Old 04-30-2013, 22:37   #1
Sdiver
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Right lower leg Fx

Not to be a ghoul, but with a lot of this same type of injury seen in Boston, thought I'd bring this over here. Although the MOI is vastly different, the injury is somewhat similar.

26 year old Male at a party at a creek up in the mountains. Patient has consumed 12-14 beers and smoked liberal amount of recreational drugs. On a dare, decided to jump off the creek bridge into the water below. Due to a recent dry spell the water was only 1 foot deep. 12-15 foot drop.
Bystanders deny LOC due to the screams after the fall. You arrive to find several other equally intoxicated bystanders holding patient down as he is yelling and screaming. PD arrives and wrangles all the drunks up.

SCENE IS SECURE.

Patient complaining of right lower leg pain, and pain to left ankle and bilateral arms. Unable to answer regarding neck or back pain and just screams “My leg hurts”

PMHX – ETOH Abuse, Asthma
MEDS- Albuterol
ALL- Sulfa, Codeine

BP- 72/42
HR – 128 regular
RR- 22 Non Labored
HEENT – Pupils 4mm sluggish, abrasions to forehead
Neck- No crep or deformity
Chest- Intact, Bruising and abrasions to right mid axillary
Abd- Soft NT/ND, No obv trauma
PEL- Intact
Extrem- Open FX to right lower, unable to find pulse in foot, + sensory, grips good
Neuro- other than above intact.

You are up in the mountains. Drive time to Level I trauma center 75 minutes.
Helo is available .... 12 minute spool up time, with 35 minute flight time to LZ set up by PD.
LZ is 10 minute drive time from POI.

What is your treatment going to be?
How will you immob this?
Any Special Considerations or concerns?
Attached Images
File Type: jpg leg.jpg (42.1 KB, 110 views)
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Old 05-01-2013, 10:24   #2
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What is my level of license?
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Old 05-02-2013, 18:33   #3
Scamilton
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TQ immediately on the leg. Have my buddy perform manual c-spine stabilization as I administer 15 lpm O2 by nasal cannula. Before we get him on a spine board, establish vascular access and begin with 1L NS fluid bolus.

Splint the leg with whatever is available. I would have an articulating splint ready that I would have made, and kept available on my rig. Pad with abdominal dressings to cover the exposed skin and keep it from moving within dead space of splint. Log roll the patient, check the back for any other trauma, place onto spine board. Secure to spine board, reassess splint and LOC. Make my first movement to helo LZ and reassess all vitals en route.

I would not worry about the arms if there was no signs of gross manipulation, and radial pulses are present. The ankle is the least of my worries, because this guy would prob lose the leg below the knee, and at the least lose most functionality.
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Old 05-02-2013, 19:36   #4
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Originally Posted by Scamilton View Post
TQ immediately on the leg. Have my buddy perform manual c-spine stabilization as I administer 15 lpm O2 by nasal cannula. Before we get him on a spine board, establish vascular access and begin with 1L NS fluid bolus.

Splint the leg with whatever is available. I would have an articulating splint ready that I would have made, and kept available on my rig. Pad with abdominal dressings to cover the exposed skin and keep it from moving within dead space of splint. Log roll the patient, check the back for any other trauma, place onto spine board. Secure to spine board, reassess splint and LOC. Make my first movement to helo LZ and reassess all vitals en route.

I would not worry about the arms if there was no signs of gross manipulation, and radial pulses are present. The ankle is the least of my worries, because this guy would prob lose the leg below the knee, and at the least lose most functionality.
Very, very good initial response/treatment. However, I think this patient may already be in stage 2 shock (compensatory stage) i.e. hyperventilation, BP, pupil response (may be due to EtOH). Given the lag time to the hospital this patient could progress rapidly to irreversible shock. Concern: may be acidotic already. Consider an ampoule of Na bicarbonate in the IV. I would also push Dextran instead of NS.

Very interesting problem by the way. Not to be insensitive to the patient since he has the worst end of this deal.
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Last edited by Trapper John; 05-02-2013 at 19:40.
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Old 05-02-2013, 21:07   #5
Sdiver
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Quote:
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What is my level of license?
What ever you currently are now. Practice within the scoop of your certification, but go ahead and think what you would do at the next level, ie. Medic level, PA, ect.

Quote:
Originally Posted by Scamilton View Post
TQ immediately on the leg. Have my buddy perform manual c-spine stabilization as I administer 15 lpm O2 by nasal cannula. Before we get him on a spine board, establish vascular access and begin with 1L NS fluid bolus.

Splint the leg with whatever is available. I would have an articulating splint ready that I would have made, and kept available on my rig. Pad with abdominal dressings to cover the exposed skin and keep it from moving within dead space of splint. Log roll the patient, check the back for any other trauma, place onto spine board. Secure to spine board, reassess splint and LOC. Make my first movement to helo LZ and reassess all vitals en route.

I would not worry about the arms if there was no signs of gross manipulation, and radial pulses are present. The ankle is the least of my worries, because this guy would prob lose the leg below the knee, and at the least lose most functionality.
Are you sure you'd want to establish an IV first before extracting the Pt from the area?
This guy is a definite "Load and Go" .... Chopper GO !!!!
You could get the Pt. on a board, away from the creek bed (remember you're 12-15 feet away from the road on an incline, and figure another 10 to 25 feet away from your rig) get him up the hill, load him up and have partner start driving to LZ and establish lines, meds, ect.
Helo has another 25 minute flight time to your location.

Get him into your "world".

Also not to nit pick but, "15 lpm O2 by nasal cannula" ..... ?????
Remember what the flow rates (as well as percentage of O2 delivered) are for the various O2 delivery systems:
Nasal Cannula; NC
Simple Mask; SM
Non-rebreather; NRB
Bag valve mask; BVM

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Old 05-02-2013, 23:21   #6
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WTH. PTSD D&D?

Quote:
Originally Posted by Sdiver View Post
Not to be a ghoul, but with a lot of this same type of injury seen in Boston, thought I'd bring this over here. Although the MOI is vastly different, the injury is somewhat similar.

26 year old Male at a party at a creek up in the mountains. Patient has consumed 12-14 beers and smoked liberal amount of recreational drugs. On a dare, decided to jump off the creek bridge into the water below. Due to a recent dry spell the water was only 1 foot deep. 12-15 foot drop.
Bystanders deny LOC due to the screams after the fall. You arrive to find several other equally intoxicated bystanders holding patient down as he is yelling and screaming. PD arrives...
Any Special Considerations or concerns?


At my level of license...

D20 +/- modifier=6 Roll!

+="I have a belt. You have a ten minute taxi, some recreational drugs to smoke, and the credit you deserve."
-=The party probably had an after hours elsewhere. You have a ten minute taxi and I don't pray for idiots. You had better give me that belt back. That's encouragement."

At my level of license of course. The questions are great. Keep them coming!
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Old 05-03-2013, 09:02   #7
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No go on the sodium bicarb without labs. The body can tolerate acidosis better than alkalosis.

Also other drugs on board not known ie meth, heroin etc etc. You never really know for sure.

Why the Dextran? He needs a MD and good chance he will loose the leg. Notice the bleeding is minimal from the photo so the vessels may have already closed off from bleeding on the leg. Unknown internal injuries. I know the military is pushing the blood expander but again it may open up the wounds and cause more blood loss in the long run. If he is hypovolimic more fluid without the red blood cells does not help carry O2.
Disagree on Na Bicarb. Don't have time to wait for labs. Patient already in the Compensatory stage (stage 2) shock. An ampoule of bicarb in 1 L of IV won't push patient into alkalosis.

Other major concern: Patient is asthmatic. Need to have Theophyline ready.

My assessment: Patient has already lost 2+ L of blood. Bleeding is controlled by the excellent response of Scamilton. Leg immobilized. Moved out of stream bed and up to vehicle for transport and pick up. IVs started. Physical assessment does not show signs of internal bleed (didn't fall far enough, leg took the brunt of force, bad PLF form ) or other life threatening injury. Possible head injury. Watch for bilateral pupil response. Can't treat this anyway. Dextran - yes (blood expander). O2 started. All efforts should be directed towards preventing the progression of shock. Next crisis is respiratory - likely. I am anticipating the need for the IV Theo.
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Old 05-12-2013, 21:29   #8
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Yep, we should move that down to 6LPM via nasal cannula. Hah! Rookie mistake!

And I agree with the thought of getting vascular access in the vehicle. Reason I said immediately is, because he may have already lost a good amount of blood and I'd want a saline lock in now in case his veins degrade rapidly. If I don't have to go IO on the dude, I don't want to.
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Old 05-30-2013, 01:25   #9
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Agree on the early vascular access, though I'm probably leaving drip at TKO saline after I get his BP around 80 unless his vitals get worse. From your description of patient I'm worried about possible internal bleeding in head and the alcohol/narcotics complicate a difficult assessment. I'd be trying to maintain his systolic around 80 and I think it's hard to manage safely with delayed action of volume expanders. Also maybe it's implied in the assessment with asthma, but how are his right lung sounds? I feel like his fall was leg, torso/shoulder, face check.
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