Flights - A Blow to the Head

Welcome to the third 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.


By Rehman T, Ali R, Tawil I, Yonas H [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

By Rehman T, Ali R, Tawil I, Yonas H [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

You’re working as the Pod-Doc, having just taken the radio from the off-going UH-doc, you just finish admitting the patient in C40 for NSTEMI when the tones go off.

“Air Care 1 and Pod Doc respond to a scene for motorcycle crash, Northern Kentucky”

You call the B-Pod attending, sign out the pod, grab the blood from the blood cooler and head to the helipad.  Flying over the river, landing at a local firehouse’s parking lot you hop out of the back of the helicopter and head to the awaiting squad.

Your patient is a 29 year-old male who was riding his motorcycle (without a helmet) on a local country road.  Coming around a blind corner he unexpectedly found a car stopped in the middle of the road.  Striking the car from behind at ~35mph, he flew over the handlebars and impacted the back of the car.

On EMS’s arrival he was initially unconscious, but since their arrival has become increasingly combative

Physical Exam

  • Vitals: P: 110, BP: 150/90, RR: 28, O2 Sat: 96% RA, Glucose: 140 
  • General: agitated male yelling incomprehesibly at medics in the back of the squad, trying to sit up, resisting his restraints
  • HEENT: large hematoma to forhead
  • CV: tachycardic, diaphoretic
  • Pulm: Equal bilaterally, no wheezes/rales/rhonchi
  • Abdomen: soft, tenderness in bilateral upper quadrants, non-distended
  • MSK: no obvious deformities, superficial abrasions to hands
  • Neuro: awake, eyes closed except to painful stimuli, yelling and moaning incomprehensible words, localizes to painful stimuli bilaterally, equal strength throughout

Interventions PTA

  • C-Collar and backboard
  • IV established

Questions*

What medications could be used in the care of this patient? If the patient loses his IV, how does your treatment strategy change?

Are there other transport options besides flying with the patient? What factors go into that decision?

If you decide to intubate the patient, outline your airway management strategy (with particular attention to crew resource management, induction and paralytic medication choices, method of laryngoscopy).

If you decided to intubate the patient, discuss the principles of post-intubation management given the patient’s injuries.

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