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Scenarios Got a scenario you want to run by the others? This is the place.

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Old 03-08-2010, 02:33 AM   #1
8jimi8
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trauma assessment scenario


called to scene of 1 vehicle vs tree.

Initial impression: no skid marks, moderate frontal damage, no air bag, steering wheel intact, 1 patient, driver restrained - flaccid in drivers seat, driver door won't open due to impact, no entrapment of patient beyond the damaged door. Fire and LE on scene.

initial assessment:
no witnesses
Your partner takes c-spine
driver moans weakly to loud verbal stimuli, does not open eyes.
breathing is shallow and rapid 38/min breathe sounds are wet rales in all fields
circulation is weak and thready at 133 b/min
nrb 15l/min
high priority - rapid transport patient
medic alert bracelet: Cardiac history, allergy to HCTZ.

no sample or opqrst available
rapid trauma assessment reveals pms + (withdraws to painful) in all extremeties, eyes perrl, no signs of basilar skull fracture, no signs of dcapbtls or any obvious trauma (rapid trauma assessment is essentially negative except for a minor oozing laceration to the left cheek)
baseline vitals 90/50, hr 155, breathing 35 o2 sat 80
extricate with a KED and long backboard.

once the patient is loaded in the ambulance 2 large bore IVs
place the patient on the monitor reveals ...

multifocal pvcs and runs of paroxysmal vtach 8, 10 , 12
Oxygen saturation reads 75, patient is breathing 28 /min

what do you do.


call out your interventions once the ambulance starts moving. 15-20 minutes until the hospital. you can have 1 MFR/firefighter in the patient compartment with you.


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Old 03-08-2010, 02:35 AM   #2
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oops glucose is 136 and 4 mm st-depression in AVf
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Old 03-08-2010, 03:08 AM   #3
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Seems like LVF, or maybe a cardiac contusion (but you did say there was no obvious signs of trauma). Either way, I would think this patient is probably pretty stuffed.

My job in this situation would be simply to call MICA. Could try some suction.

From a MICA perspective, this patient would want intubating and an adrenaline infusion with some fluid boluses I suppose.
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Old 03-08-2010, 03:46 AM   #4
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are you sure you want to bolus?
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Old 03-08-2010, 03:46 AM   #5
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oh pt is 67 years old
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Old 03-08-2010, 03:58 AM   #6
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I would say this patient is pretty buggered myself.

1. Remove Firefighter from ambulance, this is not a fire truck
2. Fluid bolus
3. Suction and laryngeal mask airway
4. Intensive Care Paramedic

My guess is myocardial injury.

Any sign of a haemopneumothorax, unstable pelvis or internal bleeding?
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Old 03-08-2010, 04:02 AM   #7
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I'm fairly certain the MICA deal in this kind of scenario is a fluid bolus once/if the chest clears up, with the adrenaline, yes.
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Old 03-08-2010, 04:08 AM   #8
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Quote:
Originally Posted by 8jimi8 View Post
driver moans weakly to loud verbal stimuli, does not open eyes.
I'm not sure he'd take an LMA. Whats his motor response, so we can complte a GCS, 8jimi8.

Whats your rationale for fluid before inotropes? Surely that'd drown him further.


If he was really going down s**t creek, you could try some manual PEEP, I'm not personally of that persuasion, but some here are.
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Old 03-08-2010, 06:00 AM   #9
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are you sure this is a trauma scenario?

It sounds like a cardiac scenario uncleverly disguised as trauma.

There are a lot of findingss here, but what does the pt. look like? I would guess cyanotic, perhaps pale. Skinny? Fat? Is his spine abnormally kyphotic? What are the angle of his femurs? Dependant Edema? internal Pacemaker/defibrilator? Surgical scars? Urinated on himself?

For clarification there was no airbag or the airbag was not deployed?

That will make a difference on index of suspicion. Damage to the vehicle is an outdated measurement.

Is there a "seatbelt" sign?

No eye opening: 1
Moans: 2
withdraws to pain: 4

with a GCS of 7, I have no idea why you would waste time with a KED unless you were going to not use a backboard to protect his breathing.

With the exception of a minor laceration, this seems to be a cardiac problem so far. His BP, while low and definately a concern with his EKG doesn't seem overly low if he is on an ACE inhibitor or non thiazide diuretic. It doesn't seem like there is significant beta blockade with a rate of 155 either, but still possible. Wet lung sounds also point to a cardiogenic shock type scenario from left sided failure. I think this was included specifically to rule out a fluid bolus.

Dobutamine or dopamine sounds like a good idea. I think would start with that.

An aggressive approach would be to wait for a v-tach and cardiovert him, but I am not predisposed/condoning doing that. Just keeping options open.

Positive pressure ventilation may help as well.

The backboard will not help his respiratory efforts, you may have to forgo it in this case, or incline the head as much as safely possible.
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Old 03-08-2010, 06:31 AM   #10
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Any drainage or bleeding from the ears, nose, or mouth? Any jugular venous distension? Are the heart sounds clear and crisp or muffled? Any pitting edema in the lower extremities? How are the pupils? Is the pelvis stable and firm? Any signs of possible femur fractures? Is the abdomen soft and nontender without masses, distension, rigidity, or guarding? Does he have a pacemaker? What is the baseline rhythm of his EKG? Sinus tachycardia with multifocal PVCs and paroxysmal ventricular tachycardia, or atrial fibrillation with multifocal PVCs and paroxysmal ventricular tachycardia, or something else?

While awaiting answers to these questions...

Treatment: 15lpm NRB, extrication straight to a long back board (no KED, this patient is in too poor a condition to waste that time), IV access, 12-lead EKG, definitely a candidate for intubation. Am I working in a system that allows paramedics to RSI? I wouldn't worry about the hypotension too much, maybe give a small fluid bolus to get his systolic pressure above 100. As for the PVCs and runs of V-tach, I would treat him with lidocaine once I got his pressure up, depending on the frequency of PVCs and runs.

The big question here is did he crash because he's having an MI and the PVCs and V-tach made him hypotensive and he blacked out, or are the PVCs and V-tach a symptom of cardiac contusion?

Very good scenario!
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