Paramedic Basics

- Fingertip injuries

Whilst not often life threatening, finger tip injuries are common and painful. Some will benefit from treatment at hospital, however it’s important that we only transport patients who actually require our services

BACKGROUND
📕 Most common in children < 5 years (exploring) and adults > 65 years
📕 Common mechanisms are crush (fingers in car door), laceration and amputation
📕 3:1 male to female incidence

ANATOMY
👉🏼 Nail plate - the part we commonly refer to as nail
👉🏼 Nail bed - the vascular structure that feeds the nail
👉🏼 Germinal matrix - the origin of the nail plate
👉🏼 Pulp - the flesh around the finger bone
👉🏼 Distal phalange - the bone making up the finger tip

COMMON PROBLEMS
🛠️ SUBUNGUAL HAEMATOMA
A collection of blood under the nail plate, can be quite painful due to pressure buildup. Usually described as the % surface area of the nail that the haematoma covers. Can be managed conservatively, with a bore hole (trephination) or nail removal. Haematomas > 50% suggest nail be laceration

🛠️ NAIL BED LACERATION
Lac impacting both the nail plate and nail bed. Infection and nail by growth disruption are both risks. Managed by removing the nail, delicately suturing the nail bed and returning the nail

🛠️ FRACTURE
Can occur with any fingertip injury, needs xray to rule out. Several types, notably a Seymour fracture, a serious finger fracture which impacts the growth plate in children

PARAMEDIC MANAGEMENT
🚑 Control haemorrhage
🚑 Analgesia
🚑 All paeds should be assessed at hospital to rule out Seymour fracture
🚑 Adults with subungual haematoma < 25% and controlled pain can manage with self care (analgesia, ice, elevation)
🚑 Haematoma 25 - 50% with controlled pain should be referred to GP/urgent care for review and possible trephination
🚑 > 50% subungual haematoma should be reviewed at hospital for nail bed repair
🚑 For all patients with controlled pain and no other injuries/reason for transport, consider alternative means of transport

- Chest Pain DDx

Chest pain is a common reason for calls to emergency services. In Victoria it makes up 9.4% of ambulance attendances. Whilst common, diagnosing chest pain can be challenging. Given that the causes range from trivial to life threatening, it is something that paramedics want to get right every time.

One study found the causes of chest pain as:
- non-specific: 46% [30 day mortality 0.5%]
- NSTEMI: 5.3% [1.3%]
- pneumonia: 3.8% [3.9%]
- stable angina: 3.5% [0.8%]
- unstable angina: 3.3% [1.3%]
- STEMI: 2.8% [7.0%]
- pulmonary embolism: 0.7% [3.2%]
- aortic pathologies: 0.2% [22.2%]

(Dawson et al, 2022)

Given the number of differential diagnoses, it is easy to feel overwhelmed or out of your depth. Some paramedics will suggest ‘just treat them all as cardiac’. Whilst pay off principle is legit, we don’t want to be blindly treating (and transporting!) every chest pain as cardiac.

Today’s whiteboard offers some clinical findings which will assist in pointing you into the right direction. Some are based off guidelines, whilst others are based of clinical experience/conventional wisdom. It’s also worth remembering that there are abnormal/atypical presentations of all conditions.

Paramedics can and should diagnose problems. By assessing the patient, their history and preceding events, it is often possible to get the diagnosis right without imaging/pathology. We can then work on treating and conveying the patient to the right hospital based off that diagnosis.

It is okay to change your mind or re-consider a diagnosis - that’s why we reassess!

Always treat the patient in front of you and try to do what’s best for them

- Intussusception

More than just a mouthful to say, intussusception is a potentially serious conditions effecting 1 in 2000 children annually in the US. When detected and treated early, prognosis is very good

PATHOPHYSIOLOGY:
- 90% of cases are idiopathic
- one part of the bowel is propelled into the next bit, causing a ‘telescopic bowel’
- usually the proximal bowel is lodged in the distal bowel, due to peristaltic (digestive) movement of the gut
- the stuck section of bowel can lose its blood supply, becoming ischaemic
- if left untreated, bowel perforation, necrosis and sepsis can occur

CLINICAL PICTURE:
- usually aged 2 months to 2 years, but can occur at any age (including adults)
- typically occurs around age 5 months
- boys more affected than girls (3:1)
- child appears very distressed and in pain, occurring episodically
- associated vomiting, lethargy, pallor
- sausage shaped mass may be felt over the right side of abdomen
- may initially have diarrhoea, which can lead to a misdiagnosis of gastroenteritis
- re**al bleeding / red currant jelly stool is a late sign

MANAGEMENT:
- nil by mouth in case surgery is needed and to reduce pain
- IN Fentanyl
- Ondansetron wafer
- if shocked, request MICA for fluid resuscitation (20mL/kg)
- transport to paed surgical hospital

PEARLS:
- intussusception usually isn’t associated with fever, whereas gastroenteritis is
- remember that patients may appear very well between episodes of pain - if not providing transport, ensure there is rigorous safety netting and referrals are in place
- the younger (or less verbal) the patient is, the more thorough your physical exam should be

- Different IV Fluids

If your service is anything like mine, we’ve been relying on good old fashioned 0.9% Sodium Chloride (Normal Saline or “pasta water”) for quite a while

As a cheap, compatible, isotonic fluid, it is ubiquitous around the globe. However issues with supply means that we are now facing an international shortage of our favourite salty water

In response, Ambulance Victoria has introduced two additional fluids to service - Compound Sodium Lactate (Hartmann’s) and Plasma Lyte 148

Both are so-called ‘balanced crystalloids’, as they have electrolytes dissolved in them to more closely mimic blood plasma. Whilst they will have broadly the same indications as Normal Saline, there are a few nuances to be aware of

💧0.9% Sodium Chloride
- should be saved for patients with TBI, as it may be associated with lower mortality than balanced crystalloids
- avoid using 500mL/1000mL bags to draw up flushes (use ampoules)
- avoid hanging ‘just in case’ or TKVO

💧CSL
- not compatible with blood products (causes coagulation)
- not compatible with Ceftriaxone (causes calcium precipitation). The effect is so significant that they cannot both be given to infants < 28 days, even via separate lines. For patients older than 28 days, they can be co-administered but NOT via the same line
- can’t be used to reconstitute powdered medications due to lack of research

💧Plasma Lyte 148
- incompatible with Amiodarone and Propofol
- can’t be used to reconstitute powdered medications due to lack of research

My general approach?
1️⃣ Use Normal Saline for head injured patients

2️⃣ For all other patients older than 28 days, use Hartmann’s.
If not available, then use Plasma Lyte 148

3️⃣ For patients < 28 days requiring fluid resuscitation, use Plasma Lyte 148.
My thought here is that they will likely receive antibiotic cover and we don’t want to limit options

💰 Also worth noting that Plasma Lyte 148 is more expensive than Normal Saline and Hartmann’s. Although money isn’t everything, if the patient gets the same effect then we have a job to spend healthcare resources wisely