How would you triage this pt?

[orderly]

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Hey guys,

Had an interesting case at work.

Ambulance service consults our ED saying that they are bringing in a 20 something year old male who has been playing sport. While playing sport he has been elbowed in the right eye socket. Nil LOC can hazily recall the event. BP 110/60, Sp02 98% @ 8L/min, GCS 14. Pt states he is cold, has had nausea. The interesting thing is that the heart rate was fluctuating from around 45bpm to 70 in a sinus arrhythmia (no reported history or arrhythmia).

My facilities trauma rules are:

Level 1 Trauma:

Physiological (worst prehospital or on arrival status):

• SBP: <90
• HR: <40 or >120
• GCS: </=13
• RR: <10 or >30

Injury profile:

• Airway compromise
• Penetrating injury to head, neck or torso
• Flail chest
• Spinal injury with neurological signs
• Femur fracture plus one other long bone fracture
• Amputation or severe crush proximal to wrist/ankle
• Pulseless limg
• Burns >20% BSA or airway burns
• Ongoing uncontrolled significant haemorrhage
• Complex pelvic fractures (eg open book)
• MedSTAR Primary Trauma Retrieval (eg direct from scene)

Level 2 Trauma:

• Ejection from vehicle/death of occupant
• Cyclist (pedal or motor) or pedestrian vs vehicle over 30kph
• Prolonged extrication (>30mins)
• Fall >3m
• MedSTAR Secondary Trauma Retrieval (eg interfacility transfer)

IAT - Injury Assessment Team:

Call out used when ever the triage nurse believes that the patients injuries would be best managed in the trauma rooms. A broad definition so the triage nurse can use their experience and feel for how busy the department is to make this call.

Examples:

• The patient is just outside level 2 criteria but triage are still concerned
• Significant pain to multiple body parts
• Neurovascular compromise
• Pain management

Triage nurse decided that the pt did not meet L1, 2 or IAT criteria and triaged as a priority 2 to the normal diagnostic area of ED. Paramedics felt it was best for him to go to Resus/trauma rooms. Pt said he felt cold and was visibly shaking. I said I would get him a warm blanket, but the Paramedic said to check with the nursing staff first because the temperature of the blanket could cause vasodilation which would cause hypotension which could cause him to faint. The pt's BP was fine at this stage.

On arrival to the cubicle in ED after being connected to the ED monitor, his heart rate decreased to 39 bpm which made the nurses call a Critical Response Team to his cubicle. Upon arrival of the ED Consultant, his heart rate was back up to around 70.

How would you have triaged this patient? Do you think he should have been in the trauma rooms?

 

[Arcan57]

What would you do for the patient in a trauma room that you couldn't do in a monitored bed? It doesn't sound like he was bradycardic secondary to large intracranial hemorrhage. Likely he was bradycardic because of the eye trauma, which is activating the ocularcardiac reflex. Important points in triaging the patient would be to make sure BP is stable (young people tolerate bradycardia relatively well), document visual acuity and pupil reactivity, assess for other injuries and get them to a monitored bed.

 

[orderly]

Just be dealt with quicker. Have a trauma series of xrays done. Paramedics added as a side note that the pt was complaining of high cervical neck pain, but didn't appear too troubled upon examination by the triage nurse.

I personally think the right decision was made, his only problem aside from the trauma to the face was the bradycardia, but it was noted he was returning to a nice rate autonomically.

Was given a small amount of Morphine and Maxalon on route. The morph would not help the heart rate either.

 

[tremulousNeedle]

What would you do for the patient in a trauma room that you couldn't do in a monitored bed? It doesn't sound like he was bradycardic secondary to large intracranial hemorrhage. Likely he was bradycardic because of the eye trauma, which is activating the ocularcardiac reflex. Important points in triaging the patient would be to make sure BP is stable (young people tolerate bradycardia relatively well), document visual acuity and pupil reactivity, assess for other injuries and get them to a monitored bed.

👍 I definitely agree with all this.

Also, 1 blanket stat, non-warmed if you share the paramedics concerns about vasodilation. Based on the information you provided I would have low concern for an adverse response to warm blankets (sinus arrhythmia in a young athlete with an isolated potential eye injury gives me low concern for hemodynamic instability - at least with the vitals and story you described). 🙂

 

[deleted65604]

It is not my job to triage. I leave that duty up to the triage nurse, who will do what they think is appropriate. I hope that they don't second guess my decisions without a complete set of information and I try not to second guess theirs without additional information. Trauma bays are nice to have critical patients in because they are roomier and can fit more supplies in. What is the worst case scenario here? A brain bleed? Not something that is going to require a bedside procedure on.

 

[orderly]

I'm not second guessing the triage nurses decision, she is very able and experienced and knows her stuff. Nor am I attempting to degrade the Paramedics, something can look a lot worse out in the field compared to the relative safety of a level 1 trauma centre/major teaching hospital. It was just interesting to see the debate and I thought it would be interesting if this debate continued amongst you guys as well, so far it seems that you all agree the right decision was made, which I think too.

I was also keen to hear the physiology behind the bradycardia, which has been explained to me now, so if I get the same problem when I'm a Paramedic, I'll relax a bit!

I did think the blanket thing was a bit silly though, hard to believe a warm blanket will vasodilate someone so much that their normal BP will drop to syncope levels.

 

[deleted109597]

He would go to the waiting room with a blanket. He got elbowed in the eye, not hit with a Holden.