Procare Ambulance
August Presentation
Kraig Melville, MD, FACEP
Pulmonary Embolism
• Pulmonary embolism is a condition that
occurs when one or more arteries in your
lungs become blocked. In most cases,
pulmonary embolism is caused by blood
clots that travel to your lungs from
another part of your body — most
commonly, your legs
• Globally more people die from PE than MI
Pulmonary Embolism
• Sources:
– Lower: about 80-90%
– Upper
– Pelvis
– Cardiac ventricle
Pulmonary Embolism
• Symptoms that should provoke a suspicion of pulmonary
embolism:
–
–
–
–
–
–
–
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chest pain
chest wall tenderness
back pain, shoulder pain, upper abdominal pain
Syncope
Hemoptysis
shortness of breath, painful respiration, new onset of wheezing
any new cardiac arrhythmia
any other unexplained symptom referable to the thorax.
Pulmonary Embolism
• The classic triad of signs and symptoms of PE
(hemoptysis, dyspnea, chest pain) are neither
sensitive nor specific.
– occur in fewer than 20% of patients in whom the
diagnosis of PE is made
– most patients with those symptoms are found to have
some etiology other than PE to account for them.
– Of patients who go on to die from massive PE, only
60% have dyspnea, 17% have chest pain, and 3%
have hemoptysis.
Pulmonary Embolism
Pulmonary Embolism
Pulmonary Embolism
• Treatment in the Ambulance
– Oxygen
– Pressure Support
• IV fluids
• Dopamine
• (Dobutamine)
– ?Aspirin
– Avoid: NTG
Cervical Spine Fracture in the
Elderly
• Mechanism:
displacement may be anterior (hyperflexion) or
posterior (hyperextension)
– anterior displacement is associated with transverse
ligament failure and atlanto-axial instability
– posterior displacement by direct impact from the
anterior arch of atlas during hyperextension (the
“face plant”)
Cervical Spine Fracture in the
Elderly
• Most common fracture of axis
• Occur in bimodal fashion in elderly and young
•
patients
elderly
– common, often missed, and caused by simple falls
– High risk due to fragility of bone
– Canadian C-spine Rule lists age > or + to 65 as a
high-risk patient
Cervical Spine Fracture in the
Elderly
Cervical Spine Fracture in the
Elderly
Cervical Spine Fracture in the
Elderly
• Must maintain high level of suspicion and
low threshold for spinal immobilization
• Elderly patients difficult to clear by Nexxus
Criteria
– Dementia/ anxiety
– High rate of distracting injuries
– Medication effects
Trauma Immobolization
• Classic definition:
– Rigid cervical collar, coupled with
– Rigid backboard (note variation in type)
Trauma Immobolization
• Spinal immobilization can reduce untoward movement of
the cervical spine and can reduce the likelihood of
neurological deterioration in patients with unstable
cervical spinal injuries following trauma. Immobilization
of the entire spinal column is necessary in these patients
until a spinal column injury (or multiple injuries) or a
spinal cord injury has been excluded or until appropriate
treatment has been initiated. While not supported by
Class I or Class II medical evidence, this effective, timetested practice is based on anatomic and mechanical
considerations in attempt to prevent spinal cord injury
and is supported by years of cumulative trauma and
triage clinical experience.
• Source: ATLS Manual
Trauma Immobolization
• The variety of techniques employed and the lack
of definitive evidence to advocate a uniform
device for spinal immobilization, make
immobilization technique and device
recommendations difficult. It appears that a
combination of rigid cervical collar with
supportive blocks on a rigid backboard with
straps is effective at achieving safe, effective
spinal immobilization for transport.
• Source: ATLS Manual
Trauma Immobolization
Trauma Immobolization
• DO the right thing
– If no contraindication, collar and back-board
– Ask for written order
– Avoid conflict: board them in the ambulance