I would value advice on the pre-hosp management of the following case. I've
had this nagging feeling I could/should have done something different, but
happily he is now off the ventilator (alive!).

Single car RTA. Mechanism probably was hit soft verge at speed,
roll-over/take off, followed by impact with first floor of barn, finally
coming to rest hanging vertically by wheels from a high stone wall!  5 cas,
4 of whom had only minor injuries. Main cas, male ~20yrs,  was ejected from
car & found lying on boulders.
I arrived after 20 mins; initial assessment, strapped in a KED (no
long-boards yet!), talking, airway clear except for small amount of frothy
blood at mouth, RR 30/min, radial pulse 110/min, no sensation below waist.
Loaded into ambulance & set off.  Further assessment of chest, trachea
central, equal movements, but 'palpable creps',  no surgical emphysema, PN
prob equal but difficult to hear due noise, air entry all areas but sounds
'bubbly' all over. I can't think of the jargon descriptive words at present!
As expected he rapidly deteriorated, RR 40/min, probable left haemothorax,
BP 60/40, sats 70% (? reliable as v.cold), abdo soft. Partial improvement
with assisted vent & rapid infusion of  hartmans. 2 brief episodes of resp
arrest. His conscious level varied from V to P on the AVPU scale, but never
quite deep enough to tolerate an OP/NP airway.  25 minute travel time to
hosp on bad roads.
He actually had bilat haemothoraces, lung contusions and fractured C4 & T10.
All neuro deficit is T10 related.
He has survived, but only just! My nagging doubt is would more aggressive
management at scene, ie paralyse & tube have helped him? My feelings were
that propofol would have caused his BP to vanish although I did briefly
consider ketamine/sux. With hindsight, I am glad I didn't try to tube him in
view of his C4 fracture which I didn't know about, so perhaps I shouldn't
feel uneasy about it anyway!
John Apps
Basics North East




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