The Freddy Will Blog

    Never Ignoring the Original Truth

    SCENE

    A BP Canada filling station on Lakeshore Blvd. in Etobicoke, On. Canada.

    INCIDENT HISTORY

    10:25 am/Monday: 33-year-old Rochelle was fueling her 2011 Chevy Malibu at a BP Canada filling station when a 2007 Camaro plunged into Rochelle’s fuel dispenser. The Camaro also sideswiped a car that was pulling out of another fuel dispenser. Both of its front airbags were deployed as Rochelle’s fuel dispenser shattered to the ground. Reacting quickly, she dropped her fuel pump and fled. 

    As she did, her fuel dispenser caught on fire. As the flames spread to the Camaro’s engine, she looked and saw that the driver was slumped in his seat. Realizing that he is unconscious in a car that is about to explode next to a fuel dispenser, she hurried over, flung open his driver side door, unfastened his seat belt, pulled him out of the car and dragged him away. Seconds later, the fuel dispenser, the Camaro, and Rochelle’s Malibu exploded. 

    A passerby rushed over to help as she dragged the unconscious man away from the crash scene. Startled, Rochelle could not gather her thoughts so the passerby also called 911 to request urgent medical assistance for Rochelle and the unconscious driver.

    A man was dragged from the wreckage by a customer who was fueling her car
    at the time of the accident.”

    Photo credit: www.shutterstock.com

    CALL INFORMATION

    Etobicoke Paramedics received a code 4 for an MVC (motor vehicle collision) at a BP Canada fueling station on Lakeshore Blvd involving a crash into a fuel dispenser. A man was dragged from the wreckage by a customer who was fueling her car at the time of the accident.

    Medics were informed that there had been several explosions and the male may have smoke inhalation and burns. Arriving in five minutes, they found a noticeably rattled Rochelle and a bystander. Laying on the ground, a hundred feet from the two car inferno is an unconscious male. A crowd of onlookers had gathered and CP24 News were also on the scene.

    INCIDENT HISTORY cont…

    Upon contact, the patient’s eyes were closed while he responded to voice and stimuli (AVPU). His Glasgow coma scale was 8. He mumbled some words about chest tightness and sharp pains in his left arm. Paramedics wore personal protective equipment (gloves, mask, and goggles) as firefighters extinguished the blaze.

    The environment was relatively safe, there were two casualties, Rochelle, and the semi-conscious male, mechanism of injury was a semi-conscious male who may have smoke inhalation and burns and a female who is startled. Allied assistance (police and fire) were on the scene (P-EMCA). Calling for an additional unit a paramedic determined with a primary assessment that Rochelle showed no signs of trauma, pain, bleeding or infection.

    She gave her 15 liters of oxygen on a non-rebreather mask and advised her to see a physician for a detailed check up. The paramedic then released Rochelle to the police for a statement.

    He noticed first degree burns on his face (9% using the rule of nines). His airway was clear with no angioedema found but his breath gave off a sweet smell.”

    The other medic asked his partner who was through with Rochelle to hold C-Spine. As he confirmed the patient’s full present, equal and matching carotid and radial pulse. He noticed first-degree burns on his face (9% using the rule of nines). His airway was clear with no angioedema found but his breath gave off a sweet smell. His breathing was Kussmaul at 42 breaths a minute  (CAB).

    The medic put dry sterile dressing between the mask and the first-degree burn on the patient’s face and gave him 15 liters of humidified oxygen on a non-rebreather mask. He palpated his cervical vertebrae for crepitus, deformities, step offs and abnormalities; none were found. C-spine could not be ruled out so a collar was administered.

    They inspected his head for contusions, lacerations, abrasions and puncture or swelling (CLAPS) and felt for tenderness, instability, crepitus and swelling (TICS), none were found. There was no rhinorrhea, otorrhea, cerebrospinal fluid (CSF), mastoid bruising or jugular vein distention. His trachea was in its normal anatomy showing no signs of pneumothorax. Patient’s breathing was not flailed.

    Photo credit: www.shutterstock.com

    Preparing to backboard him, vital signs were taken (see below), his clavicle, chest, sternum and ribs were inspected for CLAPS and palpated for TICS. First degree burns were found on his chest (18%) with second-degree burns on his right arm (9%). His upper right left and lower right and left abdominal quadrants were palpated for anomalies but none were found.

    A woman identifying herself as the patient’s mother arrived on scene. She divulges his name and explained that he is a type one diabetic who may have forgotten to taken his insulin after he found out his wife was divorcing him for the cable guy. From this information, the paramedics presumed that his mechanism of injury should be upgraded to diabetic ketoacidosis with first and second-degree burns to his face, arms, and chest.

    Paramedics immediately administered insulin to the patient, the dry sterile dressing was applied to the first degree burns on his chest and a moist sterile dressing was applied for the second degree burnt region on his right arm. The arm was then placed in a sling. The patient was dosing in and out of consciousness.

    She divulge his name and explained that he is a type one diabetic who may have forgotten to taken his insulin after he found out his wife was…”

    The medic pressed in, pulled out and pushed down on Steinberger’s pelvis to ascertain dislocation, fracture or internal bleeding; none were found. Opposing force was applied on both of his thighs to ascertain a femur fracture or internal bleeding; none were found. The paramedic asked his partner (holding C-spine) to count to three as they turned the patient on his side to inspect his back, thoracic and lumbar vertebrae for CLAPS and TICS; none found.

    The patient was then auscultated with 4 points, apex to base bilaterally no adventitious sounds were heard. There were no penetrating wounds only a slightly pale skin discoloration. A gross wet check ascertained no external bleeding nor medical bracelets or alerts found.  They applied cervical safeguard, back boarded him, loaded him on the stretcher and took his second vital signs.

    They boarded the ambulance.

    CHIEF COMPLAINT

    Photo credit: Photo credit: newsfirst.lk

    The chief complaint from Rochelle was that she was breathing fast because she was startled from the ordeal. She had just run and dragged a 250 lbs male from a burning car. She was not hit by debris, did not inhale anything nor was she injured. Steinberger’s chief complaint was burned.

    Upon contact with him, paramedics did not know yet that he was a type one diabetic so they were more concerned about a possible fracture, smoke inhalation, spinal cord injury and/or pneumothorax from an impaled object. His Kussmaul breathing led them to assume he was hypoglycemic until his mother confirmed that he is a type one diabetic who took insulin.

    VITAL SIGNS

    FIRST VITAL SIGNS SECOND VITAL SIGNS THIRD VITAL SIGNS
    BP – 168/100 – Flushed skin BP – 132/86 – Skin – pink BP – 124/52 – Skin – pink
    Temp – 98.0 Temp – 98.4 Temp – 98.0
    Pulse – 92 Full Pulse – 86 Full Pulse – 70 Full
    Resp. – 42 Full Resp. – 30 Full Resp. – 24 Full
    SP02 – 89% SP02 – 94% SPO2 -96%
    Glasgow Coma Scale – 8 Glasgow Coma Scale – 10 Glasgow Coma Scale – 10
    Pupils – 3mm round/matching Pupils – 6mm round/matching Pupils – 6mm round/matching

     

    PATHOLOGY

    Photo credit: www.forensicmed.co.uk

    Burns: Thermal burns occur when skin is exposed to temperatures higher than 44 degrees centigrade. The severity of thermal injury correlates directly with temperature, concentration or amount of heat energy possessed by the object or substance and the duration of exposure. Superficial burns involve the epidermis only with skin redness and swelling. Partial thickness burns involve the epidermis and varying degrees of dermis with pain and blistering. 

    Full thickness burns involve the destruction of both layers including basement membrane of dermis thus making it incapable of self-regeneration. Full thickness burns are painless and have a waxy appearance. The total body surface area burned is calculated using the rule of nines. Others are the rule of palms and Lund and Browder chart. During first 24 hours, fluid resuscitation is important to prevent burn shock. Burn shock is a result of hypovolemia caused by fluid shifts.

    Upon contact with him paramedics did not know yet that he was a type one diabetic
    so they were more concerned about a possible fracture, smoke inhalation, spinal cord injury and/or pneumothorax from an  impaled object.”

    Photo credit: www.gassaferegister.co.uk

    Carbon Monoxide Poisoning: Carbon monoxide has no smell, taste or color. Its effects are silently poisonous. In the case of fire, it is a likely cause of death. Carbon monoxide is a by-product of burning natural gas, gasoline, propane, wood or coal. Its hazard is expanded when that incineration is in a closed environment. It also builds to hazardous levels from the exhaust of generators, heaters, barbecue grills or other appliances meant for use in well-ventilated spaces. 

    CO is particularly dangerous since there are no obvious signs of its initial build up in the air. During perfusion, it can prevent oxygen from bonding with hemoglobin in the blood. This can cause hypoxia and/or hypoxemia. Since our patient was unconscious it was easy to assume he had carbon monoxide poisoning. In his case, it was ruled out because he did not complain of a headache, was not fatigue with shortness of breath nor was his motor functions impaired.

    In fact, he had Kussmaul breathing. He complained of tightness in the chest instead of chest pain and he did not convulse. He did not throw up either. So this condition was not applicable.

    Photo credit: www.studyblue.com

    Diabetic Ketoacidosis: The human body needs the energy to function. Cells metabolize glucose to produce energy. For glucose to get into a cell it requires insulin to admit its entry into the cell. Once inside the cell, glucose undertakes the process of glycolysis which transforms it to pyruvate. Pyruvate enters the mitochondria of the cell and undertakes a kerb cycle to become ATP (adenosine triphosphate). 

    ATP is the body’s main source of energy. Without glucose tissues such as the heart, brain, kidneys or liver starve for energy. Insulin is also needed within the cell to inhibit fatty acids from being transported to the matrix of the mitochondria to take part in glycolysis and the Krebs cycle.

    When there is no insulin, glucose remains in the bloodstream. This leads to hyperglycemia (too much glucose in the bloodstream). The kidneys will flush out excess glucose by causing thirst and frequent urination. Hyperglycemia can be seen on people who have not eaten in hours (fasting hyperglycemia) or those who have eaten within the hour (postprandial hyperglycemia). Whatever the case, polydipsia, polyuria, and polyphagia become present. The cells of the body metabolize fatty acids to create energy since there is no insulin to admit glucose into the cell.

    The LB hydroxyacyl CoA is dehydrogenated again to create B ketoacyl CoA through B hydroxyacyl CoA dehydrogenase.”

    This is done by beta-oxidation where chains of fatty acids go through dehydrogenation to create a paired link of C2 and C3. The resulting acyl-CoA produces a trans 2 enoyl-CoA delta. Trans 2 delta enoyl-CoA is then hydrated at the paired bond to produce LB hydroxy acyl-CoA. The LB hydroxy acyl CoA is dehydrogenated again to create B ketoacyl-CoA through B-hydroxy acyl-CoA dehydrogenase.

    NADH are used as an electron acceptor and thiolysis occurs between C2 and C3 (alpha and beta carbons) to produce B ketoacyl-CoA. Thiolase enzyme catalyzes the reaction wherein new molecules of coenzyme A breaks the bond by nucleophilic attack on C3. This discharges the first two carbon units, as acetyl-CoA and a fatty acyl-CoA minus two carbons. This process will continue to repeat itself until all carbons in the fatty acid are turned into acetyl-CoA and ketone bodies are produced. Those ketones can then be used as substitutes of ATP which will provide energy in the body.

    Photo credit: www.derangedphysiology.com

    Ketone bodies are acidic and high in potassium. When Ketone bodies migrate from the cell in diabetic ketoacidosis they ooze into the bloodstream. The kidneys recognize the imbalance and over excess of glucose and ketones in the bloodstream. This causes them to trigger an osmotic diuresis of the excess water which was drunk as a result of polydipsia, to flush out the excess glucose and ketone bodies through urination. Osmotic diuresis leads to dehydration.

    The increase of ketone bodies in the bloodstream also causes a drop in the PH level. With a system that’s high in glucose and imbalanced amounts of ketones, the kidney works overtime to expel the excess of glucose and ketone bodies which are high in potassium. The expulsion of that much potassium too fast can prompt the heart to malfunction.

    They concluded that Steinberger blacked out behind the wheel due to a diabetic shock.”

    In Steinberger’s case, paramedics affirmed that he was suffering from dehydration, metabolic acidosis, depletion of potassium and a lack of insulin with an excess of glucose and ketone bodies. The Kussmaul breathing was his lungs attempt to rid his blood of its excess carbon dioxide which is waste products from beta oxidation. They also suspected ischemia.

    They concluded that Steinberger blacked out behind the wheel due to a diabetic shock. They resolved that he was burned while passed out in the car where he did not suffer carbon monoxide poisoning because he was pulled out by Rochelle. Had he stayed in the car he would also have more severe burns?

    SIGNS AND SYMPTOMS

    Burns: With superficial burns, the skin is red and swollen and when touched the color will blanch and return. Patient experience pain because nerve endings are exposed to the air. Partial thickness burns are more painful and blisters. A full thickness burn appears white and waxy brown and leathery or charred. Inhalation burns and intoxication are major problems which may cause angioedema and block airways. 

    There may cause a headache, dizziness, shortness of breath, irritation of eyes, nose, throat and chest hence assess for signs of inhalation such as smoky breath odor, burns to lips, carbon particles in saliva, crackles on chest auscultation and decreased air entry.

    Carbon Monoxide Poisoning: Patient did not complain of a headache. The patient was not fatigued with shortness of breath nor was his motor functions impaired. In fact, he had Kussmaul breathing. The patient complained of tightness in the chest instead of chest pain, he did not convulse. His unconscious state was due to acidosis from lack of insulin.

    Diabetic Ketoacidosis: Patient’s Kussmaul breathing was a leading indication. His acetone breath signaled that he was acidotic. Acidity triggered his hyperventilation as his lungs rid his body of excess carbon monoxide. His skin was flushed, he was unconscious, hyperthermia and had urinated. Since he had not taken his insulin he was having a diabetes mellitus as well as osmotic diuresis. It was deemed that low potassium from osmotic diuresis could also make him hypokalemic and trigger a cardiac arrest.

    Photo credit: hospitalnews.com

    INCIDENT HISTORY cont…

    In route to the closest hospital, paramedics noticed that the patient’s condition was improving. He was incontinent of urine at the scene but now his consciousness was improving. Since they administered his insulin his breathing was slowly becoming normal. He was now partially awake. He explained that the tightness in his chest and pain in his left arm was gone but he really needed to urinate. The patient was asked:

    The onset of the event: As he drove to work he felt some tightness in his chest and thought it was stress. He said he started hyperventilating once he pulled into the BP Canada filling station and does not remember what happened after that.

    Provocation or palliation: Patient said he was on his way to work. He had an argument with his wife earlier, she informed him their marriage was over she’d been seeing the cable guy. He was upset, he stormed out and forgot to take his insulin. He was too upset.

    As he drove to work he realized he needed to buy gas so he pulled into the BP Canada station.”

    The quality of pain: Patient said there was a throbbing pain in his left arm but it’s gone.

    Region and Radiation: The pain was only in his left arm, it did not radiate to his chest, jaw or any other part of his body.

    Severity: Patient explained that when the pain was at its worst on a scale of 10, it was 4.

    Time (History): Patient said he was fine until the argument. Once they argued he felt a little panic on his way to work. He did not remember to take his insulin. As he drove to work he realized he needed to buy gas so he pulled into the BP Canada station. As he did he began to hyperventilate, felt tightness in his chest with pains in his left arm. He soon felt light headed and don’t remember what happened afterward.

    Photo credit: womensbrainhealth.org

    BLS TREATMENT

    Burns:

    Stop the burning process by using dry sterile dressing on his face which had first degree burns and a moist dressing applied for the chest and right arm where he had second-degree burns.

    They performed a rapid trauma assessment.”

    Administer high concentration humidified oxygen. In the case of facial burns like in this case, gauze pads are placed on the edges of the oxygen mask to decrease pain and irritation.

    For 1st and 2nd-degree burns <10 -15% cover with wet sterile dressings; cover more extensive 2nd-degree burns and all 3rd degree burns with a dry clean sheet or dressing.

    Elevate affected part.

    Leave blisters intact and dress digits individually.

    Cover affected eyes with moist dressings.

    Initiate rapid transport if indicated.

    Enroute monitor, re-evaluate and manage as required for concurrent injuries

     i) emesis

     ii) seizures, combative behavior, the decline in the level of consciousness

     iii) hypotension, shock

     iv) airway obstruction and distress

    Diabetic Ketoacidosis:

    Paramedics assumed patient was hypoglycemic when they were informed that he is a diabetic.

    They performed a primary assessment on the patient. Due to the MVC, the call was now a trauma even though the patient only showed signs of medical issues. They performed a rapid trauma assessment. They initiated cardiac monitoring (patient pulse rate normalized after his insulin was administered to him). They performed his blood sugar glucometer

    Vital signs included:

    Skin assessment of his color, condition, and state of dehydration. Mouth, in which his airway, breath odor and state of dehydration. Central nervous system, in which the patient’s pupils were assessed, his Glasgow Coma Scale was assessed along with sensory motor functions. Three different vital signs were taken.

    Carbon Monoxide Poisoning:

    Paramedics were told during the call that the patient could be a case of potential carbon monoxide poisoning since he was in a burning car. However, upon assessment, he showed no signs of having been poisoned. There were no signs that he was under the influence of drugs or alcohol. The patient showed no signs of self-infliction of bodily harm.

    A head to toe rapid trauma assessment was done and redone periodically, only his Glasgow Coma Scale improved from 8 to 10. His papillary size was equal and its reactivity was normal.

    Patient’s skin color was getting normal. Three full vital signs were collected.

    CRITICAL ERRORS/FLAGS

    Cooling of extensive burns with dressing may cause shivering and hypotension thus uses wet dressing covered with a dry dressing to prevent heat loss.

    Delay in fluid resuscitation may lead to burning shock.

    SAMPLE

    Signs and Symptoms – Burns on the face, hand, and chest. Unconsciousness, Kussmaul breathing, and acetone breath smell, chest tightness, and redness of the face, chest, and arm.

    Allergies – None

    Medications – Lipitor, insulin

    Past Medical History – Type one diabetes

    The last Intake – Took insulin previous night.

    Events Leading Up the Incident – Patient was in a heated argument with his wife when she told him she was already talking to divorce lawyers. He stormed out of the house without taking his medications. While driving into a BP Canada gas station, he became unconscious. The patient does not remember what happened next. He was going in and out of consciousness when paramedics arrived.*

    REFERENCES

    Nancy Caroline’s Emergency Care in the Streets

    Basic Life Support

    Patient Care Standards

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