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DartmouthDave

Depressed Man with Bad Luck

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Hello,

You are transferring care of a stable patient at the local ED when you hear that a trauma patient is being transfered in with a BLS crew. You and your partner are asked to stay and assist the local ED staff.

The hospital has basic laboratory capacity, x-ray, u/s and a small blood bank. On duty are 2 ER Nurse, 1 ER DR and a RT.

The BLS crew arrives and gives a report on their patient.

A 70 year-old male was driving his SUV when he fell asleep at the wheel and drove into a cement divider at highway speed. Their was extensive damage to the vehicle and the air bags deployed. Lucky, the patient was wearing a seat belt at the time. The patient was not entrapped and was extricated quickly by Fire and EMS.

The patient was secured on a back board and a c-collar applied. He has one #18G IV in his left ACF and has a NRB@15 lpm.

His VS are as follows:

GCS 15/15

BP 110/80

HR 120-130

EKG A.Fib with frequent PVC's

Temp 35.8

Resp 32-34 Rapid/Shallow

Spo2 94-95%

BGL 18 mmol/l

The patient is moaning in pain and shivering. He complains of sharp pains on the left and right side of his chest and pain in his right leg. Also, the patient c/o suprapubic pain. He keeps trying to sit up because it is hard to breathe on his back with all of this pain. The right leg is shortened are rotated externally.

The patient is fully clothed and wet. It is a cool wet spring day.

The BLS crew states that the patient has a history of CAD, AF, HTN, Dyslipidemia, DM II and depression and ETOH abuse. The depression and drinking has been going on for three months since his wife died. Before this, he seldom drank.

He can not recall all of his medications. He takes ASA and a green pill to 'thin things out' for his irregular heart beat. His Dr started him on an antidepressant but he never started to take it. He figured he would come around on his own.

Cheers

Edited by DartmouthDave

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BLS in my state cannot start IV's so where did the IV come from?

What are the patients lung sounds? i'm going to want a portable chest X-ray right away to determine the presence of a pneumo.

That's for starters

I'm also going to want the following

1. Baseline labs along with an ETOH level and a drug screen

2. Foley cath this guy

3. Chest x-ray, cspine, lspine, tspine, Chest abdominal Pelvic CT scan which more than likely will take the place of the conventional x-rays for a quick look

This guy isn't going to be at your hospital for long, you can always get the labs to the receiving hospital after the patient has left via either air or by the original posters ambulance.

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Car accident with damage and deployment and your Pt comes in with cloths on? wet ones too? FAIL time for the BLS crew to take a refresher on trauma triage. This guy should have been down to his underware and had a warm blanket on.

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Car accident with damage and deployment and your Pt comes in with cloths on? wet ones too? FAIL time for the BLS crew to take a refresher on trauma triage. This guy should have been down to his underware and had a warm blanket on.

I was going to point that out but this wasn't his patient so I let that one slide. Hopefully the OP let that BLS crew have it though.

Case in point on the wet clothes

Cold water drowning, Arrive as 2nd unit in to transport the other minor injury guy. Had my partner talk to the patient and I asked if there was anything I could do for the on scene crew.

They said no, we're good. I asked, are you going to cut his clothes off? I'm sure if we do that the body will warm up. The medic said "oh yeah, I was going to get to that" I did it for him, placed warm packs in all the right places and we began to get a response. He regained a pulse, started to buck the tube and all that good stuff. Can't say it was the warming but I'll bet it was a major part of it. Unfortunately the guy had been down a while and he didn't really come fully back, but he did survive and does odd jobs around his town. Wouldn't trust him with the keys to the nuclear missiles but he does work a cash register at the local mom and pop gas station.

Every time we see each other he smiles and says "My hero"

Edited by Ruffems

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The patient is moaning in pain and shivering. He complains of sharp pains on the left and right side of his chest and pain in his right leg. Also, the patient c/o suprapubic pain. He keeps trying to sit up because it is hard to breathe on his back with all of this pain. The right leg is shortened are rotated externally.

Still fairly new to EMS/EMT so please be gentle:

With a shallow Resp rate and the fact he keeps sitting up I'm thinking possible pneuomothroax or hemothorax, people usually sit in the a position where they can get the most air. Or is there any punctures or contusions near the sites? (Did I miss that?)

Also, had he recently stopped drinking his usual amount?

Still contemplating the other problems.

-MetalMedic

Edited by MetalMedic

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Hello,

Excellent work.

The patient is exposed. A seat belt sign is noted across his chest and abd. Blood is also noted at urinary meatus as well so a hold on the foley for now.

Also, increased work of breathing is noted. Resp of 30+ and shallow. 'It hurts too much to breathe!!!'

The abd is tender to the touch.

The right leg is shortened and rotated. The foot is cool to the touch and has no pulse.

A bear huger is applied to the patient.

There is no CT scanner at this hospital.

There is xray and u/s.

I will post more latter. I need a nap before night shift.

Cheers

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The abd is tender to the touch.

The right leg is shortened and rotated. The foot is cool to the touch and has no pulse.

Was there any crepitis in the pelvic region? Any DCAP-BLTS in the right leg? I'm looking for a possible closed fracture - possible issue with the femoral atery.

Any blood in urine- was seatbelt on properly? Is there a possible tear in the bladder?

I'm still really leaning toward the pneumothroax in the chest and adding some internal bleeding in the abd. What quadrant is the tenderness located in? It also may show more signs/symptoms of the issues with breathing depending on where the problem is.

-MetalMedic

*Edit I'll check in after class tonight!

And again, if I'm way off please explain where I'm off. It is much appreciated. :)

Edited by MetalMedic

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So far spot on Metalmedic :thumbsup: The fact the leg is shortened and rotated already tells you that the femur is injured. Nothing penetrating tells of closed fracture.

Quick assesment will tell where the break is located if low enough (mid femur) then a traction splint would be advised. Higher or lower then thankfully he is in the ED and the Docs will be able to set it properly. If it was out in the field then either a reverse KED or regular splintin would be advised as well as some traction before placement to get PMS in the foot.

As far as the OP goes. Get this man warmed up and get me Xrays being no CT is available. The tender ab is worrisome. Im thinking spleen at this point. Bloody urine is noted but also a seat belt mark, so the urine could just be from the impact (had a few accidents myself and peed blood for a few days after do to the second and third organ impacts) depending on the amount of blood though.

Breathing is leaning me twords either a punctured lung (any bloody sputem noted?) or ribs. Due to the other vitals I am not leaning twords a tension pneumo. The fact that POC breathing will help leads me twords ribs (they suck being broken).

Until we know more I will monitor breathing and vitals, get traction on that leg to restore PMS then splint or set in place, want Xrays or even a ultrasound for the abdo to check the spleen and other organs.

Can't wait to hear more

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A bear huger is applied to the patient.

A zot here. What is ZOT? Perhaps I know of this in a different wording.

Pleasae advise.

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He needs to be in this hospital for as short a time as possible. Arrange urgent transfer to highest level trauma service immediately.

Get another line in him (large bore) and get some blood and products up from the bank. Get some decent pain relief on board, see what happens with his respirations following that. I prefer ketamine, but whatever floats your boat. Once he's breathing easier, reassess, he may have low sats purely from poor effort secondary to pain. Low sats in the setting of a pneumothorax would normally be expected later in the evolution of the injury rather than earlier. He could also have lung contusions of course. Regardless, he needs pain relief and plenty of it.

If there is going to be any imaging done, it's a toss up between portable x-ray and a FAST. On one hand, portable chest (AP and lateral) may show us a pneumo, but as he is supine it will be difficult to tell. A FAST will show us the free fluid in the abdomen, but lets face it, we can be reasonably certain he has blood in his belly, so is it really going to change anything we do now? I'm glad there is no CT, the last thing he needs to be is a VOMIT.

Splint his pelvis, it is quite possible he has a fractured pelvis and subsequent bladder injury which is a nasty, nasty thing to have. Align and splint the leg to regain pulses, it doesn't really matter how it is done, the orthopods are sharpening their chisels even as we speak. It may not be worth the time putting a traction splint on if we can get good pulses back with anatomical splinting, and being worried about a pelvic fracture would make you worry about tractioning off that.

Finally: get him the hell out of there!

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