1) The Story.


You respond to a call about a 27 year old male who flew off his dirtbike without a helmet. The accident was not witness and the man was found by another biker laying on the ground making "grunting sounds".


On arrival the story you get from EMS is:


EMS was called to a local area known for offroad dirtbikes and ATVs. Calls normally double on the weekend and holidays, its sunday. EMS arrived and had to trek 10 minutes by foot to get to the patient. On their arrival they stated they found this unidentified 27 year old male on the ground face up being attended to by the local biker who found him.


EMS has already started an IV and is bagging the patient on your arrival. He has a huge full thickness lac/avulsion on his forehead and the skin is basically crushed. You also note there is signifigant blood comming from his mouth and EMS is suctioning with a V-Vac (bwhahaha) without much success. Lastly, you note his left eye has a lac below it and has suffered some trauma. It appears he has bilateral midshaft femur fractures. He is being held in cspine by the EMT and bagged by the medic. Pt is grunting.


EMS only arrived 5 min before you. They do not have the monitor hooked up yet.


Pt is wearing a full offroad motorcycle suit extending from bottom of mandible to top of ankles.


2) History


UNK

3) Meds


Unknown

4) Allg.


Unknown

5) Obvious Pertinent Physcial findings


- Pt has ALOC

- Pt is not ventilating appropriately

- Pt has bilat femur fx's

- Pt has facial/eye trauma

- Pt has airway anatomy trauma

- You note blood on face & Scalp


Vitals On arrival:

None taken.


6) Images


All examples not actual patient.

http://i36.photobucket.com/albums/e44/mmackinnon/case%209/MH-before.jpg

http://i36.photobucket.com/albums/e44/mmackinnon/case%209/lantrau1.jpg

http://i36.photobucket.com/albums/e44/mmackinnon/case%209/mandi01.jpg

http://i36.photobucket.com/albums/e44/mmackinnon/case%209/814315.jpg

7) Discussion Points


The discussion points are:


Facility appropriateness

Possible secondary Differential Diagnosis

Concerns

Treatment plan


Issues:


Nearest trauma center is 45 min by rotor.

 

I will add more later

discuss...................

Well, first we need to remember our ABCs. Sounds too like there is most likely a head injury with his grunting and the fact that he was found face down. We can make a pretty good guess that he has some internal bleeding going on.

Better get some vital signs on this guy

Working Diagnoses’.  1. airway obstruction

                               2. Thoracic Injury

                                3. Traumatic Brain Injury

                              4.   Femur Fractures

                              5. Pulmonary injury

                               6. Internal bleed

I would think that you would want to get any bystanders away from there and keep the place as quiet as possible. Get all the ATVs and bikes as far away as possible.

Level 1, but seeing it's 45 mintues away I'd go to Level 2 if there's one closer.


Diff Dxs without much of an assesment:


1) TBI/ICH/Basilar skull fx/Frontal skull fx

2) Upper/large airway disruption

3) Airway Obstruction

4) Pulmonary Injury/Pneumo/Cardiac Tamponade

5) Thoracic Injury/Large vessel Injury

6) Bilat femur fxs


Concerns:

1) Complete airway obstruction from blood/teeth

2) Herniation from TBI

3) Blood loss/shock from femur fx's and possible

thoracic injury

4) Pulmonary Injury/hemo, pneumo, or

hemopneumothorax including Pulm. Contusion


P: 1) BSI, scene safety,

2)Airway-jawthrust, suction/ simple adjunct

until intubation. YES, I would intubate this

guy RIGHT AWAY. RSI with additional airway

adjuncts at my side ( combitube, surgical

cric, and bougie)

3) Breathing- assisted ventilations for grunting.

Grunting is a bad thing. CLEAR airway prior.

Assess breath sounds. Decompress if

Indicated. What are the LS by the way?

4) Circulation- Skin temp,conditoin, color?

Peripheral pulses present? Rate? Quality?

CONTROL major bleeding.

5) SOMEONE get some vital signs while

ANOTHER does a QUICK assessment.

Vital signs to INCLUDE pupils, and heart

rhythm and GCS? Posturing? FSBS?

6) Stabilize femurs with traction if not

contraindicated. I would consider MAST

also if traction not available. EXPOSE!!

7) Start a second PIV ASAP( preferably in

heli. seeing he has 1 IV already). If

hypotensive adminster 2L of NaCl.

8) Haul butt to the helicopter. Have

Mannitol ready as well as other meds.

yup, that's where we first discussed it .

now ya gave away all the answers

another spot for CCS some with final  testing results

http://www.neuro.jhmi.edu/MedScape/index.html

First thing, a rapid head-to-toe to find all other injuries.  First in EMS stopped at Airway, though why they did the IV before the VS is kinda backwards.  With all the blood in the oropharynx, a rapid induction sequence may be helpful for intubation and patient movement.  The grunting resps is an indication of a possible flail chest and BVM is the best treatment.  C-Spine precautions, Splint the femur fxs, 2nd IV, call for flight, and go for the Level 1 Trauma center; the extra 20 minutes enroute is hours at the hospital without the appropriate surgical treatment.  With his obvious head injury, and a GCS of 3, it's his best chance of saving his noodle.  Also, doesn't flight carry blood?

dmaze: it does look deliberate  does it not?   By the way, this is a good site for learning. Thanks guys.