Flights - A Stab in the Dark

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Welcome to the second case in our Air Care and Mobile Care Flight Orientation Curriculum! 

Every few weeks throughout the spring and early summer, there will be a series of posts and cases published to help spur some thought and discussion on the management of the critically ill patients we take care of in the pre-hospital environment.  These virtual flights will be used to highlight some key considerations in the management of blunt trauma, penetrating trauma, STEMI, and several other common disease processes seen on Air Care.

Comments will be open for 2 weeks after which time, a post containing expert commentary and curated commentary from the community will be published to reinforce the key learning points brought up in discussion.

Source: http://pixabay.com/p-29308/?no_redirect

Source: http://pixabay.com/p-29308/?no_redirect

You are working overnight as the H2 doc based at Butler County Regional Airport.  It’s bitter cold out (for Ohio that is).  Its only 11 PM and already the temperature has dropped to 9 degrees fahrenheit on its way to a low of 0.  You are in the lounge refamiliarizing yourself with the contents of the critical care cells when the tones go off: “Scene: stab wound – Hamilton Ohio”

You and the nurse grab your equipment, the blood cooler, and head to the helicopter.  You put the critical care cells back in their spot in the rear of the helicopter and then buckle in for the short flight to the scene.

Your patient is a 23 year-old female who was in an argument with her boyfriend earlier in the evening.  The verbal argument quickly escalated, her boyfrienf pulling a knife and stabbing her multiple times in the right arm and right chest.  He fled the scene and she managed to call 911.  The first responders found the patient with significant active bleeding from her arm as well as chest.  She was initially responsive, but is now only awake to painful stimuli.

You meet the EMS crew in the back of the squad truck and assess the patient from the head of the bed.

Physical Exam

  • Vitals: P: 130, BP: 60/30, RR: 28, O2 Sat: 96% NRB, Glucose: 112

  • General: in acute distress, lethargic in back of squad, but responsive to painful stimuli and will answer questions

  • CV: tachycardic, diaphoretic

  • Pulm: Decreased BS to the right chest, 1cm puncture wound to right chest wall, left chest clear

  • Abdomen: soft, NT, ND

  • MSK: multiple lacerations to the right upper extremity with bright red blood squirting from the antecubital fossa

  • Neuro: lethargic, opens eyes to painful stimuli, will answer questions with stimulation

Interventions PTA

  • Gauze applied to wound on RUE with direct pressure, now soaked with blood

  • Gauze over right chest wall laceration

  • IV established in LAC with NS infusing

Questions*

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Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

Do any procedures need to be performed on this patient?  If so, who performs the procedures? In what order should they be done? Where do you do these procedures (squad/in flight/receiving hospital)?

What medications should be used in the care of this patient?  Should this patient receive blood products? If so, what type and in what order?

Given the environmental conditions, what additional steps should be taken in the care of the patient?

*To help facilitate discussion, when commenting please precede your answer to a particular question with Q1, Q2, etc.