Case Week 6 (w/c 07/11/11)
This weeks case takes us into the Pre-hospital arena.
You are working as part of a doctor paramedic HEMS team. You are tasked to attend to an adult male who has fallen from a height. Ambulance control reports that a witness claims the height is at least 3 stories. You have no other information. You are 6 mins away.
Police and a road paramedic crew have also been dispatched. Due to the location it is likely that you will be first on scene.
Describe any preparative steps you will make en-route and what your immediate priorities will be upon landing?
On your arrival at scene you find an adult male. Whilst working on a roof he has fallen through a roof light, approximately 10 metres high.
The scene is safe, other than glass on the floor. It was witnessed by a colleague, who called the ambulance. The patient is still face down when you arrive.
There is a large pool of blood around his head. One leg is obviously deformed and appears shortened.
He is pale, radial pulse is barely palpable. Cap refil time is 5 sec. There is no trace on SpO2. He is making groaning sounds only and doesn’t localise to pain (?flexes)
Describe your next few steps. For the benefit of others, explain any resuscitation efforts including end points?
The patient is carefully rolled into the supine position. The airway begins to obstruct and requires support.
The leg fracture is reduced and a pelvic binder is applied. IV/IO access is obtained and a fluid bolus using radial pulse as an end point is given.
As you begin to prepare for RSI, the patient has a generalised seizure.
How would you manage this? Discuss any drug choices including those used for RSI in this circumstance?
This case is an example of a fairly typical pre-hospital major trauma case. Whilst these cases can often seem very ‘protocolised’ (I would just follow ABC, ATLS etc) in reality they can be very difficult to deal with.
The majority of patients involved in major trauma are young males. Trauma is a serious multi system disease. The socioeconomic burden of trauma is said to be bigger than that of cancer and ischaemic heart disease combined.
One thing that the pre-hospital environment provides practioners, is a better appreciation for the mechanism of injury (kinematics). The clinical information suggested a very significant mechanism of injury (fall from over 6 – 10 foot is considered significant – this case was 10 meters.) It seems appropriate to think about patterns of injury whilst en-route (or waiting for the patient in resus) based on the information available. However, as was mentioned in the discussion, in these cases it is best to be prepared for anything. Information passed via the ambulance service is often third hand and can be very unreliable.
On scene we were presented with a multiply injured patient. He was obviously shocked and it was apparent he had a low GCS, suggesting Traumatic Brain Injury. The important thing to realise here is that this patient is ‘time critical’ and whilst resuscitation involves several processes, a short on scene time is key (Don’t stay and play).
The important resuscitative steps feature in many texts and many people mentioned the <C>ABC approach. There is increasing recognition that control of major haemorrhage should take a high priority as well as a general move toward circulation preservation. The kinematics of this injury open up the possibility of lower limb fractures, pelvic fractures (vertical shear) and abdominal injury, all of which are potential sources of haemorrhage.
As with many situations, there is not one correct answer about how to induce anaesthesia in this patient. The important thing is to recognise the potential pitfalls. Not only is this patient shocked but he has a potential brain injury. Avoidance of hypoxia and hypotension have been proven to be the key factors when dealing with head injured patients.
Anaesthesia for this case should only be practised within a well defined clinical governance system and it is likely that there will be defined protocols for inducing shocked patients and patients with head injury. Whilst the exact agents used can be debated, the most important factor is that the practioner is experienced and comfortable enough with the drug used to understand how to use it in this context.
That being said, Ketamine has gained wide acceptance in the pre-hospital community for a wide variety of reasons (Provides analgaesia, sedation and anaesthesia by varying the dose. Larger margin for error than some other drugs. Cardiovascularly stable. Can be given intramuscularly etc)
The final stumbling block was the patient having a seizure just prior to RSI. This is a very difficult situation as it is a manifestation of the clinical urgency yet may require some additional thought about induction of anaesthesia. Again there is no right answer here as the anticonvulsant properties of ketamine and etomidate are not as potent as say thiopental. They are however much more cardiostable and it is this dilemma that the clinician must face…
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