On Wednesday, I posted the latest installment of “What Would You Do?” Wednesday; I gave you a video of a mountain bike crash to watch, and I asked you to share your thoughts and treatment plans. If you haven’t had a chance to watch the video yet, you should take a few moments to watch it now. It’s a bit of a long video, but its a rare look at the period of time between initial injury (which happens right around 0:40 in the video) and the arrival of EMS on scene.
So, what are some things you noticed? This is what I saw.
- MOI, MOI, MOI: MOI stands for mechanism of injury, or what actually caused the injuries the patient presents with. Based on MOI, we can generally come up with a pretty reasonable guess as to what injuries to look for. This guy is moving pretty fast, goes over the handlebars, and lands on his head/face. Based on this mechanism, I’d look for head/neck/spine injuries, consider spinal management/immobilization in my initial assessment of the patient, and be alert for respiratory compromise and bleeding. In urban settings, its entirely normal to base the rest of the patient’s treatment and transport on what the MOI was. We don’t teach this in wilderness medicine for several reasons. First, we want our treatment decisions to be based off of the patient’s actual presentation and assessment findings, rather than just what they were doing that caused the accident. Second, since transport times will be extended, we don’t want to immobilize someone for extended periods of time without justification.
- Level of Consciousness: Pretty clear loss of consciousness here, implying high potential for brain injury. He pretty much just stopped himself with his head and face; he’s not a small dude, and he had a backpack and a bike drive him headfirst into the ground. Watching the timer, it looks like he’s unconscious for around 2.5 minutes.
- I’d like to just point out that he hit hard enough that it looks like he broke the chin strap on his helmet. Either that, or the other rider unclipped it in a way I didn’t catch.
- Airway: At around 1:13 or so, you can hear the patient having noisy/”snoring” respirations. This implies a partially obstructed airway, with (probably) the patient’s tongue getting in the way of good airflow. When the patient sits up, its clear he’s bleeding from his mouth and nose.
- Breathing: He’s got some interesting respirations going on right after the accident. They appear to be Kussmaul respirations (pronounced “kooz-maul”), which are characterized by rapid, deep inhalations. I like how the biker who takes the lead in caring for him takes initial control of his head, and maintains a recovery position on the pt’s side, just in case he were to vomit.
- Spinal restrictions: This is definitely a patient we would want to maintain in spinal control, at least until we can get through the secondary assessment and start considering spinal clearance. The patient, however, was altered enough that he was uncooperative, and would have none of it. This isn’t so much a problem with the patient being a jerk; if I suddenly woke up, surrounded by strangers, with someone holding my head still, I think I’d try to sit up too!
- Calling for help: The biker in charge made a very quick assessment of his situation, and determined he would need help with this patient; you can hear him direct another biker to “dial 999” (the UK’s 911 equivalent), and he also directs them to use a GPS to determine their exact location.
So, how would I manage this patient? Here are my thoughts.
- Maintain patient and rescuer safety: Let’s post someone up the trail to warn other riders that there is something going on below. If this cannot be reasonably accomplished, let’s do a quick, spine-safe move out of the trail.
- C-spine control: While the patient is unconscious, let’s move him onto his back and maintain c-spine in neutral alignment with manual control. Let’s have a couple people come around and be ready to quickly and smoothly roll him if he vomits. If the patient insists on sitting up once he regains some consciousness, we’ll weigh the situation carefully; if we can reason with him and convince him to lay still, great! If we can’t, we won’t fight him, but maybe take manual control on his head and neck when he’s sitting up.
- Airway: Let’s look in his mouth and make sure that he doesn’t have blood or teeth occluding the airway. If we see anything, let’s carefully remove it. While the patient is unconscious and unable to maintain his own airway, we can use a jaw-thrust to keep his airway open. We’ll avoid the chin-lift/head-tilt method, as this would flex his cervical spine.
- Breathing: I’m fairly happy with his respiratory drive. We’ll keep a close eye on that; if his breathing doesn’t return to normal, we can figure something out later.
- Cardiovascular/Bleeding: Patient has a pulse, and appears to be perfusing well. We’ll keep our eyes out for signs of shock or internal bleeding, since hitting that hard can easily cause internal injuries. We’ll manage any external bleeding with direct pressure and bandages.
- If we were way out in the mountains, I’d maintain in place and see if the patient recovered normal mental status. At that point, I’d consider a focused spinal assessment with the aim of clearing his spine so we could evacuate.
What types of injuries should we expect?
- I’d expect a concussion. Loss of consciousness followed by a period of AMS suggests brain injury of some kind.
- Facial/mouth injuries. Lacerations to the face, to the tongue (from biting it), or missing teeth. These will bleed a lot, and may be airway management challenges.
- Expect neck soreness. That amount of weight (not a small dude, plus is pack, plus his bike) driving his head/face into the ground at that speed could do serious damage to the spinal column and the muscles running through the neck.
- Clavicle and shoulder injuries: Look for fractures, separations, or dislocations in the shoulders and the clavicles. Its pretty common, in these types of crashes, for the rider to put out a hand or hands to try and catch his fall. The force from landing on his hands can be transferred up the arm to the shoulder joint.
This patient should be taken to the emergency department as soon as feasible. He’ll probably need a head, neck, and back scan to rule out injuries, as well as observation for the head injury.
If you have any suggestions for future “What Would You Do?” Wednesdays, let me know!