motorcylce accident

cointosser13

cointosser13

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Yesterday I ran a call, where a female in her 30's on her motorcycle, was hit by a car. She was going 40 or so mph, and a car to her left turned into her lane without realizing she was there. When we got to the scene the engine crew were already back boarding the motorcyclist. When we got the patient in the back of the ambulance, we found out that she hit her head pretty bad (she was wearing a helmet) there was a lot of blood on her face, and she had a pelvic fracture (not a hip fracture). I found out that she had AMS because she couldn't quite tell what was going on. Two weird signs that I observed as we transported the patient to the hospital:

-the blood pressure was quite high. like 160/90, and yes I made sure the cuff was properly attached (patient had no history of hypertension). Pulse was like 100, and her Spo2 was at 97%.
-respirations were quite slow. I mean they were in the normal range, 12-16. But I thought they were slow for a person who was just hit by a car going 40-50 mph?

Is anything weird about those vital signs (high blood pressure/low to average respirations)? Doesn't that mean there's a severe head injury, or am I thinking of something else?
 
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DesertMedic66

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Someone please correct me if I'm wrong but with ICP you get an elevated BP, decreased pulse, greater pulse pressure, and respirations can change up to some different "patterns".
 
kindofafireguy

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Could be indicative of cushing's triad (increased%2
 
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NomadicMedic

NomadicMedic

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I'd think after a motorcycle accident, my BP would be a bit elevated, too.

This is a good learning case for the OP. What would you, as the EMT, do for this patient, if there was no medic available? What would you say to the doc or nurse when you arrived? What are the important points to tell them? Do you think this patinet has a head injury? Is this a trauma alert? Backboard and collar?
 
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DesertMedic66

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kindofafireguy

kindofafireguy

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Hmm apparently it deleted the rest Of my post.

I had also mentioned that she would need bradycardia and irregular respiratory pattern for it to be cushings. More likely her pressure and pulse are up due to pain and sympathetic response.
 
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DesertMedic66

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kindofafireguy said:
Hmm apparently it deleted the rest Of my post.

I had also mentioned that she would need bradycardia and irregular respiratory pattern for it to be cushings. More likely her pressure and pulse are up due to pain and sympathetic response.
Click to expand...

Being in a traffic collision tends to increase ones BP and pulse.
 
TheLocalMedic

TheLocalMedic

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Generally when people are displaying Cushing's Triad they're pretty jacked up and there isn't any question as to whether or not they have a head injury. Had one a few months ago from an assault, and I didn't need to examine his vitals to tell you that he had a major head injury. What got interesting was watching his respiratory status change (waiting for a helicopter) before I intubated. Went from Cheyne-Stokes to Biot's, which I assume doesn't indicate a very good prognosis...
 
kindofafireguy

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Well I brought up Cushing because I felt that was what the OP was hinting at. Personally those vitals look like normal pain and stress to me.
 
MSDeltaFlt

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Cointosser,

AMS? What was her GCS? Alert and oriented to what? Not oriented to what? If you don't remember what is going on, you're not in Cushing's Triad. Every patient I've seen in Cushing's Triad either wouldn't respond at all (GCS = 3), or would only respond with decerebrate posturing (GCS = 4 @ 1/1/2), or with decorticate posturing (GCS = 5 @ 1/1/3).

In what condition was the helmet? How much blood was on the face? Remember, the vasculature of the head and face is exstensive. "A lot of blood" is not a lot of blood until there is so much pouring out that you go into shock.

How do you know the pelvis was fractured? From X-Rays at ER? Or was clinical presentation that obvious? And if so, how?

I don't want to sound like I'm judging you. There's just not enough information to go on.

The BP is elevated, but the HR and RR are not. For right now I wouldn't worry about that at all.
 
Household6

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DEmedic said:
I'd think after a motorcycle accident, my BP would be a bit elevated, too.

This is a good learning case for the OP. What would you, as the EMT, do for this patient, if there was no medic available? What would you say to the doc or nurse when you arrived? What are the important points to tell them? Do you think this patinet has a head injury? Is this a trauma alert? Backboard and collar?
Click to expand...

JMO, but I would probably have a conversation with the FD about the necessity of removing a helmet on a patient with such MOI, right? Or am I thinking by my Limmer book too hard?

The cool thing about helmets, they're still supportive, and unless you need to provide an advanced airway, they don't NEED to come off right away. I was schooled that pulling a helmet off a head with a compromised c-spine can cause further damage.. You can still assess ABCs, pupils, even place an NRB on her face with a helmet on her head, no?
 
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DesertMedic66

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Household6 said:
JMO, but I would probably have a conversation with the FD about the necessity of removing a helmet on a patient with such MOI, right? Or am I thinking by my Limmer book too hard?

The cool thing about helmets, they're still supportive, and unless you need to provide an advanced airway, they don't NEED to come off right away. I was schooled that pulling a helmet off a head with a compromised c-spine can cause further damage.. You can still assess ABCs, pupils, even place an NRB on her face with a helmet on her head, no?
Click to expand...

I've always been trained to remove all helmets unless it is a football helmet and there are shoulder pads.
 
IslandTime

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Household6 said:
The cool thing about helmets, they're still supportive, and unless you need to provide an advanced airway, they don't NEED to come off right away. I was schooled that pulling a helmet off a head with a compromised c-spine can cause further damage.. You can still assess ABCs, pupils, even place an NRB on her face with a helmet on her head, no?
Click to expand...

And that PT doesn't complain if you use plenty of tape on the helmet to immobilize the neck which is a lot easier than blocks and strips applied across the forehead.
 
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Aprz

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Household6 said:
JMO, but I would probably have a conversation with the FD about the necessity of removing a helmet on a patient with such MOI, right? Or am I thinking by my Limmer book too hard?

The cool thing about helmets, they're still supportive, and unless you need to provide an advanced airway, they don't NEED to come off right away. I was schooled that pulling a helmet off a head with a compromised c-spine can cause further damage.. You can still assess ABCs, pupils, even place an NRB on her face with a helmet on her head, no?
Click to expand...
In my opinion, leaving on the helmet is a very bad idea.

Steve Whitehead from TheEMTSpot.com wrote a pretty good article on it. http://theemtspot.com/2010/04/03/the-c-spine-helmet-issue/
 
Household6

Household6

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Aprz said:
In my opinion, leaving on the helmet is a very bad idea.

Steve Whitehead from TheEMTSpot.com wrote a pretty good article on it. http://theemtspot.com/2010/04/03/the-c-spine-helmet-issue/
Click to expand...

Fantastic article, this is absolutely something that I think we need to discuss and practice our skillzz class.. Great information, the collective knowledge around here is so helpful to me.

We haven't got to that part in our book yet, but the EMR class last semester did. As an EMR, we followed the guidelines in the book which said not to remove them. Of course EMTB/P will have completely different protocols.

DesertEMT66, did you practice helmet removal in skills?
 
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Aprz

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I attended two different EMT programs at the same time. In one program, they didn't discuss helmet removal at all, and we didn't practice it. In the other program I attended, it was a skill that they taught separately from backboarding and had us practice for several days at one station, and then they included it as a part of the final skill tests with backboarding.

If the patient is able to follow commands, I personally believe the safest option is for the patient to remove their own helmet (just like I believe the patient should walk to the gurney rather than be backboard). Most people aren't on board (no pun intedned) with this still though. If they are unable to follow commands (eg unconscious), I believe there is less potential for harm if two providers are removing the helmet. I am not super concerned about maintaining c-spine or keeping the neck in the inline neutral position, however, if the patient is unable to do things like say "ow", I am afraid that the helmet could be removed too forcefully injuring the neck.

Leaving the helmet on could make it difficult to quickly safely assess and manage the patient's airway (ie insert an airway or suction). I believe that even if the patient was wearing a helmet, it's still important to assess their head too. If a paramedic needs to intubate the patient, he may have a difficult time opening the mouth and putting the patient in the sniffing position to view the cords and insert a endotracheal tube.

If you are concerned about c-spine, I believe most helmets will not allow the patient to lay supine with the helmet on while keeping the neck in the inline neutral position. If you remove the helmet by yourself, you may manipulate the neck too much. That's one reason you probably shouldn't backboard a patient with a motorcycle helmet on in regard to c-spine. Also I don't believe you can apply a c-collar on the patient's neck with the motorcycle on and the helmet doesn't help minimize movement with the neck, which is another reason you probably shouldn't backboard a patient with a motorcycle helmet on in regard to c-spine.

[YOUTUBE]http://www.youtube.com/watch?v=geKGLez5ga4[/YOUTUBE]

By the way, some motorcycle helmets have foam inside that is easily removable. I need to go, and I cannot find an immediate picture for you. Try searching online if interested.
 
mycrofft

mycrofft

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Always take of the helmet versus always leave the helmet on.

Because MVA's ALWAYS have the same degree and directions of force-moments, the victims ALWAYS experience the same degree and types of injury, and ALL helmets are made the same and ALWAYS have the same damage.

Same as NEVER use a long spineboard versus ALWAYS use a long spine board.

How about this one: NEVER do anything to the patient which will not yield a better level of care versus the risk inherent on THAT PARTICULAR CASE.

PS: airway airway airway.
 
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