Risks Tied with Treating a Hypotensive Patient with a Penetrating Chest Wound with Crystalloid Fluids and Alternative Pre-Hospital Treatment - Case Study Example

Critical Thinking Name University Date Critical Thinking You are called to attend to a hypotensive patient with a penetrating chest wound inflicted by a 25 cm blade.  What are the risks associated with treating this patient with crystalloid fluids and what alternative treatments could be implemented in pre-hospital setting? Crystalloid resuscitation fluids contain balanced salt solutions (BSS) as well as hypotonic solutions. The balanced salt solution usually saline contains 0.9 % NaCl (Sodium Chloride), Plasmalytes, Ringer’s solution and Normosol. The electrolyte composition of the BSS solution exhibits a considerable osmolality compared to that of plasma. The solution distributes to extracellular spaces (Cohn, 2007). A quarter of the volume of these salts administered to a trauma patient remains in vascular space while as three quarters of the remaining solution distributes into the interstitial/ extravascular space. Following resuscitation using high volumes of crystalloid solutions, the extracellular space expands. As a result, the ratio noted above distorts thereby favoring amplified interstitial water and causes edema of the peripherals and interstitial tissues as manifested by numerous patients. Also, patients with hypotension may experience blocking of the vascular lumen due to induced thickening of blood (sludge). The administration crystalloids to penetrating trauma patients presenting with hypotension so as to restore normal blood pressure may be questioned. Victims of trauma continue to loose blood due to injury of a vascular system. Delayed control of the vascular interruption promotes a further hemorrhage to take place (Cohn, 2007). Crystalloid fluids mostly used for initial resuscitation lacks red blood cells (erythrocytes) or any blood clotting agents. Therefore, the use of these fluids could result in poor control of blood loss in addition to impaired transport of oxygen to the tissues. Such outcomes can be attributed to the dilution of blood clotting factors in the body and the red blood cells. Eventually, more ischemic damage may be exhibited by the patient. In addition to facts stated above, crystalloids have a notably high pH. Administration of high volumes of isotonic or mildly hypertonic crystalloid fluids like Lactated Ringer’s or 0.9% NaCl (normal saline) could result in intensified metabolic acidosis and could cause a decreased myocardial function. Massive use of crystalloids in resuscitation leads to early and severe increase in blood pressure against the induced sludge. Also, in such a scenario, the clot on the injury may have barely stabilized and could result in increased blood flow through the clot. Therefore, the alternative pre hospital treatment for a patient presenting penetrating chest wound would be that o delayed resuscitation (In DiPiro et al., 2014). Such patients exhibit high survival rates following controlled under-resuscitation or delayed resuscitation. Argumentatively, such an approach tends to reverse vasoconstriction of injured blood vessels. Also, early thrombus could be dislodged or inhibited. Administration of high volumes of crystalloid solutions helps to dilute coagulants in the blood as well as changing blood viscosity to increase flow (In DiPiro et al., 2014). In a randomized study conducted by Bickel to compare delayed versus immediate fluid resuscitation for hypotensive victims of penetrating injuries of the torso, the former intervention registered more survival rates. In the immediate resuscitation study, patients received Ringer’s acetate solution, an isotonic infusion, through intravenous catheters inserted at the site of injury. In the delayed intervention, patients had flushed and capped intravenous catheters inserted at the site of injury (In DiPiro et al., 2014). On arrival at the hospital, patients in both groups were given packed erythrocytes and crystalloid in order normalizes systolic blood pressure. Out of the 598 enrolled in the study, 70 of them died before getting surgery. Therefore, rates of survival tend to be higher at 70% for patients in the group of delayed resuscitation as compared to 62% for patients in the group of immediate resuscitation. Australians are susceptible to envenomation (poisoning from animal venom) from multiple sources.   What treatments are available in the pre-hospital setting?  Provide support for its use in the pre-hospital setting. In most scenarios, envenomation occurs accidentally or by chance. In the basic terms, envenomation refers to the deposition of venom into the body through a sting or a bite. Venomous creatures only lodge an attack when provoked or when threatened. Shockingly, most forms of envenomation result from creature that may look harmless or may be unnoticeable or invisible until an individual notices a bite or feels some pain (Asensio & Trunkey, 2008). Australia, the home of both land and sea creatures of poisonous venom, hosts 28 species of scorpions and spiders, 16 species of insects, 53 species of sea creatures and 61 species of snakes. Except a few cases of envenomation which require hospitalization, most of these can be addressed similarly. In the pre hospital treatment only three objectives can be fulfilled. They include managing life threatening signs, decelerating the distribution of venom and to treat other immediate symptoms (Phtls, 2004). However, before beginning any interventions, the provider needs to ensure safety for both the patient and the crew that administers treatment. Ensure that the venomous creature cannot repeat its attack on any other person. In case of the organism still lingers, take precaution and get rid of the threat. Understanding the capability of the creature may be inevitable and may require the summoning of animal control unit (Emergency Nurses Association, 2007). Upon gaining safety and access to the patient, the provider needs to assess and treat any symptoms that could be life threatening. Also, any symptoms presenting immediately thereafter needs to be treated (Phtls, 2004). These immediate symptoms could include pains, systemic and local aches as well as nausea and vomiting. Mostly, the pre hospital treatment involves repetitive reassurance as well as supportive care. Patients need to maintain calmness in order to allow effective treatment. In the objectives, we mentioned a need to slow the distribution of the poison in the body. Mostly, this mechanism always requires that the sting be cut out or the venom be sucked out. In Australia, incidences of venomous snake attack may require an application of a compression bandage (Emergency Nurses Association, 2007). The intent here mainly includes slowing the flow of lymphatic blood as well as spread of the poisonous venom in the systemic circulation and into the vital tissues and organs. On the peripheries, the provider needs to place the band midway between the heart and the injury. Cover the whole extremity leaving out the toes or the fingers to allow for circulation. On other areas or the torso, the band needs to be wrapped tightly enough but not to induce chocking or to inhibit breathing. If the scenario commands a compression bandage, the patient needs to be immobilized and strapped to a stretcher (Emergency Nurses Association, 2007). In home treatment, one should not apply cold packs or spray the wound. Also, application of alcohol or pouring of turpentine to the wound needs to be prohibited. The provider should not incise the wound or attempt to remove the venom orally. The right measures would be to ask the victim to identify the creature either by visual sighting or description. Thereafter, the provider should consult local protocols for assistance. In most cases, the antivenin drug may be necessary for very poisonous attacks. Patients over the age of 55 who experience trauma are at risk of unrecognized major injury and as a result fail to receive or receive delayed care for injuries compared to younger trauma victims.  Discuss the evidence related to recognition of major injuries in elder trauma patients. In the event of mass casualties the magnitude of the patients and severity of injuries suffered may exceed the capacity of the interventions available. Here the patients with greatest chances of survival who require least use of equipment, personnel and time tend to be treated on first priority. Treatment priorities of patients can only be established once the patients have been assessed. Assessment of such patients can be based on vital signs, injuries as well as injury mechanisms. In most cases, elderly patients succumb to trauma. As age increases, cancers and cardiovascular diseases surpass the incidence of trauma. Shockingly, for any given form of injury, the risk of death at the lowest and medium Injury Severity Score (TSS) tends to be higher for males than in females. (Emergency Nurses Association, 2007) For elderly patients, resuscitation warrants extra attention. As age increases, physiologic reserves decrease for trauma patients. Also, chronic respiratory, cardiac and metabolic infections inhibit the positive response of these patients to injury as compared to their younger counterparts. Comorbidities such as congestive heart failure, diabetes, obstructive and restrictive pulmonary diseases, cardiac disease, peripheral vascular disease as well as liver disease tend to be more common among the elderly (Emergency Nurses Association, 2007). Such ailments tend to affect outcomes related to injury among the elderly. Also, long term medication may modify the usual response to trauma. In addition the constricted therapeutic period often leads to under resuscitation or over resuscitation for patients in this group of the population. Consequently, invasive monitoring may be necessary in management. However, immediate and adequate resuscitation as well as early detection of preexisting illnesses and medication could improve survival in this group (Marx et al., 2006). For any form of diagnosis and treatment, the elderly victims of trauma require special attention. This arises from the fact that as one ages, the sympathetic activities decline with regard to the cardiovascular system. Such a decline occurs from a deficit in receptor reaction to catecholamine relatively from a decrease in manufacture of the catecholamines (Marx et al., 2006). As compared to younger victims, in the event of blood loss, the elderly exhibit a decline in cardiac compliance and thus the inability to increase efficiency of contraction of the heart muscles or heart beat rate (Marx et al., 2006). Atherosclerotic vascular occlusive disease increases sensitivity of most vital organs to the most insignificant decrease in blood flow. In many individuals of older age, volume decrease exhibits due to diuretic use for a long duration or subtle malnutrition. Therefore, such portion of the population can barely tolerate hypotension in case of trauma or injury. Reduction in diffusion capacity and pulmonary compliance in addition to weak muscles of respiration tend to increase inability of the patient to meet heightened burdens of injury on the body for gas exchange. It occurs following a cellular hypoxia due to reduction of local delivery of oxygen (Phtls, 2004). With respect to the factors stated above, rates of morbidity and mortality increase with increase in age and health status for injuries of mild or reasonably severe injuries. Despite such adversities of aging, general decrease of physiological reserves and comorbidities of preexisting illness some patients actually recover their pre-injury condition (Phtls, 2004). In order to achieve successful treatment, patients require aggressive and prompt resuscitation as well as careful observing. "Paramedics adequately manage pain in the pre-hospital setting."   Support or refute this statement.   Very briefly, outline one change that can be introduced to EMS that would improve pain management in the pre-hospital setting. Various challenges can be met in the pre hospital environment thereby decreasing the quality of care. Such challenges include longer distances, dangerous situations, inadequate supplies or equipment and disturbing injuries. Fundamentally, paramedics work towards managing pain for their victims. Such objectives can be achieved only if the environment assures safety; the procedures prove to be efficient, ease of administration of care to the patient and ultimately low potential of abuse. Pain management varies in adults and in pediatrics. In the later, the paramedic may need to be more cautious with the victim (Tintinalli, Cameron & Holliman, 2010). In a study conducted to investigate the experience and views of pain management in the pre hospital setting by paramedics and patients the researchers came up with a very contrasting conclusion. Mainly, the study aimed at improving patient care as well as the patient centered approach in practice (Marx et al., 2006). The qualitative study conducted on one emergency medical system gained its data from focus groups and semi structured questionnaires. The participants (55) included patients presenting with pain (17), clinicians in the emergency department (13) and those in ambulance service (25). The main themes included identifying values of patient and staff in pain management, widening pain assessment strategies, optimizing non drug treatment, increasing options for drug treatment and enhancing communication and management. The verbal score served the purpose of assessing pain and entonox and morphine served to reduce pain. The alternative to drugs in pain management included reassurance. The study concluded that pain may be managed poorly and could be undertreated in most cases in the pre-hospital scenario. Various areas need to be addressed in the aim of improving quality of pain management. They include; Addressing barriers to treatment, increasing pain management drugs and providing advanced paramedics training. Due to diversity in patients requiring treatment, further training needs to be administered to the paramedics. More area should be captured in the knowledge for pre-hospital care such as disaster scene triage, extrication and safety of the scene. The paramedics should further acquire accreditation upon completion of these advanced trainings. Clinical skills need to also be impacted on the paramedics thereby allowing them to practice chest tube insertion, cut down, intraosseous insertion, central line placement, escharotomy and cricothyroidotomy. Management of pain, ventilatory management, assessment skills as well as medication administration may be necessary to improve efficiency of the paramedics in any setting (Panté, Simon, Callahan, American Academy of Pediatrics & Pediatric Education for Prehospital Professionals, 2009). In addition, paramedics should question, investigate and evaluate the scenario of injury as well as that of the transport process. This helps to ensure quality of care for the patient and efficiency in pain management. Such necessary skills can only learnt through hands on experience either in a supervised patient setting or in the hospital laboratory situation. The need to improve the effectiveness and efficiency of these providers in the pre hospital setting contributes to strategic statement of healthcare in every state. Reference Asensio, J. A., & Trunkey, D. D. (2008). Current therapy of trauma and surgical critical care. Philadelphia: Mosby/Elsevier. Cohn, S. M. (2007). Complications in surgery and trauma. New York: Taylor & Francis. Emergency Nurses Association. (2007). Emergency nursing core curriculum. Philadelphia, PA: Elsevier Saunders. In DiPiro, J. T., In Talbert, R. L., In Yee, G. C., In Matzke, G. R., In Wells, B. G., & In Posey, L. M. (2014). Pharmacotherapy: A pathophysiologic approach. New York, N.Y: McGraw-Hill Education LLC. Marx, J. A., Hockberger, R. S., Walls, R. M., Adams, J., & Rosen, P. (2006). Rosen's emergency medicine: Concepts and clinical practice. Philadelphia: Mosby/Elsevier. Panté, M. D., Simon, S. G., Callahan, J. M., American Academy of Pediatrics., & Pediatric Education for Prehospital Professionals (Program). (2009). Basic life support provider: Pediatric Education for Prehospital Professionals. Sudbury, Mass: Jones and Bartlett Pub. Phtls. (2004). Mosby Inc. Tintinalli, J. E., Cameron, P., & Holliman, J. (2010). EMS: A practical global guidebook. New York: McGraw-Hill Medical. http://archive.org/stream/ATLS__Advanced_Trauma_Life_Support_for_Doctors/ATLS__Advanced_Trauma_Life_Support_for_Doctors_djvu.txt http://connection.ebscohost.com/c/articles/85651380/patients-emergency-clinicians-perceptions-improving-pre-hospital-pain-management-qualitative-study http://www.journal-surgery.net/article/S1743-9191(09)00002-8/fulltext http://www.emsworld.com/article/10324062/stings-and-bites-what-to-do-about-envenomation-injuries Read More