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Sun Jul 13 09:58:38 BST 2003

On Sat, 12 Jul 2003 09:27:23 +0100, "Black, John"
<John.Black at orh.nhs.uk> said:
> 30 year old unconscious motor cyclist injured in high speed collision.
> Significant impact damage to helmet. Has vomited at the scene.
>
> Requiring nasal airway for airway maintenance. SaO2 85% on
> non-rebreathing mask fair bilateral air entry with upper airway coarse
> crackles bilaterally.

Obviously there is a lot about the scene that you cannot convey in
your post. Why do you have any form of monitoring equipment attached
to this patient?

I would want to immobilize and move to the ambulance quickly, while
protecting the airway the best I can under those circumstances. This
leaves a lot of room for different approaches.

The reasons I would want to go to the local hospital would be for
uncontrolled airway (after a 10 minute transport with an
uncontrolled airway it probably does not matter where you are) - or
this could be a reason for a helicopter (depending on how long it
would take them to arrive at the patient - you state immediately
available. Immediate dispatch is available? how long to arrival at
the patient?...), but uncontrolled airway does not appear to be the
case here (at least not yet).

> A right needle thoracocentesis has previously been undertaken by the
> first responder with no effect.

Leaves me wondering about a lot of things.

Is there a tension pneumothorax?

Was there a tension pneumothorax?

Did the needle reach the pleural space?

By no effect do you mean no change? a change, but no improvement?
continued worsening of the patient?....

Was the BP good at the time of the needle thoracentesis? If so why do it?

This raises more questions than it answers.

> Pale and sweaty, cool peripheries but BP maintained >90 systolic.

"Maintained" - by the patient? by bleeding control? by fluid?

BP, along with SpO2, is another bit of information I do not need (but
would like if it does not delay things) prior to transport. Or are you
assuming that the presence of a certain pulse means that the BP is >90
systolic (this would be a mistake).

> Pupils equal and reactive, AVPU: V,  GCS 9 (E2, V2,
> M5), moving all 4 limbs.

AVPU: V? E2 = Eye opening to pain, V2 = Incomprehensible sounds, M5 =
Localising pain.

Two of these are to pain (E2 and M5), and the other can only get worse by
becoming absent. (I cut and pasted from Trauma.org, but the GCS scale can
be found anywhere.)

Why classified as AVPU: V?

> No other clinically overt injuries identified.

With continual reassessment that may change.

>
> Nearest ED (District General Hospital with anaesthesia & general
> surgery/orthopaedics/ENT surgical services on site) 10 minutes by road.

I suspect that even with the extra travel time, the time to arrival in
the OR will be about the same.

Except for airway (may be necessary) or external bleeding control
(appears to be under control) this is what will make the most difference
in the survival of the patient. Loss of pulses would be a reason for
going to the local hospital.

If the local hospital has the patient in surgery 10 minutes (or even 20
minutes) sooner than he would be by going to the trauma center by ground,
how experienced (at trauma) is the surgeon?

How experienced is the ED (Accident and Emergency) at recognizing
occult injuries?

"No other clinically overt injuries identified." Yet he has a
low/borderline blood pressure? Depends on interpretation of "BP
maintained >90 systolic." A low/borderline BP very strong suggests other
injuries, with the abdomen being the most likely place to hide stuff -
thorax is good, too.

So, under these circumstances, I would go to the trauma center.

I would probably go by ground.

If I knew that an excellent trauma surgeon was at the local hospital
(rarely, but not never happens around here, some miss the local hospital
work - nostalgia?) I would call first and ask the trauma surgeon for a
destination decision.

> Nearest multidisciplinary trauma centre (with all surgical disciplines)
> 40 minutes by road, 20 minutes by air ambulance.
>
> Both forms of transport are immediately available and in close
> proximity to the ambulance services at the scene.

There are often delays in transferring a patient to the helicopter. The
helicopter is a less favorable environment to continually reassess the
patient. Worst case - the ambulance can be stopped for reassessment.
Ditto for the suddenly aggitated/violent patient the patient who needs
airway interventions.

Some helicopters have a lot of room to work on the patient (one of the
local hospitals has one large enough that they could almost fit an
ambulance in the back; they can take and treat two unstable patients),
but most do not around here.

Obviously there is a lot about the scene that you cannot convey in your
post. If I have misinterpreted things please corrct me.

>
> Questions:
>
> 1.      What clinical interventions should be undertaken at the scene?

My impression is that I would just immobilize and suction/position (jaw
thrust) the airway. Ther usually is not be a need for extrication with
pedestrians and motorcyclists.

>
> 2.      Under what circumstances should the nearest hospital be
>         bypassed?

Almost all (the exceptions are noted above) for unstable truma and
pediatric patients.

I have been ordered by medical command to take both to the closest
hospital (I do not have that problem now). I have seen both trauma and
peds mismanaged at the local hospital with the patients ending up in the
morgue. Perhaps they would have died anyway, but the extra drive time
would NOT have hurt them. One thing that EMS usually does well is focus
on ABC's and move quickly. This is an area that is often overlooked by
local ED's when faced with an unstable trauma or peds patient.

>
> 3.      How should the patient be transported to hospital?

Ground.

Tim Noonan.

>
>
> I would be particularly interested to learn of any algorithims you
> would use to guide your decision making.........
>
>
> John Black Oxford, UK

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