It’s that time of the week again, where we ask “What would you do?” Several days ago, I posted a video showing the aftermath of an ATV accident; I asked you to watch the video, and consider what sorts of injuries you’d look for, as well as how you’d manage the patient. Today, I’m going to share my thoughts. If you haven’t taken the time to watch the video yet, take a few minutes and watch it. It’s short!
I’m a bit late with my response; those who read this blog regularly may recall that my week has been a bit busy. I crave your patience.
So, here are my thoughts:
- Scene safety: Motor vehicle accidents are something EMS folks deal with routinely in front country situations; they’re much more rare in the backcountry. Dealing with vehicles adds a layer of complexity to scene safety. Look for leaking fluids, as these are fire hazards. If the vehicle’s engine isn’t already shut down, turn it off and remove the key. If fluids are leaking, move the patient away to a better location. If the patient is soaked in fuel, you’ll have to clean the patient.
- So, what actually happened? This video is a bit different from a few others that I’ve posted because we don’t actually see the incident, we just see the aftermath. You should get used to being a bit of a detective in some situations, as more often than not you’ll arrive sometime after the injury, and you’ll have to reconstruct the incident. We can get some clues from the patient, who says he dropped a wheel and rolled the ATV. A question to ask her would be “Did the ATV roll over you, or did you just fall off?” That questions leads us to my next point:
- MOI: Do we have mechanism that could cause head, neck, and spine injuries? Oh yes. This is definitely a situation in which we should manage the spine until we can rule injuries out. You should consider several factors. First, we don’t know how fast he was going, or how he landed. Second, those ATVs weigh around 500 pounds (some weigh even more), and being rolled over could cause serious injury to the head, neck, and spine. Also be alert for injuries to the ribcage and pelvis, which are round-shaped structures and therefore generally pretty resilient; if you find these types of injuries, they should clue you to how much force the patient was subjected to! At least it appears he was wearing a helmet!
- Lower extremity injuries: I’d have high suspicion for lower extremity injuries. When an ATV rolls to the side, it’s very easy for the rider’s leg to be trapped under the machine. This can cause crush injuries, fractures, and (if the rider’s leg is trapped against the engine) burns.
- Upper extremity injuries: This is generally something we see in mountain bikers, but it’s definitely a risk here as well. Our natural impulse when we tip to the side is to put out an arm and attempt to catch ourselves. The bone structure in our arms is not built to take that much force. The most common injuries seen here are wrist or forearm fractures and dislocated shoulders from the force being transmitted up the arm.
- Soft tissue injuries: The patient is wearing heavy clothing. This will make it more difficult to determine if the patient has lacerations or burns. Having a leg trapped under a large, heavy machine like that can easily cause cuts, bruises, and burns.
The obvious elephant in the room is the loss of consciousness that occurs right at 1:20, and I’d like to take an extra moment to talk about it. The episode lasts about 25 seconds. The patient is on his feet, appears to sway back and forth, and then falls to the ground. He appears completely limp; you can see his head flop around when his friend tries to revive him. He then responds “what?!?” to his friend calling his name. When I read the information on the video, the person that uploaded the video writes that he thinks his friend had a seizure. I’m not so sure, for several reasons.
- No rigidity or tonic/clonic movement: In a typical seizure, the patient goes unresponsive, then starts to have full-body convulsions. Now, before we go to far, there are seizures which do not have convulsions; patients will go unresponsive, stare off into space, or be disoriented for a few seconds. However, this patient fell to the ground and was limp.
- No postictal period: A typical patient is disoriented and confused following a seizure; this is called the postictal period. I work in a front-country EMS system, and more often than not the actual seizure will be done before we get there. Typical patients, however, do not suddenly sit up and say “what?!?” following their seizure.
- Report of dizziness: At the end of the video, it’s revealed that the patient reported being dizzy as they rode out of the woods. This tidbit, coupled with the way he went from standing, to standing with obvious discomfort/weaving, and then fell, makes me more inclined to believe this is a fainting spell or syncopal episode than a seizure.
So, my thought is that this is syncope, which is a big fancy way of saying “he fainted.” Syncopal episodes are caused by a momentary lack of blood flow to the brain; this can be caused by stress, by pain, by standing up too quickly, by a heart problem, by being dehydrated, and by a multitude of other causes. Typically the patient reports dizziness or light-headedness on standing, followed by a fall to the ground and a brief (usually no more than 30 seconds) period of unresponsiveness. Bystanders usually report “his eyes rolled into the back of his head,” and frequently mistake them for seizures. Once the patient is horizontal, and blood is able to get to the brain more easily, the patient typically revives with no serious consequences.
In emergency medicine, and especially in wilderness medicine, we frequently have no way of confirming our suspicions, and this is no exception; I could be wrong. Head injuries do cause seizures. This patient could have a history of seizures, and may not have classic Grand Mal seizures (the ones that cause convulsions). However, we make decisions based on what we see, and what the patient’s symptoms look like the most. Based on what I see here, I’m more inclined to believe syncope over seizure. For reference, here is a chart comparing the two:
So, how would I manage this patient? Here are my thoughts.
- Scene safety: Let’s turn off the ATV, and move it away from everything. I don’t see any leaking fuel, so that’s good. Let’s make sure we’re not going to have someone else roll into our scene without seeing us by posting someone up trail to warn approaching riders of the incident ahead.
- Spinal Precautions: Let’s take control of the patient’s head and neck with inline stabilization. I’m going to try to clear his spine in a bit, but for now let’s assume the worst and make sure I’m not going to cause further damage. Above all, though, let’s not let this patient stand up right now!
- Airway, Breathing, Circulation: Airway is patent, breathing looks good, and I don’t see any significant bleeding. Let’s move or remove some outer clothing, just to make sure we aren’t missing anything, and bandage whatever we find.
- Secondary assessment: This is where I start deciding if this patient needs a rapid evacuation, or if we can move at a more leisurely pace. I really want to check the chest, the abdomen, and the pelvis, as well as the femurs. If I find instability or pain in the chest wall, I’ll support the chest wall as best I can with slinging/swathing the arm on that side. Unless the chest wall is punctured or I’m seeing signs of a pneumothorax (accumulation of air in the chest cavity), rib injuries do not necessarily require rapid evacuation. I’ll also be looking for signs of abdominal bleeding, such as rigidity, bruising, tenderness, or a “hot” sensation in the abdomen. Abdominal bleeding must be rapidly evacuated. When I check the pelvis, I want to look for signs of pelvic fracture; these include tenderness on palpation, crepitus (the sound and feeling of bones moving against each other), and instability. I’d also check the femurs for angulation (deformity) and shortening/rotation. If the patient shows signs of pelvic fracture or femur fracture, the patient must be rapidly evacuated. If the patient has a mid-shaft femur fracture, I’d pull traction on the extremity until the legs are of equal length, then immobilize the leg in that position.
- Once the patient goes unresponsive: Hopefully, we’d have the patient lying down prior to loosing consciousness. Once the patient goes unresponsive, let’s assess the patient to make sure he’s still breathing and has a pulse. If he doesn’t, we’re going to do CPR, rescue breathing, or both. If the patient still has a pulse and is still breathing, we’ll manage his airway. Since we haven’t cleared his spine yet and because there is mechanism for spinal injury, we’ll use a jaw thrust maneuver (if you want to brush up on your skill, take a look at this video).
- After the patient regains consciousness: Let’s reassess his level of consciousness/responsiveness. We’ll ask him these questions every five to fifteen minutes so we can get an idea if he’s getting better, staying the same, or getting worse.
- Focused spinal clearance: Assuming that the patient is AO x 4, and that we’ve managed his other injuries, I’d consider doing a focused assessment of his spine and clearing him. This will make evacuation way easier.
- Prepare for evacuation: If I don’t find anything more serious than a closed chest wall injury (several broken ribs) and the patient’s mental status is good, and I was able to clear his spine, we can self evacuate. If I find evidence of further injury, or the patient is unable to be cleared, we may have to call for assistance. I may have someone else drive the patient’s ATV and have him ride, especially since he’s still dizzy.
This patient should go to the hospital, though I don’t think he’d need to go by ambulance unless something changes. He’ll need some x-rays, and he should probably be seen by his doctor just to make sure the syncopal episode was not caused by a heart problem.
Thanks for tuning in! We’ll have our next “What Would You Do? Wednesday” later this week. In the meantime, share your thoughts with me here in the comments, or on Twitter using the tag #wwydwednesday.