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It is a cold winter day in what has otherwise been a great winter so far, at least compared to last year. You are working in a small city today of about 25,000 people. Your ALS ambulance is staffed with one PCP and one ACP. You have two ALS units on night shift and both units are doing their fair share of the emergency calls.

You are dispatched to a snowmobile accident approximately 17 km north of your city. Your dispatcher states a 12 y/o old male child has hit a barbed wire fence while driving a snowmobile in a farmer’s field. You start responding and it will take you approximately 15 to 20 minutes to reach the scene. You also have police, and the local fire department responding with their rescue unit to assist with patient care. Once you arrive you find the local police already on scene. The fire rescue crew is right behind you. You see a patient up against a barbed wire fence with bystanders attempting to keep him still. The patient is in obvious emotional distress and trying to remove himself from the barbed wire.

His initial vital signs are:

  • HR: 124 bpm
  • RR: 32
  • BP: 128/78
  • SPO2 is not available now due to the cold initially
  • BGL: 5.3 mmol/l
  • Cardiac Monitor: sinus tachycardia
  • Temp: 34.5° Celsius

On your initial exam, you find that the patient has the wire caught in his clothes and find that barbed wire is buried in a deep laceration in the anterior portion of his neck and left shoulder. You hear a slight stridor as you assess the airway for breathing which causes you to recognize the potential for serious airway compromise with this patient.

You notify your dispatcher that you need assistance from the provincial air ambulance, who are dispatched immediately and will meet you at the scene. If available, they are attempting to include an ER physician and an anesthesiologist with their crew. You have started extrication and then package the patient for immediate transport as the air ambulance will arrive within 15 to 20 minutes. The police will arrange a landing zone.

1. From your patient presentation you know that the patient is awake and upset. The immediate goal would be to:
2. The best oxygen therapy for this patient would be:
3. If the patient is awake, talking in a non-confused state and moves his extremity to command his GCS is likely a ____/15
4. What can cause stridor with normal respirations in this case?
5. This patient has the wire stuck to the shoulder’s soft tissues and it is also imbedded in the anterior neck tissues. The best thing to do with the wire would be to:
6. This patient’s rapid breathing can be from:
7. What is the best way to maintain in-line cervical stabilization?
8. On your primary examination you find the patient has subcutaneous emphysema on examination to the sides of the neck and to the left chest area starting to be palpable. This is most likely from:
9. This patient has tachycardia with rapid and weak pulses. This is a common sign of:
10. The outside temperatures are below freezing. Hypothermia causes:
11. What is likely causing this patient to have hypothermia?
12. The abdomen is distended and tender on palpation to the RUQ and RLQ. This can be from:
13. You have established an IV in the left A/C. How much fluid is required now?
14. You have moved the patient to the unit. As you lay him flat he has more trouble breathing. In order to sit the patient upright you could use:
15. Where is the only foreign body that should be removed in the prehospital care setting found normally?
16. The best medication to help decrease the pain would be:
17. Sedation can be accomplished by administering:
18. The air ambulance crew is landing now. The breathing has not improved and the stridor is not improved. There is decreased air entry to the left chest now. If the patient starts to drop his BP it is a sign of a _________________ pneumothorax. The treat- ment would be to perform________________ of the patient followed by ________________.
19. Is there a role in the prehospital care setting for magnesium sulfate in this case to decrease the stridor?
20. The anesthesiologist is present and would like to intubate the patient before flight. The physician is going to try with a Glidescope initially and the air medical crew is setting up for retrograde intubation and/or a surgical cricothyrotomy if that fails. Of the following medications, which ones would be selected to perform an RSS or RSI?
21. After a difficult intubation the patient tends to be harder to ventilate than what you would expect normally. This is most likely from a:
22. The patient’s BP drops post-intubation. This can be from:
23. After your interventions the BP is now stable. The best way to ensure the patient does not move and is easier to ventilate would be to:
24. The best way to ensure severe internal injuries in the abdomen are not present would be to perform a:
25. The surgeon is prepping to take the patient to the OR to remove the wire from the neck and the chest. The chest X-ray is displaying some white patchy areas over the left chest. This is most likely from: