You are working as a double Paramedic crew on an Ambulance, you have just been called to an RTC on a busy A road stretch 15 minutes away. The reports are of a head on collision between an HGV lorry and a car. There are 2 casualties reported, the lorry driver, and driver of the car. The person in the car appears to be trapped. Control informs you that there are multiple vehicles being deployed to scene including another Ambulance, a Critical Care Doctor, Helimed, and members from HART. You will be first on scene along with Police.
As you approach the scene you can see there is significant debris on the road, Police have set up a cordon and have made the scene safe. Looking at the car, you can see there is significant damage and intrusion of the engine into the cab. You don your RTC jacket and helmet and carry kit over to the scene. You can see one patient sat in the driver seat of the car, and there is a man who has a head injury with blood on his face and jumper speaking to a Police officer. You decide to split up and triage/treat the patients individually until more help arrives. You head over to the person trapped in the car.
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As you step around to the drivers’ side door with the response kit, you see a 21-year-old male in the drivers’ seat. There is no one else in the car. From a quick look over the patient, you see he is pale, slumped forward making a snoring noise with his breathing. There is a lot of metal work from the intrusion of the engine pinning his lower thighs/knees to the seat. You look into the footwell and see a lot of blood pooling, there also seems to be metal penetrating his calves with significant blood flow from the site. What is your first priority
You quickly try and get a good look at his lower legs and can see significant blood loss from the multiple penetrations in both limbs. There is a lot of metal work in the way so you are unable to directly access the wounds. What are your next actions
You quickly tighten up both tourniquets to the point where the bleeding has stopped. The patient gives a groan when you are doing this. A Police officer comes up to you with clinical gloves on and asks if he can help with anything. What is your next System management
You gently straighten the patient up in a central/neutral c-spine position in order to manage the airway. The Police officer helps you and maintains c-spine support from behind the patient. Blood is drooling from the patient’s mouth and in this more upright position he starts gargling on it. What can you do to alleviate this
You suction away the blood, he doesn’t react or gag to the suction device in his throat, but the airway remains noisy and ineffective with his respiration’s decreasing and O2 levels low. What actions can you follow to help correct this
You quickly work through your step-wise approach but you are now at your LMA device, and there is still blood collecting in his airway disrupting the effectiveness of the LMA. What further steps are you able to take
With continuous suction and use of video assisted intubation device, you are able to successfully intubate the patient in an upright position. You have the airway secured and are reading good capnography on your defibrillator. A further Police officer is called over to you and you instruct them on how to squeeze the bag gently every time the patient takes a breath. You now move onto breathing management. You place 100% O2 on the patient. What mnemonic can you use to assist with your assessment
You conduct your assessment of breathing and note little air entry on the left side with no rise or fall, there is also significant bruising, hyperresonance and a tracheal tug. What does this indicate
What action will you conduct next
You conduct the needle thoracocentesis with your decompression device and have a positive hiss of air. You re-assess the breathing and hear a better air entry on the left side. With this another Paramedic arrives to assist you with the patient. You quickly give a handover and continue with your treatment. Your colleague starts cannulating, and you continue your treatment into Circulation. What should you re-check at this point
The tourniquets are still controlling any haemorrhage and you suspect there is multiple sites of internal haemorrhage. What drug can you administer to help stop the breakdown of any clots
Your colleague goes to set up sodium chloride for the patient, however the patients’ blood pressure returns as 92/47. For penetrating limb trauma, sodium chloride should be given to maintain a systolic blood pressure of
You ask your colleague to not give any Sodium Chloride at the moment as the systolic is maintaining around 90 mmHg. The Fire Service arrive and set about a plan of freeing the trapped patient. The Basics Doctor has come over to you, taken your handover, and is reviewing what further treatment they can give. Your colleagues are continuing to gain observations. You are in the Disability assessment, your colleagues are gain observations, what further considerations can you give to the environment and factors on the patient
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