EMS and ER Response for an Unconscious Female Trauma Patient

Ginger Asks

I have a 23-year-old woman with an obvious head wound (she got hit with the butt of a gun, but the first responders don’t know that) who’s been outside in 20’ish degree weather without a coat for an undetermined amount of time. She’s unconscious. Obviously an IV is started, but what else will paramedics do to treat her? Warming blankets? What would happen when she got to the ER?

Jordyn Says:

Thanks for sending me your question.
EMS Response:

For an unconscious patient with an obvious head wound, but is unable to tell how her injury happened should be placed in C-spine precautions. That means C-collar and backboard. IV– yes. And warming. They’d get a set of vital signs, put her on a monitor and then do a full assessment to look for other injuries.

Checking her blood sugar is warranted because why is she unconscious? Did the injury to her head happen because she passed out from low blood sugar? Or is it too high? Looking for medical alert bracelets as well. They’d probably key in on a good neuro exam like are her pupils equal and reactive to light? What type of stimulation does she respond to (voice, touch or pain?) They might even give a dose of Narcan to rule out opiate overdose (like heroin.)  

In the ER:

Full assessment as above and we’ll look for other injures. We’ll maintain C-spine precautions. She would be completely undressed (again– looking for other injuries.) We have a better ability to monitor temperature so we’ll know exactly where she’s at and work to rewarm her. This could range from warm blankets to warming lights and heated IV fluids. Full set of vital signs. We’d place her on the monitor as well to watch her HR, breathing and oxygen levels continuously.
As far as testing and procedures go, if she remains unconscious, I would say the following:

1. Spine X-rays. 
2. CT of the head (to look for bleeding, stroke, tumor.)
3. Labs: Full metabolic panel (this will check blood sugar again), complete blood counts, alcohol level, aspirin level, Tylenol level. Tylenol and aspirin are drugs people will overdose on that can be very serious.
4. Urine toxicology panel (this would pick up on major substances of abuse but not everything.) Also urine pregnancy test. 
5. ECG. To see if a heart arrhythmia or heart attack could be an explanation for her passing out.
Unless we know the exact mechanism of the injury we have to consider both inflicted wounds from another person but also that she might have just passed out and hit her head and what the reason for that might be.

If she’s truly unconscious and doesn’t respond to pain– she’d likely get a tube in every orifice as they say and they’d have to consider whether or not to intubate her (put a breathing tube in) to protect her airway. If that happens, then NG tube (placed probably through the mouth into the stomach) and a Foley catheter which drains your urine into a bag.

If she’s somewhat responsive but immediately drifts off– they could hold off on tube placements, check the tests I’ve listed, and give her some time to see if she wakes up on her own if she’s breathing well on her own.

Author Question: Motor Vehicle Collision 1/2

Susan Asks:

I found your site while I was researching some things for a story I’m writing. I’m not sure I will ever try to get this story published or anything, but I wanted to get all my details as accurate as possible.  
In the story two people are involved in a car accident.

Patient #1: The driver, twenty-three- year-old male. Hits the steering wheel and ruptures his aorta. This character dies.

My questions are

1.  Could he be conscious immediately following this?
2. Would he make it to a hospital about 4 miles away in an ambulance or likely die at the scene?
3. How would he look in the hospital after death (coloring, would they leave his clothing on if he just died)?
4. Would they let his sister see his body?

Jordyn Says:
1. Would he be conscious? Yes, it’s possible but for a very short amount of time following his injury. Your aorta is a very large vessel that comes right off the heart. If it is entirely ruptured—you’ll bleed out in one to two minutes. The quicker the blood loss the sooner unconscious sets it because blood supplies oxygen to the brain and the brain is a very oxygen sensitive organ.
2. This character would likely die at the scene.
3. What you might want to look into is reasons an EMS provider is allowed to call death at the scene. Patients who are obviously dead may not even go to the hospital. Let’s say they do “work” him and bring him to the hospital where he is declared dead shortly after. Likely, his clothes are on with the exception of the care EMS provided. It’s atypical for them to cut off all their clothes like a trauma center will. He’ll be extremely pale with areas of blueness. Livor Mortis begins fairly quickly where the blood will be begin to settle in dependent areas of the body. This looks like bruising. If he lying on this back—it would settle all along his backside.

4. Yes, the sister would be allowed to see his body. Nurses are pretty sensitive to this so they’ll try to make the body as presentable as they can and explain what the sister will see before she views the body.
We’ll tackle Susan’s second patient in the next post.