Flight Nurse Case Study 1

[Robert F]

You and your partner are sitting at the base watching a football game on TV. Just as the game returns from its commercial break, a call comes in.

"Nurse Star I, Trauma Patient, three counties away....[followed by LZ information for the pilots".

You are made aware by dispatch and ground EMS that the patient is a 16 year old male who is unconscious on scene after being ejected during a high speed collision on the interstate into the median. The passenger of the vehicle, a 15 year old girl was deceased on the scene, while the 16 year old boy in the bag suffers from only a broken leg and a few minor injuries.

Your partner grabs the blood from the fridge and makes one last check over the Jump kits as the Pilot readies the chopper for takeoff.


Prepared for anything, you ready your RSI equipment and double check your laryngoscopes on the way. Upon final approach, you note that a paramedic unit is on the scene and a couple of fire trucks accompany the unit. You ask the ground crew the status of your patient, they explain to you that his vitals 10 minutes ago were as follows:

BP: 150/100, Pulse: 60 Resp: 23 and becoming more and more irregular.

The Paramedic on scene alerts you that the patient was conscious on the scene when they arrived, when they took this pressure, but after a brief moment of lucidity, lost consciousness.

You have 2 Large Bore IV's in the right and Left AC, the patient is intubated after losing consciousness. As you land, you approach the patient and notice positive battle's sign, and notice the car(a 1999 Oldsmobile Alero) has crashed into the median and scraped it's way for what seems to be at least 10 feet, on the drivers side. You also notice that the window on the driver's side is shattered. You ask the Firefighters if they had to break it to get access, they reply no. The tire marks on the road leading up to the median show that the car had somewhat of a spinning motion, leading you to further believe that it was the jarring motion that ejected this patient out the window as the car made one last spin back into traffic after hitting the median(allowing your patient to be ejected through the busted window).


What is your next step? What do you suspect? What role could the jarring motion of this MVC play in this patient's injuries(kinematics wise)?

[AmandaWIRN]

Ok, I'm not a flight nurse, but I'll give it a try....

First things first, confirm tube placement, check for thoracic trauma, & get another set of vitals.

With the battle's sign, I'm suspecting posterior cerebral trauma or hemorrhage, possible posterior skull fx. Mechanism of brain injury, from the jarring motion, would most likely be coup contra coup, so I might also suspect a frontal lobe injury (raccoon eyes might not have shown up yet).

En route to the the trauma center, I'd be watching for a drop in BP, which I'd manage with crystalloid, O Neg, &/or pressors.

So, how'd I do? Am I ready to take flight??? Too bad I'd probably vomit if I ever found myself in a helicopter!

[Robert F]

good work, and great pickup on Coupe Contra Coupe. I am not going to reveal the underlying condition just yet, I want to give the others chance to come in and perform their assessments.

Please note, you can ask me any information you would like with regard to vitals, patient condition, etc. Please note however, I cannot give you things like ICP on the scene, obviously. However, if you are slick, you can get yourself a MAP.(This one is for all the student nurses out there)

Formula for Map is as follows

(2(d) + S) / 3

Where d = diastolic BP and S = Systolic BP.

or

Diastolic + 1/3 Pulse Pressure

You want to keep the MAP > 70 mmHg; 60 mmHg is the absolute lowest point, as anything below this would fail to properly perfuse the organs.

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Mannitol is on board as your clinical intuition tells you that the brain tissue is becoming more and more edematous. The effects of this intracranial swelling results in the compression of the cerebral arteries thus decreasing cerebral blood flow and subsequently leading to the death of brain cells and loss of 02. Knowing what you know, it is only a matter of time before the brain stem takes a hit; this is noted by the impingement of the third cranial nerve as indicated by ipsilateral pupil dilation. I would almost bet that were this patient awake, he would be experiencing hemipariesis.

Is there any type of intervention you would like; such as a surgical intervention perhaps?

[AmandaWIRN]

Well, I would want the pt to have a crani.... can I drill a burr hole in the helicopter??? hehe....

[Robert F]

lol, unfortunately no. One decision we have to make as flight personnel is where to divert the patient based on the capabilities of the receiving trauma center. Usually in this case, it is best to go ahead and alert the Trauma team so they can get Neurosurgery paged and standing by.