Introduction to case study

Scenario

John is a recreational motorbike rider who is the proud owner of a hybrid sports bike and a cruiser motorcycle. John is a safe and mature rider who wears safety gear at all times. While on a weekend ride with a group of friends through the Gold Coast hinterland, John’s bike is clipped by a car; he is knocked off the bike and slides several metres through gravel and into a metal guardrail at moderate speed and impact. A passer-by calls the paramedics and police, who arrive at the scene within 10 minutes.

Primary survey by paramedics

John is rapidly assessed by paramedics using the DRABC mnemonic:

• Danger
• Response
• Airway
• Breathing
• Circulation

After ensuring their own safety and that of the patient and other bystanders, the paramedic team assesses John’s level of consciousness using the alert, verbal, pain, and unresponsive (AVPU) scale (Janagama et al, 2022). John is found to be alert with a normal level of responsiveness. The paramedics then assess John’s airway for signs of obstruction. John is found to have normal breath sounds and no obvious airway obstruction. In line with Queensland Ambulance Service policy, the paramedics remove John’s helmet using a two-operator process that provides support at the mandible and occiput and reduces the risk of destabilising and cervical spine injury. John is breathing in a regular pattern, with equal chest wall movement bilaterally. John’s respiratory rate is 22 breaths per minute. In assessing circulation, John’s blood pressure is 118/86 and he is found to have adequate central and peripheral perfusion.

The initial treatment involves protecting the cervical spine (also known as the C-spine) in case of vertebral injury, which may result in spinal instability and damage to the spinal cord. The paramedics apply a cervical collar to limit movement and support the C-spine. They establish intravenous access with an 18g peripheral cannula (PIVC) into the left arm antecubital fossa.

Secondary survey by paramedics

The paramedics gather further information about the accident, including information from bystanders, and conduct a more focused assessment. This head-to-toe physical assessment includes a more comprehensive history, including pain assessment and vital signs. John complains of moderate pain in his lower back and abdomen, radiating into the right groin. There are no visible deformities of the head, neck or chest. John does report some tenderness over the right clavicle on palpation. Auscultation of the chest reveals undiminished heart and lung sounds, with no additional sounds. Inspection of the abdomen shows some bruising and extensive grazes from the right hip into the right lower quadrant. John experiences moderate pain on palpation and passive movement of the hip. There is no obvious deformity of the lower limbs. John’s boots are removed to assess for rotation or shortening of the legs; however, both legs are naturally positioned and of equal length.

John’s vital signs remain stable.

• Respiratory rate: 22, bilateral equal chest movement
• SpO2: 97% on room air
• Blood pressure: 124/ 89
• Heart rate: 96, regular
• GCS:15 (E4, V5, M6)

Prepare for transport to hospital

Using spinal precautions, the paramedics recruit bystanders to help them transfer John to the spinal board which is then lifted onto a stretcher. John’s pain worsens on movement, intensifying in the right hip and radiating from the right groin down into the leg. The pain is spasmodic or cramping in nature; John says that the pain score is now 8 out of 10. Paramedics administer intravenous fentanyl in 25 microgram increments and inhaled methoxyflurane (Penthrox) until the pain is more manageable.

When John failed to arrive at the meeting point, two of his friends rode back and arrived at the scene. One of his friends (Mark) agreed with the police that he would contact Nigel to let him know what had happened. On receiving Mark’s phone call, Nigel said he would come to the hospital straight away.

Key information and links to other resources

• Emergency Care Institute NSW: Maintaining cervical spine precautions
• Trauma Victoria: Pre-hospital triage

Case study 3 summary

This case study explores the pre-hospital care provided to John before he is transferred to the emergency department (ED). The primary and secondary survey has been presented and you have had the opportunity to consider pain relief and the use of spinal immobilisation in line with current evidence. In the next case study, you will follow John’s story as he is admitted to the ED.

References

Janagama, S. R., Newberry, J. A., Kohn, M. A., Rao, G. V. R., Strehlow, M. C., & Mahadevan, S. V. (2022). Is AVPU comparable to GCS in critical prehospital decisions? – A cross-sectional study. The American Journal of Emergency Medicine, 59, 106–110. https://doi.org/10.1016/j.ajem.2022.06.042