Carlos,
I'm still not happy about that neck (JRSM 1985 Redmond, Plunkett and
Billsborough)!
Nevertheless, with significant respiratory/ventilatory compromise in an
elderly client (see, I'm into Social Care as well), I'd intubate and
ventilate - despite his CO2 retention - the degree of which is not clearly
defined in your posting.
>From my experience, although getting to 96 yoa shows you're as tough as old
boots, your margins for error are extremely tight.
Again, from bitter experience, I'd place bilateral chest drains prior to
IPPV, as the rate of demise in the elderly with tension pneumothorax has to
be seen to be believed (and there's no coming back)
Despite the prohibition on referral to unregistered practitioners, I think
I'd seek advice/assistance from a padre/rabbi/imam/shaman!!
-----Original Message-----
From: Carlos Arturo Perez Avila <[log in to unmask]>
To: INTERNET:[log in to unmask] <[log in to unmask]>
Date: 14 October 1998 20:37
Subject: Trauma in the elderly
>Yesturday I received a stable trauma (one that has no physiological
>abnormality i.e. normal Triage Trauma Score). I wander if the list can let
>me know waht they would have done with him. In a couple of days I will let
>you know what we did with him.
>
>96 year old male with a hsitory of COPD on ventolin and becotide. Very deaf
>was walking between two park cars and as he crossed the road was hit by a
>car travelling at 30 mph. Impact on the right knee thrown in to air hit A
>pillar dent it and fell cakwards onto road. KOD for a few minutes but GCS
>14 on ambulance arrival, one point down on verbal. BP 110/70 at scene P 100
>RR 18. Refused to allow cervical collar and oxygen mask.
>
>On arrival in A+E assessed by Rapid Assessment Team i.e Consultant two
>nurse and two SHO's. X2 venflon placed primary survery Airway nad Breathing
>rapid 22 per minute but with normal air entry on both fields no flail
>segments no trachea deviation no deformity of the chest wall other than
>barrel chest. Circulation pulse 100 x min . Hartaman solution started.
>Oxygen sats 85% with no oxygen 90% with oxygen on and off as he removed the
>re-breathing bag. Gases COS tetention low Oxygen saturation.
>
>Secondary survey and log roll: Laceration to the occiput 3.5 cms with no
>underlying fracture (finger sweep). Neck no pain, refusing to allow hard
>collar an moving it in all directions. Chest pain in the lateral chest wall
>both right and left but no obvious fracture crepitus or sub cutaneous
>emphysema. No wheeze and good air entry. Abdomen distended bowel sound
>apparently abscent very tender. Limbs and pelvis no pain in springing. Log
>rolled no pain in the C/T/L spine no steps.
>
>In view of the concern of the abdomen we did a DPL negative. Urinary
>catheter clear urine negative dipstick.
>
>RAdiographs: CSpien gross OA but no abnormality Skull no fracture, Chest
>Fracture of the right first rib and 5 more on that side, no flail segment
>On the left fracture of the 4th 5th 6th and 7th.Lung parenchyma staring to
>show signs of lunng contusion bilaterally. Pelvis fracture of the right
>iliac crest and the right inferior pubic ramus.
>
>Patient referred to surgeons and orthopaedics for in patient management.
>Was given Morphine 5 mgs IV with good control of the pain and no
>significant reduction in RR or O2 sats.
>
>What would you have done with this patient?
>
>a) Intubate and ventilate?
>b) Control pain and keep calm and hydrated.
>c) Nothing other than what was done in A+E?
>
>Carlos.
>
>
>
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