Paramedic Case Studies

Name

Institution

Table of Contents Introduction 3

1.1 Clinical plans are prior to arrival on the scene. 4

1.2 Patient selection Criteria for RSI 5

1.3 Steps in an RSI Procedure 6

Step 1 - Preparation 6

Step 2- Preoxygenation 6

Step 3- Pretreatment 7

Step 4- Rapid sequence Induction and Paralysis 7

Step 5- Protection and Positioning 7

Step 6- Placement of the Endotracheal Tube in the Trachea 8

Step 7- Post-intubation Management 8

1.4 Risks and benefits associated with RSI 9

Case 2 10

2.1 Discussion 10

2.2 Clinic plan and initial management 10

2.3 Notification of Arrival 11

Conclusion 11

Case 3 12

Introduction 12

Incident 1 12

Incident 2 13

Incident 3 13

Incident 4 14

Case 4 15

Conclusion 16

References 17

Introduction The basic concept of retrieval medicine is a combination of transfer and care of a patient from one medical institution, site of trauma, and pre-hospital management to a medical institution to provide higher and better level of care. The transfer and retrieval of severely ill and wounded patients entail high-risk activities (Ellis & Hooper, 2010). This paper looks into various case studies to determine the various control measures that might and should be put in place in various retrieval situations so as to increase patient safety and efficiency in pre-hospital care. This comprises of communication procedures, team resource management, audit and training important event analysis and the pre-hospital operating care clinical plan.

Patients with severe fatalities put up poorly with transportation. Highly sensitive care is thus required to reduce the probability of occurrence conditions such as hypoxia or hypertension and general clinical deterioration. However, due to the effects that come with transportation, at least 15% of retrieval cases are ensued with these conditions. Communication and control are equally vital essentials in retrieval processes. Timely communication with the appropriate recipient hospital department is vital. It is of priority to notify the responsible senior clinician on location. Still, systems of patient retrieval that are seemingly organized in-cooperate a wide variety of time and mean the fluctuation in the caring for a patient (Davis, Moore, & Cocanour, 2008).

The use of rapid sequence intubation is crucial in emergency airway treatment, which is among the fundamental skills that any emergency department practitioner should possess. It is because failing to secure a sufficient airway treatment could rapidly result in disability or death. The reference to the procedure as “rapid” is because it involves the use of succinylcholine to achieve concurrent initiation of neuromuscular obstruction and sedation (Daniel, Hoyt, & Fortlage, 2009).

1. Clinical plans are prior to arrival on the scene. The patient is a casualty of a road accident and is not responding but is breathing. The clinical plans prior to our arrival on the scene of the accident will thus include assembling equipment necessary for the prevention of possible hemorrhage, endotracheal intubation equipment such as cardiac monitors, suction, laryngoscope, various sizes of endotracheal tubes if necessary, oxygen supply equipment (Strayer & Nelson, 2011). Airway obstruction is a major cause of deaths that could have been prevented in trauma patients who have hemorrhage. Hypoxia is similarly common in trauma patients; therefore, supplementary oxygen should be considered in this case.

The patient’s GCS is below 8 indicating intensive cognitive deficiency which may result in aspiration induced secretions, regurgitation, foreign bodies or teeth or blood. Therefore in order to ensure efficient airway care and reduced aspiration risk, it is recommended that Rapid sequence intubation be employed (Romano-Girard, Malerba, & Cravoisy, 2011).

1.2 Patient selection Criteria for RSI It at times is difficult to decide whether or not to intubate a patient. It, therefore, requires clinical experience to identify the symptoms of imminent failure in a patient’s respiratory system. The accident level in question however leads to the anticipation of deteriorating course implying that the patient might eventually be unable to maintain his airway patency (Blanchfield & Schlesinger, 2011). The low GCS (below 8) also indicates extreme cognitive impairment which means the patient is unable to protect his airway from aspiration. Both of these are indicators that make the patient viable for an RSI.

It should however be noted that any hereditary syndromes, anatomic abnormalities, cervical spine difficulties and gastric reflux may lead to difficulty in intubation. We shall thus conduct the airway assessment beginning with looking at the external predictors which include; facial trauma, beard or moustache, large tongue and large incisors. This is followed by evaluation using the 3-3-2 rule, which is; evaluating incisor distance at 3, three finger-breadths, hyoid mental distance, three finger-breadths, thyroid to mouth distance, two finger breadths. The Mallampati score is then evaluated after which we check for any obstruction that is, presence of conditions such as epiglottitis, peritonsillar abscess or trauma (Pallin, 2013). Lastly, we evaluate neck mobility. A high LEMON score usually indicates that the patient is likely to present difficulty in intubation. In such a case where endotracheal intubation fails, we then thus shall resort to bag valve mask ventilation.

1.3 Steps in an RSI Procedure
Step 1 - Preparation Preparation encompasses ensuring having all the required provisions and equipment. It includes; necessary medication for emergency endotracheal intubation, oxygen, laryngoscope and blades, bag-valve mask, resuscitation equipment provisions for rescue operations, endotracheal tubes and a stylet one size larger and one size smaller than the anticipated size of ET (Daniel, Hoyt, & Fortlage, 2009). An intravenous line is placed on the patient and monitoring initiated to determine the patient’s vital signs which include; blood pressure, heart rate and respiration and pulse oximetry. It as well includes capnography if at all possible and cardiac rhythm monitoring.

Assessment of the patient is done at this point. This institutes an intensive physical and historical examination to identify any injuries, conditions or illnesses that may obstruct the RSI procedure. Preparation is used to plot the treatment plan for endotracheal intubation using RSI as well as a backup plan to deal with any eventualities. For example, in the case of a failed intubation that is; “a cannot intubate, cannot ventilate situation” (Pillay, 2010, p. 76).

Adequate personnel assembling and delegation is key in this phase

Step 2- Preoxygenation Preoxygenation institutes are replacing the nitrogen in functional residual capacity of the patient with oxygen. Having the patient breathe 100% oxygen via a tight-fitting face mask for 3 to 5 minutes helps achieve denitrogenation (Braude, 2010). Where time is of concern, this can instead be done via four vital capacity breaths. Preoxygenation should be administered for as long as possible as determined by the given conditions then.
Given the risk of vomiting and gastric insufflation, positive pressure ventilation should preferably be avoided during Preoxygenation.
Step 3- Pretreatment Preoxygenation and pretreatment can and most often occur instantaneously in most cases of RSI in the emergency department. Here there is the administration of supplementary medication so as to alleviate the negative physiological results of endotracheal intubation. Although it is not always possible, the pretreatment drugs should precede the initiation agent by at least 3 minute to achieve maximum efficiency (Romano-Girard, Malerba, & Cravoisy, 2011). The medication to be given and their standard doses include 1.5mg/kg of lidocaine, 2-3 mcg/kg of fentanyl and 0.02mg/kg (0.1mg minimum and 0.5 maximum) of atropine.

Step 4- Rapid sequence Induction and Paralysis This involves administration of a sedative induction agent via IV push and followed immediately by administration of paralytic via IV push (Strayer & Nelson, 2011). Sedative selection is dependent upon several factors: characteristics of the sedative, experience of the clinician and the clinical situation, which includes patient detail (allergies, neurological and cardiorespiratory status and comorbidity).
Step 5- Protection and Positioning The patient’s position should be in a manner that the head and neck be protracted to increase visualization. As cervical injury is a probability in this case, intubation must be executed without movement of the head. However, to achieve the best view of the glottis opening for straight laryngoscopy by aligning the oral, pharyngeal, and laryngeal axes, positioning of the head and neck is vital (Strayer & Nelson, 2011). This is realized by raising and extending the neck with the assumption that there is no indication of further risk that might be brought such as the possibility of injury of the cervical spine. Protection, on the other hand, is the use certain necessary maneuvers to avert vomiting with possible aspiration. This is done via the use of the Sellick maneuver. It involves applying firm downward pressure on the cricoid cartilage using the thumb and the index finger anteroposteriorly (Ena, 2013). If regurgitation occurs, cricoid pressure should immediately be released. This is because of the possibility of esophageal rupture even though there is limited proof of this occurring. The possibility of active vomiting is eliminated by neuromuscular blockade.

Step 6- Placement of the Endotracheal Tube in the Trachea After the jaw becomes lax due to the paralytics, an endotracheal intubation tube of the right size is selected and inserted with the aid of a laryngoscope. It is vital for a suction and intubation boogie to be present nearby. Observing colour change on the end-tidal carbon dioxide detector to confirm correct positioning of the tube should be considered. It is essential to note that ETI should not be attempted more than three times (Pallin, 2013).

Step 7- Post-intubation Management The ET tube must be secured after placement and confirmation. It might be necessary for chest radiograph to be done in order to ensure proper placement of the tube as well as the pulmonary status and monitor any complications (Braude, 2010). The patient is now ready for transfer; it might however be required to have continuous sedation of the patient as he or she is transferred.
1.4 Risks and benefits associated with RSI RSI is employed in order to make endotracheal intubation of trauma patients safer and easier thus reducing any resultant complications from intubation. The logic in RSI is to prevent probable aspiration and its resultant problems. RSI also is aimed at increasing the systemic arterial blood pressure, plasma catecholamine release, intraocular pressure (IOP), intracranial pressure (ICP) and the heart rate (Strayer & Nelson, 2011). RSI eradicates the usual protective reflexes of the airway such as laryngospasm, coughing, gagging and increased secretions, which increase the difficulty in endotracheal intubation. The use of RSI limits cervical spine movement hence allowing for more control of the cervical spine during intubation. This reduces the potential for injury and also decreases discomfort that comes with intubation.

There is however the risk of adverse allergic reactions to the drugs administered for RSI by the patient. There is also the possible risk of overtime intubation that results into hypoxia. Given the stated circumstances, this paper thus suggests that RSI be employed as the patient has severe cognitive impairment and may not be able to secure his airway without assistance (Pillay, 2010). The patient is also at risk of aspiration, and the level of the accident provides precedence for imminent deterioration in the patient’s condition.

Case 2
2.1 Discussion Chest injuries may require no specific therapy. However, they may be indicators of more severe underlying trauma. The flail chest on the right lateral chest indicates possible rib breakage a flail chest accompanied by dyspnea is an indicator of possible pulmonary contusion, which is, bruising of lung tissue, which may interfere with the oxygenation of blood. The patient thus has difficulty in breathing but is however conscious as suggested by the GCS of 15. The visible hoof mark above the umbilicus shows signs of suspected abdominal injury. It is vital for the paramedical staff to be prompt in helping secure the patient’s airway and arrest any possible consequences or precedence of deterioration and respiratory failure. The paramedics will then ascertain the extent of trauma and identify the management options and goals for pre-hospital treatment.

2.2 Clinic plan and initial management The clinical plan will include assembling the appropriate equipment required on site that includes oxygen supply equipment and bulky dressing material. However, due to the unstable nature of chest and abdominal trauma the team is to be equipped with resuscitation equipment just in case the patient goes into shock or eventually loses consciousness (Kelly, 2013). Given the possibility of both chest and abdominal trauma, initial management of the patient would first of all entail a complete injury and hazard assessment. We then maintain the airway as necessary. Given the presence of apnea, administration of oxygen is through a Spo2: 93 %, High Concentration Oxygen Mask or assist the patient with a bag valve mask 24 times per minute to ensure a comfortable, stable respiration by the patient (Blanchfield & Schlesinger, 2011). The flail chest is then secured with bulky dressing. We then note the external bruises on the abdominal region to assist with further injury assessment. We should also be prepared for a shock given the deterioration course nature of chest and abdominal trauma patients. This may be caused by bruising of the lung tissues or spleen and liver injuries which may cause internal hemorrhage. In the case of a shock, the paramedics should prepare to perform an intravenous bolus injection.

2.3 Notification of Arrival After the patient’s chest was safely secured, and the respiration stabilized, the patient is then secured for transportation to the relevant healthcare facility. Given the possibility of the fatality of the injuries accelerating, there is a need for specialized care. We should as well check for signs of pneumothorax. Prompt transportation is advised due to the possibility of clinical deterioration of the patient (Callahan, Bixby, & Taylor, 2012)

The recipient hospital should thus be informed of him casualty’s condition. The trauma team must read the review form by our paramedic team so as to establish possible injuries and the estimated eventualities. The hospital team should also be advised to have resuscitation equipment in wait in case of shock, oxygen supply equipment and x-ray and surgical equipment as well (Romano-Girard, Malerba, & Cravoisy, 2011).

Conclusion There has been a critical review of a case study involving a patient with supposedly fatal chest and abdominal trauma in this paper. Prominence is given to stabilizing the patient’s respiration and securing the flailed chest. Prompt access to specialized medical facility is thus advised alongside the recommendation of experienced staff to attend to the casualty (Chiu, Como, & Bokhari, 2012).

Case 3
Introduction
Triage involves determining the priority of a casualty’s treatment depending on the extremity of their situation. It encompasses defining the priority and order of emergency treatment and care, emergency transport means as well as the destination of the casualty. It thus is a major component of casualty retrieval and pre-hospital management of the trauma situation. This is as triage helps prioritize patient retrieval, approximate the extent of injury and finally decide on provision of care that not only attends to the general casualty conditions but provides care specific to the casualty’s trauma situation (Barraco, 2010). Triage further helps maintain the life by employing given necessary means and tactics to maintain the casualty’s vital indications and also at least prevent further injury and deterioration until arrival to the nearest medical health care center.

Incident 1 Various causes including; poor weather conditions, and most often ignorance of traffic rules and regulation the non-use of traffic lights has led to a 78% increase in motorcycle accidents in the US. This constitutes 11% of the road accidents. The reported incident could have resulted to either of the above-mentioned causes. However, the presence of an unconscious trauma victim in an accident scene usually is the basis of the formulation of an extraction plan. Studies indicate that motorcycle accidents rarely witness fatal injuries (Dries, 2013). However, there is the presence of multiple non-fatal injuries such as forearm fracture, knee, facial, thoracic and abdominal injuries. This thus implies that our paramedical team has to comprise a physician, pilot and critical care paramedic. The team ought to be familiar with the pressures associated with attending to a trauma casualty as well as the retrieval interventions necessary for maintaining a casualty’s vitals. Given the casualty has most likely suffered multiple traumas; physicians could further examine the patient and perform emergency procedures such as tracheostomy or cricothyroidotomy as needed (Misra & McNeil, 2011). There will also be needed of extra personnel such as traffic control officers and firefighters in case of a fire breakout at the accident scene

Incident 2 The decision on usage of appropriate technology in given situations is another important aspect of triage. This thus implies that the use of aircraft based paramedical intervention should be clearly justified. If, in the cited case, access to the scene is easier by ambulance, then the use of a chopper would be unnecessary. Furthermore, air transportation has significant risk given that increased altitudes may result into unwarranted preventable complications for both the flight team and the casualty (Davis, Moore, & Cocanour, 2008). Given the risks posed to air transportation by the weather and time of day, then the risk assessment should be done separately before it is decided whether or not to dispatch the team. The medical crew should conduct an isolated risk assessment uninfluenced by the aeronautical facts and same with the air crew uninfluenced with medical facts. A merger of both sets of findings should be able to show to prepare the aeromedical team fully for the risks involved and whether or not to dispatch. Given it is indicated that the incidence is a crime scene, it should of priority to inform the police as the shooter might still be in the vicinity thus putting the lives of the paramedic team in danger. It is thus vital to keep the retrieval team from the scene until the arrival of the police. The retrieval team in this case should include a paramedic, physician and the ambulance driver.

Incident 3 The patient here is clinically dead, and if there is no detectable ROSC then, dispatch of an aeromedical team will be futile. Furthermore, if CPR still is in progress by the time the aeromedical team arrives, which would be a minimum of half an hour, retrieval by air is not advised given the possibility of an incorrect prognosis. If there still is spontaneous circulation even after CPR, then assistance from the aeromedical team would be useful. The major problem to be anticipated in this retrieval would be maintaining the patient’s health and preventing further deterioration, and the helicopter should thus be equipped with the necessary machinery and equipment (Barraco, 2010). The coordinator’s purpose here is to ensure the situation is handled in coordination and communication with the ground team on the casualty’s condition and the expected conditions on arrival. In effect, communication should be evaluated during the resuscitation as is protocol when dealing with multidisciplinary trauma. The assist team should comprise of a more qualified paramedic and physician.

Incident 4 The loss of life of an individual and the critical state of the other makes the case complicated. The decreased systolic rate is an indicator for probable internal and external haemorrhage, and the casualty is at the risk of going into hypovolemic shock. This thus justifies the use of air retrieval hence the dispatch of an aeromedical staff. Advanced equipment for the diagnosis of internal haemorrhage is thus required (Kelly, 2013). Prompt evacuation and attention involving compound retrieval procedures are required. The anticipated fatality of the wounds requires that an aero Medicare team is activated. The pilot should be aware of the environmental hazards that might be encountered at the scene, which would cause problems for proper landing.

The coordinator here should collect information on the number of casualties and the accident details in order to mobilize the required number of aero Medicare team. He/she should also mobilize other necessary personnel such as fire-fighters and road traffic control officers. The team should comprise of a flight medic, physician, critical care paramedic and pilot.

Case 4 It is paramount to keep in mind aerospace principles while dealing with this case because temperature and pressure are the main elements affecting human bodies. Even the smallest fluctuations in the condition of the environment can lead to disturbed hemodynamic (Gold, 2009). At high altitudes, air pressure decreases thus interfering with proper breathing. The change in pressure can cause air entrapment in body cavities thus interfering with proper functioning of paramedical equipment. The casualty’s situation has it that, it would be best to use a fixed winged aircraft as it is highly beneficial in terms of speed, limited vibration, movement at 0-35000ft and noise (Dhillon, 2012). This thus minimizes time consumption and increases efficiency in the retrieval procedure.

The high cabin pressure might expose the casualty to the risk of hypoxia while acceleration may cause hypotension thus the pilot should be advised to take a gradual approach at key flight stages. When ascending or descending, the intubation tube should be properly secured, and the patient’s head should be properly positioned to prevent complications such as the rise in intracranial pressure. To minimize the occurrence of possible deterioration, ventilation with a high concentration of oxygen should be done throughout the flight (Frein & Sheerin, 2008).

It is crucial to have effective monitoring of the pressure changes to prevent any further complexities. The patient should also be kept sedated to maintain the intracranial pressure. It is further recommended that the cabin pressure should be equal to that of the point of casualty retrieval and should never exceed 20000 ft (Matheson, Meeuwisse, Mellete, & Boissy, 2011). This is because the strains of long air transport could be dangerous.

Conclusion Body functions critical support and apt assessment of the patient and offering individually targeted life supporting therapies are the vital protocols for aero Medicare. There is a need for the coordinator to evaluate the suitable conditions of the patient so as to activate the right retrieval theme (Black, 2013). He or she should notify the team on anticipated problems and ensure the team is prepared.

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References
Barraco, R. D. (2010). Triage of the Trauma Patient. East Association Trauma Surgery, 56(6), 1114-1123.

Black, D. (2013). Treating Cervical Spinal Neck Injuries when Disaster Strikes. US Row, 5(2), 16-18.

Blanchfield, D., & Schlesinger, S. (2011). Modified Rapid-Sequence Induction of Anesthesia. AANA Journal, 44(7), 272-279.

Braude, D. (2010). Rapid Sequence Intubation and Rapid Sequence Airway: An Airway 911 Guide. New Jersey: University of New Mexico.

Callahan, M. J., Bixby, S. D., & Taylor, G. A. (2012). Imaging in pediatric blunt abdominal trauma. Semin Roentgenol, 21(5), 151-174.

Chiu, E. G., Como, J. J., & Bokhari, F. (2012). Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma, 12(4), 23-45.

Daniel, D., Hoyt, D. B., & Fortlage, D. (2009). The Effect of Paramedic Rapid Sequence Intubation on Outcome in Patients with Severe Traumatic Brain Injury. Journal of Trauma-Injury Infection & Critical Care, 54(3), 444-456.

Davis, J. W., Moore, F. A., & Cocanour, C. R. (2008). Western Trauma Association (WTA) Critical Decisions in Trauma: Management of Adult Blunt Splenic Trauma. J Trauma, 67(33), 1008-1011.

Dhillon, M. S. (2012). First Aid and Emergency Management in Orthopedic Injuries. New York: Jaypee Brothers, Medical Publishers Pvt. Ltd.

Dries, D. J. (2013). Initial Evaluation of the Trauma Patient. Medscape, 4(4), 141-145.

Ena, R. J. (2013). Rapid Sequence Intubation. New York: Emergency Nurses Association.

Frein, R., & Sheerin, F. (2008). He Occipital and Sacral Pressures Experienced by Healthy Volunteers Under spinal immobilization: A Trial of Three Surface. Journal of Emergency Nursing, 34(7), 151-167.

Gold, C. R. (2009). Prehospital advanced life support vs. “Scoop and Run” in trauma management. Annals of Emergency Medicine, 67(7), 439-459.

Kelly, M. (2013). First Aid/Chest & Abdominal Injuries. New jersey: Wiley.

Matheson, G., Meeuwisse, W., Mellete, J., & Boissy, P. (2011). Effectiveness of Cervical Spine Stabilization Techniques. Clin J Sports Med, 22(5), 87-92.

Misra, M. B., & McNeil, J. B. (2011). The Hospital Trauma Team: A Model for Trauma Management. Journal of Trauma-Injury Infection & Critical Care, 67(7), 112-116.

Pallin, D. J. (2013). Standardized Rapid Sequence Intubation with Ketamine. Journal Watch, 14(9), 111-119.

Pillay, Y. (2010). Paramedic Rapid Sequence Intubation: A Framework for Decision Making. New York: LAP LAMBERT Academic Publishing.

Romano-Girard, F., Malerba, G., & Cravoisy, A. (2011). Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Intensive Care Med, 34(7), 151-165.

Strayer R. J., & Nelson, L. S. (2011). Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med, 26(4), 118-128.