Sunday, May 26, 2013

BLAST INJURIES: ESSENTIAL FACTS


In lieu of recent events, I contemplated doing a post on this completely myself, but the more I read, the more I realized that it would be re-inventing the wheel on my part as there are EXCELLENT resources out there on this topic. Below you will find one of the best, down and dirty reviews on BLAST injuries, their treatment, monitoring, and disposition courtesy of the CDC. It is a fairly long review, so feel free to browse through it, read only parts of it, and share it away. I modified this slightly by highlighting the key points with my own comments after them.

Any EMS, public safety or medical personnel need to be aware of at least the following basics when dealing with blast patients:

1) Key Concepts:

- Bombs and explosions can cause unique patterns of injury seldom seen outside combat
- Expect HALF of all initial casualties to seek medical care over a ONE-HOUR period
- Most severely injured arrive AFTER the less injured, who bypass EMS triage and go directly to the closest hospitals
- Predominant injuries involve multiple penetrating injuries and blunt trauma
- Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with GREATER morbidity and mortality
- Primary blast injuries in survivors are predominantly seen in confined space explosions
- Repeatedly examine and assess patients exposed to a blast
- All bomb events have the potential for chemical and/or radiological contamination
- Triage and life saving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the RISK OF EXPOSURE to caregivers is SMALL
- Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers... this means that you need to wear it!
- For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current)

2) Blast Injuries:

- PRIMARY: Injury from over-pressurization force (blast wave) impacting the body surface resulting in:
TM rupture, pulmonary damage and air embolization, hollow viscus injury

- SECONDARY: Injury from projectiles (bomb fragments, flying debris) resulting in:
Penetrating trauma, fragmentation injuries, blunt trauma

- TERTIARY: Injuries from displacement of victim by the blast wind resulting in:
Blunt/penetrating trauma, fractures and traumatic amputations

- QUATERNARY: All other injuries from the blast:
Crush injuries, burns, asphyxia, toxic exposures, exacerbations of chronic illness

PRIMARY BLAST INJURY:

1) Lung Injury:

-Signs usually present at time of initial evaluation, but MAY BE DELAYED up to 48 hrs
- Reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head or torso
- Varies from scattered petechiae (pin-point hemorrhages of the skin) to confluent hemorrhages
- Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast
- CXR: “butterfly” pattern
- High flow O2 sufficient to prevent hypoxemia via NRB mask, CPAP, or ET tube
- Fluid management similar to pulmonary contusion; ensure tissue perfusion but avoid volume overload
- Endotracheal intubation for massive hemoptysis, impending airway compromise or respiratory failure... common sense here, if you suspect airway deterioration of the pt, then tube them while you still can!
- Consider selective bronchial intubation for significant air leaks or massive hemoptysis
- Positive pressure may risk alveolar rupture or air embolism
- Prompt decompression for clinical evidence of pneumothorax or hemothorax... remember it is better to decompress if you suspect a tension PTX than NOT... if the pt turned out to have a HEMOthorax, then you will only get blood back! That is OK, put a stopcock on it, and move on, at least you now know the cause of their hemodynamic collapse!!!
- Consider prophylactic chest tube before general anesthesia or air transport... this is CRITICAL for those of you working in smaller outlying hospitals to which patients may show up for INITIAL stabilization... if you are a flight crew or an EMS transport agency picking this patient up, make sure this is done!
- Air embolism can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, claudication
- High flow O2; prone, semi-left lateral, or left lateral position
- Consider transfer for hyperbaric O2 therapy... know where your hyperbaric hospitals are, many cities only have ONE or none!

2) Abdominal Injury:

- Gas-filled structures most vulnerable (esp. colon)
- Bowel perforation, hemorrhage (small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture
- Suspect in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia
- Clinical signs can be initially subtle until acute abdomen or sepsis is advanced

3) Ear Injury:

- Tympanic membrane MOST COMMON PRIMARY BLAST INJURY!
- Signs of ear injury usually evident on presentation (hearing loss, tinnitus, otalgia, vertigo, bleeding from external canal, otorrhea)

4) Other Injury:

- Traumatic amputation of any limb is a marker for multi-system injuries... this may seem common sense, but we all too often TUNNEL VISION on these injuries due to their graphic & horrifying nature... throw a tourniquet, and move on with your primary assessment! Once you stop the external bleeding, it is the other stuff that will kill them... PTX, head injury with increased ICP, internal bleeding, perforated organs, etc... don't forget that!
- Concussions are common and easily overlooked
- Consider delayed primary closure for grossly contaminated wounds, and assess tetanus immunization status
- Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings
- Consider possibility of exposure to inhaled toxins (CO, CN, MetHgb) in both industrial and terrorist explosions
- Significant percentage of survivors will have serious eye injuries

DISPOSITION:

- No definitive guidelines for observation, admission, or discharge
- Discharge decisions will also depend upon associated injuries
- Admit 2nd and 3rd trimester pregnancies for monitoring
- Close follow-up of wounds, head injury, eye, ear, and stress-related complaints
- Patients with ear injury may have tinnitus or deafness; communications and instructions may need to be written

Please see the full resource text for further info at:
http://emergency.cdc.gov/HAN/han00346.asp

I would like to thank the CDC website and Epocrates for this detailed summary.

Stay safe!

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT DO NOT DISREGARD YOUR COMMON SENSE.

~EMSDoc911

Monday, May 20, 2013

A pregnant conundrum?


20yoF ~9mo pregnant (aka due any minute) called us for labor in progress... pt is a G3P1011 (this indicates 3 pregnancies, with 1 term births, 0 preterm births, 1 induced abortion or miscarriage, and 1 living kids).

Pt indicates that she is having strong contractions every 2-3mins apart lasting ~30sec ever since her water broke ~30min prior... she delayed calling 911 or having anyone take her because she wanted to "check" with her OB/GYN as to what she should do... who told her to come in to the hospital immediately as the pt is status post 1 C-section already, and has been scheduled for another one 1wk from now.... per her doctor the pt absolutely CANNOT have a VBAC (Vaginal Birth After C-section) because of some unknown complication that occurred with her first birth putting her at higher risk for uterine rupture... and most certain maternal & fetal death.

The problem.... her doctor's hospital is 25mins away Lights & Sirens or 45mins through rush hour traffic non-emergent... vs. the closest Obstetric Hospital which is 5mins away. The pt absolutely refuses to go to any other hospital other than the one where her physician is...

For anyone that knows me, if there is any chance of a delivery... I get off the scene quicker than if this was a trauma... aka... I'm on scene 5mins or less usually... so approximately 5mins into on scene time, and despite exhaustive efforts at convincing pt (visibly uncomfortable from her contractions) that it would be the safest to take her to the closest facility, the pt gets off the stretcher starting to walk back out of my ambulance & indicates that she will REFUSE if I take her anywhere other than her hospital. My partner offers to have our supervisor meet us on scene (eta ~15min) to see if he can remedy this situation.

So my question to YOU is...
1) Do you take her to her hospital of choice, knowing that you may be risking a vaginal delivery in the truck on the way there? And/or the possibility of uterine rupture?
2) Do you wait for your supervisor to show up & settle this?
3) Do you get her family involved, and try convincing her further to go to the closest hospital?

Any other suggestions?

__________________________________________________

First off, I must say that this may have been one of the most commented on posts (on EMSDoc911 Facebook page) that I've had in a while... which is great, because my intention for posting these cases is to stimulate a flow of ideas between the many professions that are within the realm of EMS and medicine.  It is always very interesting to see the variety of approaches to the same issue at hand... because how a paramedic may handle this may not be the same as a nurse or another professional... there were even a multitude of different/contradictory responses by paramedics that are of the same certification level.

This case was NOT clear cut... EMS rarely is... so the way I approached it, you may disagree with, and that is OK.  The last thing any of us need is a medic that second guesses you or me from the comfort of his couch.  Learn, don't second guess.

But to the case...

The one thing that I will never be able to adequately describe to you is the true feel of the scene, the gut feeling while in it, and the chaos of the real world.  Even though my call may be very similar to yours, every scene is dynamic, and never exactly the same.  My patient was in pain... but not too much pain... she looked like she was going to deliver... but not right now... she needed to be taken to the hospital... but the closest one? Not yet. Did I feel comfortable risking a 25min drive in rush hour traffic?

I was.

The most important point out of this is the fact that taking her to the closest facility AGAINST her will... is kidnapping, plain and simple.  Several of you suggested doing this... this is against the law.  It is NEVER ok to drag somebody to a facility without their explicit consent (unless implied consent of course)... this would be an ambulance chaser lawyer's dream.

Air transport from the scene is RARELY (if ever) utilized when intra-city, particularly when there are more hospitals scattered in the city than the local 711s, hence risks of flight/landing itself outweigh any benefits of expedited transport by this mode.  Any time you consider AIR transport, ask yourself this, what is the benefit that this patient will be receiving?  If you are 20-30mins away by ground from the facility of choice, is it really quicker?  If not, then what would this patient be gaining by flying?

Let's take our case, if I was to activate a helicopter:
2min from my call to activation of the flight crew
3min for warming of heli & crew readying
5min flight to scene (we assume heli is close... not always)
5min for scene time: pt packaging, take-off, etc
5min flight to hospital
5min from safe landing on the roof, pt extrication out of heli, elevator to ED or L&D

Total time:  25min!  And this is on the LOW end!!!

Exact same time that it would have taken me to transport this pt emergent to the EXACT same hospital... WITHOUT the extra utilization of fire/ems units for landing site prep, shutting down traffic, dangers of flight itself... and the exponentially higher bill for the air transport... for what?  Benefit?

Some indicated that it looked like she had "a while before delivery" as her contractions were still far apart... remember, the BEST place for a delivery to take place is in the comfort of a L&D dept, and not our MRSA infested trucks.  When was the last time you honestly deconed your ENTIRE truck after EVERY patient?  Furthermore, when deliveries go bad, they go REALLY bad... there is no in between.  Err on the side of caution, particularly with higher risk deliveries, and not the complacency of her "contractions are still far apart," we have NO fetal monitoring equipment in EMS... and by the point WE realize fetal distress, it is usually too late.

Others of you wanted to involve the patient's OB/GYN physician... a wise choice at first glance, but impractical when you have limited time.  Calling AND getting a hold of a physician that will ALSO give you a time a day can be worse than getting a customer service representative from a cell phone company.  In my opinion, it is time wasted when time counts... however, a wise choice when you have the luxury to play with time.

Calling med control.  Even though you will get an ER doc much quicker on the phone, don't forget that you may be on hold for a while as well... they may be busy doing a procedure, in with a patient... all too often I have been asked to call back OR have been on hold for up to 10-15mins waiting to get an attending to pick up... again time wasted, when you don't have much to spare.  Furthermore, unless the physician you are calling has a decent professional relationship with you, trusts you, I would bet that they would be hard pressed to offer you any other advice other than TAKE HER TO THE CLOSEST HOSPITAL.  A sentiment you already knew, and your patient rejected.  By the looks of my patient, some random ER doc telling her the same thing I did, would not have cut it.

Remember, that in that moment, you are attempting to relinquish the responsibility for making the tough, "life & death" decision by calling the ED doc... but this goes both ways... it would take a LOT for me as the doctor to take on that liability from you, if I was on the receiving end.  If this is the first time that I have ever spoken to you, and you ask me whether you should/should not take this pt to the closest facility AND/OR getting me to talk to the patient... yea, I will be erring on the side of caution, I'm not there on scene with you, I don't have the full picture... and will tell you the SAFEST thing to do... which may NOT be the BEST thing to do.  Makes sense?

My patient was determined to go to her doc, and I was NOT going to stand in her way OR waste time.  For those of you that frequent the inner city populace as your patients, do know that heated scenes can explode in seconds.  This was one of those times.  Everyone was outside, everyone was yelling, everyone was putting in their two cents, and everyone wanted to get in my truck.... ummm no.  Family help has its merits, this wasn't one of those cases.

Waiting for the sup?  As you can probably already tell, that would be an incredible waste of precious time... I will let you fill in the blanks as to why I think that is a bad idea.

After unsuccessfully attempting to reason with my determined patient, I agreed to take her to her hospital 25mins away under the following conditions:

1) If there was ANY worsening (sudden bleeding, imminent delivery, significant vital sign deterioration), I would divert to a closer OB capable facility, there were going to be TWO that we were passing on the way, ~10mins apart, giving me ample buffer in case I needed to divert.
2) I would be the judge of her deterioration if any, and my decision would be final.
3) She would be signing a refusal acknowledging the fact that she disregarded my medical advice at the potential risk of harming her unborn fetus AND herself.

The patient agreed to all terms.  The transport was uneventful, and she delivered a healthy baby boy later that afternoon by her doctor.

Moral of this long, dragged out post, if you made it this far reading it... sometimes what you feel is the best for the patient, is in reality what is actually best for you, and not necessarily for your patient.  Our job is not easy... our patients are not always reasonable with what YOU want (even though sometimes it may be what is best for them)... but a compromise can usually be obtained if YOU are reasonable to their demands.  We are here to serve THEM... even though the patients sometimes may not want to serve themselves.

Her actions could.... key word COULD... could have been disastrous.  But they were HER actions, and we must respect that... to a degree.  My rule of thumb is:

The more UNSTABLE a pt is, the LESS bargaining power THEY have.

The more STABLE a pt is, the LESS bargaining power I have.

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT DO NOT DISREGARD YOUR COMMON SENSE.

Stay safe!

~EMSDoc911

Wednesday, May 15, 2013

The monitor is deceiving... no, I was just lazy.

Yup, precisely that... I was too lazy to reach over the stretcher & press the PRINT button... even though I have made it a habit to try and do so... but occasionally we get lazy, tired, frustrated, annoyed, or whatever... so we don't do what we "always" do... and we get burned... as did I one night.

55yoM found unconscious on the side of the street... highly intoxicated or so I stereotyped him given the time of day, the location, and the plethora of empty ETOH containers around him. Upon loading him up & doing the usual VOMIT protocol (Vitals, Oxygen, Monitor, IV, transport), I noticed that his heart rhythm was borderline brady & a bit irregular... those were my first and last two clues... but again, I was lazy, tired, de-caffed, or whatever... he had a good pressure, and otherwise stable, other than his inebriated status bordering on needing a tube... he was just peachy... so I did NOT print out a strip.

How many of you have ran that or a similar type of call? How many of you have ignored your better judgement because you decided to slack off a bit... or cause you woke up from that deep 3am sleep still trying to figure out how you even got to the call? If you have been doing this long enough, it has happened... if it hasn't yet, just wait.

I took the patient to the local non-specialty hospital ED that was 0.6mi away (aka 6 blocks)... vs taking the pt to a referral facility 2.5mi away. Upon arriving at the ED, giving my turnover report to the staff, and the patient being hooked up to their monitor... a 2nd degree type II block came out clear as day.........

**facepalm** this time it was on me.

My point in describing this little story is that it happened to me... I got too comfortable on my own bench seat... this happened recently... not when I was a new medic... so if it can happen to me now, it can and will happen to me again... and can happen to you as well. I let my guard down... and I got burned... the pt did fine, was fine... but I was not fine... he should have gone to a cardiac facility, and it was on me... I deserved every crooked look that the nurses gave me.

EMS... emergency medicine... public safety... will grind you till you can't go any further... but the pt's don't know that, and they don't care what faze of your sleeping cycle you were in when they called... or how much caffeine you've had or did not have... they don't care if you just broke up with your boyfriend/girlfriend/husband/wife or if your dog died or you wrecked your car... they will call you expecting you to be at your BEST from the moment you show up... no matter what is going on in your life, at that moment... they are a PRIORITY... we are there for them on their BAD day... no one cares about our day.

I will continue having patients like this that will slap me upside the head & pull me out of whatever slumber or lazy haze I am in at that moment... but I hope to minimize those instances... never let your guard down... that is when we get burned.

Stay safe.

~EMSDoc911