End of Semester Case Study Assessment Task 5
This assessment consists of one case study divided into six (6) questions (1a,1b,1c, 1d,1e & 1f)
There is a total of 16 pages.
Answer all questions on the paper.
This assessment task has a maximum limit of 18 pages, any answers beyond this limit will not be marked [excluding ]
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In terms of scope of practice, assume you are an Australian Critical Care Paramedic (CCP) or Intensive Care Paramedic (ICP); expect to answer questions in line with guidelines from the Australian New Zealand Committee on Resuscitation (ANZCOR) and Pre-Hospital Trauma Life Support (PHTLS). You will also beexpected to consider options such as Rapid Sequence Induction (RSI), finger thoracostomy, blood products, inotropes etc.
Please note interventions that you consider but reject (rationale).
Equipment: assume you have the necessary equipment for advanced life support, including syringe drivers and a simple transport ventilator.
Total number of marks = 100.
Once you have completed the assignment please submit as a PDF via Assessment 5 End of Semester Case Study Assignment page (select Start Assignment in the top right box)
Papers will be marked in line with the rubric.
The emphasis should be on demonstrating a clear connection between the diagnosis, appropriate investigations and relevant treatment supported with convincing rationale based on contemporary evidence-based practice.
Evidence. APA in-text and end-text referencing IS required for this assessment task.
Being able to paraphrase is an important academic skill and demonstrates that you have understood the material in your own words. DO NOT copy/paste (from an external source or from your own work submitted in another unit) because this does not meet the academic writing expectations that are outlined in the marking rubric.
Text boxes for answers should give you a guide as the length of the answer expected. There is no need to delete questions/instructions etc. The answer box lengths are there for a reason.
You can submit more than once – the latest version will be marked.
Gaps in formatting – the marker will apply common sense. If you have a blank half page which you cannot delete, this will be taken into account.
You are working as a Critical Care Paramedic (CCP) on a medium lift Emergency Medical Service (EMS) rotary wing aircraft (helicopter). The three-person crew consists of a pilot, aircrew and yourself. The aircrew is trained to the level of basic life support (BLS) and can assist under your direction on the ground and in the rear of the aircraft when not assisting the pilot with navigation. The aircraft can accommodate two seated or stretcher patients and has sufficient equipment for ALS interventions/transport for two ventilated patients. The aircraft can carry six persons in total.
Note: In terms of definitions of skill sets, assume that CCP is synonymous with the highest tier of paramedic practitioner in the Australian context.
Call received: 0100hrs
You are tasked to attend a motor vehicle crash on a country road, 60 minutes flight time from your base. You are advised it is car v car. There are two adults in car 1, and one adult in car 2. All are described as time critical. There is one road ambulance at the scene, with a crew mix of one basic life support (BLS) and one advanced life support (ALS) officer. There is no further information at this time. You are airborne within 15 minutes of receiving the call.
Question 1a, 1b, 1c, 1d, 1e, 1f (90 marks) [Rubric criteria: Pathophysiology of clinical condition, considered relevant differential diagnosis, stated provisional diagnosis, management in accordance with provisional diagnosis, treatment in accordance with best practice for the specified diagnosis &treatment and interventions articulated (considered and implemented/rejected with rationale]
During your 60-minute flight time, what arrangements, instructions, equipment or medications would you prepare, given that you will be working in a dark, remote environment with limited backup?
According to the ANZCOR Guideline Updates 2016 (2022), I will pre-inform the level 1 trauma facility that will admit the victim. A pre-notification is essential to allow resources (equipment and human) mobilisation required to provide urgent and appropriate care to the patients. In the course of my 60-minute flight to the scene, I will ask the team (EMS staff onsite) to provide me with the victims details such as age, gender, mechanism of the physical injuries, past and current medical conditions, use of alcohol or any drugs and vital signs. Collecting the victims details will be crucial in developing a response plan. I will advise the ALS officer at the site to place the victims on advanced life support before I arrive at site. Also, I will recommend the EMS staff to focus on evaluating and managing the victims ABC (airway, breathing, and circulation), spinal-linked injuries, bleeding, and removing any objects to minimise further risks and enhance their safety. These actions will help in determining whether the victims have experienced physiological degradation.
Moreover, I will direct the EMS personnel to maintain the victim body temperature to prevent hypothermia. The information gathered by the staff at the scene will help me in getting appropriate equipment to aid in managing the patient such as defibrillators, 12-Lead ECG, mechanical ventilators, fire extinguishers, radio communication, and PPE. Motor vehicle crash can cause injuries to the head, internal body organs damage, fractures and burns. Therefore, I will ensure the availability of oxygen supplementation, intravenous fluid therapy, and C-spine stabilisation. These would help manage the victims trauma during in-flight evacuation. Important medications on site will be pain relievers such as morphine to manage the patients pain. Since the scene will be dark, I will make sure floor lighting is available at the location.
On arrival at scene: 0215hrs
You land on the unlit, country main road. The scene has been secured by police and fire appliances. There is one road ambulance crew at the scene.
You see a late model, large 4WD passenger vehicle (car 1) lying on its left side, twenty metres from the road shoulder. There is a light utility (car 2) on the road, close to the apparent site of impact. The crash site is at a T-junction where the bitumen road is intersected by a minor, unsealed, gravel road. There are no skid marks evident prior to the site.
Police report they believe the 4WD had been travelling on the bitumen road (110kph speed limit) when it was struck by the utility which failed to give way whilst travelling along the intersecting gravel road. The speed limit of this gravel road is 60kph.
The 4WD has significant impact to the right side, driver’s door area, with intrusion of approximately 0.5m into the driver’s seating area. The vehicle appears to have rolled laterally to the left multiple times. Airbags have not deployed. There is some damage to the roof of the 4WD.
The utility has significant impact to the front of the bonnet. The windscreen is shattered, and airbags have deployed. The engine block has been dislodged by the force.
All three patients were extricated prior to your arrival and are being attended to by the road crew. Police report that the crash was not witnessed; it was discovered by another road user at 0100hrs. The engines were still warm at this time, so it is assumed the crash occurred shortly prior.
You are given the following handover by the ALS officer:
1. Driver in utility / car 2. (Seatbelt on). Significant head and thoracic trauma evident. Male, approximately 40 years of age. CPR in progress by fire crew and police.
2. 4WD / car 1. Front left side passenger (seatbelt on) had self-extricated and was ambulant when ambulance crew arrived. Male, 25 years of age. Complaining of c-spine tenderness. Glasgow coma score (GCS) 14, mildly confused and unable to provide previous medical details of other occupants. Denies alcohol or drugs taken by himself or driver. This patient is now supine on ground, spinal precautions in situ. Being monitored by BLS officer.
3. 4WD / car 1. Driver (seatbelt on). Male, approximately 20 years old. Patient was trapped in the vehicle between the door intrusion and the vehicle’s centre console. He was extricated by the fire crew and is now in the ambulance being treated by the ALS officer who states:
AIRWAY: Patent but at risk due to lowered GCS and blood in mouth.
BREATHING: Breathing is laboured, shallow and irregular. Air entry is significantly reduced on the right side. Respirations are approximately 36/minute. SpO2 was 70% on arrival and is now 86% on 10L/minute via non-rebreather mask (NRBM). Trachea appears midline.
CIRCULATION: Brachial pulse is regular, rapid and weak at 140bpm. ECG shows sinus tachycardia with some PVCs. Blood pressure is 82/50mmHg and equal bilaterally. Blanch is delayed at 3 seconds. There is one patent, large bore cannula in situ in left antecubital fossa (ACF), with isotonic crystalloid running at keep vein open (KVO).
DISABILITY: Blood sugar level (BSL) is 6.7mmol/L. GCS 13 (eyes 4, verbal 4, motor 5). Pupils are both sluggish to react but equal. Patient can move all four limbs; right leg mobility limited by pain in upper leg.
EXPOSURE: Clothing has been cut away and a blanket is in situ. The night temperature is 11 degrees Celsius. The patient feels cool to touch peripherally.
SECONDARY: Injuries noted include:
Multiple external venous bleeds and lacerations which have been addressed by ambulance crew
There is a boggy mass palpable in the right temporal area
There is developing ecchymosis to the right side of chest
Right upper leg is rigid and painful to touch
Patient is complaining of pain to right side of his head/face, right side of chest and flank, and right upper leg.
Your own observations confirm the above.
Past medical history, medications, allergies all unknown.
A rural hospital with a general practitioner (GP) is 15 minutes away, compared with a flight time of 60 minutes to a tertiary, level 1 State trauma centre.
What is your choice of destination?
How many patients will you transport under your care?
Justify your rationale.
I will choose the level 1 trauma facility as the patients destination. This facility has better equipment and infrastructure to manage all types of injuries and care services covering prevention and rehabilitation. Nevertheless, hospitals in rural settings lack appropriate and sufficient resources to manage these victims.
The aircraft has advanced life support systems and can only airlift two victims on stretchers or sitting positions. Therefore, under my care, I will prioritise the driver of the utility car with severe head and thoracic injuries and the driver of the 4WD vehicle with low oxygen saturation levels despite being put on 10L/min oxygen via NRBM and a low level of consciousness. These two patients are in an emergency and require immediate management under my care in the trauma facility. Therefore these two will be airlifted to the trauma facility immediately. However, the 4WD cars passengers vital signs reveal that he is not in great danger; hence I will leave him under the care of the EMS staff.
During the handover by the ALS paramedic and during your initial assessment, you note the patient is experiencing more respiratory distress, is becoming more hypotensive and less responsive.
GCS 8 (E2, V2, M4)
Patient is becoming agitated and combative when stimulated
BP 70/- mmHg
What are your provisional diagnoses for this patient?
Which injury is the most urgent?
Justify your answers.
This patient would have various diagnoses such as traumatic brain injury, traumatic subarachnoid haemorrhage, epidural haemorrhage, haemorrhagic shock, subdural haemorrhage, spontaneous intracranial hypotension, epileptiform encephalopathies, cerebral aneurysms, brain metastasis. Also other diagnoses include encephalitis, hydrocephalus, multiple sclerosis, frontal lobe syndromes, , and temporal lobe epilepsy. However, the victims details indicate unconsciousness and loss of speech; therefore, the primary diagnosis for this patient would be traumatic brain damage. The rapid movements during the crash could have caused the bruising of the brain blood vessels and tissues, which is common in traumatic brain injuries.
Head injury which is indicated by low level of consciousness, and a low GCS score, is the most urgent clinical manifestation of the victim. This is consistent with the ANZCOR guidelines (ANZCOR Guideline Updates 2016, 2022). Prolonged unconscious levels can be fatal if not managed. Diminished oxygen supply to the brain causes brain damage. Immediate patient resuscitation is required to stabilise the patient.
Outline your management of this patient in his current presentation. You should sequentially list your clinical management choices and provide a clear rationale for each. Note any interventions you may consider but reject, again with justification.
You should focus on airway, breathing and circulation. Your answer should specify landmarks, equipment choices and sizes, and drug dosages.
You are not required to include simple steps such as extrication.
The deteriorating patient’s GCS score at 8(E2, V2, M4) indicates an urgently required management plan and options. According to the ANZCOR recommendations (2022) and the clients vital signs, he should be on advanced life support. Endotracheal intubation is required for this patient since with a deteriorating GSC score. This medical procedure should be performed cautiously, especially in patients with GCS scores between 6 and 8, to reduce the risk of death or prolonged hospitalisation. Nonetheless, the ANZCOR guidelines state that such a patient requires endotracheal intubation through the mouth to avoid aspiration, with can lead to pulmonary infections.
Management of the Airway
My priority will be managing the patients airway due to the low GCS score. To prevent disc tearing, I will handle the client gently to avoid dislocating the neck and spine, which can be fatal. I will move his head carefully to confirm a clear airway. I will handle the patient regarding the ANZCOR emergency airway management regulations. Afterwards, I will examine the victim’s mouth for the presence of any foreign objects or secretions such as blood, vomitus, or food particles that could obstruct the airway. I will remove any foreign objects found in his mouth immediately and perform suctioning in the presence of any secretions. I will apply the jaw thrust method to ensure the patient’s airway is clear. However, I will not consider a head tilt since it increases the risk of C-spine injury. The jaw thrust method ensures the neck remains in its natural position.
I will continuously monitor the victims breathing by checking the movements of his lower chest and upper stomach (ANZCOR Guideline Updates 2016, 2022). Also, I will watch and feel for air movement out of the nose and mouth. Moreover, I will continue checking the patients chest movement.
I will commence chest compressions and rescue breathing if the patient shows abnormal breathing and unresponsiveness. I will perform 30 chest compressions by placing one palm over the other at the tip of the breast bone, followed by two rescue breathes by utilising a by an assistant. I will allow one second between each ventilation. The bag valve mask is essential in the process because it ensures the correct tidal volumes of air are delivered to the lungs. I will consider endotracheal intubation only if I achieve spontaneous circulation. Endotracheal intubation involves inserting a tube into the windpipe, beyond the larynx and near the tracheal branches. I will then connect the tube to a mechanical ventilator.
Moreover, endotracheal intubation helpsopen the patient’s airway, deliver oxygen, tracheal suctioning, and a route for medication administration. Furthermore, I will continue performing CPR per the ANZCOR guidelines. I will inflate the cuff to prevent air from escaping after inserting the tube. Also, I will perform chest inflation, chest auscultation, wave capnography, and monitoring to ensure the tube is firmly placed.
The patients hypotensive state makes the possibility of bleeding high. Therefore, I will take action by initiating fluid resuscitation. I will administer 20 mL/Kg isotonic saline per ANZCOR recommendations (ANZCOR Guideline Updates 2016, 2022). I will continually check the client for potential bleeding, and if noticed, I will perform proximal compression using a manual blood pressure cuff and elevation which helps in managing external arterial bleeding. However, if I notice venous bleeding, I will apply direct pressure. I will use a pelvic binder to control bleeding for major pelvic injuries.
Other manging actions
For pain management, I will consider intravenous administration of analgesics such as morphine due to their effectiveness in managing severe pain. Nonetheless, I will avoid high dosages of morphine because it may worsen the pain. Thus, I will administer 2.4 mg of morphine intravenously or intraosseous at 5-minute intervals until 10mg is attained.
With regard to Rapid Sequence Induction (RSI) intubation:
a) Differentiate between the actions of (i) neuromuscular blocking agents, and (ii) sedative or induction agents.
b) Why is it important to administer both classes of drugs when performing RSI?
c) Give an example of each class of drug.
d) Discuss the use of reversal agents for neuromuscular blocking agents.
a) Neuromuscular blocking agents mechanism of action by inhibiting neuromuscular transmission at the synaptic junction on the post-synaptic acetylcholine receptors paralysing the affected skeletal muscles. However, sedative agents modify nerve communications in the CNS to the brain, slowing down brain activity and relaxing the body. Induction agents make the neurotransmitter GABA (gamma-aminobutyric acid) work overtime by inhibiting excitability.
b) Administering neuromuscular blocking agents and sedatives when performing RSI is essential to lower the level of consciousness and cause flaccid paralysis, thus supporting endotracheal tube insertion via the airways and reducing the risk of aspiration.
c) Atracurium is a neuromuscular inhibiting agent, whereas ketamine is an induction agent.
d) Reversal drugs for neuromuscular drugs oppose the effects of neuromuscular blockade by increasing the effect of the neurotransmitter (acetylcholine) at the synaptic junction or aiding the drugs metabolism or elimination from the body.
Regardless of your previous management choices, you are now in flight at 2500 feet with your patient intubated and mechanically ventilated, 20 minutes from your destination.
The patient has been becoming progressively more hypotensive. The peak inspiratory pressure (PIP) alarm on the monitor keeps alarming.
What could be the cause of this increased PIP, and how could you address this? Comment on the relevant flight physiology concepts.
Diminished lung function, increased secretions, bronchospasms, and tube ventilation blockage result in the hardening of the lungs, hence elevated PIP (peak inspiratory pressure).
The victims deteriorating hypotensive state could be due to generalised hypoxia.
At 2500 feet, the lungs oxygen pressure may reduce due to insufficient oxygen supply during evacuation to the trauma facility. Moreover, a high altitude during evacuation and a restricted gaseous exchange area may have caused low oxygen levels in the blood, leading to significant physiological deficits. Therefore, I will make sure the ventilator works effectively to manage PIP. Furthermore, ventilator adjustments would aid in monitoring the volume of air moving in and out. Consequently, this action will enhance the continuous air supply for the victims utilisation while transported to a tertiary facility.
ANZCOR Guideline Updates 2016. (2022, February 28). Australian Resuscitation Council. https://resus.org.au/guidelines/anzcor-guidelines/#:%7E:text=ANZCOR%20guidelines%20are%20informed%20by,in%20Australia%20and%20New%20Zealand.
End of Case Study Assignment
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