Transcript Case Presentation

Case Presentation: BLS to ALS Handoff
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21 year old male
Unrestrained driver, single vehicle MVC
20mph; sedan vs. concrete barrier
No airbag
Starred windshield
+ LOC
Initial Assessment
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Patient has clear airway
Bilateral breath sounds
Strong radial pulse of 100
Blood Pressure 120/80
Speaking spontaneously
Additional information?
• Respiratory rate/ quality–16 good movement
• O2 sat – 100%
Physical and Neurological Evaluation
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Found out of vehicle walking near accident scene
3x5cm Hematoma/ contusion left forehead
Opens eyes spontaneously
Alert to person & place, but confused to month
and year
• Follows motor commands
• GCS =
▫ 14
Additional information?
• Pupils
Treatment and Interventions
• Immobilization with cervical collar and
backboard
• Reassess vital signs & neuro exam Q5 min
• Administer supplemental oxygen as needed to
maintain SaO2 > 90%
• Rule out other causes of altered mental status
• BLS - Medic Eval?
• ALS - establish IV access
Causes of Altered Mental Status
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Hypovolemia
Hypoxia
Hypoglycemia
Pain/Discomfort
Traumatic Brain Injury
Additional causes?
• Alcohol
• Drugs
Transport Decisions
• Destination
▫ Mild TBI
▫ GCS 14
• Emergency Department
Reassessment enroute: ABC’s
• Vital signs remain stable
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Patent airway
Bilateral breath sounds
Pulse 96
BP 116/76
Additional information?
▫ Respiratory rate/ quality – 12 regular
▫ O2 sat – 92%
Reassessment: Neuro Exam
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Eyes open to painful stimuli
Speech is incomprehensible
Localizes to painful stimuli
Pupils 3mm bi-lat. with brisk reaction to light
• GCS =
▫9
Treatment and Interventions
• Cervical spine immobilized
• Backboard in place
• O2 administered via NRM
▫ Critical value – SpO2 < 90%
• BLS- Medic Eval?
• ALS - IV access established with NS infusing
▫ Critical value – SBP < 90mm Hg
Transport Decisions
• Destination
▫ Moderate TBI
▫ GCS 9
• Trauma Center
Reassessment: ABC’s
• Changes in vital signs
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Respiratory rate 8
SaO2 90% on NRM
Pulse 112
BP 80/60
• Additional Information?
▫ Respiratory effectiveness –
Irregular/ poor air exchange
Reassessment: Neuro Exam
• Patient is unresponsive
▫ Eyes – no response
▫ Motor – bilateral extensor posturing
▫ Verbal – no response
• Pupils
▫ Right 4mm & reactive
▫ Left 3mm & reactive
• GCS =
▫ 4
• BLS to ALS Handoff
ALS Treatment Interventions
o Establish a patent airway
o Vigorous IV fluid administration (Keep SBP > 90mm Hg)
o Supplemental oxygen
o Hyperventilation @ 20 breaths/minute
o Only when suspected cerebral herniation
o Capnography/ ETCO2 used to:
▫ Confirm endotracheal tube placement
▫ Measure the adequacy of ventilation.
 Target range: 35 – 40 mm Hg
▫ Guide hyperventilation therapy
 Severe hyperventilation: < 30 mm Hg
 ETCO2 < 25 mm Hg is not recommended
Transport Decisions
• Destination
▫ Severe TBI
▫ GCS 4
• Level One Trauma Center with TBI capabilities
Transport Decisions
• Level One Trauma Center with TBI capabilities
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24 hour available CT scan
24 hour available operating room
Prompt neurosurgical care
Ability to monitor intracranial pressure
Ability to treat intracranial hypertension
Summary
• Provide oxygen and ventilation to maintain oxygen
saturation >90%
• Provide adequate fluid to maintain SBP >90mm Hg
• Continuously look for S & S of Cerebral herniation
▫ Pupil abnormalities
▫ HA, N/V
▫ Cushings Triade - SBP,
HR, Irreg. resps.
• Select the most appropriate facility and mode of
transportation for admission of the TBI patient
Additional information?
• Continually reassess and document:
▫ Component GCS, VS, post intubation RR, and Capnography
values .