Case Review-EMS View-Trauma patient

[emtcsmith]

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"Attention Medic XX respond 17th St and Skyline Blvd for a reported MVC, time out 0130"

Already on the road your responce time is under two minuets and you arrive to find a small crowd of bystanders on the sidewalk, an SUV approx 3/4th of the way down a city sized block and a female patient lying supine next to a sidewalk on the street. The patient per bystanders was struck by the SUV while riding her bicycle at a moderate rate of speed and bystanders report the suv "is messed up." The patient is a female in her twenties and appears to be approx 25-30ft from the inital impact and is also approx 10ft from both of her shoes. The patient has a standard bicycle helmet on and bicycle has been moved away from the patient.

You and your partner are both Paramedics, working in an urban setting where a Level I/University level trauma center is 5min away. On arrival your partner approaches the patient as you gather the equipment. The patient is rolled with assitance of bystanders onto a LSB, C-Spine, CIDS, etc packaging is preforming rapidly on scene. The patient is found have no purposeful movements, a small laceration next to her left eye, and dilated pupials, the paient's respirations are shallow, and radial pulse is weak. You request the Engine Company from your station (approx 5 blocks away) to respond for manpower as you move to the ambulance.

The patient's clothing is removed and abrasions are noted on the left arm and leg, the patient continuse to have no response to painful stimuli. 02 via NRB is placed, and vitals are as follows, BP 70/40, HR 38, Resp 10-12, EKG-Sinus Braycardia, Sp02 100% on 02. Bilateral 16g IV are established, and BVM ventilations w/OPA replace the NRB. On arrival of the Engine Company (approx 2min later) you instruct your officer "I just need a driver, lights and sirens, fast, go now." En route a approx 200cc NSS is admin for hypotension, 1mg Atropine is admin for Bradycadia, the heart rate increases to 90, the hospital is notified and you arrive within 3min.

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On arrival at the Trauma Center the patient is intubated after several attempts, assessed and found after scans to have serious brain injury.

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I'm looking for what you would have done/or do differently in this situation. Also any specific studies in regards to Braycardia and the use of Atopine in these patient's.

 

[Apollyon]

This patient sounds fubar-ed, but the external package is intact. You had minimal time on location, and the vital signs are not a classic "Cushing's triad", which, instead of herniation, makes me think the brain-box is just mush, instead of increasing ICP. The atropine isn't bad, but you're trying to put Humpty Dumpty back together.

I am happy that you did not "stay and play". The prognosis is not good (to be euphemistic).

Immobilized, recognized what you had, and got the right patient to the right place at the right (best as was possible) time. You did the right thing.

 

[kungfufishing]

I'd have not wrecked the car. The rest of it is pretty futile.

 

[Hawkeye Kid]

This patient sounds fubar-ed, but the external package is intact. You had minimal time on location, and the vital signs are not a classic "Cushing's triad", which, instead of herniation, makes me think the brain-box is just mush, instead of increasing ICP. The atropine isn't bad, but you're trying to put Humpty Dumpty back together.

I am happy that you did not "stay and play". The prognosis is not good (to be euphemistic).

Immobilized, recognized what you had, and got the right patient to the right place at the right (best as was possible) time. You did the right thing.

Agreed. This is all I would ask for/expect from EMS. Sounds like you appropriately assessed, triaged, treated, transported. The atropine part is probably debatable, but I've done the same in the ED and probably would again. Based on the info you had, the biggest thing the patient might need is a neurosurgeon, and you got her closer to that as fast as possible.

 

[leviathan]

Sounds good. I'd hold off on the IVs until you're en route to hospital, but in this case it sounds like you were held back waiting for a driver to arrive anyway.

 

[DoctorMedic]

sounds like what i would have done. she needed diesel and a few thousand prayers, guess she probably got one and not the other

 

[diphenyl]

Sounds like a great job. You followed protocol. You decided to bag her w/ a BVM which was a great decision, with all that head trauma the best place to try and tube her would be in a trauma bay. Atropine great choice once those large bore IV's were in. Quick response time and quick transport time. Couldn't have gone any better.

 

[emtcsmith]

Obviously in urban EMS you can hit a trauma center within 5-15min regardless of your location in the city, so our typical practice in "leg trauma patient's" is the first IV on scene while the other is removing the cloths, airway, ekg, etc and the second en route. I've found at least that the typical 30-60sec it takes to start the IV is better spent in the controlled setting then buring down the highway and hoping its in place by the time you get there.

I'm hard on myself and my partner about sticking to the 10min and under rule for trauma patient's and typically we are right at or below that mark. This call in specific we were on scene for 11min, some calls are much shorter because we arrive after the Engine Company who should/does have these patients already packaged when we arrive.

We had a similar case a few weeks back where a ped was hit by a car at a high rate of speed and I chose intubation on scene/en route. That patient had agonal respiartions with blood in the airway and more obvious external injuries. It was likely in retrospect that the patient "looked" dramatically sicker and that is why I went for the advanced airway. Once this patient recieve BVM, then ETI ventilations there heart rate improved from the 40's, unlike the bicycle patient who regardless of how the airway was address the heart rate didn't improve. For the record to the PA ALS protocals don't have a specific "traumatic bradycardia" section just a general Trauma, then treat specific issues or "Bradycardia" under the Cardiac Section.

 

[canjosh]

Do you not automatically get an engine with a reported MVC?? WTF?

I would have gotten over a liter of NS in, but it's not clear from your story whether you gave 200cc and then TKO'd, or if 200cc is all that had time to infuse. Not that the outcome would have been any different.

 

[leviathan]

Do you not automatically get an engine with a reported MVC?? WTF?

I would have gotten over a liter of NS in, but it's not clear from your story whether you gave 200cc and then TKO'd, or if 200cc is all that had time to infuse. Not that the outcome would have been any different.

At a systolic of 70 I'd probably be doing 500 cc boluses at most and seeing the response to make sure they stay under a systolic of 90.

 

[emtcsmith]

We got about 200-300cc NSS in and didn't have a second blood pressure, but for what its worth I heard the "two liters wide open" order from a doctor in the hospital after we arrived. So who knows if they simply don't follow permssive hypotension, were going for the 'one for three' idea, or whatever he was thinking.

I believe our policy reads...
A "First Responder Company" (Engine/Ladder) are dispatched to ALS/Trauma Responces when the responding medic unit is responding from greather then three locals over. On "Expressway" Incidents you recieve an Engine, Ladder who responds as a traffic safety Company and medic unit.

 

[ERNerd]

We got about 200-300cc NSS in and didn't have a second blood pressure, but for what its worth I heard the "two liters wide open" order from a doctor in the hospital after we arrived. So who knows if they simply don't follow permssive hypotension, were going for the 'one for three' idea, or whatever he was thinking....

I think you managed the situation appropriately. This patient was hosed no matter what anyone did.

Regarding permissive hypotension, there is a trend toward running penetrating trauma patients drier, but permissive hypotension is much more controversial for blunt trauma patients. In a blunt trauma patient with obvious head injury and significant hypotension, I would give the first liter wide open.