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Case #42 Football Player Collapses


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#1 Mike MacKinnon

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Posted 03 August 2008 - 01:58 AM

You are kicked out to a rural high school for a football player who collapsed on the field, the report is that he is "down"


The Report:

Your dispatch tells you that the patient is a 17 y/o male who was playing football and all the sudden collapsed on the field. There are no medical resources on scene except the local volunteer FD who called you. One of them is an EMT and his report is that the pt has a "sky high" heart rate and is "breathing funny".

Hx: None

Allg: NKDA.

Arrival on Scene

You land on the football field with easily 50 onlookers and and see not far from the aircraft where the boy is.

As you walk over you see that he has been boarded and they have a NRM mask on him. He appears to be breathing on his own but working very hard and very anxious, they are fighting to keep him down. He is a big boy, easily 200 lbs and about 6 feet tall.

Everyone around him appears very upset.

Vitals:

HR: 132
BP: 90/60
RR: 30
Sat: 88% on NRM
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#2 rfdsdoc

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Posted 03 August 2008 - 03:04 AM

Hey Mike et al

Let him situp if he wants as long as there was no good history of trauma to suggest he might have hit his head or hurt his neck.
Cardiac monitor on. IV access. Lung auscultation.

What's the heart rhythm? Are his lungs wet? How far away is a suitable ED? Do we have CPAP available in our retrieval gear?

Regards
Minh
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Minh Le Cong
Medical Officer
MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#3 Gila

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Posted 03 August 2008 - 04:53 AM

Lung sounds? Possible spontaneous pneumothorax? Any history?
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Christopher Bare
"Non fui, fui, non sum, non curo "

#4 EDMEDIC

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Posted 03 August 2008 - 01:48 PM

Any neuro deficits to suggest closed head injury or C-spine injury, parasthesia in his extremities? lung sounds? What does his initial ECG rhythm look like? long Q-T? Do we know anything about his PMHx? Can we do a quick 12 lead? Initial thoughts are adequate airway and ventilation, chest injury, sudden arrythmia from being tackled. my .02, Brian
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Brian EMT-P/CC
"failing to prepare is preparing to fail"
" you don't know what you don't know"

#5 Speed

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Posted 03 August 2008 - 02:43 PM

Lung sounds? Possible spontaneous pneumothorax? Any history?


Yeah, that's the first thing I'd want to rule out.
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Mike Williams CCEMT-P/FP-C

#6 HELOSRCOOL

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Posted 03 August 2008 - 02:50 PM

After ABC's and lung ausc., what's the environment like? Is it hot? Has this kid just started two-a-days? Drinking lots? Dispatch said breathing funny? What is the rate depth and quality? Are we perfusing well with this HR and BP? What was he doing before all this started?
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Bill
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#7 Mike MacKinnon

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Posted 03 August 2008 - 05:15 PM

[quote]Let him situp if he wants as long as there was no good history of trauma to suggest he might have hit his head or hurt his neck.
Cardiac monitor on. IV access. Lung auscultation.[/quote]

He fell to his knees then to his back then tried to sit up during which he was trounced on by the "lay flat and keep your head still" people.

Cardiac monitor = Sinus Tach
IV access gained

You sit pt up but he isnt breathing much better, he is less combative but still appears somewhat confused or disoriented

Sat now 82%

NO lung sounds over right side of chest.

[quote]How far away is a suitable ED?[/quote]

35 min flight


[quote]Do we have CPAP available in our retrieval gear?[/quote]

Yes
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#8 PeroMHC

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Posted 03 August 2008 - 06:03 PM

still appears somewhat confused or disoriented

Sat now 82%

NO lung sounds over right side of chest.


From reading other scenarios, I'd be surprised if this was as easy as a spontaneous pneumo.. So are there other s/sx of pneumothorax/tension pneumo? Thinking SQ air, tracheal deviation? While we are considering our next intervention, I vote for positioning this kid on his left side to maximize perfusion to the good lung.

While I'm looking at his breathing, hopefully my partner is giving a fluid bolus. Fluid probably can't hurt this kid, and some of his tachycardia and hypotension might be d/t hypovolemia..

Hypotension and low sats make we worried though... I'd be thinking about needle compression.
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#9 rfdsdoc

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Posted 03 August 2008 - 06:37 PM

yeah he needs pleural decompression now.

How long are the needles you folks carry?

in this guy I worry it may not be long enough!

and if he has tensioned from a spontaneous pneumothorax I'd worry one needle wouldn't be enough!

needle decompression now but be prepared to do a simple thoracostomy (NOT thoracotomy!)
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Minh Le Cong
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MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#10 Gila

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Posted 03 August 2008 - 08:06 PM

I agree. It may be something different such as an obstruction. However, I have to go with treating the immediate life threat. Immediate needle decompression, reassessment, and prepare for chest tube placement. Any additional history on this patient?
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Christopher Bare
"Non fui, fui, non sum, non curo "

#11 PeroMHC

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Posted 03 August 2008 - 09:19 PM

I agree. It may be something different such as an obstruction.


Right, was this kid chewing gum or something and now has a right mainstem obstruction?? Sure would be nice to know before we stick a large needle into his chest..
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#12 Mike MacKinnon

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Posted 03 August 2008 - 09:45 PM

Thats all the information at the moment

Sats now 75% BP 80/55 HR 140, gonna needle or no?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#13 PeroMHC

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Posted 03 August 2008 - 09:53 PM

Thats all the information at the moment

Sats now 75% BP 80/55 HR 140, gonna needle or no?


I'm not 100% convinced that it is a tension pneumo, but right now the risk of NOT doing it is greater than the risk of doing it unnecessarily.

If this is all we have to go on, we have to needle the chest.
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#14 BackcountryMedic

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Posted 03 August 2008 - 10:29 PM

Thats all the information at the moment

Sats now 75% BP 80/55 HR 140, gonna needle or no?


Could be an obstruction, but how would that result in the low BP? Needle 'em!
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#15 B. Cornelius RN EMT-P

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Posted 04 August 2008 - 05:02 AM

The increased thoracic pressure and corresponding low cardiac output could be causing the hypotension. How's his skin turgor and mucus membranes, has he been adequately hydrated. Any pre-existing history we're aware of? Does anyone know anything about this kid? Parents around-for better or worse? Any previous surgical scars? How are the lung sounds on the right? Any JVD or other correspondence for the pneumo? As was previously mentioned have they recently started increased practice or anything that may cause electrolyte deficency? Any palsy's or parasthesias? Can we get a quick fingerstick? If we don't find any answers i think we're left with little option other than to decompress. If he didn't have a pneumo he does now.
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#16 jay

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Posted 04 August 2008 - 07:15 AM

Once more into the breech....

While everything else is going on I want some more story...preferable the coach and parents. Has he been playing or sitting the bench? Did he take any memorably hard or unusual hits? How long has he been playing (what is the weather like? is it a ridiculously hot day?) What was he doing just before he started having difficulty? How did it start? Has he been out of sight recently?

1st I want IV access if it hasn't been obtained yet, shouldn't be a problem getting a good 14g in a young, athletic kid for starters.

A&B- This kid is getting tubed. I'd like to listen to lung and heart sounds before RSI meds are given. Lungs clear and =? Missing on one side? heart tones present and normal? If yes, then pretreat c lido, then etomidate and sux. Bag him up to a good sat once he is down if possible, then secure his airway. I would wan to make extra certain that I had good tube confirmation (EQUAL breath sounds, no gurgling, color change) and that he was easy to bag (and his sats got better). If anything makes me suspicious of a tension pneumo then I'd also needle his chest. If his lungs are clear and = and he bags easy then onto C.

C- 2nd large bore IV, open fluids, d-stick, any JVD?.

D- Pupil exam (the original description pretty much rounds out the rest of my neuro exam) Maintain c-spine and backboard, sedate c benzos and maintain paralysis c roc or vec.

E- I want all of his clothes/pads off to look for trauma. Any ecchymosis on chest or abd? any crepitus or paradoxical chest movement? belly hard or soft? Anything noteworthy on his extremities?


DIff: Tension pnuemo/lung contusion, blunt abd trauma c internal bleeding, pericardial tamponade, aortic injury (mech would seem low for football injury, but ya never know), Worn out/run down/hot, CHI/bleed (doesn't really fit the whole picture unless it is in combination with something else though)

I'm leaning toward the thoracic trauma diagnoses, but couldn't say for sure without hearing more info about his assessment/hx.

jay

EDIT: After reading the responses and further info on the case, I'm definitely going in c the needle. Then reassess and see where we are at.
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#17 MSDeltaFlt

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Posted 04 August 2008 - 01:44 PM

Dart him. Assess his neuro after he's darted to get a better history from the horses mouth. Atheletes bounce back rather quickly; especially when their "fight or flight" mechanism is already in high gear from being in the game.
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Mike Hester, RRT/NRP/FP-C
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#18 Gila

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Posted 04 August 2008 - 02:31 PM

I agree. The immediate life threat is a possible pneumothorax. We need to decompress.
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Christopher Bare
"Non fui, fui, non sum, non curo "

#19 BackcountryMedic

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Posted 04 August 2008 - 02:43 PM

How long are the needles you folks carry?
in this guy I worry it may not be long enough!


We carry the long Cook pneumo kit needles, which would be plenty long enough for this boy. Of course it is only 1. After that I have some 10ga 4in angio's. Should do the trick.

This guy has all the hallmarks of tension pneumo (decrease breath sounds, tachy, low BP, low sats), but this is a Mike Mac scenario so I'm sure it's not that straight forward. What happens after we dart him? Other physical exam findings? EKG? BGL?

Other treatments: O2 (hold off on positive pressure vent if still breathing and we figure out this pneumo thing), IVx2 with bolus, correct environmental problems (cool if hot, warm if cold). I think the Hx is non-trauma so sitting up should be fine.

Need more Hx from family, coach and other players.
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"If everybody is thinking alike, then somebody isn't thinking" - Patton

#20 RoadieRN

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Posted 04 August 2008 - 03:05 PM

Does this guy maybe have a diaphragmatic hernia as result of being hit during the game? Any BS on the right chest? I agree to definitely dart the guy and see where it takes us. We carry 1 Cook catheter kit, in addition to a couple of 14G 1.25in needles. I've also got a 12 G 3in and a 16g 5.25in. With that being said, dart him, see if he improves. If not, get the RSI ready with your two large bores and let his VS and exam guide you along the way.
Sounds like a dozy!
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!