By Dr. Ken Lavelle, MD, NREMT-P
Your crew is the third ambulance in. You are a paramedic with an EMT partner who has been assigned the following patient:
JR is a 22-year-old male who jumped from the second floor of this apartment building. He is in severe pain from an obvious deformity on the left arm.
So where do you start?
Scene safety is always important, especially near a working fire. Make sure you are not too close to the building or any other risks. Move the patient rapidly if necessary. The next step is the same that we practice on trauma patients at any level — ABCs with C-spine. Do not be distracted by the arm injury — it is unlikely to kill the patient in the near future. However missed major trauma could, and it is not unreasonable that this patient could have major traumatic injuries from the fall.
I will usually tell the patient who I am and not to move, while moving to immobilize his cervical spine. If you just grab his head, he will likely try to resist, especially if suffering from an altered mental status from injury or drugs. Explaining who you are and why you are doing what you are doing will go a long way to facilitate his cooperation.
The best way to assess his airway is simply to ask him, "What happened?" How he responds tells you much about the patency of his airway, ability to breath and his mental status. His ability to speak clearly and explain what happened is a good indicator that at least for now, his airway is open. You will need to monitor it carefully, but he is unlikely to need either a basic adjunct such as an OPA (oral pharyngeal airway) or NPA (nasal pharyngeal airway) or an advanced airway right away. If the patient is not able to speak clearly, or has some other threat such as blood or vomit present, manage the issue immediately. Suction his mouth and nose and place an adjunct. If he gags on the OPA, remove it and consider placing an NPA. You may need to intubate him soon, but it is appropriate to manage the airway from a basic standpoint for a minute or two while you complete your rapid trauma assessment. You would need to gather your equipment anyway which will take some time. Our patient in this case is screaming in pain and has a patent airway. Let's move on.
If you are the primary care giver or crew leader, you now have two choices: either have someone replace you, holding the cervical spine so you can complete the assessment, or trust your partner(s) to be able to do the remainder of the assessment. Your decision will be based on the level of experience of your crew.
Either way, the next step is to assess his breathing. Expose his chest to observe the work of breathing and look for bruising, penetrating trauma or other signs of injury. Auscultate the lung fields, in particular listening for unequal sounds that may indicate an injury such as a pneumothorax. Listen in at least four locations on the anterior chest, and directly on the skin — not through clothing. Count the respiratory rate and place the patient on oxygen, increase flow based on the mechanism of injury. If you find no respiratory system involvement and determine that their oxygenation would be adequate on less oxygen later you can change the amount provided later, but initially it is best to just place them on high flow.
Eventually, if not now, you will need to roll the patient. The back is just as close to the lungs as the chest, and it must be assessed as well to look for trauma that could affect the breathing. If the breathing rate and depth is not adequate, initiate assisted ventilations with a bag-valve-mask (BVM) ventilator. If you are able to move air and ventilate effectively, immediate intubation may be delayed for a moment. Intubation of trauma patients by paramedics is controversial in some areas. While I feel it is appropriate for paramedics to intubate a trauma patient as long as they have the right tools and experience, recognize that the act of intubation does have some risk including increased intracranial pressure, hypotension and prolonged hypoxia. Follow local protocol.
Next is the assessment of the patient's circulatory status. Look for any life-threatening bleeding and control it. The use of tourniquets for severe extremity bleeding has been found to be beneficial. They allow you to rapidly control the bleeding and move on, and the risks of a tourniquet are not nearly as bad as once thought. Determine the pulse rate and the presence of a distal pulse. A radial pulse generally indicates the blood pressure is at least 80 mmHg systolic. While not often considered part of the primary assessment, I often will palpate the abdomen, the pelvis and the thighs while assessing circulation. Fractures of the pelvis or femur can result in significant blood loss and a firm or hard abdomen may indicate serious internal injuries have occurred. Being aware of these injuries will help you maintain vigilance while monitoring the patient for shock.
The next step is D – Disability. For the most part this involves determining the patient's ability to move his extremities, and placing a cervical collar on their neck. Log rolling the patient often occurs here, while placing them on a long spine board. While we know that we sometimes over-immobilize patients, it is the standard of care on a significant mechanism such as this one.
Last we expose so we can see any other injuries or signs that we may have missed. Once we do so, re-cover the patient to keep them warm. Cold affects patients with traumatic injuries greatly.
After the primary assessment is completed, it is time to initiate transport. Your goal should be to be off the scene within 10 minutes, unless there is entrapment or other extenuating circumstances. If a trauma center is within a reasonable distance, then this type of fall would usually meet criteria for a trauma center as a destination. Consider a helicopter transport for very long distances, but this is probably not necessary if you can ground transport within 20 to 30 minutes. Follow your state or region's protocol. IVs can be started en route, and if the blood pressure is stable and above 90 systolic, they are generally run at a KVO (keep vein open) rate.
In the past we used to push one to two liters of normal saline into our normotensive trauma patients, but we now know this was harmful. Pain management should be considered with medical command orders, if required. Fentanyl is an excellent choice, if available, as it can be titrated slowly and does not affect the blood pressure as much as morphine. En route, complete a secondary assessment if time allows. Give the hospital advanced notice and the trauma team a brief report on arrival of the mechanism, what you have found and what you have done.
This actual patient while thought to have only an arm injury, ended up having multiple back, pelvis and leg fractures. If you don't look for injuries and have a healthy index of suspicion, you won't find the injuries. Follow a systematic approach to a trauma assessment and you will find most if not all of the injuries that a provider could find in the pre-hospital environment.