Scenario...with dual applications(TBI)

[shadowflyer]

We havent done a scenario in quite awhile and I was thinking of something that could be interesting and could relate to something any medic could encounter.

PT is found laying left lateral recumber unconscious and unresponsive with blood coming from his mouth and nose. Male in is mid 20's snoring respirations noted. Pt is displaying signs of decorticate posturing. PT was witnessed as having taken a fall of about 8 feet from a moving bicycle as he was doing tricks on it. PT was not wearing a helmet. No known history or allergies noted. Pupils noted to be unequal and unresponsive to light.

Possible twist to that scenario could be intersection of MSR Tampa as a humvee has collided into the back of another Humvee secondary to an IED intiation. You as the medic notice a soldier laying outside the humvee without his helmet on displaying the same symptoms as our bike rider. Oh by the way ...you are taking small arms fire by this time and as you make it over to the PT a RPG wizzes over your head narrowly missing the humvee you are near.

Assume the skill level of a paramedic/(18D) or higher in both scenarios.

Lets discuss how the stabilization and treatment and care of the 2 patients will differ from the Civilian world to the Military scenario.







Hope this will be educational for everyone and spark some good discussion.


Jason
NREMT-I85/GAEMT-I

[The Reaper]

I think you mean RPG.

IMHO, the best thing you can do for a patient under fire is to return effective fire.

TR

[shadowflyer]

I agree 100 percent Sir. Hopefully I wont have to use any of my skills while I am in Iraq. I would be tickled pink to come back with no casualties.


Best Regards,

Jason

[fran]

I'm a grunt with no medical training who wants to be an 18D; I hope I'm not stepping on any toes by taking a stab at this.

According to google and my CMDT, the decorticate posturing and unresponsiveness point to contusion or lesions at or just above the brain stem. The unequal, unreactive pupils indicate a rise in intracranial pressure, which is potentially life-threatening.

I'm guessing the blood from his nose and mouth suggests the impact was to the face, which seems consistent with both bicycle and vehicle accidents.

The stabilization options I can come up with are the same for both scenarios, except the IED one starts off with "METT-T depending": roll the patient from his side onto a spineboard; he's now on his back and bleeding into his mouth, so airway management is obviously a concern. How risky is it to emplace an endotracheal tube on a guy with a brain stem injury?

I'll leave the treatment and care questions alone.

Fran
:munchin

[AF IDMT]

Civilian: Check the back for any deformities, since it's already exposed. Place a C-collar and get the long board behind him for the log roll. Do I have Life Flight? If so I'd use them. Blood from the mouth and nose makes me wonder about a Le Forte fx. If my civilian protocols allowed it I would criq him. Do my rapid assessment looking for any other bleeding/deformities and treat as and when appropriate. Sink two 14-18 gauge IV's depending on what I could get in. I would keep them running very slowly until I could get a BP. I would think that with his skull possibly filling with blood if I start flooding his system with a bolus of fluid that will only make the problem worse. Get a set of V/S and start all over with my assessment while I either wait on the chopper or in the back of the ambulance while we are hauling @$$ to the nearest trauma center.

Military: Shoot back. When shooting stops I would c-collar and KED him (probably won't have a long spine board and may not have a Ked.) Again, how far from help am I? Can I call for an evac or are we it? Rapid trauma assessment looking for bleeders and plug any holes I find. Once that is done I'd start dealing with the airway. If I am able to take the time I would secure his airway with a criq and then get some IV access. Once we have determined how we are going to get the pt to the next echelon of care I would reassess him as we are transporting or waiting for transport.

Hmmm, I feel like I'm forgetting something, but it's not coming to mind right now.

:munchin

[x SF med]

There is Head and Neck involvement - no question - how bad is it?

airway- snoring respirations w/ brb(?) from mouth and nose suggest upper airway involvement - possible broken nose, possible larynx fx if air is passing, continue assessment.

bleeding- partially assessed in airway, any missing/broken teeth?, is tongue intact? any other facial involvement? full body check for blood or fx.

any deformities noted with scalp/cranium? any deformities in c-spine/t-spine. what is the position of the head in relation to the rest of the body - abnormal twist? decorticate is bad! follow spinal column down check for lower deformity.
collaring depends on head position/deformities found -current placement stabilization may be indicated dependent on the presence of C,T, Axis or Atlas deformity (don't fuck with moving a neck back injury out of position)- board is indicated - in current L lateral recumbent position if possible. Due to nature of incident - foosh bilaterally is expected, bilateral knee involvement expected, abdominal/pelvic/ thoracic involvement highly probable.
2 large bores, set TKO - volume depends on bleeding versus change in GCS and pupillary state showing change in tracranial pressure - volume can kill the guy - either too much or too little...
Vitals q 5-10 min -constant reassessment until the cavalry arrives
Transport expeditiously!!

In the combat situation - where is the fire coming from? What's the cover/concealment like, is there backup? What size is your Team/Group/detatchment? Tx wants to be consistent with above based on situation and terrain - save yourself and Team first, protect Pt as best as can be done w/o compromise of Team. Use your weapon. Use common sense. If the only way to save the Pt is to move him unceremoniously - so be it, but will this movement cause further injury or exacerbate those already noted, if so it's life vs. quality of life - and you need to know your Teamies' wishes. What's the team SOP on critically injured in a bug-out? Always give the best care for the situation, but never compromise others. There is no good answer in the combat situation - none, period.

Sorry if the combat answer freaks some of you out, unless you are there, you just don't know what you will really be able to do while it's hot.

[Rumblyguts]

Hello,

Great thread. I'm just a prior grunt who had CLS back in the 90's and have had a Wilderness First Responder cert erver since. I'm curious about two things that I've seen in this thread.

First, there's a difference between x_sf_medic's and AF_IDMT's civlian scenario posts. X_sf_medic's post is very much lined up with the ABC's and primary/secondary surveys. AF_IDMT's seems to be jumping around a bit with doing complete spine imobilizatoin then continuing on with his "rapid assessment" (which I'm interpreting as the primary survey).

I understand the need for spine immobilization, but in my trainings, I would have been gigged for not completing the primary survey before complete immobilization. Note the head and neck trauma, immobilize neck to best of immediate ability, see if the airway could be quickly cleared (if not, at least there is air getting in), and finish the primary survey (looking for massive bleeders) without disturbing the patient's positioning. What I'm getting at is getting stuck on the first injury (TBI/spine which is somewhat stable and not much can be done for it, or if done correctly, could take several minutes to move and board) as opposed to finishing the primary sweep looking for more immediatly life threating injuries (bleed-outs). Does that make sense? Am I just nit-picking?

The second deals wiht the IV's. I don't know much about IV's, and don't plan on using any. I'm just wondering why the IV's were started. Is it to expedite future Tx's (med deliveries)? As noted with the TBI, brain pressure apears to be the issue, so why start an IV? Again, IV's are a dark area for me (other than CLS), so please be gentle :)

Hopefully this post made sense. I'd apreciate any input.

Thanks,
Bill D.

[x SF med]

Bill-
I'm an old, out of date 18D - get air in, stop blood out, finish primary; start IVs; start 2ndary; then immobilize, patch, and transport if possible.

IVs are to allow for any Meds needed, or to increase volume if needed later - ICP requires that little if no extra fluid be introduced, but bleeding, and possible abdominal injuryu with internal bleeding may require volemic stabilization - this guy's a mess - you are damned if you do, and damned if you don't. The doctor is going to appreciate the fact he's got entries already in place for his IV meds, and the entry is at TKO so the volume s/b <=10 gtt/min/IV an insignificant volume since there was bleeding noted. My Tx could be completely wrong by today's standards - head+neck+back+probable internal injuries - this guy has to get to a trauma center 30 minutes ago. All I want to do is keep the body functioning long enough for a Doctor to call the code.

[Rumblyguts]

X_sf_medic

Yep, what you are saying makes sense and works with what I know. As you say, this guy is in bad shape. The abreviation CTD comes to mind. At least it looks like he's in an urban setting.

Thanks for the input.

Bill D.

[AF IDMT]

Hello,
AF_IDMT's seems to be jumping around a bit with doing complete spine imobilizatoin then continuing on with his "rapid assessment" (which I'm interpreting as the primary survey).

True statement. My reasoning for doing the spinal imobilization early was this: He's on his side already, check his back and roll him onto the board so that I can get a better look at the rest of him without having to move him too much. Flawed, though my logic may be, that was what/how I was thinking at the time I answered this.

[Rumblyguts]

No problems, I understand where you're coming from.

Thanks for extra "inside" info :)

Cheers

[18C/GS 0602]

Shadowflyer- great thread. Thanks for posting.

A few points about the case-

1. TBI: With traumatic brain injury the most important things you can do in the pre-hospital environment is to insure good cerebral perfusion pressure (the pressure driving blood to the brain), and good oxygenation. With TBI there are areas of brain that are injured, but have the potential to recover. With hypotension or hypoxia you end up not getting enough oxygen and nutrients to the area of potential salvageable brain, thus causing irreversibly injury. Although current teaching is to use hypotensive resuscitation, this patient does have a TBI and he should receive aggressive fluid resuscitation. Because of the need for optimal oxygenation, and given that this guy is not protecting his airway he probably needs be intubated. A nasotracheal intubation should not be attempted because of his likely facial fractures.

2. Other injuries- In the IED scenario it is very easy to overlook injuries because you are distracted by the significant head injury. Yes this guy has a very bad head injury that might eventually be fatal. However, he might also have shrapnel wound to his upper back causing a tension pneumothorax that could be fetal in the next few minutes. Important things like small entry wounds can be very easily missed when there is a big distracting injury. That is why primary and secondary surveys are important, and why you always want to evaluate trauma in the same systematic way so you do not miss anything. Obviously being in a combat environment makes this even more difficult, and not always possible.

[82ndsig]

Hey,
I didnt see anything about having suction ready (V-Vac), or 02 applied (lack of would dialate the sinus's in the brain causing further compression right?), form a perimeter civilian or military, the lookee loo's get in the way, get ALS enroute ASAP chopper or ambulance, LB IV's TKO, C- Collar, longboard (secured to), Headbed or Tape, Assess, assess,assess.

[x SF med]

82ndsig - as a first responder in the situations mentioned - you generally are not carrying either suction nor O2 - I guess I could use my Pela 6000 oil extractor if it happens to be in the car as a civilian - but that's really not even clean. I took the scenario to mean that you had the gear you would normally carry as an 18D or a field paramedic without an ambulance.

[AF IDMT]

Shadowflyer- great thread. Thanks for posting.

A few points about the case-

1. TBI: With traumatic brain injury the most important things you can do in the pre-hospital environment is to insure good cerebral perfusion pressure (the pressure driving blood to the brain), and good oxygenation. With TBI there are areas of brain that are injured, but have the potential to recover. With hypotension or hypoxia you end up not getting enough oxygen and nutrients to the area of potential salvageable brain, thus causing irreversibly injury. Although current teaching is to use hypotensive resuscitation, this patient does have a TBI and he should receive aggressive fluid resuscitation. Because of the need for optimal oxygenation, and given that this guy is not protecting his airway he probably needs be intubated. A nasotracheal intubation should not be attempted because of his likely facial fractures.

Since reading this post I am wading through my fourth TBI article with many more to go. One item I did run across was the statement that hyperventilation while useful in controlling intercranial pressure due to vasoconstriction if continued long term (relative?) could prove harmful due to lack of blood flow to the injured area. My question is in a field setting at what point do you stop hyperventilating the patient if you have a long transport time to the trauma center? I am still trying to find some more info on fluid resuscitation but I haven't , , , yet! :lifter

[18C/GS 0602]

Since reading this post I am wading through my fourth TBI article with many more to go. One item I did run across was the statement that hyperventilation while useful in controlling intercranial pressure due to vasoconstriction if continued long term (relative?) could prove harmful due to lack of blood flow to the injured area. My question is in a field setting at what point do you stop hyperventilating the patient if you have a long transport time to the trauma center? I am still trying to find some more info on fluid resuscitation but I haven't , , , yet! :lifter

Hyperventilation is used to treat patients with increased intracranial pressure. It causes vasoconstriction, which prevents blood flow to the brain. In patients with bad head injuries they have an increase in their intracranial pressure and by decreasing the amount of the blood flow to the brain you decrease the pressure in the brain. Decreasing the blood flow to your brain is not always the best thing to do. In the past people were pretty aggressive about hyperventilating patients with significant head injuries, but as you mentioned there have been some new studies that showed that prolonged hyperventilation can be harmful. The practice pattern by the neurocritical care people at my institution is to withhold significant hyperventilation until a patient appears to be herniating. In this particular setting the patient appears to be herniating and it would be indicated to proceed with hyperventilation. If I was taking care of this patient and I was in the field I would hyperventilate him as long as it takes regardless of transport time given his significant head injury with likely herniation.

Here are some good articles about fluid resuscitation.

1. Butler, F K Jr; Hagmann, J; Butler, E G. Tactical combat casualty care in special operations. Military medicine. 1996; 161 Supplement: 3-16.
2. Bickell WH, Wall MJ, Pepe PE, Martin RR, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. The New England journal of medicine. 1994; 331: 1105-1109.

[AF IDMT]

Here are some good articles about fluid resuscitation.

1. Butler, F K Jr; Hagmann, J; Butler, E G. Tactical combat casualty care in special operations. Military medicine. 1996; 161 Supplement: 3-16.
2. Bickell WH, Wall MJ, Pepe PE, Martin RR, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. The New England journal of medicine. 1994; 331: 1105-1109.
Thanks, sir!