head injuries and first aid

[SOTB]

Hey guys. Got a question for one of the medics here. Bear with me while I give some background.

This morning a schoolgirl got hit by a vw bug right behind me (and ironically enough, directly underneath the pedestrian bridge for crossing the road). The car hit her about waist level, she bounced of the windshield (broke it with the left rear of her head, I think), then landed on her upper back and head on the asphalt. I'm thinking her forward movement of her body from impact was only about a foot. So the worse part was impact of head on windshield and fall onto head from about 3 feet?

When I got there, maybe 10 seconds later, she was ¿conscious? but in a state of siezure-like movements with the eyes, head, right arm, and some movement of the upper body. She made no response to questions about how she felt, name, etc. I had her head/neck immobilized and was doing the ABC thing. Breathing was good, although rapid, her tongue wasn't blocking her airway, it did seem kinda "there" but again she seemed to be breathing fine, and the doctor who was assisting me (was in the car behind her) said she had a good pulse. Oh, and she had a slight amount of drool with trace of blood coming out of the mouth, but when I looked in there, I saw nothing damaged nor anything blocking the airway.

The whole time we were telling her that everything was OK, and that the ambulances were on the way (man I love cellphones), although she wasn't acknowledging our attempts to communicate to her. She "came to" after about 2 minutes of this and was able to communicate to us that she "felt OK", said responded "yes" that she knew her telephone number but she couldn't seem to get the first number out of her mouth. And then she began to become very relaxed. At first I thought she might be dying, but she continued to breathe normally and then the Red Cross arrived, I gave them the info I had on her condition and what happened, gave my business card to the cops, and came into work.

For curiosity I checked the web for head injuries, and specifically siezures and found this:

Following the seizure, the child will probably fall into a deep sleep. This is known medically as the postictal period. This is normal, and you should not try to wake him.

My question is that I had always believed that you should try and keep the patient talking to you. I have no clue now where I remember that from, but in all of the medical trg I have received (obviously not enough), I don't remember being told to allow the patient to drift off into unconsciousness. I would have never "shaken" someone or slapped them, but I just had the idea we were supposed to keep them from "headed to the light".

Anyway, if one of you guys that has mouth-to-mouthed some poor innocent goat could comment, I'd be grateful.

Andy

[Sneaky SF Dude]

I would try to KEEP her awake, but not wake her up if she went out. I think you did just fine. IMO, stabiling for neck injuries was the most important thing. The rest of that shit is for the neurosurgeons. Doc and some of the others that are still doing it may have a differnet opinion.

[RsovRanger]

Siezures due to trauma are something I don't know anything about. I would have checked PERL and checked for CSF from the ears and nose, steppoffs and deviations... standard detailed assessment.. if she didn't have PERL then she'd probably have a head injury, possible brain contusion/epidural/subdural hematoma and that's something you really can't do much for... I would honestly bust out the book as per drug type treatments that would reduce the effects... she'd have a fucked up pupil on the oppisite side of the injury, correct me if I'm wrong. Manitol is one drug that will lower ICP if she does have a hematoma occuring...


Keeping her mentation is important. if someone loses conciousness you can yell or stuff but actually physically trying to wake them other than by resusitation methods is something I would never do... not gonna do it, wouldn't be prudent

[Sneaky SF Dude]

Why would you check Pearl? She didn't get run over, it was a school girl. Hey SOB, next time STOP the car before you let your dates out.

[RIT_MEDIC]

I have not given M-T-M to a goat, but I see a good many head injuries, so I am going to chime in here.

Sounds like you covered the basics; C-spine and the A,B,C's.

The seizure type activity is pretty common in head injuries. The neurons in the brain are firing kinda out of control and that is the source of the tremors. A person loses control of bodily function during a seizure, depending on the type experienced (wont go into that). The lucid state after a seizure is a rest period where the body tries to reset itself. This is also normal. You cannot keep someone from becoming unconscious by talking to them. The purpose of keeping someone awake following a head injury is so you can identify if they become unconscious. If for one reason or another someone begins to go unconscious there is nothing you can do about it.

As for the blood issue, there are plenty of places for that to come from...just dont EVER stick your fingers in there to find it. You might lose your trigger finger is they seize.

You did fine. Wish there were more citizens here who had the sense of mind you did.


James D. NREMT-P

[ussfpa]

done good!!! Concurr with Sneaky on C-Spine stuff and Level of Consciousness (LOC), yes full assessment was in order, CSF / halo testing (tasting for inc glucose is HIGHLY discouraged). ABC's until the rig gets there.
Rsov Dude:
Your memory is correct on the mannitol. Mannitol is an agent which lowers ICP, BUT is very touchy to administer and would leave up to those more speciality trained. It is a Glomerular Diuretic (not a loop diuretic like Lasix {furosimide}), this means that it will blow out fluid...LOTS of FLUID FAST. Potentially making your pt. Hypotensive and you in a race to refill the pipes.
Technical stuff:
It is usually dosed at 20% solution at .25-2g / kgIV over 30-60 mins.
Most protocols advocate 1g/kg IV Push over 20 mins ever 4-6 hours as needed, but this is an unapproved use by FDA.

I think he was checking Pearl 'cause she gave him "the look" ;)

Primum non Nocere

[SOTB]

Sneaky SF Dude,

You funny GI. Bedy funny.

Everyone (including Sneaky),

Thanks guys. Just wondering if you were supposed to keep them conscious. Wouldn't dream of sticking 'em with sharp objects to get their attention, but I thought it was interesting the idea that they would pass out and that you should be cool about it (that is to say, not trying to keep them awake and having them try and describe whatever pain they have, POC numbers, allergies, etc.). I just don't remember anyone ever saying that before.

I have ZERO IDEA WTF PERL or her sister Pearl or their brother CSF are or why I would want to screw with them. But they already sound way over my head (although Pearl has a nice ring to her). I do have the rapid dial for the Red Cross on my cellphone, though.

Good point on the finger thing. Don't know why I had thought her tongue looked so strange, but it just seemed so "there". Anyway, glad she didn't decide to bite the hand that was helping her.

Tomorrow, I'll pull over to the shoulder of the road before picking up/dropping off any 17-18 year olds..............

[Sneaky SF Dude]

Oh, there's one other way to know if you did the right things or not...


Was she still alive and in better shape when they carried off than she was when you got out of your car?

If so, you done good.

[SOTB]

Yup, still alive although she never was able to give us her number or say anything other than "OK".

I'm glad I was able to help.

Still find it so ironic that after having spent so much money building these foot bridges, why 1) almost no one uses them and 2) why the authorities don't build the correct attitude towards using them.

I imagine there will be another similar event there within the next couple of months before school lets out...........

[Sneaky SF Dude]

They're probably scared of heights. That's the case here. They won't use the bridges and we get several deaths every year.

[SOTB]

You know, I have never thought of that. Had always chalked it up to laziness. But it could be. I just know they avoid them like the plague unless its raining, and then just as a 100ft umbrella.

Don't know if you have this problem where you are, but in most of México (suprisingly, the problem isn't prevelant in Mexico City), the busses don't obey any signage for authorized busstops. Even if they have stopped 100 mts prior, they will stop again at any point to pick up(drop off).

Its "interesting" driving in-town with people bailing from busses and immediately crossing traffic. Certainly keeps you from changing the station on the radio very often.........

[Sneaky SF Dude]

You must be kidding. Stop signs are a suggestion here, forget about bus stops.

[cj]

Originally posted by Sneaky SF Dude
You must be kidding. Stop signs are a suggestion here, forget about bus stops.

If its at night and you slow down for a red light, you WILL get rear ended in some parts of town. Although with the new 'Trans Millenium (public transport bus system) in Bogota, the street situation is somewhat less chaotic. However, in Janaury, FARC blew up one of those buses on the TM-killed one passenger.

FWIW: Bogota's Mayor Mockus is a wacko, but he has some very innovative ideas regarding mass transit and he is implementing some of them with excellent results.

[SOTB]

About 3-4 years ago, stop-light car assaults/secuestros express began to take on an interesting MO in Mexico City. Attackers would come from one side of the vehicle, with security placed in covering positions, and 1-2 assailants would throw a handful of spark-plug 'inners at the windows. You guys know what happens next.

You know, a couple of years before this, a whole bunch of Mexican Army dudes found their way to Range 37 for trg. Hmm........

[Sneaky SF Dude]

They were throwing snakes in the windows here for a while, but I haven't heard anything lately.

[rakkasan187]

Originally posted by Southoftheborder
Sneaky SF Dude,

I have ZERO IDEA WTF PERL or her sister Pearl or their brother CSF are or why I would want to screw with them.

PERRL or PEARL or PERL

Pupils Equal Round Reactive to Light
Pupils Equal And Reactive to Light
Pupils Equal Reactive to Light...you get the drift

CSF=Cerebral Spinal Fluid

Sounds like you did really well. Only thing to add is while not trying to wake someone from unconsciousness you should continuallly reassess someone in terms of their mental status (or altered mental status) by questioning and observation to their behavior and their LOC (level of consciousness) through stimulation whether it be verbal, pain (their reaction to it by means of withdrawal or other inapproproiate response such as posturing) or complete unresponsiveness.

Take care and good job,

rak

[SOTB]

Originally posted by rakkasan187
Only thing to add is while not trying to wake someone from unconsciousness you should continuallly reassess someone in terms of their mental status (or altered mental status)....through stimulation whether it be....pain (their reaction to it by means of withdrawal or other inapproproiate response such as posturing)....

OK. This has taken a turn MUCH for the better. So you CAN stick them with sharp objects to keep them awake.? If sharp objects are not around can you also use cigarette lighters, biting, or giving them red bellies?

:D :D :D

On a serious note, I heard from the woman that hit this girl that apparently she was still alive and that tests were still being run on her. Of course NOW, there is great social exclamation about the lack of use of these foot bridges. Yeah right......

[Sneaky SF Dude]

SOB - its official - your are now a Qualified Highway Life Saver!

[SOTB]

Originally posted by Sneaky SF Dude
SOB - its official - your are now a Qualified Highway Life Saver!

Can I get a badge, or patch, or some sort of uniform adornment thing for that?:D

[Sneaky SF Dude]

Originally posted by Southoftheborder
Can I get a badge, or patch, or some sort of uniform adornment thing for that?:D

No, but you are now authorized to wear AN UNAUTHORIZED FUCKIN' COVER with any uniform you want.

[SHYTE]

Southoftheborder,

This is my first chance at looking at this thread and I'm impressed by your actions. The world needs more people with the presence of mind that you displayed. There are too many Third Watch and ER fans out there who do nothing but get in the way and do wrong things. Thank God you're not one of them.

The postictal phase is basically when a person's natural body resources are so drained that they just fall asleep. It's a result of extreme exertion from the siezure and increased ATP (produces energy in cells) use.

There is so much that you just have no way of knowing at an accident scene without the proper diagnostic equipment. Thank God you chose not to shake the kid at an obious head trauma incident. Keeping the patient talking to you primarily allows you to assess their conscious state. If they are talking to you then that means their ABC's are working fine.

Don't you just love it when guys use all kinds of acronyms when telling you correct medical procedures. You guys remind me of my first instructor, that bastard did everything he could to confuse the hell out of us. If this was your first trauma incident just be sure to thank God you didn't experience a priapism. From what you've described I think you did exactly the right thing. And as an added bonus you prevented some dumb asshole parent who watches too much TV from trying to play a hero and doing even worse damage to the poor little girl.

If you want to wear the appropriate badge or patch then you must do what all of us prehospital care providers do; take a drastic paycut, earn a fraction of what your skills are worth, and be subjected to BS from little nimrods who don't understand what you do.

[RIT_MEDIC]

Originally posted by SHYTE
If you want to wear the appropriate badge or patch then you must do what all of us prehospital care providers do; take a drastic paycut, earn a fraction of what your skills are worth, and be subjected to BS from little nimrods who don't understand what you do.

Aint that the truth.

James D.

[TerribleTed]

Just to add... a post-ictal state generally follows an epileptic seizure, not a traumatic seizure. Don't worry about trying to keep someone from "heading toward the light" during a post-ictal state. Just continue to monitor (and transport, if applicable).

Obviously with trama, a person can progress from seizures to frank unconciousness and that may seem to be a post-ictal state. At that point, check out that chick PERL to see what kind of animal you're dealing with (the history should assist here as well).