, she is anemic, and has a low K and Mg. Plus, seems a little dry due to the elevated Cr/BUN. She had various x-rays done. A FAST (ultra-sound) showed no internal injuries. So far so good. This scenario is based on a patient that was admitted to a hospital I worked at. Lots of good learning points in what could be seen as 'just' a transfer. Cheers PS....lol Looks like Mobey posted while I was typing! Edited September 19, 2010 by DartmouthDave Link to comment Share on other sites More sharing options...
DartmouthDave Posted September 21, 2010 Author Share Posted September 21, 2010 Hello, Lets gets things moving. So, the hospital gives some KCL, Mg and a little fluid and you are on the road to the University Hospital. Once you are 40 minutes outside of town the patient starts to complain of sudden onset shortness of breath and mild chest pain. VS are as follows: GCS 15 BP 170|110 RR 32 SpO2 88% on NP at 2 lpm EKG: Sinus Tachycardia at 130 Cheers Link to comment Share on other sites More sharing options...
mobey Posted September 21, 2010 Share Posted September 21, 2010 Hello, Lets gets things moving. So, the hospital gives some KCL, Mg and a little fluid and you are on the road to the University Hospital. Once you are 40 minutes outside of town the patient starts to complain of sudden onset shortness of breath and mild chest pain. VS are as follows: GCS 15 BP 170|110 RR 32 SpO2 88% on NP at 2 lpm EKG: Sinus Tachycardia at 130 Cheers EEK, this is screaming PE. Up the O2 to a a NRB. Assess air entry sounds. OPQRS on the chest pain. 12 lead svp Link to comment Share on other sites More sharing options...
DartmouthDave Posted September 23, 2010 Author Share Posted September 23, 2010 EEK, this is screaming PE. Up the O2 to a a NRB. Assess air entry sounds. OPQRS on the chest pain. 12 lead svp Hello Mobey, The patient is placed on a NRB and the sats don't perk up. Around 86-87%. Also, the patient is becoming more agitated and restless. A 12-lead shows Sinus Tachycardia (sorry I don't have a scanned copy). The pain was sudden onset and described as heavy and it hurt to breathe. Currently, the patient is too confused to give more information. Lastly, you are on the right track with a PE. However, there is an other pathology going on here. Cheers Link to comment Share on other sites More sharing options...
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