Can't see how a bit of diamorph will do any harm, Vic, fracture or no
fracture. After all, anaesthetists are very fond of squirting it into
epidural and subarachnoid spaces with gay abandon! But as Rowley has
cautioned with benzos, I would still be wary of opioids where you have
limited access to the patient (and his airway) and no i.v. access. Why not
stick with ketamine, with its intrinsic analgesic properties, but safe in
the knowledge that it maintains the patient's airway and resps?
Sounds like a fascinating, and very challenging case, Vic. Looks like you
did a good job though, despite your self-flagellation for insufficient
analgesia! And it was a good call to run with the patient; I suspect many
crews would be worried about being "told off" for arriving at hospital with
a poorly worked-up patient, but it takes more guts to just deliver 'em that
way, and it's often the right thing to do. Well done!
AF
----- Original Message -----
From: "Vic Calland" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, April 30, 2003 7:49 PM
Subject: Re: Ideas please....
> Perhaps some did not appreciate the fact we had nowhere for i.v. access,
> or was there somewhere else I could have gone (no reminders about an old
> line of argument with dog's corpora cavernosa please). What about
> intranasal with the skull fracture?
>
> Vic Calland
> Eventmed UK Ltd
> Training & Development beyond First-Aid
> Visit the website: http://www.eventmed.co.uk
>
> -----Original Message-----
> From: [log in to unmask]
> [mailto:[log in to unmask]] On Behalf Of Vic Calland
> Sent: 30 April 2003 10:54
> To: [log in to unmask]
> Subject: Ideas please....
>
> Attended a MVC last night. Driver doing a 100mph plus put his car under
> the end of an HGV only doing 50mph. Dragged 200-300 yards down the road
> as the driver of the lorry regained control and came to a halt.
>
> Driver was late twenties, physically fit but on the heavier end of
> normal weight range. Trapped upright until the fire crew did a dash
> roll. Had 8cm transverse laceration of forehead with bit of skull in
> wound but amazingly had GCS of 12-13. Had bilateral bracing fractures;
> left elbow was a posterior dislocation, radius & ulna a comminuted
> compound fracture as crunchy as a bag of crisps; his right was a more
> classical Monteggia apart from the fact it was compound and the bone was
> protruding. He also has a fractured pelvis with a dislocation of the
> left hip.
>
> He had breath sounds bilaterally so we didn't realise he had a ruptured
> left hemidiaphragm until the CXR came back. At the time he wasn't too
> shut down, so we splinted the arms, gave him 50mg Ketamine im and free
> flow Entonox for the extrication (long board to the rear). We were only
> 5 minutes from the hospital so we ran with him rather than established
> an i.v. on scene. There they ended up with a right femoral vein access
> with a "security guard" watching it.
>
> I'd be interested to know if anyone has clever ideas for dealing with
> this kind of situation because his pain relief was not ideal by any
> means.
>
> Vic Calland
>
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