Mike asks
I would appreciate comments from the mailbase on the following case and the
clinical implications for the administration of Nubain on this patient.
12 yr old female, pedestrian RTA hit by car travelling between 15 - 20mph.
Patient was taken up onto the bonnet of the car (no damage) and hit screen
of car (broken screen but not bowl shaped). Patient then came off the near
side and landed onto road. The car then ran over the childs right leg with
the back nearside wheel.
OBS
AVPU - A. Not KO'd at any time.
Airway - clear, no blood oro-pharynx
C-Spine, No pain/ache and in line support from off duty nurse prior to our
arrival and full spinal protocols throughout our treatment.
Breathing - Bilateral, clear 4 fields.
Circulation - <30ml blood loss from nose injury - no other indication of
major overt or covert blood loss.
Injuries.
Small cut to inside of nose and a fractured Right Tibia and Fibula - with
crepitus and extreme pain. No other apparent injury.
Normally I would have done my ACBC's, entonox, IV access and pain relieve
and got her on a board and GO.
I had a work based trainer with me on that call who expressed concerns about
the mechanism of injury and the potential for head injury. As we couldn't
move this poor little girl in so much pain without pain relief and the WBT
suggested that it may be Nubain contraindicated we called a SIMCAS (BASICS)
doctor out. When he arrived he administered Cyclamorph - 5mg morphine and
25mg cylaclazine. We then loaded and went to A&E.
We did waste time waiting for the doctor but at least the child got the pain
relief she deserved.
Here's my problem... I considered the injury to the nose as insignificant -
minor head injury. The work based trainers regarded it as potentially
serious. As such I went on the side of caution and withheld Nubain due to
peer pressure alone. I am not comfortable with this and don't want to be
placed in this situation again.
Q. When is a head injury significant enough to be classifed as
contraindicated for Entonox and Nubain administration. I asked the WBT and
he didn't know.
I looked on Pub med under - head injury - severity - prehospital. But all it
came up with was serious head injury, head injury deaths and other stuff
like that. I wan't advise on the other end of the spectrum.
Mike Bjarkoy
Paramedic
Sussex
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