Cases from the Streets. Kelly Buchanan MD, ATC/L EMS Fellow December, 2011
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1 Cases from the Streets Kelly Buchanan MD, ATC/L EMS Fellow December, 2011
2 The Scene Car vs Light Pole, 35 mph, front right side damage 10 with no PCI + airbag deployment, starring on windshield Given the snow, obviously not the real car in this case, but you get the idea. t/freezing-rain-adds-souths-headaches/#.tups02nfu7s
3 The Patient Not really, but a similar patient 81 y.o. F, restrained front seat passenger + airbag deployment, selfextricated, no LOC, ambulatory on scene PMH: CVA, nerve issues, insomnia Meds: multivitamins Allergies: codeine, morphine
4 NO chest pain, syncope, SOB, HA, weakness or paresthesias, visual changes, back pain, extremity pain The Patient Complains of mild bilateral neck pain, mild sternal pain
5 Pre-hospital Physical Exam Primary Survey A = protecting airway B = breath sounds equal C = no bleeding
6 Pre-hospital Physical Exam (cont.) Secondary Survey VS: HR 95, BP 158/80, RR 18, 86% RA Pt calm & collected, no acute distress observed Neck: Tenderness to lateral neck bilaterally, no midline TTP Chest: symmetric movement, mild sternal TTP, no seatbelt sign, no crepitus Abdomen: soft, non-tender, no seatbelt sign Back/Pelvis: atraumatic Extremities: skin tear to right knee, full ROM, nontender
7 Pre-hospital Course Repeat VS: HR 75, BP 104/76, RR 18, 86% RA Pt refused transport to hospital for evaluation why?? Once arrangements made to care for her dog, patient consented to transport Transported to non-trauma facility in spine precautions (didn t meet TFTC).
8 Take Home Point #1 If your patient doesn t want to be transported, find out WHY (especially if you think they need further evaluation). Sometimes it s a simple fix (ask the neighbor to take care of the dog, turn off the stove, lock the door, etc)
9 Hospital Course Patient scanned at hospital and found to have several injuries: Right sided rib fractures 25% pneumothorax Remember the sat of 86%? Required a chest tube C2 body fracture C5-C7 spinous process fx Thoracic body fractures SubQ air PTX All images found with google images searches
10 Take Home Point #2 DO NOT IGNORE ABNORMAL VITAL SIGNS!! (esp low oxygen sats, hypotension) Remember meds may block tachycardic response (beta-blockers)
11 Hospital Course Patient was scanned and stabilized (chest tube) at non-trauma facility, then transferred to a trauma facility. Stayed in the hospital for 4 days, then transferred to rehab Current patient in a SNF (skilled nursing facility) recuperating
12 Geriatric Trauma Number of geriatric trauma patients is on the rise (currently approx 30% of trauma patients 1 ) # on the rise with the aging of the Baby Boomers Many unique characteristics that predispose elderly patients to serious injury/worse outcomes Physiologic changes Pre-existing conditions Medications (i.e. blood thinners) Severity of initial injury under-recognized 1
13 Physiologic Changes in the Elderly Cerebral Atrophy Increased movement of brain in the skull increased rate of subdural hematomas, with delayed presentation due to extra space in the skull Decreased Cardiovascular Reserve Can t cope well with intravascular volume depletion, can also cause cardiac ischemia from increased demands on the heart Decreased cardiac output can cause hypoxia due to ventilation/perfusion mismatch in the lungs Decreased renal function
14 Underlying Conditions / Meds Cardiac Disease Coronary Artery Disease (aspirin/plavix) Coronary artery lesions can cause ischemia under increased demand of trauma A Fib (coumadin) Osteoporosis Increased risk of fractures (spine & long bone)
15 Current Trauma Field Triage Criteria Physiologic Criteria GCS < 14 SBP <90 mmhg OR RR < 10 or > 29 (< 20 in infant <1 y.o.) Note NO oxygen sats or HR in criteria Anatomic Criteria Penetrating injury to head, neck, torso, or extremities proximal to knee or elbow Flail chest 2 proximal long bone fxs Crushed, degloved or mangled fractures Amputation proximal to wrist/ankle Pelvic fx Open or depressed skull fx Paralysis
16 Current Trauma Field Triage Criteria Mechanism of Injury (Step 3) Fall from 20 ft MVCs with: 40 mph prior to accident 20 in. of severe damage to vehicle 12 in. Passenger compartment intrusion 20+ min extrication time MVC Rollover Motorcycle going 20+ mph Auto v Ped at 6 mph Pedestrian run over or thrown, regardless of vehicle speed
17 Coming Up New Trauma Field Triage Criteria due to be released by the ACS (American College of Surgeons) in January 2012 Entire CME on geriatric trauma, due out in 2012 after the new ACS TFTC released.
18 Take Home Points If a patient resists treatment/transport, find out WHY, and address their concerns if possible Don t ignore abnormal vital signs, but realize that they be normal in severely injured geriatric trauma patients Geriatric trauma patients tend to have worse outcomes/more severe injuries due to physiologic changes, medications, and delayed presentation of severe injury.
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