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DesertEMT

Impaled by fence

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It's an idle Sunday afternoon when you and your partner are called to a residential neighborhood, dispatch says a man has been impaled on a fence. When you arrive you find the patient suspended by the dart of a steel fence, the dart appears to have impaled the man in the right posterior-axillar line upwards about 15cm. You notice what appears to be moderate blood loss, though the bleeding seems to have stopped. The patient is conscious AOx4 and collaborating with firefighters who use a pneumatic cutter to first detach the impaled man from the fence and then remove the dart end of the pole (which had a base diameter of 2cm).

Now that the firefighters part of this is done, treat this patient

(This is my first time giving a scenario so please excuse any mistakes I may make in doing this. I'm hoping to use this as a sort of practice for myself when it comes to trauma scenarios, as they are my weak point)

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This is a great idea for a scenario. I am glad you are running it.

Is the piece of fence still in him or did the FF pull it out?

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Spinal him and load. Start moving to closest trauma centre.

Helo available?

Vitals?

Air entry sounds?

Skin colour?

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This is a great idea for a scenario. I am glad you are running it.

Is the piece of fence still in him or did the FF pull it out?

Yes the pole is still in him, but the dart at the end was removed

Spinal him and load. Start moving to closest trauma centre.

Helo available?

Vitals?

Air entry sounds?

Skin colour?

What position do you want the patient to be on the backboard? bear in mind the pole is still in him.

Hr 80, BP 150/70, GCS 15, SpO2 98%

Normal lung sounds

Skin normal p/w/d

Edited by DesertEMT

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Yes the pole is still in him, but the dart at the end was removed

What position do you want the patient to be on the backboard? bear in mind the pole is still in him.

Hr 80, BP 150/70, GCS 15, SpO2 98%

Normal lung sounds

Skin normal p/w/d

I don't really get where this pole is at... lateral chest? Either way it has to be secured in place, yet allowed to vent.

If we can't board him, then so be it.

Vitals are good for now.

Is there bubbling around the pole?

Allergies?

Medications?

Lets get a couple I.V.'s TKVO, and get some pain control on board.

Start with fentanyl 100mcg (asuming this is an average size adult.

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If its still in him leave it there, if its bleeding try to pack some bulky combine dressings around it

Gain IV access but no IV fluid for now; pain relief is going to be quite important I would imagine

Put him on the scoop and transport, I wouldn't worry about spinal precautions.

There is only a role for a helicopter if the patient is more than 60 minutes by road to an appropriate hospital

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2 large bore IV's set for TKO. 100mcg fentanyl. Also would place him on cardiac montior as well. Package for transport in position of comfort. make sure the piece is stabilized and bleeding is being controlled. constantly be reassessing for s/s of cardiac tamponade or hemo/pneumo/tension pneumo. Monitor vitals closely and head to nearest trauma facility code three

*By the way not a paramedic yet. however Im trying to begin applying the skills I have already learned in the scenarios.* Can I go ahead and also administer 4 mg of zofran when administering the fentanyl or is their a contraindication or caution in this scenario Im missing. Or would it be better to with hold the zofran only if needed

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...the dart appears to have impaled the man in the right posterior-axillar line upwards about 15cm...

First off, good on you. I think few realize that it takes balls to post scenarios, to try and come up with something that you're confident that you can recall, or create every conceivable sign or symptom. I've been at the City for a few weeks now and I still get nervous every time I do so.

What angle did the post go in at? How did he end up on it? Trip while playing grab ass? Get thrown from a horse? Fall while standing on his truck driving it in?

In most scenarios that I'd imagine it most likely went in at a shallow angle, sounds like it pierced his Lat which is a pretty big muscle that bled for a bit but then spasm'd around the post making the external bleeding self limiting. And his vitals seem to support this assuming his rate and pressure are not chemically controlled.

My treatment will depend in a very large part on the angle of entry. Though with his vitals and exam (as above) I'm confident that this will not be a terribly significant wound from an EMS point of view, unless we change it during transport and make it so.

I'm surprised, (genuinely, not in a 'what a bunch of idiots' way) that so many would choose Fentanyl for this guy. Particularly, depending somewhat on size, at 100mcgs. It's possible that he's shocky in the area of injury and in very little pain. But if he's screaming I'd expect Fentanyl to be about as effective as spitting on the wound, at those doses, with this injury. But, experiences differ, as seen in other threads.

I would choose morphine not only because in my experience it would kick him much harder, but it would also last longer, and will likely, again in my experience, be what they continue him on at the ER.

Interesting scenario. I look forward to your updates!

Dwayne

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It sounds like bleeding has been relatively well controlled and there are no signs of hypovolaemia which is why I wouldn't be administering any fluid.

There is no contraindication to ondansetron in trauma patients or in patients receiving concurrent opiate analgesia however there is also probably no role for prophylactic anti emetic either.

For pain relief in this patient I'd be more inclined to use ketamine. If he required pain relief very quickly and we didn't have a drip in him I'd get the fireys to stop extrication, give him some entonox and IN fentanyl then have them resume cutting him out.

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I'm surprised, (genuinely, not in a 'what a bunch of idiots' way) that so many would choose Fentanyl for this guy. Particularly, depending somewhat on size, at 100mcgs. It's possible that he's shocky in the area of injury and in very little pain. But if he's screaming I'd expect Fentanyl to be about as effective as spitting on the wound, at those doses, with this injury. But, experiences differ, as seen in other threads.

I choose Fentanyl in patients when I am concerned there is going to be a BP problem in the near future or if nausea is going to be an issue.

Morphine is a dirty drug IMO and I really only give it in people with extremity trauma, or abd pain.

The 100mcg is just my standard starting point. It is a good start point to judge response to the drug.

The only other drug I would give this guy is Ketamine.... But it just does not fit right now.

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