Trauma case study - what would you do?

[ParamedicPrepper]

So following on from MedicMarks topic and trauma specifically blunt trauma, I would like to give you a job I attended with a description of the incident (protecting confidentiality of patient of course) and see how everyone would treat at their varying levels and experience of first aid. But how you would treat in an everyday case and the differences of any to a SHTF scenario.

So here's a link with a couple of pictures of the scene. Look at the mechanism and where the police officers are kneeling down in the distance is where the patient landed. This is in the media so I'm not giving away anything that isn't already public knowledge

http://www.standard.co.uk/news/london/m ... 98261.html

So on arrival the pictures set the scene. There's a male laying on his back not responding with a crash helmet on, with a massive crack down the body of the helmet. You can hear snoring sounds and bubbling coming from the airway and his right leg is an open tib fib fracture that is bent back on itself. He is still fully clothed but it is all ripped with a considerable amount of blood around the busted leg.
What you do at this point could save his life, what would you do?

So without giving too much away as to what to do you now have the opportunity to fully assess the body how would you do it an what would you pay particular attention to giving the mechanism we have seen?

Full assessment shows a large head injury at the occiput with a boggy mass (skull fracture google a picture) asymmetrical chest, distended abdomen, abnormal looking pelvis with a massive lump and bruising on the left femur and open tib fib on the right as we know.

Where to start?

Observations were

Respiratory rate 11 inadequate ventilation
Pulse 45
Blood pressure unreadable
Level of consciousness GCS 3. - as low as it can get

It's you and two police officers what now? Your immediate action could save his life at least in the short term

What injuries do you suspect and what's there significance?

I will give a follow up as to what we done and the outcome and suspected injuries and actual injuries and there significance

[sethorly]

In a SHTF situation with no proper help incoming, I'd consider using my med kit bag to smother his nose and mouth.

[ParamedicPrepper]

In a SHTF situation with no proper help incoming, I'd consider using my med kit bag to smother his nose and mouth.

Fair play. You sound like a realist! Although I don't know if it would be necessary with those observations he is already well down the garden path so to speak

[medicmark]

not going to make to much of a comment but FUBARD comes to mind.
As we medics keep saying in A SHTF situation triage your care and resources, do the best for the most.
Mark

[Yorkshire Andy]

Well he's in a mess!

Well if my humble 3 day first aid at work comes to my memory correctly:

Safety first etc gloves high vis hope plods police cars glassy lights scare people into looking what they are doing and put their phones down....

CAT the smashed leg (no time to worry about it been broken) but get the catastrophic bleeding slowed / stopped.. (One in door pocket)

Now let's provoke total no no you can't take his helmet off ...

Take helmet off (yes it might cause damage but he can't breath so 2 person removal thank you officer)

To clear airway not enough people for log roll so stoke manavle recovery position to get him. On his side and let mouth and nose drain...

Ideally onto the side with the most brain fluid oozing from to allow CSF to drain or the good Lung to the top (priority is breathing)

Hope by now what's left is breathing... Address and bleeding and keep warm till the Morrison's van comes try to locate donor card

[ParamedicPrepper]

CAT is an interesting thought. We didn't CAT the leg for 3 reasons

1. Tib fib is two bones and CAT should not be used on these as can cause more damage
2. Neutral alignment is best so pull it straight and get that smiley officer to keep hold of it
3. Airway needs all my attention at this point

Helmet off and quick get him on his side as you said c spine is important but he's peri-arrest and without massive intervention with the airway he will be dead in the next minute or two

[Yorkshire Andy]

Fair enough thought it was severe bleeding from the leg if it was to be catted I'd have gone above the knee .. Never been shown how to deal with broken bones just control bleeding so if bleeding not catastrophic would be ignored till breathing sorted then pressure dressed

[ParamedicPrepper]

CAT not wrong and this is all a matter of opinion really so no shout down for CAT but airway important here

[Yorkshire Andy]

CAT not wrong and this is all a matter of opinion really so no shout down for CAT but airway important here

Was told recently to go for big bleeds first as if you dont stop them before trying to get them breathing / going on with CPR you might as well not bother as no blood in the body or using CPR to pump out what is left = dead


Not sure if you have seen this:

http://www.qualsafeawards.org/2015Resus ... Guidelines


Not sure if its a way of dumbing down the training in some areas? such as the 3 side taped dressings been dumped so you leave someone with a punctured chest alone and allow the lung to stay collapsed

. Sucking chest wounds should be left open to the environment - Three sided dressings are no longer recommended.

Due to clinical experience of both improvised and purpose made dressings inadvertently becoming occlusive, the ERC guidelines recommend to ‘leave the wound in open communication with the environment’. This means that there is no longer a requirement to cover it with a dressing. The main emphasis on providing care should be to ‘do no harm’, and the risk of dressings becoming occlusive is significant.

and about the Raising bleeding limbs we discussed the other night

viewtopic.php?f=19&t=14019&start=50#p156279

4. Elevation and Indirect pressure points are no longer recommended for the treatment of bleeding.

Elevation and indirect pressure have been removed due to a lack of evidence that either is effective in stopping bleeding, particularly life-threatening bleeding.

[ParamedicPrepper]

Yeah so DRCABC catastrophic bleeds first

Hard to explain a visual but this wasn't a catastrophic bleed so my fault for not explaining what I could see and remember and people trying to gauge a situation from description

Should have said a lower limb bleed from a compound tib fib fracture that rectified with realignment back onto neutral alignment

This chaps airway was the big killer

The three sided tape dressing is good going to help stop the pneumothorax turning into a tension pneumothorax but unlikely on its own to rein flare the lung
The obstructive part of the shock is the tension so the cavity fills with air squashing the collapsed lung but has no relief valve if you like meaning the heart and other lung will get squashed by the building air pressure turning the pneumothorax into a tension pneumothorax, which will quickly kill you. We stick a large bore needle in to release the pressure and rectify the tension but unlikely fix the pneumothorax

I think like a lot of things that can be deemed complicated in an unfamiliar situation to the detriment of the basics such as airway are quickly dropped in first aid. It will help but some people will get sucked into placing a dressing and neatly taping it three sides on a sweaty blood covered chest and miss the fact the patients not breathing anymore, with the stress this happens