Fall from a roof

[Handsome Robb]

Alright, your dispatched to a single family home for a fall.

U/A neighbor meets you and says he saw his neighbor hanging christmas lights on his garage when he fell from the roof.

Fall of about 15' and landed on his head.

Pt withdraws from painful stimuli, GCS of 7, has blood and broken teeth in his mouth, HR of 106, BP of 116/78, RR 26 and labored, SPO2 92%, BGL 90, Skin is cool and dry, no family present, neighbor doesn't really know the man.

Head: You notice blood coming from ears and nose, obvious depressed skull fx, left pupil is fixed and dilated.

Neck: No JVD, trachea midline, atraumatic

Chest: Paradoxical movement on the left side with clear breath sounds decreased on the left.

Abdomen: Soft, non-tender

Pelvis: Stable, atraumatic

Genitalia: Atraumatic

Lower Extremities: Atraumatic, CMS good

Upper Extremities: Right arm has a distal open fx, Left arm is atraumatic, both have good CMS

Back: Atraumatic

Had this as a scenario in class, and this is what I did, I want to know what you would do.

Grabbed c-spine, suctioned the airway then dropped an OPA and NRB @ 15lpm, left the nose/ears alone to let the fluid drain, noted the skull fx, there's nothing I can really do for it so I left it be. I stabilized the chest wall with a bulky dressing, boarded him, started transport SPO2 dropped to 86% so I dropped a tube and started the vent, splinted the arm en-route, also established a large bore IV hung NS @ KVO, 4 lead reassessing every 5 minutes.

Was told that I should have treated for shock. With the bleeding from the ears/nose, and depressed skull fx and GCS of 7 makes me think his ICP is rising, so no trendelenburg's and no reason to run the IV WFO since he isnt hypotensive, this was my thought process but I was told that it was incorrect. I'm just looking for some constructive criticism.

 

[Veneficus]

Alright, your dispatched to a single family home for a fall.

U/A neighbor meets you and says he saw his neighbor hanging christmas lights on his garage when he fell from the roof.

Fall of about 15' and landed on his head.

Pt withdraws from painful stimuli, GCS of 7, has blood and broken teeth in his mouth, HR of 106, BP of 116/78, RR 26 and labored, SPO2 92%, BGL 90, Skin is cool and dry, no family present, neighbor doesn't really know the man.

Head: You notice blood coming from ears and nose, obvious depressed skull fx, left pupil is fixed and dilated.

Neck: No JVD, trachea midline, atraumatic

Chest: Paradoxical movement on the left side with clear breath sounds decreased on the left.

Abdomen: Soft, non-tender

Pelvis: Stable, atraumatic

Genitalia: Atraumatic

Lower Extremities: Atraumatic, CMS good

Upper Extremities: Right arm has a distal open fx, Left arm is atraumatic, both have good CMS

Back: Atraumatic

Had this as a scenario in class, and this is what I did, I want to know what you would do.

Grabbed c-spine, suctioned the airway then dropped an OPA and NRB @ 15lpm, left the nose/ears alone to let the fluid drain, noted the skull fx, there's nothing I can really do for it so I left it be. I stabilized the chest wall with a bulky dressing, boarded him, started transport SPO2 dropped to 86% so I dropped a tube and started the vent, splinted the arm en-route, also established a large bore IV hung NS @ KVO, 4 lead reassessing every 5 minutes.

Was told that I should have treated for shock. With the bleeding from the ears/nose, and depressed skull fx and GCS of 7 makes me think his ICP is rising, so no trendelenburg's and no reason to run the IV WFO since he isnt hypotensive, this was my thought process but I was told that it was incorrect. I'm just looking for some constructive criticism.

I agree that by the book, wide open fluid is indicated.

I strongly disagree with the book. Curriculum is from 1985.

 

[MS Medic]

The only thing I can see I would have done is intubate rather than drop an OPA so I did not get behind the ball and have to drop a tube when I was too late. I know it is not clinically indicated by the book but the pt condition was not going to get any better in the field, your assessment shows he has the potential for airway compromise if not an actual compromised and no gag reflex.

 

[Handsome Robb]

The only thing I can see I would have done is intubate rather than drop an OPA so I did not get behind the ball and have to drop a tube when I was too late. I know it is not clinically indicated by the book but the pt condition was not going to get any better in the field, your assessment shows he has the potential for airway compromise if not an actual compromised and no gag reflex.

This was another question I meant to ask, but you answered it without me asking haha. Thank you. I thought about dropping the tube to begin with but my thought was that I need to get this guy loaded and moving towards a trauma center now and I can drop it in the rig enroute if the OPA isn't cutting it.

Transport time was less than 10 minutes as well.

 

[MrBrown]

Where is that RSI qualified Intensive Care Paramedic or Doctor when you need one?

Hemm yes Brown will have an awful awful, Oz, what do you wan....hang on
Hmmm it looks like a go Oz, fall from height, ambulance on scene, best we get going

Medivac airborne, thousand and below, northbound, VFR, vicinity of Stead (four sierra delta) changing local traffic, call you on the way out ....

 

[MS Medic]

This was another question I meant to ask, but you answered it without me asking haha. Thank you. I thought about dropping the tube to begin with but my thought was that I need to get this guy loaded and moving towards a trauma center now and I can drop it in the rig enroute if the OPA isn't cutting it.

Transport time was less than 10 minutes as well.

You can drop the tube en route. It is something you should learn to do, like tubing on a code without stopping compressions. But it is something that comes with practice.
On the other hand stabilizing the airway is the only thing I will stay on scene for and then it will be 1 or 2 attempt before I go to a combitube, if I don't use that in the first place.

 

[Handsome Robb]

You can drop the tube en route. It is something you should learn to do, like tubing on a code without stopping compressions. But it is something that comes with practice.
On the other hand stabilizing the airway is the only thing I will stay on scene for and then it will be 1 or 2 attempt before I go to a combitube, if I don't use that in the first place.

Thats what I decided to do. I decided it was better to get him assessed and packaged and to begin transport since the OPA was maintaining his airway for the time being. Another thought that crossed my mind once he accepted the OPA was to pull it and drop a king since it is more effective than the OPA but I discarded that pretty quickly.

Dropping a tube with chest compressions going sounds like a rough skill to learn.

 

[MS Medic]

Thats what I decided to do. I decided it was better to get him assessed and packaged and to begin transport since the OPA was maintaining his airway for the time being. Another thought that crossed my mind once he accepted the OPA was to pull it and drop a king since it is more effective than the OPA but I discarded that pretty quickly.

We don't have the kings on the truck here in MS, hence I called for a combitube. For the purposes of passing a test, you did the right thing. Just remember though, that it is easier and better for the pt to get a secure airway as soon as reasonable with a pt like that because 95-99% of the time they will deteriorate on you.

Dropping a tube with chest compressions going sounds like a rough skill to learn.

Just remember to use cric pressure. It is your friend.

 

[truetiger]

You may consider hyperventilating the pt at 12-20 with an ET tube in place.

 

[MS Medic]

You may consider hyperventilating the pt at 12-20 with an ET tube in place.

Thanks. I thought about that and then did not post it.:blush:
That would make getting the airway secured even more important, considering that you did recognize the possible rise in ICP.

 

[Handsome Robb]

I've heard of hyperventilation for head injury pts, but it was not very briefly covered and I wouldn't feel comfortable doing it without knowing more about it.

 

[truetiger]

One thing I forgot, while I certainly wouldn't run fluids "wide open", you might consider a bolus to keep the blood pressure above 110, hypotension and head injuries don't do well together...

 

[Akulahawk]

Alright, your dispatched to a single family home for a fall.

U/A neighbor meets you and says he saw his neighbor hanging christmas lights on his garage when he fell from the roof.

Fall of about 15' and landed on his head.

Pt withdraws from painful stimuli, GCS of 7, has blood and broken teeth in his mouth, HR of 106, BP of 116/78, RR 26 and labored, SPO2 92%, BGL 90, Skin is cool and dry, no family present, neighbor doesn't really know the man.

Head: You notice blood coming from ears and nose, obvious depressed skull fx, left pupil is fixed and dilated.

Neck: No JVD, trachea midline, atraumatic

Chest: Paradoxical movement on the left side with clear breath sounds decreased on the left.

Abdomen: Soft, non-tender

Pelvis: Stable, atraumatic

Genitalia: Atraumatic

Lower Extremities: Atraumatic, CMS good

Upper Extremities: Right arm has a distal open fx, Left arm is atraumatic, both have good CMS

Back: Atraumatic

Had this as a scenario in class, and this is what I did, I want to know what you would do.

Grabbed c-spine, suctioned the airway then dropped an OPA and NRB @ 15lpm, left the nose/ears alone to let the fluid drain, noted the skull fx, there's nothing I can really do for it so I left it be. I stabilized the chest wall with a bulky dressing, boarded him, started transport SPO2 dropped to 86% so I dropped a tube and started the vent, splinted the arm en-route, also established a large bore IV hung NS @ KVO, 4 lead reassessing every 5 minutes.

Was told that I should have treated for shock. With the bleeding from the ears/nose, and depressed skull fx and GCS of 7 makes me think his ICP is rising, so no trendelenburg's and no reason to run the IV WFO since he isnt hypotensive, this was my thought process but I was told that it was incorrect. I'm just looking for some constructive criticism.

Given that scenario AND what I know:
Note likely C-spine on arrival, have someone take c-spine. Note the head/neuro and chest injuries, flail segment on left with decreased breath sounds. Put on O2 @ 15LPM briefly for pre-oxygenation while prepping for boarding and intubating him. Put patient on a LSB, C-collar at the ready. Intubate ASAP. Perhaps give him a small amount of PEEP to keep the flail segment from causing more pain. Put collar on, secure head to board at that time. This guy's not going to get better any time soon. Begin transport to a trauma center. I want to be off scene before I got there...

En-Route: IV, large bore x2, keep him dry, TKO. There's no need to flood him at this point. Monitor ETCO2, keep him in a physiological normal range, consult with OLMC about mild hyperventilation, but I think his brain injuries are primarily due to the Fx, not herniation. Not yet. Monitor V/S and patient closely for signs of decompensation. Attend to the right arm if I have time.

 

[MS Medic]

I've heard of hyperventilation for head injury pts, but it was not very briefly covered and I wouldn't feel comfortable doing it without knowing more about it.

The reason you hyperventilate pt with a head injury is because CO2 causes vasodialation, so hyperventilating these pts will blow off CO2 causing vasoconstriction and help decrease ICP.

That is the short verson. Really need to study the pathophysiology to get a better understanding.

 

[MS Medic]

Let me back track. I just reviewed the vitals and the pt is not showing s/s of Cushing's reflex so there's not really any concern for increased ICP "yet". But, I'd still get that airway.

 

[Aidey]

I don't know that I would use a combitube on this patient becuase of the potential for bulb to displace anything else that may be fractured. ICP is a concern, but if he is bleeding out the ears and nose there is somewhat of an "outlet" for the pressure. I would also be prepared to decompress that left side if he isn't getting better after being intubated.

 

[Handsome Robb]

Cushing's ssi Tachycardia, HTN, and decreased resps, correct?

Aidey, I agree about being ready to decompress the chest.

 

[truetiger]

Bradycardia, HTN, and respirations could be increased, decreased, or irregular.

 

[Smash]

Righto then.

What are this patient's problems?

A: Yep, this is a problem; unable to maintain it himself, loose teeth and blood.
B: Flail segment so B is a problem, SpO2 is pretty low, respirations are laboured.
C: Not currently an issue. Possibility for hemothorax in back of mind, but nothing else sinister at this stage.
D: Deficits? We'll assume so because he has an actual nasty mechanism in axial loading that will lead me to be concerned about compression/burst fractures of the vertebral bodies.

Secondary survey? He has a traumatic brain injury, a flail segment, a fractured ??ulna/radius (I assume this is what is meant by distal arm, not distal humerus) and a potential c-spine injury.
So, what do we do about it?

First of all A: Suction what we can, manual airway management without compromising c-spine alignment, but ultimately A comes first and to the best of my knowledge there is no evidence that us doing anything to necks actually does any more harm. Now, I would not place an OPA or other adjunct at this stage unless I am absolutely unable to manage his airway without it. I want to avoid stimulating a rise in ICP as much as possible, and being lazy with an airway when manual care will suffice is a good way to do that.
100% oxygen to pre-oxygenate whilst I prepare for intubation. At this stage I am also going to decompress his chest. He has poor sats, his perfusion is not great and he has a clear chest injury. Tension pneumothorax is notoriously difficult to diagnose in the field and I am about to give him drugs that will potentially affect his perfusion as well, so I want to eliminate any other causes of poor perfusion. We know that any episodes of hypotension in the TBI patient causes a significant increase in mortality, so lets avoid that by all means possible.

Lets get some large bore IV access, preferably 2. I am going to give this patient a small bolus of fluid (500ml or so) to preload him before I give him some vasoactive medications and hopefully therefore avoid any further drop in BP. He does NOT need aggressive cyclical crystalloid resuscitation.

So, now we are ready to RSI, so the sedation, then suxamethonium goes on board, and as soon as we have the ETT secured, the pancuronium goes on to ensure that we don't get any return of airway reflexes that will stimulate an uncontrolled rise in ICP. Sedation is maintained with a morphine/versed infusion, with an eagle eye on perfusion at all times (I'd love to have invasive BP, but sadly that's not an option for me at the moment). Positive pressure ventilation and sedation together may cause some fall, so we need to be careful. On the plus side, we have dealt with his airway, his flail and his TBI at one fell swoop.

I will not be hyperventilating this patient, I will be aiming to maintain "normal" EtCO2 of about 35mmHg. Hyperventilation of the TBI is a last ditch "Oh well, he's stuffed anyway" type of thing. There is no evidence that hyperventilation improves outcome, and in fact there is compelling evidence that it worsens outcome. The things that really impact badly on secondary brain injuries are: hypoxia, hypotension, hypercapnea and hypocapnea. The trouble with hypocapnea is that we might think that it causes vasoconstriction, but if it does it does so at the cost of cerebral blood flow. We need to have flow as well as pressure to keep the old grey matter alive, and anything that impacts on either of those things will cause harm. The San Diego RSI trial showed this quite dramatically.

Fortunately for us we have Australians to do the research America can't, and we now know that RSI, carried out well in appropriate patients has a clear long term benefit in outcomes for TBI patients. Hooray! (Bernard et al. 2010 Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury A Randomized Controlled Trial. Annals of Surgery. 252:6, 959-965)

So A and B are now sorted. Lets splint up that arm, because splinting is not optional. Everything that we can do to eliminate stimulus is good, because it means less sedation is needed, so less impact on perfusion.
Reassess frequently, manage any further problems that arrive.

Now what?
Notify the Trauma Center, drive to the Trauma Center, hand patient over to the Trauma Center people, drink the coffee from the good cafe just down the road from the Trauma Center, back to base in time to watch the UFC. Yay!

 

[Akulahawk]

Unlike Smash, I'm not as worried about an axial load problem on this guy's cervical spine. This patient still reportedly has good distal motor function (he's moving his limbs). The flail segment of the left chest tells me that he didn't land directly on the top of his head like the proverbial lawn dart. He probably landed on his left side, while looking to his left, trying to cushion his fall (and his head) with his right arm. In other words, looking at his injury pattern, I'm not seeing a mechanism that supports an axially loaded cervical spine upon impact.

Like Smash, I'm a little worried about the possible hemo/pneumo thorax along with pulmonary contusion. I'll prep for a chest decompression later, if needed. If I see the need for to decompress his chest, and if authorized, I'd rather insert a thoracostomy tube than a large angiocath. Personally, I suspect his rapid & labored breathing is from the flail segment than a Cushing's Reflex at this point. His airway needs to be cleared of fluid & debris as well anyway. Suction that out and see if his WOB improves. If not, track his breathing with a BVM and provide him with PPV, in a poor-man's BiPAP manner. I want to secure his airway ASAP anyway. RSI if available. Once on a vent or Bag that I can provide some PEEP, that should take care of any discomfort of the flail segment.

As to any hyperventilation, I'd still keep him within a physiologic norm, perhaps a tad toward the low end of norm, but still within a normal range of typical ETCO2 measurements, if that is necessary. Otherwise, keep him mid-range. Once he's being ventilated, reassess the chest for signs of increasing thoracic pressure. He may already be heading down that path from the lower BP, tachy HR and labored breathing, however, that's what the reassessment is for. I'd rather not do something that may/will result in him getting a thoracostomy tube if he wouldn't have needed it otherwise. If he DOES need the decompression, I'm more than happy to aggressively attempt to provide the pressure release he'd need.

I do agree with sedating the patient if possible. It'll make the ride much more tolerable and he won't fight the tube as much. RSI is a great tool, but in the short-term, I want to be able to provide that relief. After the Roc or the Vec has been administered, your patient will be paralyzed for quite a while and unable to indicate whether or not he's in discomfort/pain. Keep him well snowed, but I also want to watch him move and note if he's still taking spontaneous breaths.

Splinting that right arm, to me, is more optional than not. More than likely, it'll be splinted when I get a chance to also bandage any wounds he has for bleeding control. His airway/breathing, head injury and flail chest take precedence.

His hospital stay won't be a short one, if he survives.