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You are working in a BLS ambulance in a small city with a huge rural area. There is ALS backup available if you need it.  Today is a cold fall day and the outside temperature is around 0ºC and windy.  You are dispatched to a farming accident; a farmer is caught in a power take-off shaft. Your ALS unit is also dispatched but will be delayed in responding as they are just finishing a call.  Your response time is 20 minutes and the ALS response time is 30 minutes.  Transport time is another 50 to 60 minutes. You notify dispatch to see if the air ambulance is available and also if they can bring a doctor and blood, if required.

 

On scene the fire department has arrived and is attempting to assess the patient. Your patient is a 23-year-old female, found lying with her right leg wrapped around a power take-off shaft, which is powered by a 2090 Case IH tractor and hooked onto a grain auger. The fire department members are holding her up as well as holding C-spine. They are also trying to stop the visible bleeding, but with some difficulty. 

 

The patient appears to be awake but seems to have lost considerable amounts of blood. She is obviously experiencing hypovolemic shock.  She is very cool, pale and diaphoretic.  There are no other signs of trauma or injury.  The patient looks to have been stepping off the tractor to start the grain auger when her pants or leg were caught up. The leg is wrapped around the shaft to about the mid femur. Apparently the tractor stalled or the PTO was stopped, but it is a devastating injury. You are worried already. You notify the air ambulance and ALS unit that you need help–a trauma surgeon and a blood bank would be helpful as well.

 

You complete a set of vitals and find:
  • HR: 146 strong, regular
  • RR: 34 shallow
  • BP: 84/42
  • SPO2: N/A initially
  • Cardiac monitor: sinus tachycardia
  • 12-lead: sinus tachycardia 
  • Temperature: 36.2ºC
  • History:  As above.
  • Past Medical Hx:  Appendix removed in 93, Tonsils and adenoids out as a child
  • Medications:  BCP and Tylenol for pain prn.

Quiz 12

Quiz 12

1. What is your first priority when arriving on-scene?
2. Your patient is awake but has a decreased ability to respond to your questions and does not look alert. What could this be a sign of?
3. From your initial assessment, a priority for treatment for this patient is and should be done as fast as possible. The initial priority is to:
4. The fire department members can remove the shaft to help extricate the mangled leg, if helpful, in a relatively rapid fashion, but no two scenes or situations are the same. They might attempt to:
5. The problem with control of the bleeding is:
6. You now realize the bleeding is critical. You also know from ITLS it is life over limb and it is getting to that point already. If extrication is going to be delayed an emergency amputation should be done by the surgeon.
7. You also know a traumatic injury can cause other complications. This patient could also have:
8. You complete a secondary examination as well as the rapid trauma survey. What do the vital signs tell you so far?
9. What would be a great tool to immobilize the patient’s C-spine as well as hold her until her right leg can be freed?
10. You start an IV but you can only get a 20-gauge initially. What would be the appropriate amount of fluid to start administering now?
11. The fast heart rate can be from many things in this situation. It would most likely be from:
12. The helicopter is 13 minutes out. The fire department is setting up a landing zone already. The parents have arrived on-scene and are also in shock. Your ALS unit has just arrived as well. What would be the best mode of transfer for the parents to the trauma hospital?
13. The fire department has removed the power take-off shaft and mangled leg. The best method to transport the leg would be to:
14. As you lay the patient down you notice she has an increased respiratory effort. This can be from:
15. This patient’s BP is still critically low. The heart rate is still very rapid. You don’t have radial pulses now but you have femoral pulses. This estimates the BP of somewhere around ______ diastolic now.
16. The surgeon and ALS have arrived. The BP is still very low and the heart rate is about 160/minute despite an IV bolus. The best intervention would be to start:
17. The ALS crew gets a second IV with a 16-gauge now. Should we still administer normal saline as well as the blood products?
18. Your patient develops increased SOB and now has decreased air entry to the right chest. You percuss the chest and you hear hyper-resonance sounds. You should _________________________ immediately.
19. The team decides to intubate her immediately as well. What medications can be used in a hypotensive patient as in this case?
20. If you decide you have a pneumothorax as well as a need to intubate you now should perform:
21. There are several other considerations and you know this patient might also benefit from:
22. The gold standard in treating an amputated limb injury is OR for replantation within a maximum of __________ with modern microsurgery. Any time it has been longer the chances are diminished drastically.
23. We know traumatic injuries are hard on everyone involved. We also know that traumatic amputations occur to 15 to 40-year-old male patients about ___________of the time, as compared to females.
24. We know hospitals utilize a strict protocol to administer blood products. We know that blood after being sent to be used in prehospital care setting needs to be used within:
25. One of the common side effects of rapid blood transfusions can be: