This case study was donated by a friend of the show that works in a large metropolitan area. Let us know what you think!
You and your partner work for an urban EMS system and are dispatched to a reported “jumper” from a bridge nearby. As you enter the scene, you and the responding fire crew are guided to the back of an industrial park with no obvious hazards noted. A few bystanders that are present inform you that the patient, an approximate 20yom, jumped off of a nearby bridge into a ditch. The bridge was estimated to be fifty feet high. You and your partner set up your stretcher at the nearest access point. After hiking down into the ditch with a few members of the fire crew, you note that the patient is lying supine on the ground and is only responsive to painful stimuli, occasionally opening his left eye and groaning. You rapidly immobilize the patient with a c-collar and extricate him out of the ditch on a scoop stretcher. Transferring him to the pram, you note the patient has an approximate baseball-sized indentation in the posterior region of the head, bilaterally deformity to the ankles, left-sided deformity to the lower leg, and right-sided depression to the chest with clear and equal lung sounds that are maintained throughout care. There is notable dilation in the left pupil and the right is constricted. Blood and clear fluid are noted from the left ear canal.
- Patient remains only responsive to painful stimuli and is given a GCS of 9
- Skin is profoundly pale, diaphoretic, and cool
- Respirations appear shallow and irregular ranging from 10-28
- Strong, regular radial pulses in the 70s
- BP: 152/86
- HR: 76
- SpO2: 91% on room air
- RR: Irregular; ranging from 10-28
- EtCO2: 39mmHg
- BGL: 157mg/dl
TRANSPORT AND TREATMENT
Patient transported to a local Level I trauma center that is approximately 15 minutes away from the scene. En route, patient mentation decreases to a GCS of 8 with markedly reduced respiratory rate at 6bpm. Nasal airway placed and BVM ventilation commenced with improved SpO2% to 98 and an EtCO2 maintaining between 36-39mmHg. Crew considered advanced airway placement, but withheld due to lack of paralytics and significant trismus noted. Two large bore IV lines established. Patient maintains clear and equal bilateral breath sounds. Pelvis is splinted prophylactically. Left lower leg, left ankle, and right ankle splinted.
VITAL SIGNS AT TRANSFER OF CARE
- BP: 164/92
- HR: 64
- SpO2: 98% with BVM Ventilation
- RR: Pt is now apneic and being ventilated at 20bpm
- EtCO2: 38mmHg
Patient is diagnosed with a subarachnoid hemorrhage, basilar skull fracture, three broken ribs on the right side and two on the left, bilateral ankle fractures, a left-sided tibia/fibula fracture, and an L4-L5 fracture. Patient rapidly transferred to the surgical department where he arrested and was later pronounced.
- What would be your first priority for this patient?
- How would your care change if you were a rural provider as opposed to an urban medic?
- If you had access to paralytics or induction agents, would you have attempted to chemically facilitated intubation?
- What would you have done differently?