Hip/Leg deformity

[Sizz]

Hey all

Ran a run yesterday w/local volunteer dept man vs tree. Apparently the tree was being cut down and fell onto a young adult male it was un-witnessed and he cannot remember what happened. Upon arrival the pt was lying supine alert and oriented , base line vitals good, no life threatening injuries. He did have a 2 inch laceration on this posterior side of the skull, obvious left hip/knee/leg deformity along with his left shoulder / scapula being out of whack. We boarded the pt and immobilize his c spine and then worked on the joint injuries.

My questions is how would you have dealt with this injury of his left hip injury. His leg was up in the L shape and turned 45 degree outward away from his body. Picture laying on your back knees up in the air leg straight forward and then 1 of them turned outward very far in pretty bad position.

Pt would not tolerate any pain , severe screamer would not allow any other position other than the way it was found for comfort. The lead Emt went for the vacuum splint in which we put under his buttocks all the way down to his ankle area but really it wasn't very supportive. We then attached the 2 legs together to help some with moving but it still was limbo up in the air packaged as best as we could get for time being , someone was holding it steady( or at least trying) en route to the hospital. KED for something that turned around and upright? I did not see any SAM splint on the rig just vacuum , traction, KED and a few ridge splints 1 short 1 long I believe.

Whats your thoughts I'm interested in making it much better next go around.

 

[firetender]

His leg was up in the L shape and turned 45 degree outward away from his body. Picture laying on your back knees up in the air leg straight forward and then 1 of them turned outward very far in pretty bad position.

...screamer would not allow any other position other than the way it was found for comfort.

In this case, trust your Screamer! I used to work in Daytona Beach during "Motorcycle Week". Injuries like this were not uncommon. Any manipulation you would do with such an injury on-scene would most likely cause more tissue/muscle damage, injure the patient and make you liable for going beyond your scope of practice.

The best you can do is "do no further harm!"

(This stuff, by the way, was some of the "funnest" for the challenge of learning to IMPROVISE a Rube Goldberg device for stabilization!)

 

[Sizz]

Thanks

Your right any extra movement would have been really odd, I'm just unsure if we had it stable enough. It did not swing around or bounce to much but in the upwright posistion cocked to the left was pretty had to stable 100% I feel. I've never delt with this type of an injury so it's good to hear some response. I've heard the KED for hip dislocations but does that really work for badly deformed / dislocated hip injuries? I believe the most challenging part was his leg up in the air in limbo. All ended up well afterwards I'm always looking for other's prospectives since my experiance is limited some things.

Thank you in advance.

 

[akflightmedic]

A medic and drugs...only way to make that situation better.

 

[mycrofft]

Pillows blankets and duct tape.

There is a reason Mother Nature put so many consarnded pain nerves next to the femoral artery, right?

A benzo might have lessened muscle spasm and calmed the pt without respiratory depression.

If the said injuries did not obviously exhibit crushing mechanics, basal skull fx and spinal insult need to be entertained, (wine and dancing will do) since he may have jumped or fallen onto locked or folded knees, transmitting shock through the femurs then spine.

"Splint in position" can epitomize "do no harm".

 

[PotashRLS]

I agree totally.

Pillows, blankets and duct tape.........the splinting world's most underestimated and underadvertised brand.

 

[mycrofft]

As I tried to post three times before...

Oh, look, it posted!

Never mind...

 

[abckidsmom]

I agree totally.

Pillows, blankets and duct tape.........the splinting world's most underestimated and underadvertised brand.

And no admin type ever agrees with me on how much linen is actually needed. One agency I worked at wanted us to have 1 pillow, 2 blankets, and 6 sheets as our par level.

That would have gotten us started with a situation like this...

 

[LondonMedic]

Ketamine.

 

[bryncvp]

If you put him on a long board..doesnt that serve as a splint for the entire body? If you secured him to the long board..its not like he is going anywhere...get him in the back of the truck...IV morphine and gas bolus..done and done..

 

[MrBrown]

Ketamine.

... and LOTS of it.

Where is that 20ml syringe? You there, make up 10mg/ml of ketamine in a pack of D5 for me.

I would be weary of trying to reduce such an injury without being an orthopaedist. My main concern is severe blood loss and causing any further aggrivation of pelvic injuries which may exist or just plain snafu'ing the whole deal up. The femoral shaft and head may have seperated or something along those lines and it's just a mess all over.

Hmmm how to proceed, hmmm ..... go for gold; 150mg of ketamine and suxamethonium, intubate and ventilate, top him off with some midaz and take him in.

While I am certinaly not a proponent of dishing out ketamine and sux whilly nilly with such a nasty injury it's going to take away all his pain and make the whole situation work better for everybody.

Hello Ambulance Control? Yes its Brown, listen this man v tree job, is HEMS avaliable at all? ....

 

[Fox800]

... and LOTS of it.

Where is that 20ml syringe? You there, make up 10mg/ml of ketamine in a pack of D5 for me.

I would be weary of trying to reduce such an injury without being an orthopaedist. My main concern is severe blood loss and causing any further aggrivation of pelvic injuries which may exist or just plain snafu'ing the whole deal up. The femoral shaft and head may have seperated or something along those lines and it's just a mess all over.

Hmmm how to proceed, hmmm ..... go for gold; 150mg of ketamine and suxamethonium, intubate and ventilate, top him off with some midaz and take him in.

While I am certinaly not a proponent of dishing out ketamine and sux whilly nilly with such a nasty injury it's going to take away all his pain and make the whole situation work better for everybody.

Hello Ambulance Control? Yes its Brown, listen this man v tree job, is HEMS avaliable at all? ....

You're going to RSI this patient? Really?

 

[MrBrown]

You're going to RSI this patient? Really?

By the sounds of it, this guy is in a rural area (BLS volunteer crew only) and probably has an extended transport time.

He will need to go to a primary level hospital which has orthopaedic facilities and within a minutes of arriving at said primary level orthopaedic capable hospital will go straight into theatre to have his injuries fixed.

The patient will be in severe, unretractable pain which needs to be bought under control in order to move and transport him.

These types of severe injuries are not likely to respond well to morphine (I am yet to see one that has, not talking a broken arm here) and any opiod analgesia comes with the potential for unwanted side effect of nausea. How are you going to position this patient if he starts chucking?

With the pain this guy is in he there is the potential for missed spinal, head, back, neck and abdominopelvic injuries too.

By knocking this guy out we achieve maximum analgesia and amnesia for the patient while ensuring minimum movement and giving us a nice, stable platform to package and transport this patient.

As I said, I do not endorse swanning in and blanketly anaesthetising and intubating people.

If you can counter my argument, please, by all means do.

 

[Sizz]

By the sounds of it, this guy is in a rural area (BLS volunteer crew only) and probably has an extended transport time.

He will need to go to a primary level hospital which has orthopaedic facilities and within a minutes of arriving at said primary level orthopaedic capable hospital will go straight into theatre to have his injuries fixed.

The patient will be in severe, unretractable pain which needs to be bought under control in order to move and transport him.

These types of severe injuries are not likely to respond well to morphine (I am yet to see one that has, not talking a broken arm here) and any opiod analgesia comes with the potential for unwanted side effect of nausea. How are you going to position this patient if he starts chucking?

With the pain this guy is in he there is the potential for missed spinal, head, back, neck and abdominopelvic injuries too.

By knocking this guy out we achieve maximum analgesia and amnesia for the patient while ensuring minimum movement and giving us a nice, stable platform to package and transport this patient.

As I said, I do not endorse swanning in and blanketly anaesthetising and intubating people.

If you can counter my argument, please, by all means do.

Yep that sounds about right on the nail. We are a BLS service in a Rural area and was about 25-30 mins from our hospital. We did tier up w/ our local county ALS about 10-15 mins out. I'm still a bit weary and uncertain w/ my experience what constitutes HEMS vs Ground ALS with certain injuries. So basically knocking the pt out and intubate and ventilate package / transport.

And sorry for my ignorance but what is RSI the pt mean?

 

[EMSLaw]

If you put him on a long board..doesnt that serve as a splint for the entire body? If you secured him to the long board..its not like he is going anywhere...get him in the back of the truck...IV morphine and gas bolus..done and done..

You're going to have to backboard him, yes, but you've still got that leg sticking out perpendicular to his body that can't be moved. You'd have to rig something up to stabilize it.

I'm thinking a long board splint and a lot of cravats for a start, along with lots of padding. Of course, you also have to be able to get him into the ambulance... But, I'd have to be there and see the patient to get an idea of what I'd likely do.

 

[Fox800]

By the sounds of it, this guy is in a rural area (BLS volunteer crew only) and probably has an extended transport time.

He will need to go to a primary level hospital which has orthopaedic facilities and within a minutes of arriving at said primary level orthopaedic capable hospital will go straight into theatre to have his injuries fixed.

The patient will be in severe, unretractable pain which needs to be bought under control in order to move and transport him.

These types of severe injuries are not likely to respond well to morphine (I am yet to see one that has, not talking a broken arm here) and any opiod analgesia comes with the potential for unwanted side effect of nausea. How are you going to position this patient if he starts chucking?

With the pain this guy is in he there is the potential for missed spinal, head, back, neck and abdominopelvic injuries too.

By knocking this guy out we achieve maximum analgesia and amnesia for the patient while ensuring minimum movement and giving us a nice, stable platform to package and transport this patient.

As I said, I do not endorse swanning in and blanketly anaesthetising and intubating people.

If you can counter my argument, please, by all means do.

Insert line about your orange jumpsuit here.

I had not really considered RSI for a severe extremity injury in the past...only for traumatic brain injuries or thoracic injuries impeding ventilation. (My system does not perform RSI).

I suppose that considering a HEMS environment, RSI would be more appropriate.

 

[MrBrown]

Insert line about your orange jumpsuit here.

LOL no no, orange jumpsuit not required for this one. Selected Intensive Care Paramedics have RSI here.

But I would never overlook having people swan in out the sky in orange jumpsuits, it does look kinda cool

I had not really considered RSI for a severe extremity injury in the past...only for traumatic brain injuries or thoracic injuries impeding ventilation. (My system does not perform RSI).

I suppose that considering a HEMS environment, RSI would be more appropriate.

I am not an advocate for the over-use of RSI which requires high levels of knowledge, skill and judgement over and above what some advanced life support providers possess as is it presents disproportinate clinical risk.

That said, it can be bloody handy sometimes

 

[Fox800]

LOL no no, orange jumpsuit not required for this one. Selected Intensive Care Paramedics have RSI here.

But I would never overlook having people swan in out the sky in orange jumpsuits, it does look kinda cool



I am not an advocate for the over-use of RSI which requires high levels of knowledge, skill and judgement over and above what some advanced life support providers possess as is it presents disproportinate clinical risk.

That said, it can be bloody handy sometimes

Agreed. This pt. is going to be in a world of pain for the forseeable future. Movement/extrication will be excruciatingly painful, and even securing him in the ambo/choppa will be a nightmare. Something dissociative and/or amnestic would do good. Ketamine or propofol come to mind.

 

[CAOX3]

Field amputation and Prosthesis fitting, schedule appointments to begin physical therapy. Back before shift change.

You guys and your limited protocols....

 

[MrBrown]

Agreed. This pt. is going to be in a world of pain for the forseeable future. Movement/extrication will be excruciatingly painful, and even securing him in the ambo/choppa will be a nightmare. Something dissociative and/or amnestic would do good. Ketamine or propofol come to mind.

Ketamine is what we use, its wonderful stuff and I love it to bits. We don't have propofol and I never see us getting it.

Small boluses of ketamine (say 20mg to start and then 10mg after that as required) is the norm here and it seems to work well.

That said it may prove better for this patient and those treating him to simply knock him out rather than having to repeatedly top his ketamine up so he is pain free and/or dose him multiple times to get his pain under control so we can extricate him.