If, in moving through your life, you find yourself lost...go back to the last place where you knew who you were, and what you were doing, and start from there. Bernice Johnson Reagon.

19 November 2013

Scenario of the day...(UPDATED)

You are dispatched for an MVC at 06:33. The location is on a rural road approximately six miles from your station. A fire officer arrives, establishes command, and tells you that you have an elderly male, unresponsive, and entrapped in the vehicle. Command notifies the dispatch center to “put a bird in the air”.
You arrive to find an approximate 65 year old male in the driver seat.  Damage is as noted in the picture. There is no passenger compartment intrusion and the patient appears to have his seat belt on. The inside of the vehicle is covered with newspapers (dozens and dozens of them) and many more are on the ground around the vehicle.
First look at the patient- GCS 1-1-1, RR 12 shallow and snoring, pale looking skin.

There is a large, dead deer lying along the roadway near the crash.

It is early morning, the sun is rising, it is cloudy, 34° F, 54% humidity, and the wind is at 15 mph out of the SW. Traffic is light. You have an EMT for a partner. You have a QRV-based supervisor within 15 minutes; your next nearest ambulance is 20+ minutes away.
What are you going to do?


The first vital signs after you get in the vehicle-

BP 94/58
HR 40 weak and irregular
RR 10 shallow and snoring
Pupils equal and reactive
Finger stick gets an ‘error’ reading
Tympanic temperature 84°F
SPO2 is 62%
Skin is pale and dry without cyanosis

The first ECG-
courtesy of Dr. Smith's ECG Blog
 Ground travel time to Level I trauma center is 15-18 minutes. Travel time to community hospital is 15-20 minutes.
The fire department has the patient free within 10 minutes. The helicopter is “five minutes out”.
Patient is exposed- no obvious deformities to any extremities. Chest expansion is equal bilaterally and lung sounds, while faint, seem to be clear. Carotids are faint- radials and pedals are absent. Upon extrication patient GCS is rated at 3-4-5.
You find three pill bottles in the vehicle (you DO take a quick look for such things, don't you?)- levothyroxine sodium, morphine sulfate, and paroxetine hydrochloride.
I have one response so far (Thanks, Cathy!). C'mon folks...
What do you think? What special things (if any) are you going to do? Is there anything different that you might do? Let's hear it.
Note: If you need a bigger copy of the ECG, email me at the address to the right.


Cathy Cockrell said...

Get him out. Full immobilization, expose. Let the bird continue to the scene (depending on time), Get him in the truck, supply supplemental O2, WARM, WARM.....check his sugar, get a line, full assessment. Lungs clear? Pupils PERRL? Treatment with assessment findings.

Anonymous said...

Handle gently, immobilize, notify trauma center, load and go, begin warming pt, O2, IV, fluid bolus, narcan...can't read theEKG because I'm on my cell, recheck FSBS, reassess

Christy Carrothers said...

Handle the patient gently, immobilize, load and go, notify trauma center, warm pt,O2, 2 large bore IV's, check FSBS, fluid bolus, continue to reassess and treat accordingly. 12 lead changes are most likely caused by the hypothermia. GCS is improving, if respiratory drive is not improving then I may consider narcan but I would probably assist ventilations instead unless pupils are pinpoint.

Lance Lynch said...

Peculiar situation to say the least... I'm more worried about ensuing hypothermia than I am the 'trauma' potential - which is still a possibility, however. He was a restrained driver, sustained no 'outward' signs of trauma (can certainly be misleading, I understand) and had no passenger compartment intrusion. Of course, the mechanism warrants spinal immobilization, but I'd also be sure to look for steering wheel deformity, windshield starring, etc. With any type of significant mechanism like this... injuries and morbidity are significantly compounded by hypothermia. As soon as I could make patient access, positive pressure ventilation would be provided and he would be 'emergently' extricated. During extrication, I'd be working with command to find a willing fire fighter to drive us, expeditiously, to the trauma center.

This is a sick patient that has apparently been there for a little while, as evidenced by his EKG. Osbourn waves globally in the EKG indicate that the tympanic temp is likely correct... or closer than we typically give them credit for being.

As soon as possible, this patient goes in the back of my toasty ambulance and is aggressively re-warmed with hot packs and warm fluids delivered IO (humeral).

- To use the whirly bird, or not to use the whirly bird? - I probably wouldn't. With the sudden rise in GCS (possibly due to a lucid interval; head injury) and relatively short transport time to definitive care, I'd venture to guess that BLS airway maneuvers would suffice. We’d probably beat the helicopter to the hospital as well. PPV would be provided PRN and a BIAD would be at hand and ready to go... just incase.

With the pill bottles found, his medical history would be on my mind... as would the potential for an overdose (even though he's currently PERRL). I'd quickly try a milligram or two of narcan IN... I'd avoid IV (if I were lucky enough to be able to land a line) due to the fact that no meds were circulate peripherally.

With the 12-lead findings (which would be obtained en route to the hospital), I'd be interested to see if the osbourn waves were hiding an MI… perhaps a posterior? I’d perform a 15-lead EKG; there is some suspicious ST depression in his septal leads. If the R. ventricle seems to be involved, a rather large IO fluid bolus would be in order - watching, of course for signs of congestion/overload. If the hypotension were refractory to fluid, I'd start a 10mcg/kg/min dose of dopamine.

I'd also repeat the finger stick – but wouldn’t hold my breath for it to work, given the patient’s likely core temp.

All-in-all, This is a Charlie-Foxtrot of a situation that would be best addressed by the 'pro's' at the local trauma/heart center. I'm sure that, after a trauma work-up, a cardiac work-up is soon to follow.

How did all this happen?? I'd be willing to be that this patient recently suffered from 'buck fever' and that the deer lying near the roadway was ejected from his truck bed... where he put it last night after he killed it (Just before he wrecked his truck). As for the news paper - perhaps he was using it to insulate his carharts... it gets cold in those tree stands this time of year and I've seen that done before. I also know a lot of old, arthritic hunters (with scripts for narcotics) that hunt from the comfort of their truck parked in a field and read while they wait for Bambi's daddy... the possibilities are endless; I'm interested to see what happened.

Anonymous said...

move the pt as gently as Px without jarring pt to reduce Px vfib arrest due to low body temp full c spine precautions reassess vitals oxygenate as needed and transport as emergent as possible without moving to quickly to the trauma center. personally would not transport by air unless passive warming was available IV o2 monitor of course.

The Happy Medic said...

Immobilize as indicated, cancel the flying ambulance and get going to the level 1trajma center. If this is a medical zebra lying in wait that level 1 can likely perform PCI if indicated.