Scenario

[Guest guest]

Here's a scenario from my class tonight on shock/trauma.   My students got

it.   See how you do.

This is for EMT-Intermediates and Paramedics, but EMT Basics can learn from

it also.

You are called to a motor vehicle collision, motorcycle vs. bridge abutment.

On arrival you find a young male lying prone on the pavement about 30 feet

from his motorcycle.   There is no helmet in view, and he has an obvious

depression to his forehead and face.   You think " Le Fort IV. "   He is

unresponsive

to painful stimuli, breathing about 30 times a minute, with noisy

respirations and a lot of blood in his mouth and nose;   his heart rate is 44

and

regular, and his BP is 92/48.   Pulse Ox shows 89-90%.   He responds to

painful

stimuli by flexing his arms and extending his legs.   His verbal response is

none.

After exposing him you find an obvious clavicular fracture.   His chest is

red and his sternum feels somewhat unstable on palpation.   His abdomen is

distended and rigid.

You do a 12-lead and find sinus bradycardia with ST elevation in V1-V4.

As you prepare him for transport and continue your assessment, you note that

his right pupil is larger than his left pupil.   His respirations are now

becoming irregular.

Please answer the following questions:

1.   What is a Le Fort IV fracture?

2.   What is this patient's mean arterial pressure (MAP)?

3.   What is this patient's estimated   intracranial pressure (ICP)? [What is

ICP?   What is normal ICP? How does one estimate ICP in a patient like this?

Why is ICP important?]

4.   What is this patient's estimated cerebral perfusion pressure (CPP)?

What is normal CPP?   What is the minimum CPP that ought to be maintained?

Why

is CPP important?

5.   Why does this patient have bradycardia and also low BP?

6. Why is this patient showing ST elevation in V1-V4?

6.   What is the most important thing to do for this patient immediately?

5.   What other actions will you take, and why?

GG.

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[Guest guest]

I'm going to take a stab at this one

1.La Forte IV fracture is a Le Forte III Fx with extension into the

frontal sinuses. Basically, total separation of the facial bones from

the cranial bones with involvement of the sinuses.

2.MAP = 62mmHg. MAP = [(2 x diastolic)+systolic] / 3

3.Estimated ICP = 30mmHg or greater. Normal ICP = 5-13mmHg. Estimate

according to GCS if there is present head injury and no sedatives on

board. If GCS is 13-15 and pt is drowsy and confused then ICP=20. If

GCS is <8 then ICP=30. Important because increased ICP can cause

herniation of the brain, decreased cerebral perfusion, and eventual

death.

4.Estimated CPP=32 calculated by subtracting the ICP from the MAP in

other words CPP=MAP - ICP. Normal CPP=80. Minimum CPP to be

maintained is at least 70. CPP is basically the amount of pressure

that is perfusing the brain

5.Bradycardia and hypotension are present because of a mechanism

known as autoregulation. This mechanism induces vasodilation and

decreases BP in order to decrease cerebral blood flow (CBF) thereby

decreasing ICP. However, this cycle actually results in an increase

in ICP because of the decreased CBF. Hypotension should be managed

but only by keeping the systolic pressure above 90mmHg

6.I have no idea why this patient would have ST elevation. I'm

interested in learning the cause.

7.Immediately, CABC's, with an emphasis on airway, airway, airway.

This is difficult because of the facial trauma but must be done.

Raise the head to 30 degrees in an attempt to let gravity work on the

ICP. Hyperventilation is also effective in helping to decrease ICP

but only short term. IV access is important as fluids may be needed

to manage BP.

8.Other actions, besides sprouting wings, flying to the trauma

center, and changing my pants after the call, would be assessment

based. Obviously, EKG and full neuro assessment.

That is all I can come up with at the moment but I'm tired. I'm very

interested in hearing other responses. Good scenario!

Amber Anaya, NREMT-P