Great participation guys and gals! Sorry for the delayed response, you've all been very patient and it's appreciated! I'll go through a few of the posts then wrap it up, next time you'll get more interaction from me. Thanks again everyone!
Showtime - Great assessment! 911 says they'll be able to deploy SAR but they have no timeline and no air assets. Your partner maintains C-spine stabilization while you perform your rapid trauma assessment. (+) PMS in extremities x4, DCAP-BTLS - Goose egg on pt's right forehead, raised and tender to the touch Road rash lacerations on her upper shoulders,arms and legs. Negative blood, raccoon eyes, Battles sign or presence of any fluid. Strong radial and pedal pulses. GCS after fall (per boyfriends description) 3, GCS now 14. Patient answers questions appropriately, Alert PPTE. No known allergies, ate breakfast of oatmeal early this morning. Complains of pain in her head, no neck pain, no spine pain, able to recall detailed description of the climb up to the fall. Good job on the blanket! She's now wanting to sit up and drink some water. What do you do?
Ninja Medic - Good call for street medicine. A higher respiration rate combined with pink, warm skin can mean many things; shock-y trauma to recent physical activity. In this situation I'd chalk both findings up to the physical activity lacking any other findings of shock or injury.
croaker260 - Jaw thrust opens her airway and she becomes more alert. The rest of the findings are shown above. You're scan for life threats is negative (good job mentioning that scan SPECIFICALLY and differentiating between a detailed scan and a life-threat scan!! +500) Another +500 on detailing how to improvise the C-collar and the gear you'd use. As for the hot skin, she's out in the sun, she's working out and she's got some sweat on her. In the absence of any findings to the contrary I'd assume that she's producing a lot of heat.
AZMedic - She's smoking hot, yoga pants and a halter top hot.
SCBrian - Heat exhaustion is a good finding from the > rate of breath, warm, sweaty skin and known physical activity.
offcamber - Wilderness (and Zombie) situations call for improvisation man, it's just the nature of the beast. The best motto for wilderness emergencies, whether as a professional or lay responder, is "It's their emergency, not mine!". If the best you can do is rig up a poncho and paddle stretcher and carry them out then you've done your best. If they wanted to have a backboard evacuation they should have brought their own LSB! Most likely you contributed to the chain of events that saved her life. Righteous!
VXMerlinXV - Thanks for the kind words partner! I think that an evacuation might be a bit premature, let me go over the way this actually turned out.
The patient gradually became more responsive and remembered all events taking place up to the fall event. She was not restrained or tied into any protection and fell from about ten feet with the natural curvature of the boulder slowing her fall and causing the lacerations to her shoulders and legs. A complete neurological function test was administered and she was cleared to have cervical and spine protection removed. Her increase pulse rate, warm skin and sweaty body were due to the physical exertion and demonstrate how all vital signs need to be taken in the context of the situation. Head injuries in the back country are scary events and it's important to stay calm and do a thorough assessment. If the GCS is rising from 3 (i.e. shes knocked out) to 13-15 (she's a little groggy but is improving) that's a great sign. I wouldn't initiate any sort of evacuation or call to 911/SAR at this point. The thing that I wanted to talk about here was Intracranial Pressure (ICP) and the signs of a worsening head injury. http://en.wikipedia.org/wiki/Intracranial_pressure
Minimal increases in ICP due to compensatory mechanisms is known as stage 1 of intracranial hypertension. When the lesion volume continues to increase beyond the point of compensation, the ICP has no other resource, but to increase. Any change in volume greater than 100–120 mL would mean a drastic increase in ICP. This is stage 2 of intracranial hypertension. Characteristics of stage 2 of intracranial hypertension include compromise of neuronal oxygenation and systemic arteriolar vasoconstriction to increase MAP and CPP. Stage 3 intracranial hypertension is characterised by a sustained increased ICP, with dramatic changes in ICP with small changes in volume. In stage 3, as the ICP approaches the MAP, it becomes more and more difficult to squeeze blood into the intracranial space. The body’s response to a decrease in CPP is to raise blood pressure and dilate blood vessels in the brain. This results in increased cerebral blood volume, which increases ICP, lowering CPP and perpetuating this vicious cycle. This results in widespread reduction in cerebral flow and perfusion, eventually leading to ischemia and brain infarction. Neurologic changes seen in increased ICP are mostly due to hypoxia and hypercapnea and are as follows: decreased level of consciousness (LOC), Cheyne-Stokes respirations, hyperventilation, sluggish dilated pupils and widened pulse pressure.
The whole article is worth a read and is well written but the emphasized parts are what really applies here. If this young lady had chronically worsening conditions throughout the evening, specifically the findings associated with Cushings Triad, the decisions regarding care and evacuation would be vastly different.http://en.wikipedia.org/wiki/Cushing's_triad
- hypertension, bradycardia, irregular respirations
It's important to know these s/s because they differ so widely, especially at their early stages, from shock. Shock-y patients are hypotensive in later stages and exhibit tachycardia in early stages. It's important to manage a head wound in the back country with a very high index of suspicion. Do you stop a multi-day climbing trip because someone has fallen and knocked their head? Stop an expedition? Evacuate or send a runner for help? Those are the questions that make wilderness medicine a different animal than street medicine.
Thanks again guys for participating, you all did a great job. I'll have another one in a few days after we get some boats wet and some new guides broken in.
As a quick post script, I'd say that the most important part of the detailed physical examination here is the neurological examination. http://cloud.med.nyu.edu/modules/pub/neurosurgery/
Excellent links to a great nearly tool-free assessment of a patient. http://www.wrems.com/Downloads/Educatio ... andout.pdf
And another one...
Again, thank you all very much! Please post any questions or criticisms you may have.
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