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.

21 November 2013

Scenario of the day...part II


The "Scenario of the Day" was presented here. If you did not check it out, go on over.
OK…in looking at what you were presented, it is apparent that the driver struck the deer and veered off of the roadway then overturned. The signs and symptoms presented, along with the vital signs, suggest that the patient is hypothermic, highly probably given the patient’s age and the ambient surroundings. The inside of the vehicle being ‘covered with newspapers’ was an indication that maybe this guy is a newspaper delivery person and this occurred a little while ago and was only recently discovered. Nobody specifically asked, but that was the deal.
Couple of points about the vital signs-

As the body’s core temperature cools the blood pressure drops, the heart rate slows, peripheral pulses fade out, and the respiratory rate slows. If you cannot get a good blood sample, you may get to get the ‘error’ message on the glucometer and you are probably not going to be able to get a good sample. The temperature is a deal clincher, but then the ECG provided the next big clue- Osborn waves, which are prominent as the core temperature goes below 90°F. Blankets are in order- surely more than one. And be wary of exposing the patient- we have to, but remember that the body loses heat by way of convection and radiation. If it is cold outside, put a blanket on the backboard to act as a little bit of a barrier between the patient and the cold backboard. And don’t forget to warm up the ambulance. If you’re comfortable, it ain’t warm enough- turn up the heat.

Even though the SPO2 is only 62%, remember, that peripheral circulation is slowed due to vasoconstriction during hypothermia, which reduces the ability to get a good reading with a pulse oximeter. The lack of cyanosis could be a good clue that the patient is still oxygenating. Given that we lose body heat through respiration, judicious use of oxygen, especially arbitrarily via NRB, should be considered.
Given the patient’s depressed mental status, it is reasonable to go with spinal motion restriction precautions (be alert to potential airway compromise if the patient vomits). There are no apparent extremity injuries, and even though many would consider the blood pressure as ‘low’, it is still above 90 mmHg systolic, so be judicious with the fluids. Also, ‘warmed’ fluids would be appropriate, but be careful not to rewarm the patient too fast. Don't have an IV fluid warmer? There are some ways to accomplish that, but...you're not trying to rewarm them, just stave off the continued drop.

With the fast extrication he obviously was not pinned. There were no obvious injuries, however, just due to the GCS and his age in the setting of a potential traumatic event, he meets Trauma Notification Criteria per CDC guidelines. However, that does not necessarily indicate flying him out. With the short drive time, it will be doubtful if there is any true time savings going by air. If you're not going to save any clinically significant time, why bother. I know, helicopters are sexy.
Cancel the bird.
But what if the helicopter lands? Well, if the patient needs it, and the helicopter is going to save a significant amount of time, the put them on it. But, when you figure in the turnover time, the loading time, the take-off and flight time, along with the off-loading time and going into the hospital, you are not saving anything over a 20 minute ground transport time. This guy is fine to go by ground.

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