Prehospital Practice Hypothetically Speaking: Volume 2 Second edition

By Jeff kenneally

This second edition of volume 2 continues the case study scenario based theme began in volume 1 and culminating in volume 3.  Each is an easy to read short story format that begins by creating a common medical or traumatic emergency scenario, adding patient physical assessment presentations that result, blending the underlying pathophysiolo

• Language: English
• Publisher: Prehemt
• Release date: Apr 8, 2017
• ISBN: 9780992552671

Jeff kenneally

Intensive care paramedic for almost 25 years Manager clinical practice guidelines and clinical work instructions Road accident rescue team leader and trainer University lecturer

Book preview

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Second

edition

Volume 2

Pre-Hospital Practice Hypothetically Speaking

Jeff Kenneally

Published in Melbourne by:

PrehEMT Pty Ltd

[e-mail]

www.prehemt.com

First published 2014

Second Edition 2017

National Library of Australia

Cataloguing-in-Publication entry:

Kenneally, Jeff author.

Pre-hospital practice : hypothetically speaking /

Jeff Kenneally.

ISBN 978-0-9925526-7-1 (ebook)

Medical emergencies—Australia—Textbooks.

Assistance in emergencies—Australia—Textbooks.

First aid in illness and injury—Australia—Textbooks.

Copyright ©2017 Jeff Kenneally

All rights reserved. Reproduction of any part of this book without the publishers written permission is prohibited.

This material is intended for educational use by pre-hospital medical emergency responders. It should be read in conjunction with traditional relevant educational programs that provide for Australian first aid and emergency medical and trauma response. It does not intend to replace other education or training.

PrehEMT makes every effort to ensure the quality and currency of this information. It intends to provide guidance to applying appropriate pre-hospital emergency care to common medical and traumatic emergencies. It cannot cover every situation specifically as each patient and circumstance can vary from case to case. Before implementing any clinical practice or patient care the appropriate clinical practice guidelines, protocols and work instructions for the relevant organisation should be consulted and deferred to in all situations.

contents

5 Pre-hospital emergencies hypothetically speaking introduction

Hypotheticals

7 Opioid side effects

17 Fractured pelvis

29 Renal failure

43 Tricyclic overdose

53 Trauma and obstetrics

67 Autonomic hyper-reflexia

75 More left heart failure

87 Femur fracture

99 GHB overdose

107 Dystonic reaction

115 Road trauma

129 The seizing child

139 Sepsis and septic shock

155 Crush injury and syndrome

169 Right ventricular infarct

185 Motorcycle ‘accident’

199 Newborn emergencies

211 Vehicle airbags and trauma

219 The major incident hypothetical

235 Patient care record documentation hypothetical

244 glossary of abbreviations

Pre-hospital practice

hypothetically speaking

The role of pre-hospital emergency responder is a lot of things. It is challenging. It is daunting. It is tiring. It is incredibly satisfying. It is unique in many ways. It is a bit first aid, a bit doctor, a bit social worker and almost always jack of all trades. The call outs never stop coming and you never quite get to that point where you have seen it all. University education is common in the modern pre-hospital era but that only prepares you to start your learning. When you finally start you would once have been called an ambulance driver or officer. Now that is far more likely to be a paramedic or emergency medical technician.

Whatever you get called there is one certainty – you will be a novice in this working world that is like few others. Working against you are precious few diagnostic tools, language barriers, extremes of emotion and the worst of the elements as your constant companion.

There is an expression that says experience is something you get just after you need it. Experience is something every pre-hospital responder needs. You will gain a lot of it over the years of a career. Much of it will come under duress and the hard way through error or your partner putting you right just before. But what if you could learn through sharing the experience of others? You might avoid some of those errors or close call moments. You would certainly be much better prepared for the differing situations as they arise.

These hypotheticals are all based on real call outs, real patients and real situations. These are the cases where experience came just after it was needed the first time. It doesn’t have to be this way for others though. They encompass typical medical and traumatic emergencies as confront pre-hospital responders and look beyond the simple written guidelines and protocols provided. They are not based on the practices of any one organisation and reference to the applicable specific guidelines should be sought before putting these experiences into action.

Jeff

Opioid drug side effects

hypothetical

You have been called out this evening to a lady who has been complaining of a severe headache for several hours. She has had numerous headaches over the last few months but has not had them properly investigated in any way. Her sister suffers from migraines and, assuming this problem may be the same, has given to her several of her own panadeine forte tablets to take if she feels the need. Tonight is the first time she has felt this need and so she took two of them about an hour ago.

The plan has not followed the path she anticipated though as her husband has found her lying in bed drowsy and nauseated. Soon after she vomited; not long after that, again. With rising anxiety, her husband called soon after for ambulance help.

A full set of vital signs is always an important way to begin a detailed patient examination and you decide to begin this one with her conscious state assessment. On examination, she has no apparent motor neurological deficit on either side being able to obey simple command left and right equally. She can answer your questions with oriented answers. She is quite drowsy with eye opening to voice hence her GCS is 14.

She still has a generalised headache, the same that has plagued her all this time but it doesn’t feel too bad at the moment. In your assessment of symptoms she denies any neck stiffness or photophobia. Holding her wrist you note her pulse to be 74 beats per minute. Her blood pressure is 130/75mmHg and she has warm, dry and normal skin colour for her. Her breathing appears relaxed and normal pulse oximetry of 97%.

(1) What is her main presenting problem at this point? Is there any particular urgency in this presentation?

In this case, this lady has a history of occasional headaches over a period of months leading up to this acute episode of the last few hours. The headaches are as yet undiagnosed. Whilst you are not in any hurry to rule out the more serious possibilities, we do find ourselves asking why has the ambulance been called tonight and not on any other occasion? This is always a good question to politely ask at some stage. It is a good question for helping recognise, for example, that the puffing COPD patient has actually called you for their cellulitis inflamed leg.

Exactly why has the ambulance been called this evening? is an essential question right from the start to enable examination and questioning to focus in on the main complaint. Or complaints; there might be more than one problem.

History is an important part of patient assessment. There is the past history of what has gone on before anything happened today. In this case it is clear enough. Also there is current history that explains exactly what has happened today or relating to this event. It explains why you are here now. She has a past history of headaches, albeit undiagnosed. The current history though appears to be the lady becoming drowsy and vomiting as well. This is different for her headaches. Her husband has seen her with severe headaches before and has urged her to have them investigated. Tonight appeared at first to be just another night of headache. However these additional complications are the unusual part and are what concerns her husband.

(2) What could account for this difference from previous occasions?

Panadeine forte tablets contain an amount of codeine, typically thirty milligrams in each. This is a relatively large amount of opioid. For comparison, a standard panadeine tablet contains only eight milligrams. It is quite possible the drowsiness, nausea and vomiting are side effects of the codeine since they are amongst the most common side effects observed with the use of this drug.

Further, the effectiveness of codeine is considered unpredictable with benefits sometimes outweighed by adverse events. The likelihood of problems increases with dose. Sixty milligrams is a significant dose. To be effective, codeine must first be converted to morphine in the body, something which occurs variably and unpredictably6. The discussion here is one of side effects or even sensitivity rather than overdose or allergy. This is an important point of differentiation. This isn’t anaphylaxis. The drug is causing more of its predictable problems within the usual dose amount.

(3) What management options are there if you suspect codeine is a problem here?

Managing the headache pain presents some difficulty. Opioids are usually ill advised unless the patient has severe pain that is not resolving to any other option. It should be considered as a rescue therapy of last resort1,3,4,5. The best way to manage any headache is to diagnose it then match the therapy to the cause. Other analgesics may have some temporary effect such as the inhalation options.

The use of anti-emetic drugs prochlorperazine or metoclopramide may be of use in the management of diagnosed severe migraine pain. They can block dopamine neurotransmitter action in the brain which is useful if this action is causing vascular responses that are producing the pain. These are not always front line hospital options however they have been shown to be of use in many instances2,4. They can make useful prehospital therapies for acute severe migraine headache. Prochlorperazine can adversely affect consciousness so has a small amount of risk for this patient. However our patient’s headache intensity itself isn’t too bad right at the moment so you choose not to do anything about it for now.

After having assessed the patient, you advise the patient that an emergency department attendance tonight would be the wisest thing to do. Whilst your partner is outside getting the stretcher, you consider that the pain may not be too bad but the other problems of nausea and drowsiness are. You could offer her an antiemetic. An option such as ondansetron may not be a problem but prochlorperazine or metoclopramide could even worsen the drowsiness.

Instead, you rethink the option of naloxone administration. The patient has no respiratory depression and doesn’t really fit into any of the usual indications or guidelines for using this drug.

(4) How might you justify a plan for opioid antagonist administration?

Medical consultation works best when you provide clear understanding of the patient’s presentation along with a suitable suggested management plan. Provide an accurate patient presentation, particularly about the nature of the problem and your differential diagnosis. To support any plan you might have, the consultant needs to be satisfied you are on the right path and have considered the serious possibilities.

You decide to call the ambulance clinician on the radio. You discuss with her that you consider that since one to two milligrams of naloxone normally is enough to arouse a comatose patient, this dose may be quite excessive for this drowsy but still oriented patient.

The clinician thinks it is fine for you to administer naloxone just as long as you transport the patient to hospital for assessment. You have no problems with that as that is what you were planning. She agrees that a smaller amount would probably be effective. She makes the suggestion for a small 100 microgram dose of naloxone, still via intramuscular injection and this seems quite reasonable.

You inject the dose of naloxone into a deltoid muscle and find within a few minutes all of the side effects rapidly reolve. The lady becomes alert again and says that she is now free from her nausea. Well assessed and managed, you think as you quietly congratulate yourself. You prudently transport her off to hospital.

Later in the shift, sitting back at your station, you overhear another crew discussing an elderly patient they attended who presented similarly drowsy and nauseated. You immediately think this may have been the same thing occurring as you have just attended. Listening to the story though she didn’t have any headache to complain of. Instead she had significant abdominal pain caused by her diverticular disease. An hour after the locum doctor attended and gave her a suppository she had an onset of her problem signs and symptoms.

Switched on to this presentation, you ask casually what the suppository was. ‘Oxycodone’ says your colleague, reading off the patient care record. ‘I’ve not heard of it before’, he shrugs.

(5) What is this drug?

As with so many drugs, the elderly can be vulnerable to opioid medications. The elderly are particularly susceptible to the effects of oxycodone with reduced clearance and prolonged duration of action8. This lady could easily have succumbed to the actions of the tablet. Providing analgesia to the elderly is challenging. Frailty and alterations in awareness and other central nervous system functions make it more difficult to identify pain and to assess the effectiveness of treatment. Timidity with analgesia often means patients, including the elderly, are under analgised. The corollary of this though is that the elderly frequently require smaller doses of opioid drugs to provide effective pain relief9,10,11,12,13.

Even with small titrated drug dose, problems such as this can easily occur. You propose to your colleagues that they could have consulted to administer naloxone for this lady just as you have recently done. They both concede they hadn’t even considered this possibility.

Given its comparative strength, it is probably no surprise that oxycodone has become increasingly implicated in both accidental and intentional overdose. Users of illicit drugs have been known to turn to oxycodone, dissolving and injecting it with or instead of other intravenous drugs16.

Following the discussion, curiosity gets you so you follow up on the patient by calling the emergency department. You enquire as to what they did for the lady. Apparently they suspected the drug as well and found that she became alert and without nausea within a few minutes of naloxone administration. Then they had to find another way of dealing with her pain.

(6) If you consult and successfully manage a patient in this situation, is there still a need to transport the patient to hospital?

With both of these patients there has been a good chance to improve the patient’s condition without introducing other problems or complications. Administration of a small dose of naloxone seems justified on a cost versus benefit approach. Medications are administered in good faith where the benefits are believed to outweigh any problems or down side. Unfortunately it doesn’t always go to such plan.

Now that you have become truly aware of this problem, it just seems to keep on appearing. A few weeks later you are confronted once again with a similar situation to ponder. This time you find yourself caring for a young lady who has deliberately overdosed on a cocktail of oral medication that includes a quantity of codeine tablets as well as some other sedatives. She doesn’t appear to have vomited at all though you roll her onto her side just in case she does decide to or has some unsuspected passive aspiration.

Beginning your patient assessment whilst your partner gathers up the now empty medication packets in the bathroom and on the bedroom floor, you find she has some signs of respiratory depression with a respiratory rate of ten and shallow. Her conscious state is altered with her GCS being only 9. She opens her eyes and has mumbling incomprehensible speech when provided with sternum pressure. She also localises to the sternum stimuli.

(7) Would naloxone administration be appropriate here?

It is some months on and you are attending to a quite elderly woman who is presenting with a complaint that you are managing as cardiac chest pain. Amongst other therapies that you provide, you administer to her a very small bolus of intravenous morphine. You have intentionally chosen a very small dose given your knowledge of the increased sensitivity of the older and frailer patients.

Within a few minutes and despite your caution, you note that she has become drowsy. She opens her eyes to your voice but is slow and quietly spoken in her replies. Her blood pressure has gone from 130/80 to 80/50mmHg with little change to the pulse rate. She is now complaining of nausea. Quickly you reflect on your discussion with oxycodone and its dramatic effect. Suddenly empathising a whole lot more easily with the prescribing doctor you lament that you appear to have arrived in much the same place yourself.

(8) Given your recent experiences with opioid drugs, what management options do you feel you have here?

Once you have taken the opioid away with naloxone, it is likely that pain severity will increase again. The analgesia effect may not be lost entirely. Very small doses of naloxone may not negate all of the opioid receptors that are stimulated leaving some ongoing action. There is also the option of using an alternative analgesia for the prehospital period. Inhaled options such as methoxyflurane or nitrous oxide may provide suitable short term therapy.

Finally, it is late on a Saturday night shift. Despite not having eaten yet, or watched the recorded episode of ‘The Walking Dead’, you find yourself attending to a patient living in a boarding room in an inner city suburb. The suburb is one you usually only visit for drug overdose calls. The patient is a young man, about twenty years of age. He has very short, cropped hair and multiple facial piercings strikingly evident. Several of his friends of similar appearance are with him. Your bias continues as you note to yourself that he looks like a man who would use illicit drugs. The friends have called you because the man has become very drowsy and almost unable to be roused. You inspect his pupils and find them to be pin-point. His respiration is a little shallow but still around eight breaths per minute. Yep, you think, what else was it ever going to be?

When asked if he has used any illicit drugs such as heroin recently, you get a fairly genuine denial. Used to receiving the most shocked denials every time you enquire if illicit drugs have been involved you remain sceptical given his presentation. You continue to look for evidence of recent self injection. You find none in any place you can think to look. It is repeatedly stated that he has been a heroin user in the past but is definitely not on ‘the stuff’ now. Reluctant to give up on your ‘all signs point to this’ diagnosis, you now have doubts that this man has used heroin on this occasion and wonder what else could be the problem.

(9) How could this be a narcotic overdose and how should you treat him?

Methadone is commonly prescribed as an oral alternative that blocks the euphoric response to opioids, reduces the dysfunctional responses that occur in opioid withdrawal and allows time for the patient to readjust to life without drugs. The patient can then be more easily weened off the methadone. A patient can overdose and succumb to opioid effects just as easily with methadone and so for many it is typically carefully prescribed and administered in hospital. However there is extensive use of private clinics and between all of them the approach to administration varies. It is possible for some addicts and narcotic users to takeaway and store their doses and later take them in excess. They could also take them with other opioid and non opioid medication which can lead to harmful overdose and even death15.

Suggested Answers

As with every patient, don’t leap to a diagnosis quickly. It isn’t the role of the paramedic to diagnose anyway so in this early state consider what are the main presenting signs and symptoms of concern and keep in mind the realistically possible serious causes for this. The main presenting problems she has are acute headache, nausea and drowsiness. The most serious complication that must be ruled out with any headache presentation is an acute cerebral event, most notably some form of intracranial haemorrhage. A subarachnoid haemorrhage must always be a serious consideration in the setting of undiagnosed headache, especially if it becomes severe or the patient collapses. For the time being treat her but keep this serious option on the short list. A meningeal infection is another serious possibility to keep in mind. If you feel just a tiny bit nervous dealing with the patient with an undiagnosed headache, hold that thought..

Previous events may have been warning episodes to the real thing tonight. The transient ischemic attack for instance can forewarn of an impending stroke. Or perhaps there is something else entirely going on. Firstly, she may have some other additional illness happening tonight, such as a febrile or gastric illness or even meningitis, accounting for the new signs and symptoms. Alternatively the whole thing may be something new and different all together. When accounting for a patient’s signs and symptoms, you have to account for them all. Finally, the difference may have been brought about by something that has happened or that she has done differently tonight. One thing she has done differently is to take those panadeine forte tablets..

Before you move on, at the very top of the list is the concern that you are selecting one of the least serious possibilities from the list of options. You may be right but you should be at least just a little apprehensive about discounting more serious possibilities so readily. Don’t forget any of them completely yet. No specific instruction usually covers this patient presentation. You can choose to take the minimalist approach and transfer the lady just as she is to hospital. This would provide a suitable payoff approach to a patient who may still be suffering an acute intracranial event. A headache is not really suitable for a doctor referral given the risks of it being something serious. If she is too unwell to be referred to a doctor then clearly our lady must also be discouraged from remaining at home. The investigation of these headaches is long overdue. You can also consider your options for managing the pain of this headache. What is also worth considering is the administration of the opioid antagonist naloxone as you would with any other problematic opioid/narcotic.

Consult for advice is often a useful means of devising a plan in unusual circumstances. You could contact the patients’ own doctor and explain the presentation and circumstances. You could consult with the admitting officer of the nearest emergency department. If there was one, a better plan might be to consult with a paramedic clinician in the radio dispatch centre if there is one available to discuss any management plan. What you do know is that there are no compelling factors that suggest intracranial haemorrhage or meningeal infection at this point in your assessment. You do know this presentation is consistent with codeine sensitivity and side effects and you do know that you can easily remove this with an opioid antagonist. Whilst not entirely removing the serious options from consideration, the use of naloxone in this instance may bring improvement without great disadvantage

Oxycodone is yet another opioid preparation for treating pain7,16. It can be taken variously but is often given as a suppository, commonly for abdominal complaints and frequently cancer problems. Its effects can last for several hours. It is a strong medication and finds the rectal mucosa very effective at allowing absorption. It also comes in oral tablets of varying strength8.

Yes there is. You cannot be expected to fully understand all of the underlying problems the patient may have. The cause of the pain is not yet managed and the pain may very well worsen as you reverse the effect of the analgesia. You certainly haven’t done anything to manage the original problem, simply resolve the side effect problem. Naloxone may wear off before the opioid drug does making it possible for you to get a repeat call back in a couple of hours for the same thing. Every patient must be provided with a management plan that leads them to where a solution can be found. Leaving a patient without further care is not usually providing them with a solution to their problem.

This situation is not clear cut at all. What you want is to be able to manage the patient in the best interim condition to get to hospital. If you have a plan that can improve the patient’s condition then that will likely be the thing to do. On the other hand, if the patient cannot be improved in any way, the most important role will be a rear guard one where you aim to stop them from deteriorating. Improving the patient is one thing but allowing them to get worse is most undesirable. So your question will be, will this patient improve with the administration of naloxone? Of course you cannot answer this easily. Clinical judgement will be a part of the answer. If there are multiple drugs involved all impacting on presentation, then even after naloxone administration you will still have management problems. In this case it may be better to avoid naloxone. If however the codeine is the biggest offending agent and there isn’t much else, then perhaps an opioid antagonist would be useful. A drowsy patient isn’t desirable however a state of mild sedation may be helpful if the patient only becomes agitated and uncooperative following your therapy. The definite answer with this patient is maybe, maybe not. Probably not with this patient.

When somebody exhibits side effects of opioid drug soon after receiving an opioid drug, oddly enough it is often likely the opioid drug that is to blame. What is that expression about looking like and quacking like a duck? Few conditions benefit from hypotension and cardiac pain is not one of them. You will need to do something for this lady, even if it means that you have to give up the benefit of pain relief. The first idea would be to try and increase her level of arousal through direct tactile and verbal stimuli. Ensure she has high flow oxygen and encourage her to take deeper breaths. Pulse oximetry can help to monitor the effectiveness of her ventilation. A crystalloid fluid push to try to increase the blood pressure may also help. Improving her blood pressure could possibly improve her level of alertness.

Ultimately, she may need to be properly aroused with an opioid antagonist such as naloxone. In this case a small dose of one or two hundred micrograms could again be quite adequate. Intramuscular injection would work however if you have inserted an intravenous line this might be a more predictable route for now. As before, a consultation with the doctor, ambulance clinician or even a doctor from the local emergency department, for approval may be desirable for this course of action if it isn’t covered in local clinical practice guidelines.

With no evidence of other drug involvement or any suggestion of any other medical problem (that is, his other vital signs are acceptable, BSL normal, he is normothermic) you have no other working option but to treat him as an acute altered conscious state consistent with narcotic drug overdose. There are still findings that support this view including the depressed respiration, consciousness and pinpoint pupils. It is possible that this man has used heroin and you simply are unable to find the injection site. Perhaps he isn’t honest with his friends. Oddly enough, some people lie to paramedics and this might be the case here. Consider also, that as he has been a significant user of such drugs, he may have access to other forms of it. He may be in the methadone program for instance. He is required to drink this, not inject it. It is possible that he may be under the influence of a narcotic, but without the usual clue of injection site.

References

1. Cinzia Finocchi, Erica Viani. Opioids can be useful in the treatment of headache. Neurological Sciences. May 2013;34(1):119-124

2. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials Ian Colman, Michael D Brown, Grant D Innes, Eric Grafstein, Ted E Roberts, Brian H Rowe BMJ 2004;329:1369 (11 December)

3. Stewart J. Tepper. Opioids should not be used in migraine. Headache: The Journal of Head and Face Pain. Special Issue: Proceedings of the Inaugural Southern Headache Society Meeting. May 2012;52(s1):30-34

4. Nancy E. Kelley, Deborah E. Tepper. Rescue Therapy for Acute Migraine, Part 3: Opioids, NSAIDs, Steroids, and Post-Discharge Medications. Headache: The Journal of Head and Face Pain. March 2012;52(3):467-482

5. Morris Levin. Opioids in Headache. Headache: The Journal of Head and Face Pain. January 2014;54(1):12-21

6. Joel Iedema. Cautions with codeine. Aust Prescr 2011;34:133-5

7. Klaus T. Olkkola, Vesa K. Kontinen, Teijo I. Saari, Eija A. Kalso. Does the pharmacology of oxycodone justify its increasing use as an analgesic? Trends in Pharmacological Sciences. April 2013;34(4):206–214

8. T. I. Saari, H. Ihmsen, P. J. Neuvonen, K. T. Olkkola, H. Schwilden. Oxycodone clearance is markedly reduced with advancing age: a population pharmacokinetic study. Br. J. Anaesth. (2012) 108 (3): 491-498.

9. William C. Becker, MD; Patrick G. O’Connor, MD, MPH The Safety of Opioid Analgesics in the Elderly: New Data Raise New ConcernsComment on The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults. Arch Intern Med. 2010;170(22):1986-1988

10. David Buckeridge, Allen Huang, James Hanley, Armel Kelome, Kristen Reidel, Aman Verma, Nancy Winslade PharmD, Robyn Tamblyn. Risk of Injury Associated with Opioid Use in Older Adults. Journal of the American Geriatrics Society. September 2010;58(9):1664-1670

11. Maria Papaleontiou, Charles R. Henderson Jr, Barbara J. Turner, Alison A. Moore, Yelena Olkhovskaya, Leslie Amanfo, M. Carrington Reid. Outcomes Associated with Opioid Use in the Treatment of Chronic Noncancer Pain in Older Adults: A Systematic Review and Meta-Analysis. Journal of the American Geriatrics Society. July 2010;58(7):1353–1369,

12. Perry G. Fine. Treatment Guidelines for the Pharmacological Management of Pain in Older Persons. Pain Medicine. Special Issue: Neurobiology and Clinical Implications of Pain and Aging. April 2012;13(s2): S57–S66,

13. Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P, British Geriatric Society. Guidance on the management of pain in older people. Age and Ageing 2013; 42(Suppl 1):i1-57

14. Amato L, Davoli M, Minozzi S, Ferroni E, Ali R, Ferri M. Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database of Systematic Reviews. 2013. Issue 2. Art. No: CD003409

15. Jennifer L Pilgrim. Michael McDonough, Olaf H Drummer. A review of methadone deaths between 2001 and 2005 in Victoria, Australia. Forensic Science International. March 10, 2013;226(1-3):216–222

16. Shane Darke, Johan Duflou, Michelle Torok. Toxicology and Characteristics of Fatal Oxycodone Toxicity Cases in New South Wales, Australia 1999–2008. Journal of Forensic Sciences. May 2011;56(3):690-693

Fractured pelvis

hypothetical

You ponder just how much noise and excitement there always seems to be at car crash incidents. You are on your way to another car crash and have that mix of anticipation and slight apprehension. As you approach the scene you can feel a rising level of urgency within. This crash does look serious you have to admit as you pull up so you provide a short early windscreen situation report. The number of vehicles involved, where backup vehicles should approach from, obvious hazards and so forth are all evident already so you start the information flow early.

Slowly donning your reflective vest and personal protective equipment you give yourself just a few vital moments to take in as much of the scene as possible. If you don’t think from the outset about hazards or how to manage situations where there are multiple patients, you might find yourself in trouble fighting to catch up.

An older model sedan has run head on into a light pole causing extensive intrusive damage to the car. The young woman driver is still trapped in the driver’s seat. She is conscious and in obvious pain. The fire rescue service has deployed multiple hydraulic rescue tools and a number of charged water hoses within immediate vicinity.

(1) What are your first thoughts on arrival at this scene?

As if that isn’t enough, very soon you will want to start to plan your initial management for the patient. All the while you must balance this against the rescue team’s need for full access to the vehicle to allow expeditious extrication. To know what needs to be done for the patient, the first step is to work out what is wrong with them.

Initial assessment of the patient is difficult. Between the damage to the car and the rescue team setting up to create a rescue opening you find yourself with limited access to the trapped patient. Quickly you discuss with the rescue team leader the plan of extrication. The team leader suggests a plan that makes sense and you nod in agreement. You have to trust in his judgement as you know little of their equipment. In return though you stipulate your own needs to be able to