Case History MAN vs TREE

[tniuqs]

Well lookie what I found in old files and permission to reprint (as I am the author) and signed release form in hand ... well in a manner of speaking the Mother signed as PT was right handed.

Case History:

Dispatch info;

Called for 26yo Male Pt. involved in M.V.C. with multiple #, received from P.F.C.C.

Upon arrival to Hospital Facility:

A 26 y/o male patient lying supine in ER, Pt found supine on backboard, without straps, C-collar on, two large bore IV’s in situ L arm, not on O2, Awake and Alert but appears restless.

Hx of C/C;

Was involved in MVC, Single vehicle, Crew Cab truck that at high speed departed from pavement and impacted a tree. Pt was a passenger, back seat, impact side, states was wearing seatbelt. The pt. was removed from truck by friends? And passersby’s. No report of loss of consciousness and pt. walked with assistance to passerby vehicle.

Patient was intercepted by A.L.S. unit. Advanced Care Paramedics took spinal precautions and initiated IV therapy and gave 100 mics of Fentanyl in total. Damage to Truck not observed due to logistics, too bad no one had a digital camera on scene, as this could have provided valuable info to receiving M.D.s.

PmHx;

Of: HTN? States no follow up, of smoker presently on Zyban, states H.B.D. x 1 beer this am. NKA.

C/C;

Pain moderate? To R shoulder, to Chest, to Face.

Focused assessment; No obvious signs of Respiratory Distress Sao2= 98% on R.A. RR=26 bpm. No c/o Dyspnea, Resps, Shallow, with increase in pain upon deep breath.

Rapid pre-transport assessment;

Obvious Lac to R face nasty poss. Plastics consult with 1. # to Zygomatic arch reported, 2. CXR shows # 2+3+4 Ribs anterior mid-clavicular line, no obvious air in thorax. 3 # compounded proximal end of humerous, with GROSS misplacement and dislocation of A.C. process. Rather large LAC. As observed on picture.

CNS: Alert + oriented, moves all extremities, a bit anxious and restless due to lack of padding on spine board.

CVS: Good end organ perfusion, cap refill less than 2 sec. producing urine cloudy, and a bit pinkish in color. B/P acceptable a hair on the low side but no tachycardia NSR in lead 2

Pulm: A/E decreased to bases bilaterally, no obvious adventica, auscultation over site of injury ant/post

Some crepitus noted but air entry present.

CXR: vascular lines noted to periphery no obvious pneumo/hemo present, at this time. Sao2 = 94 % on R.A. ETCO2 sidestream applied to pt. via nasal cannula, with trends around 30 to 32, even with ++ Morphine analgesia.

Abdo: soft, no c/o pain upon palpation. No obvious signs of internal hemorrhage.

GI/GU: urine as above, bowel sound present.

Labs: hgb= 15.8, increased leucocytes, ABG n/a,

Treatment: T.L.C., Hx, V/S q 15 min. by automated device, Sao2 continuous, ETCO2 side stream continuous, Monitor Lead 2, Pt. flipped, assessed, and spine board padded with flannel, fully resecured to board, also used ½ full mini-bag to occipital area secured firmly, to improve comfort level and hopefully decrease amount of analgesia required. Morphine used liberally, for movement during assessment and prior to medivac, during transport fluid bolus given due to transient drop in B/P, T.V.I = 1700 cc. N/S

Questions:

1-Why was Oxygen not used on this patient ?

A- The Paramedics were too lazy to turn on the tank.

B- There was no signs of hypoxia.

C- Content and Capacity estimated @ bedside was 20.92 vol%.

D- Careful monitoring of O2 saturations and Trending of ETCO2 could be indicative of Pnemothorax, or Respiratory depression.

E- All of the above.

2- Given the choice, should the patient be transported by a pressurized aircraft or un-pressurized aircraft. Are there any other considerations as to cabin pressure or flight planning that could be implemented?

(I did not state in the case presentation but weather was and always is a factor, in this case IFR flight planning was necessity weather was almost at limits)

3- At the Prehospital care level should the possibility of Rhabdomyalosis be considered?

If so what clinical signs may suggest, and what treatment options are available to a Flight Paramedic?

Answer:

Any Questions about abbreviations ?

Edited August 13, 2011 by tniuqs

[BushyFromOz]

Way outside my league turnip.

D for the first one, not that that they arn't all relevent but im a bit suspect you might by the attending and answer A eems unlikely and i dont understandb answer B

Pressurised for the second, though its a guess as i dont know anything about aeromed

rhabdo is a consideration. Theres damage to a large muscles group along with the fracture and possibly reduced pefusion distally, possible compartment syndrom. Either one could have similar Signs/Symptoms, severe pain, perfsuions compromise and those 5 P's, (Pallor, parasthesia, paralysis another one which i cant remember and the poliko-whatever it is where they cant regulate temp (looks a bit like polkadot with a thermia on the end))

Supine on a spine baord for how long compressing muscle groups could do the same.

Could also see peaked T waves.

No idea what a flight paramedic would do? Manage for pain, fluids and ECG with some bicarb ready?

like i said, way out of my pay grade

[tniuqs]

Way outside my league turnip.

No way mate this is a stable patient transfer, keep in mind that this was my first kick at the roo agreed "my presentation" is a bit a rough,

D for the first one,

D is correct

not that that they arn't all relevent but im a bit suspect you might by the attending and answer A eems unlikely and i dont understandb answer B

Ok now teach me ... what is eems ?

But yes to A its a teaser .... Why did you not give O2 ? This is a trauma patient ? Was the first thing I was asked giving report to the RN staff ! It was my glib answer to a ... does this patient need O2 when you have HGB and Pulse Oximetry ? Yup it sounds like a dumb ass answer but it is really not ...

Pressurised for the second, though its a guess as i dont know anything about aeromed.

Ah bless you my son, an opening for an introduction to Boyles Law ... I will get into it later if their is any interest in the thread.

rhabdo is a consideration.

Oh yes it is ... I did not include another lab value that I was presented .. next question what "lab" value could point that direction ?

There's damage to a large muscles group along with the fracture and possibly reduced pefusion distally, possible compartment syndrom. Either one could have similar Signs/Symptoms, severe pain, perfsuions compromise and those

Ah compartment syndrome .. this was a rather large wound, and open ps the dressing was removed for the pic, as was the "splints" used in transport ... I thought some one was going to rip me a "new" one for that ! Quite amazingly NO loss of distal perfusion, no neuro isues, this patient could actually squeeze my fingers, my initial thought was "buddy" was looking at a prosthetic device down the road ! Apparently he's back on his drilling rig AND was the son of a very good Parameduck Friend's who lived next door "neighbour" his MOM asked for the "before pictures" ... just weird how that stuff goes down EH ?

Counter question .. is compartment syndrome something we can treat or even can be diagnosed in the inter-facility transport ?

5 P's, (Pallor, parasthesia, paralysis another one which i cant remember and the poliko-whatever it is where they cant regulate temp (looks a bit like polkadot with a thermia on the end))

Fist bump ! ... but whats this polka dot of which you speak ?

Supine on a spine baord for how long compressing muscle groups could do the same.

Ok salient point, C spine was cleared in sending facility BUT recieving Facility is really "touchy" about that as it was a GP sending ... ah the joy of it all ! LOL.

Could also see peaked T waves.

Nice ... but seeing as its your "catch" could you go into some detail to explain to the First Responders that have monitors ? This patient was NSR .. I would have mentioned any "irregularities" but good point never the less.

No idea what a flight paramedic would do? Manage for pain, fluids and ECG with some bicarb ready?

Its just a different (can I say bus ride here) Pain was managed and the whole point of this presentation ... did I need to tube this brute, Did I even need O2 ? .. this was done in 2007 when very few used ETCO2 for anything other than Tube conformation or trending on ventilated patients that has changed, sure hope mobey sees this one.

Why would you need Bicarb .. on a spontaneous breathing patient and with ETCO2 a bit lower than expected ?

like i said, way out of my pay grade

Disagree !

Edited August 14, 2011 by tniuqs

[DFIB]

I would love to hear the take on Boyle's law,

[BushyFromOz]

Read the red bits turnip

Way outside my league turnip.

No way mate this is a stable patient transfer, keep in mind that this was my first kick at the roo agreed "my presentation" is a bit a rough,

i think i got hung up about the aeromedical questions and the ETC 02 stuff, outside of my pay grade

D for the first one,

D is correct

not that that they arn't all relevent but im a bit suspect you might by the attending and answer A eems unlikely and i dont understandb answer B

Ok now teach me ... what is eems ?

Should be "seems"

But yes to A its a teaser .... Why did you not give O2 ? This is a trauma patient ? Was the first thing I was asked giving report to the RN staff ! It was my glib answer to a ... does this patient need O2 when you have HGB and Pulse Oximetry ? Yup it sounds like a dumb ass answer but it is really not ...

Agreed. Im tired of seeing people jam 15 L/min on everybody, even when they know the patient isn't aneamic! Twisted ankle = 02, paper cut = 02, boggles the mind (and the 02 cylinder ental costs im told )

Pressurised for the second, though its a guess as i dont know anything about aeromed.

Ah bless you my son, an opening for an introduction to Boyles Law ... I will get into it later if their is any interest in the thread.

Feel free bro, even if the other munckins in here arn't paying attention to the thread

rhabdo is a consideration.

Oh yes it is ... I did not include another lab value that I was presented .. next question what "lab" value could point that direction ?

Probably myoglobin, i dont know the normal values though

There's damage to a large muscles group along with the fracture and possibly reduced pefusion distally, possible compartment syndrom. Either one could have similar Signs/Symptoms, severe pain, perfsuions compromise and those

Ah compartment syndrome .. this was a rather large wound, and open ps the dressing was removed for the pic, as was the "splints" used in transport ... I thought some one was going to rip me a "new" one for that ! Quite amazingly NO loss of distal perfusion, no neuro isues, this patient could actually squeeze my fingers, my initial thought was "buddy" was looking at a prosthetic device down the road ! Apparently he's back on his drilling rig AND was the son of a very good Parameduck Friend's who lived next door "neighbour" his MOM asked for the "before pictures" ... just weird how that stuff goes down EH ?

Counter question .. is compartment syndrome something we can treat or even can be diagnosed in the inter-facility transport ?

The fence sitter in me says technically no, but you can have a stron index of suspician

5 P's, (Pallor, parasthesia, paralysis another one which i cant remember and the poliko-whatever it is where they cant regulate temp (looks a bit like polkadot with a thermia on the end))

Fist bump ! ... but whats this polka dot of which you speak ?

Do you know how hard it is to find something in a dictionary when you dont know how to spell it

Its "poikilothermia" a failure to thermoregulate

Supine on a spine baord for how long compressing muscle groups could do the same.

Ok salient point, C spine was cleared in sending facility BUT recieving Facility is really "touchy" about that as it was a GP sending ... ah the joy of it all ! LOL.

Could also see peaked T waves.

Nice ... but seeing as its your "catch" could you go into some detail to explain to the First Responders that have monitors ? This patient was NSR .. I would have mentioned any "irregularities" but good point never the less.

No idea what a flight paramedic would do? Manage for pain, fluids and ECG with some bicarb ready?

Its just a different (can I say bus ride here) Pain was managed and the whole point of this presentation ... did I need to tube this brute, Did I even need O2 ? .. this was done in 2007 when very few used ETCO2 for anything other than Tube conformation or trending on ventilated patients that has changed, sure hope mobey sees this one.

Ill see if i can find it, but there was retrospective analysis done here on tension pneumo's that were missed in the field, led to an education pack coming out where they got us to be more aggressive in identifying and manageing, there was a good stretch in it about trending ETCo2 and the missed pneumo.

Why would you need Bicarb .. on a spontaneous breathing patient and with ETCO2 a bit lower than expected ?

Let me get back to you boke, i dont understand ETCo2 or fully remember treatment for hyperkalaemia due to my lazyness (i used to). I went to some joint once and learned some stuff then got a job and forgot most of the stuff that i learn't

like i said, way out of my pay grade

Disagree !

[tniuqs]

DFIB ... as you wish.

Mass and Temperature (remaining constant) the volume of a gas is directly proportional. That stated: with the pressure decreases there is also shift of the ODC, (the oxygen dissociation curve) which in this case presentation, So if the curve shifts with a decrease .. what happens to the affinity of the haemoglobin for oxygen ?

Hence my question for pressurised vs non pressurized, you can be in a typical helo at just 5000 ft agl but in fixed wing you can have a cabin pressure of 3000 ft agl and actually be at 25,000 ft agl and "over the weather in calm air" ... now look back at the patient picture, is the musculoskeletal injury life threatening or is something else you may wish to make note in clinical observation ???? must have been one hell of a high impact to bust buddy's arm this bad, any other concerns for going flying ?

Ah Bushy, just wake up mate ?

Agreed. Im tired of seeing people jam 15 L/min on everybody, even when they know the patient isn't aneamic! Twisted ankle = 02, paper cut = 02, boggles the mind (and the 02 cylinder rental costs im told )

I am not a fan of the toxic effects of O2 ... te he, (a high potential for ARDS) but my reasoning was, with the rather liberal amounts of analgesia that I was using to control pain, was that oximetry changes could indicate a hypoventilation state (late).. but was relying on ETCO2 as primary tool for hypoventilation, for a near conscious sedation.

I really did not want to push Narcan or have to ETI on board but with the "yet to be identified" life threatening issue, sorry no AP CXR available. (hint with the good clinical observation skills applied) and no pneumo but we are getting closer close (ps) vascular lines to periphery was the hint that no pneumo present initially although that can change when Boyle puts his physics to work , a small closed pneumo becomes a lot bigger with increase in altitude.

Probably myoglobin, i dont know the normal values though.

That is one .. myglobinuria better, any others ?

Its "poikilothermia" a failure to thermoregulate.

Ah the presenter becomes the student .. you sheep shagger !

Ill see if i can find it, but there was retrospective analysis done here on tension pneumo's that were missed in the field, led to an education pack coming out where they got us to be more aggressive in identifying and manageing, there was a good stretch in it about trending ETCo2 and the missed pneumo.

Ah send it to me svp, that svp is french btw and good thing you don't have to deal with those spy talkers like we do.

Let me get back to you boke, i dont understand ETCo2 or fully remember treatment for hyperkalaemia due to my lazyness (i used to). I went to some joint once and learned some stuff then got a job and forgot most of the stuff that i learn't

I wasn't concerned about hi K+, could give ventolin while on board, but not going the glucagon and insulin because we don't carry insulin and this was a stable no CP distress, no big ass T waves and K excelate was out definatly of the question, but we are getting a bit off topic direction.

rhabdo treatment was where I was headed ... any ideas ?

hint TVI flight time was 1.5 hours, then add 40 mins for ground transport both ends.

I was curious about the 30 to 32 ETCO2 although .. I think I can explain it but one can not be 100% why he was hyperventilating just a tad any comments ?

cheers

Edited August 15, 2011 by tniuqs

[scubanurse]

I didn't see any rib fx immediately on the shoulder xray, but pulmonary contusion could be a huge factor for this guy... the arm was clearly forced into the ribs and that could have been enough to cause a pulmonary contusion...cardiac also....maybe.

Also from the amount of facial trauma seen on the first photo, I would be for sure interested in what a facial series looked like as well as a face/brain CT.

Since he claims to have been seat-belted at the time, any signs of a lap belt injury? Would have really liked to see pictures of this accident to have an idea of the forces involved, but from the one xray you showed, must have been a good amount of force.

Side note...we once had a mid-shaft femur fracture come into us, and he was sitting up and talking completely fine.... Dropped a flat-screen tv on his thigh and snapped it in two. No other trauma occurred. Made me realize that not everything that you would think is a huge trauma, there can be freak isolated injuries that we would normally associate with more complex issues.

[tniuqs]

I didn't see any rib fx immediately on the shoulder xray, but pulmonary contusion could be a huge factor for this guy... the arm was clearly forced into the ribs and that could have been enough to cause a pulmonary contusion...cardiac also....maybe.

And Kate goes to top of the class !

PULMONARY CONTUSION ...so any shots at the possible sequela of that with high concentrations of O2 ?

Also from the amount of facial trauma seen on the first photo, I would be for sure interested in what a facial series looked like as well as a face/brain CT.

Yup no argument from me but no signs of head injury, just plastics work in the end.

Since he claims to have been seat-belted at the time, any signs of a lap belt injury? Would have really liked to see pictures of this accident to have an idea of the forces involved, but from the one xray you showed, must have been a good amount of force.

Yup good catch wearing a seatbelt "was a pt states thingy" I could not see any signs of belt marks. I did not see the intrusion into the wreck (I wasn't on scene and it occured at - 36 C, blizzard the Paramedic was a good one on the scene but I suspect when patient walked to truck bleeding, looking at a 3/4 ton crew cab rolled in the ditch against a pole/ tree was last of his priorities. I do highly suspect some a cya company policy was being covered for and driver was arrested at the scene for DUI.

Side note...we once had a mid-shaft femur fracture come into us, and he was sitting up and talking completely fine.... Dropped a flat-screen tv on his thigh and snapped it in two. No other trauma occurred. Made me realize that not everything that you would think is a huge trauma, there can be freak isolated injuries that we would normally associate with more complex issues.

Ah yet another reason I should not buy a flat screen TV ... dang you Kate !

[scubanurse]

It's been a while since I studied pulmonary contusions, but I would think that watching the trending in sPO2 and CO2 would tell us more about gas exchange condition. With adding artificial O2 to the mix, it would be difficult to tell if this guy was having issues at the gas level?

Is it safe enough to guess that the guys only issue in the end was the arm? I'm still curious about abdominal/pelvic injury.

Just don't try and mount a 50" flat screen by yourself when you're in your 70's and you'll be good

[tniuqs]

here is another pic.

It's been a while since I studied pulmonary contusions, but I would think that watching the trending in sPO2 and CO2 would tell us more about gas exchange condition. With adding artificial O2 to the mix, it would be difficult to tell if this guy was having issues at the gas level?

Shallow breathing, re chest wall pain, RR of 26 its kinda curious that ETCO2 was low 30s but trending was more of a priority to me, VQ match would have been a consideration but I would have expected norm or higher than norms. As I have said frequently maybe the patient didnt read the "Normal Lung" LOL.

Is it safe enough to guess that the guys only issue in the end was the arm? I'm still curious about abdominal/pelvic injury.

Honest injun I would have mentioned that in my presentation of History.

Just don't try and mount a 50" flat screen by yourself when you're in your 70's and you'll be good

You mean I should get one before my next birthday ?