Transcript Patients With Traumatic Injuries

Patients With Traumatic
Injuries
Condell Medical Center
EMS System
August 2008 CE
Site code #10-7200E1208
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
• Upon successful completion of this
module, the EMS provider should be able
to:
– Identify the differences between a Category
I, II and III trauma patient
– State transport decisions for trauma patients
based on Region X guidelines
– Understand what the mechanism of injury is
and the information it provides
– Understand the difference between the index
of suspicion and the general impression
Objectives cont’d
– Describe assessment and treatment appropriate for
the patient with traumatic insult based on Region X
SOP’s
• Burns, tension pneumothorax, sucking chest
wound, flail chest, pericardial tamponade,
eviscerated organs
– Successfully calculate the GCS and RTS given the
patient’s parameters
– Identify and appropriately state interventions for a
variety of EKG rhythms
– Identify ST elevation on a 12 lead EKG
– Successfully identify the landmark and perform chest
needle decompression
– Actively participate in trauma scenario discussion
– Successfully complete the quiz with a score of 80% or
better
Leading Causes of Death
• In the age groups from 1 to 44, unintentional
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injury is the leading cause of death
45 and over, the leading causes of death are
disease
– cardiovascular disease and cancers
These statistics point to a financial burden
placed on the patient as well as society for
unintentional injuries
• Source: National Vital Statistics System, National Center for Health
Statistics, CDC
Level I Trauma Centers
• Prepared and committed to handle all
types of specialty trauma 24/7
• Provides leadership and resources to other
levels of trauma care in the Region
• Participates in data collection, research,
continuing education, and public
education programs
• Level I: Evanston Hospital, St. Francis in
Evanston
• Level I non-Region X: Advocate Lutheran
General, Froedtert (Wisconsin)
Level II Trauma Centers
• Increased commitment to trauma care for
the most common trauma emergencies
with surgical capability available 24/7
• Participates in data collection, continuing
education, and public education programs
• Level II: Condell, Glenbrook, Highland
Park, Lake Forest, Rush North Shore, Vista
Medical Center East (VMH)
Additional Level II Trauma Centers
- Not Geographically In Region X
• Centegra – McHenry, Illinois
• Good Shepherd Hospital (GSH) –
Barrington, Illinois
• Northwest Community Hospital (NWCH) –
Arlington Heights
Region X SOP -Trauma Transport
• Systolic B/P < 90 on 2
consecutive readings (or peds
< 80)
–Transport to the highest level
Trauma Center within 25 minutes
–25 minute clock starts from the
time of injury
Region X SOP Trauma Transport
• Traumatic arrest, isolated burns >20%
–Transport to the closest Trauma
Center
• No airway
–Transport to the closest
Emergency Department
Region X SOP Trauma Transport
• Category I Trauma Patient
–Unstable vital signs
–Based on anatomy of the injury
–Transport to the highest level
Trauma Center within 25 minutes
–25 minute clock starts from the
time of injury
Region X SOP Trauma Transport
• Category II Trauma Patient
–Based on mechanism of injury
•High potential for injury but
patient is stable for now
–Based on existence of co-morbid
factors that increase the risk of
complications to recovery
–Transport to the closest Trauma
Center
Region X SOP Trauma Transport
• Category III Trauma Patient
– All other traumatic injuries and routine
care is being provided
– Isolated traumatic injury (generally GCS
>10)
• Isolated fractures
• Minor burns
• Lacerations
– Transport the patient to the closest
Trauma Center
Mechanism of Injury
• The process and forces that cause trauma
• Mentally recreate the incident from the
evidence noted
• Identify strength of forces involved
• Identify direction forces came from
• Identify areas of the patient’s body most
likely affected by the forces
• Start to identify the mechanism of injury
during the scene size-up
Injury Patterns – Pedestrians
• Adults
•
– Generally turn away & present lateral surfaces
– Anatomically, impact is low on the body
– Injuries to tibia, fibula, femur, knee, lateral
chest, upper extremity, then head & neck
Pediatrics
– Generally turn and face the vehicle
– Injuries anatomically higher on the body than
adults
– Injuries to femur, pelvis and then those
sustained when run over or pushed aside by the
vehicle
Injury Patterns – Motor Vehicle
• Rotational (38% of MVC)
•
– Injuries similar to frontal & lateral
– Deceleration is usually more gradual & injuries
less serious although the vehicles look worse
Frontal (32% of MVC)
– Up and over pathway
• Femur fractures
• Blunt abdominal injury via compression
• Lower chest injuries after steering wheel
impact
• Head & neck injuries with windshield
impact
Injury Patterns – Motor Vehicle
– Down and under pathway
• Lower leg injuries from sliding under the dash
• Chest injuries with steering wheel impact
• Collapsed lungs from breath holding at time of
impact
– Ejection
• 27% of fatalities
• 2 impacts – with interior vehicle & then the
objects outside the car (ground, trees, fences,
etc)
Injury Patterns – Motor Vehicle
• Lateral impact (15% of MVC; 22% of all MVC
fatalities)
– Much less structural steel for protection between
victim and impact site
– Vehicle damage may not look severe but internal
injury potential is high
– Upper & lower extremity fractures on impact side
– Lateral compression with a large amount of internal
injury to chest & abdominal organs
– Unrestrained passengers are missiles and add to
injuries other passengers already sustained
Injury Patterns – Motor Vehicle
• Rear end (9% of MVC)
– Head rotates backward and then snaps
forward
– Less neck injury if the head rest is in place
• Rollover (6% of MVC)
– Occupant experiences impact every time
vehicle impacts a point on the ground
– Vehicle sides and roof provide less crumple
zones for absorbing impact forces
– Ejection is common in unrestrained persons
Index of Suspicion
• Your anticipation of injury to a body,
region, organ, or structure based on
identification of the mechanism of
injury
• Your index of suspicion is honed from
experience and time on the job
General impression
• Formed from mechanism of injury
and index of suspicion
• Will guide the EMS provider
regarding a direction on how to
proceed in caring for this patient
and be a guideline on choosing
which SOP to follow
Documentation To Include of The
Complaint
• O - onset
• P – provocation/palliation
• Q - quality
• R - radiation
• S – severity (0 – 10)
• T – timing – when did it start
Documentation
• Provide answers to:
–Who (the patient you’re caring for)
–What (happened)
–When (did it happen)
–Where (which body part)
–How (did it occur)
Trauma Care – Amputated Parts
• Routine trauma care
• To remove gross contamination, gently rinse
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with normal saline
– DO NOT use distilled water to irrigate open
wounds
– Normal saline is isotonic and less harmful to
tissue
Cover stump with damp (normal saline) sterile
dressing and ace wrap
– Ace provides uniform pressure to stump
Cover wounds with sterile dressing
Care of Amputated Parts
• Place part in a plastic zip lock
bag
• Place bag in larger bag or
container over ice and water
• Do not ice the part alone
Pain Management Including for
Adult Burns
• Morphine for pain control
–2 mg slow IVP over 2 minutes
–May repeat every 2 minutes as
needed to a maximum of 10 mg
–Watch for respiratory depression
–Monitor for a drop in blood pressure
due to vasodilation from the
medication
Adult Burns - Electrical
• Immobilize the patient
– High potential for traumatic injury
•Muscle spasms during contact with
source
•Thrown when power source cut
– Assess for dysrhythmia – place on
cardiac monitor
– Assess distal neurovascular status of
affected part
– Cover wounds with dry sterile dressings
Adult Burns - Inhalation
• High risk for airway compromise
• Note presence of wheezing, hoarseness,
stridor, carbonaceous sputum, singed
nasal hair
• High flow oxygen via non-rebreather mask
• Monitor for need of advanced airway
device
– ETT
– Combitube if trained and approved
Adult Burns - Chemical
• Consider need for HAZ-MAT involvement
• If powdered chemical, first brush away
excess dry material
• Remove clothing if possible
• Flush burned area with sterile saline
• If eye involvement, remove contact lenses
and flush continuously with sterile saline
• Avoid contamination of noninvolved areas
Adult Burns - Thermal
• Superficial – 1st degree
– Cool burned area with saline
– <20% BSA involved, apply sterile saline
soaked dressings
– >20% BSA, apply dry sterile dressing
• Do not overcool major burns or apply ice
directly to burned areas
Adult Burns - Thermal
• Partial or full thickness (2nd or 3rd degree)
– Wear sterile gloves and mask while burn
areas are exposed
– Cover burn wound with dry sterile dressings
•Preventing air flow over exposed burn
areas reduces pain levels
– Place patient on clean sheet on stretcher
– Cover patient with dry clean sheets and
blanket – protect from hypothermia
Infant differences:
back 13%,
each buttocks 2.5%,
each entire leg 14%
Case Study #1
• Adult patient who reached over a charcoal grill just
•
as the match was thrown onto the soaked coals
Injury is restricted to the right arm
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What type of burn is this?
Using the Rule of Nines, what is the TSBA burned?
What type of care is appropriate?
How can the pain be managed?
What does the documentation look like?
Case Study #1 – Patient with Burns
Case Study #1
• Combination of superficial and partial thickness
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burns approx 4.5% TSBA (circumferential
around forearm)
– Evidence of redness with a blistered area
although blister is broken
Appropriate care includes cooling burn, applying
sterile saline soaked dressing (<20% TBSA)
Additional helpful care
– Elevation of arm, removal of ring before
fingers swell
For pain control
– Morphine 2 mg slow IVP; can repeat 2 mg in
2 minutes up to 10 mg
Case Study #1 - Documentation
• What, when, where, how
• Our 52 year-old patient received superficial and
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partial thickness burns approximately 20 minutes
ago to her right forearm when reaching across
flames from a charcoal grill.
Detailed description of injury
Description of intervention prior to EMS & that
which EMS provided
Response to intervention
Chest Injuries – Traumatic Arrest –
Category I Trauma
• Begin CPR
• Transport to closest Trauma Center
•
– A hospital on by-pass must take a patient in
life threatening condition if they are the
closest appropriate hospital
Perform bilateral chest decompression
– Use common sense – does your scene size –
up, evaluation of mechanism of injury and
general impression indicate a potential chest
wall injury?
Chest Injuries – Tension
Pneumothorax – Category I Trauma
• History of injury to the chest wall
• Diminished breath sounds
• Hyperresonance if percussion done
• Severe dyspnea
• Hyperinflation of chest
• Jugular vein distention
• Tachycardia
• Hypotension
Needle Decompression
• Landmarks anterior approach
–2nd intercostal space in the midline
of the clavicles
–Place prepared flutter valve needle
over the top of the rib
•Avoids potential injury to vessels
and nerves that run along the
bottom of the rib
Quick Way to Find 2nd ICS
• Feel for the top of the sternum
• Roll your finger tip to the anterior surface at the
•
top of the sternum
Feel the little bump near the top of the sternum
– This bump is the Angle of Louis
• From the Angle of Louis slide your fingers angled
slightly downward toward the affected side
following the rib space
– You are automatically in the 2nd ICS
• Identify the midline of the clavicle
– The midline is more lateral than persons realize and
usually runs in line with the nipple
Alternate Method to Find 2nd
Intercostal Space
• Palpate the clavicle and find the midline
– The midline is farther out (more lateral) from the
sternum than most persons realize
• Move your finger tips under the clavicle into the
1st intercostal space
– 1st rib is under the clavicle and is not palpated
– Spaces identified for the numbered rib above the
space
• Feel for the firm 2nd rib and palpate the soft
space below the rib
– This is the 2nd ICS
Needle Decompression
• Find your own 2nd ICS
• Now find your neighbor’s 2nd ICS
– Use both methods to find the landmark and
decide which is easiest for you
• Documentation
– To include signs and symptoms
– Size of needle used (length and gauge)
– Site needle inserted into
– Response from the patient
Equipment
• Long needle (preferably 2-3 inch) and large
bore needle (preferably 12-14G)
• Flutter valve
• Cleanser to prepare skin overlying the site
• Method to secure needle in place
– Skin will most likely be diaphoretic
– Tape may not stick
– May need to maintain manual control of needle
Skin Preparation
Midline of
clavicle
2nd ICS
Angle of
Louis
Inserting the
Needle
• Remove proximal end cap
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•
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from needle
– Will be able to hear trapped air escaping
Needle inserted over top of rib
– Once hiss of air heard continue to advance
catheter while withdrawing stylet
Stabilize catheter as best as possible
Patient should symptomatically improve
– Do not expect to hear improved breath
sounds; takes time for the lung to reexpand
Case Study #2
• EMS is called to the scene for a 52 year-old male
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with c/o sudden onset dyspnea with pain
between his shoulder blades while watching TV
at home. The patient is agitated, short of
breath, with increased respiratory rate and SaO2
of 89%.
Further assessment reveals decreased breath
sounds on the right and clear on the left
Vital signs: 98/62; HR 118; RR 32 and shallow
Your impression & intervention plan?
Case Study #2
• Spontaneous tension pneumothorax
– They don’t all develop from trauma
• Begin supplemental oxygen support via non•
rebreather, cardiac monitor, preparation for IV
BUT
Quickly prepare for needle decompression while
the above are being prepared
– Patients with a tension pneumothorax can’t wait and
will deteriorate without needle decompression
Sucking Chest Wound – Category I
Trauma
• Most common with penetrating wounds
• Free passage of air between the
atmosphere and pleural space if the open
wound is at least 2/3rd the size of the
diameter of the trachea
– Size of trachea about the size of pt’s 5th finger
• Air is drawn into the chest cavity
• Air replaces lung tissue
• Lung collapses
Sucking Chest Wound
• Severe dyspnea
• Open chest wound
– Check anterior, posterior, axilla areas
• Frothy blood at wound opening
• Sucking sound as air moves in and out
• Tachycardia with hypovolemia
Treatment Sucking Chest Wound
• Immediate treatment is to seal the
opening
– May start by placing a gloved hand over the
wound
– When able, place an occlusive dressing, taped
on 3 sides, over the wound
• Wound now converted to a closed
pneumothorax
• Monitor for signs of tension pneumothorax
– May need to lift a corner of the dressing to
release trapped air via burping dressing
Flail Chest – Category I Trauma
• 3 or more adjacent ribs broken in 2 or more
places
– Segment becomes free with pardoxical chest wall
motion during respirations
– Paradoxical movement more evident after the muscles
splinting the flail segment fatigue
• Usually takes a tremendous amount of blunt
•
•
trauma to cause a flail chest
Often present will be associated severe
underlying injury (ie: pulmonary contusion)
Respiratory volume reduced and respiratory
effort increased
Treatment Flail Chest
• Place patient on the injured side (may not be possible
to do this in the field based on mechanism of injury)
• High flow oxygen – nonrebreather mask
•
– Monitor for need to assist ventilations via BVM
to deliver positive pressure ventilations
• Evidence of underlying pulmonary injury
• Effort and fatigue
• Pulse oximetry
EKG monitoring
– Tremendous amount of force is delivered to the
chest wall and cardiac injury is highly likely as a
result
Pericardial Tamponade – Category I
Trauma
• Blood or other fluid fills the pericardial sac
restricting cardiac filling & contractility
• Most often related to penetrating trauma
• Venous return to the heart is restricted
• Decreased cardiac output
• Pressure on the coronary arteries restricts
blood flow to the myocardium
Pericardial Tamponade Signs &
Symptoms
• Usually history of penetrating trauma
• Agitated patient
• Diminished strength of pulses (weak and
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thready) with tachycardia
Narrowing pulse pressure
– Diastolic & systolic numbers moving closer
together
Distended neck veins (JVD)
Diaphoretic and pale
Muffled, distant heart tones
Hypotension
Treatment Pericardial Tamponade
• Treatment in the field is limited to being
supportive
• Patient requires high index of suspicion
and/or rapid identification with rapid
transport
– In ED will perform needle thoracentesis and
then transfer the patient to the OR for open
heart surgery
General Assessment Pearls
• Restlessness and agitation
– You must consider hypoxia, shock,
influence of alcohol and/or drugs
– This is one time you need to assess for
all reasons of restlessness and not just
stop when you discovered one cause –
there may be more than one pathology
going on at a time
Evaluation Pearls – Low SaO2
• SaO2 reading may be inaccurate in the presence of:
•
– Hemorrhagic shock with delayed capillary refill
– Hypothermia
– Lung damage
Evaluate all parameters together to get the best
overall picture in ventilated patient
– What does the ETCO2 indicate?
– Are you able to ventilate the patient?
– Are there extenuating circumstances where the
circulation is affected and would affect the pulse
ox reading like those listed above?
More
Case
Studies
Case Study #3
• Your 34 year-old
patient received a
GSW to the right
upper abdomen.
• They are conscious
and alert; B/P 90/62;
HR 120; RR 28;
bleeding is minimal
• Category trauma?
• What are your
interventions?
Case Study #3 – Category I Trauma
• Make sure the scene is secured
• Consider need for spinal immobilization
• During assessment of wound, consider thoracic
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injury in addition to abdominal injury depending
on the angle of the GSW.
Examine for an exit wound
– Check the back and the axilla
• Prepare for the worst – assume the patient will
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deteriorate before ED arrival
Repeat VS: B/P 80/; HR 140; RR 32, remains
conscious and in pain
Transport to the highest level Trauma Center
within 25 minutes
Case Study #3 - Treatment
• Routine trauma care
• Question – is this an isolated abdominal wound or
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•
is it a combination abdominal/ chest wound?
– Need to treat patient for potential injuries of
both body cavities
– EMS cannot determine in the field the angle of
the trajectory
Cover the wound and watch for evisceration
Fluid resuscitation – keep B/P at low levels; the
higher the B/P the faster the patient bleeds out
Case Study #3 - Documentation
• If patient states anything, put it in quotes
• If information available, add angle patient shot
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from (ie: above, below) and distance from weapon
If known, list type of weapon used
Include results of inspection, auscultation,
palpation
– Location of entrance and exit wound
– Size of wound(s)
– Assessment of the general area (ie: contusions, bleeding,
swelling/distention, pain, powder marks)
• Preserve evidence as much as possible
Case Study #4
• Your 10 year-old
patient
penetrating injury
the right leg above
knee while playing in
has a
to
the
his backyard
• Initial VS: B/P 90/70;
HR; 130; RR 32; no
active bleeding
• Category trauma? Field interventions?
Case Study #4 – Category III
• Next VS: B/P 92/64; HR 110; RR 20.
• Stabilize foreign body in place
• Obtain distal neurovascular status
– Distal pulses
– Movement – “can you wiggle your toes?”
– Sensation – “close your eyes and tell me
which toe I am touching”
• Document distal neurovascular status and
describe how the foreign object is
stabilized in place
Case Study #5
• Your 62 year-old patient had abdominal surgery
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1 week ago. Today at home he sneezed hard
and felt a tearing
sensation in his
abdomen and
called EMS.
VS: B/P 100/60;
HR 110; RR 24
No active
bleeding
What
interventions
are appropriate?
Case Study #5 - Interventions
• Immediately cover the wound
– Need to minimize contamination
– Need to prevent more organs from protruding
– Need to prevent loss of fluids
• Place a saline moistened dressing over the
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exposed tissue
Place dry gauze over the saline dressings
Can place light manual control over the organs
to prevent further evisceration especially during
movement, coughing, sneezing, deep breaths
Case Study #6
• 21 year-old drove into a metal fence. Upon EMS
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arrival, there is obvious external chest injury
with bleeding. Coming closer to the patient, EMS
can hear a sucking sound from the chest wound.
Patient is alert, in pain, severe dyspnea
VS: B/P 90/62; HR 130; RR 34; GCS 15
Breath sounds L > R
Look at the injury – what is your impression and
what interventions are necessary?
MVC Into Metal Fencing
Case Study #6 – Category I
• An adequate dressing will be difficult to
achieve with such an extensive wound
– A gloved hand just won’t be enough to get
started
• This patient may be a candidate for
conscious sedation and intubation to
provide positive pressure ventilation
• Reassessment VS: B/P 80/56; HR 140;
RR 36 GCS remains 15
• Transport is to highest level trauma center
within 25 minutes
Case Study #6 - Treatment
• Open chest wounds need to be covered ASAP
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with a non-occlusive dressing
Carefully monitor if the treatment of the open
chest wound converts the injury into a tension
pneumothorax
Carefully monitor the patient for the need for
more aggressive airway control (ie: supportive
ventilation via BVM or intubation)
– Initially can start O2 therapy with a nonrebreather mask
Case Study #6 - Documentation
• What – cause of the injury (penetration,
MVC, pedestrian, etc)
• When – the injury occurred
• Where – by body location
– “quadrant” refers to the abdomen
– Chest injuries uses reference such as anterior/
posterior, nipple line, upper/lower chest wall
• How – the injury occurred
• Expand and give detail description of the
injury, treatment rendered, pt response
Case Study #7
• Your 45 year-old patient is a construction
worker who was accidentally shot in the
head with a nail gun
• Upon arrival, the patient is awake, alert,
talking (GCS 15)
• VS: B/P 132/78; HR 96; RR 20; complains
of a minor headache; minimal bleeding at
a few puncture wounds noted on the
occipital area of the scalp (patient has
thick hair).
X-ray
from
ED
No
deficits
noted
Case Study #7 - Treatment
• Consider any injury above the level of the clavicles
•
to include a c-spine injury until proven otherwise
and immobilize the patient
Control bleeding
– The face and scalp have such a rich blood supply small
wounds tend to bleed heavily
• Protect from further contamination
– The open wound may be in direct contact with the brain
• Document neurological evaluation to establish
baseline for comparison (AVPU, GCS, movement)
Case Study #8
• You are called to the scene for a 10 year-old
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female who has been run over by a bus
As patient exited bus, she bent down to tie her
shoe and was caught under the wheels of the
bus
Upon your arrival, you note a large amount of
avulsed tissue with bleeding from the left hip,
left buttock, and left upper thigh area
The patient is screaming in pain
VS: B/P 110/70; HR 110; RR 26 GCS 15
What is your impression?
What is your treatment plan?
10 y/o run over by bus
Case Study #8 – Category I or II?
• General impression
•
– Category II minimally – pedestrian run-over
– Category I trauma – if unstable pelvis or 2 or
more long bones (proximal bones) fractured
and vital signs unstable
Potential problems to consider & address
– Massive hemorrhage & control of hemorrhage
– Spinal injury
– Additional injuries
– Airway control
– Equipment to fit a 10 year-old
– Further wound contamination
1 year F/U with skin grafts
Glasgow Coma Scale - GSC
• Tool used to evaluate and monitor a
patient’s condition
• Evaluates
Best eye opening
Best verbal response
Best motor response
• Serves as an indicator/predictor of survival
• To be performed on all EMS patients
GCS
• Possible total score 3 (lowest) – 15
(highest)
• Minor head injury – patient scores
13 – 15
• Moderate head injury – patient scores
9 – 12
• Severe head injury – patient scores <8
–Significant mortality risk
GCS Pearls
• The change in the GCS is more important than
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the absolute score
Check for associated injuries
– Manage a head injury as a multiple injured
patient until other injuries ruled out
Stabilize the neck for any head injury
Don’t assume the level of consciousness is
altered just because of ETOH and/or drugs
– Is there an occult (hidden) injury present?
Provide accurate, clear, detailed documentation
GCS – Eye Opening 1-4 Points
• Spontaneous (4) – eyes open; may or may not focus
• To voice (3) – prior to touching the patient, eyes will
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•
open to sounds around them or EMS calling/yelling
to them to open eyes
– Often difficult to accurately assess due to EMS
gaining immediate c-spine control so difficult at
times to determine if patient responded to voice
or touch (pain)
To pain (2) – doesn’t necessarily imply you must
apply painful stimulus, could be just to touch
– Flutter of eyelids is scored as 2
None (1) – eyes remain closed with no eyelid flutter
or other eye movement; eyes do not open
GCS – Verbal Response 1-5 Points
• Oriented (5)
• Confused (4)
– Words may be appropriate to situation but
pt does not respond to questions
• Inappropriate words (3)
– Words are spoken and understood but
nonsensical to the situation (“over there”)
• Incomprehensible words (2)
– Includes mumbling, unintelligible speech,
moaning
• None (1)
GCS – Motor Response 1-6 Points
• Obeys command (6)
• Localizes pain (5)
– Patient who pulls equipment off; pushes your hands
away; purposeful movement
– This patient knows where the obnoxious stimuli is
contacting his body
• Withdraws to pain (4)
– Pt cannot isolate where they feel the noxious stimuli
so just pulls back/withdraws
• Flexion (3) – arms bent towards midline when
•
•
stimulated
Extension (2) – arms extended when stimulated
None (1) – remains flaccid
GCS Pearls
• Give the patient the best score possible
– If the patient moves the right side of their
body but no movement on their left, score
them for the movement they currently exhibit
on the right
– If patient deteriorates, easier to see the drop
or change in the GCS score
• When testing for responses, watch even
for minimal activity like eyelid flutter or a
grimace
GCS Pearls
• Acceptable noxious stimuli
– Armpit pinch or nailbed pressure
– Sternal rub, pinching web space
between fingers, pinching shoulder
muscle (trapezius)
– Earlobe pinch is out of favor
•Can cause movement of head & neck
in response to the pain
RTS – Scoring 0 – 12 points
GCS & RTS Practice #1
• Patient eyes are open and they watch you
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•
•
•
•
during the examination
The patient is confused; they don’t remember
how they got hurt and can’t remember the day
of the week
When you ask the patient to “show me 2
fingers”, they respond but are slow to do so
VS: B/P 120/70; HR 88; RR 18
Total GCS?
Total RTS?
GCS & RTS Practice #2
• The patient does not open their eyes
• The patient groans when pinched or an
injured body part is touched
• The patient does not follow commands
and will push your hands away when you
touch them
• VS: B/P 96/68; HR 102; RR 22
• Total GCS?
• Total RTS?
GCS & RTS Practice #3
• The patient’s eyes are open
• When asked “what month is this?”, the
patient responds, “he, umm, he…my
jacket. I don’t ..”
• If touched or pinched, the patient pulls
away from the contact
• VS: B/P 132/72; HR 96; RR 16
• Total GCS?
• Total RTS?
GCS & RTS Practice #4
• Your patient’s eyes are closed but they
open wide if the patient’s injury is touched
• The patient yells “don’t” or “stop” when
there are pinched but does not answer
questions or speak in sentences
• The patient will push your hands away
when you touch them
• VS: B/P 108/64; HR 102; RR 18
• Total GCS?
• Total RTS?
GCS & RTS Practice #5
• The patient’s eyes are closed but the
eyelids flutter when you loudly call out
their name
• The patient does not answer questions but
will groan when touched but not say
recognizable words
• The patient does not follow commands but
will push away your hands when touched
• VS: B/P 80/52; HR 112; RR 12
• Total GCS?
• Total RTS?
GSC & RTS Practice #6
• The patient’s eyes are closed but will open when
•
•
•
•
•
the patient is touched
The patient says “leave me alone” and “what are
you doing?” and goes back to sleep. When eyes
are open they respond “I don’t know” to
questions
They do not follow command and will push your
hands away when touched
VS: B/P 110/68; HR 88; RR 20
Total GCS?
Total RTS?
GCS/RTS Practice Answers
• #1 – GCS – 14 (4, 4, 6)
• #2 –
• #3 –
• #4 –
• #5 –
• #6 –
RTS – 12 (GCS 4; RR
GCS – 8 (1, 2, 5)
RTS – 10 (GCS 2; RR
GCS – 11 (4, 3, 4)
RTS – 11 (GCS 3; RR
GCS – 11 (2, 4, 5)
RTS – 11 (GCS 3; RR
GCS – 10 (3, 2, 5)
RTS – 10 (GCS 3; RR
GCS – 11 (2, 4, 5)
RTS – 11 (GCS 3; RR
4; B/P 4)
4; B/P 4)
4; B/P 4)
4; B/P 4)
4; B/P 3)
4; B/P 4)
Identify Rhythm Strip #1
Treatment Symptomatic Bradycardia
• Bradycardia or Type I Wenckebach
– Atropine 0.5 mg rapid IVP
– May repeat every 3-5 minutes to total of 3mg
– If ineffective, begin pacing
• Type II or 3rd degree heart block
–
–
–
–
–
–
–
Begin TCP
Valium 2 mg slow IVP for discomfort
May repeat 2 mg IVP every 2 minutes to max 10 mg
TCP set at rate 80/minute and start at lowest mA
Watch for capture
If TCP not effective, give Atropine 0.5 mg rapid IVP
May repeat Atropine 0.5 mg every 3-5 minutes; max
3mg
Identify Rhythm Strip #2 –
6 second strip
Treatment Sinus Rhythm
• No treatment necessary for the rhythm
• Treat the patient’s complaint
• IF ACS, then
– Aspirin 324 mg chewed (faster absorption)
– Nitroglycerin 0.4 mg sl
• May repeat in 5 minutes; watch B/P
– Morphine if 2nd NTG dose not effective
• 2 mg slow IVP
• May repeat every 2 minutes to max 10 mg
• Screen for recent Viagra type drug usage
Identify Rhythm Strip #3 –
6 second strip
Treatment Rapid Atrial Fibrillation
• Stable patient with B/P >100 mmHg
– Verapamil 5mg SLOW IVP over 2+ minutes
– If no response in 15 minutes & B/P stable,
repeat 5mg SLOW IVP over 2+ minutes
• Unstable patient with B/P <100 mmHg
– Contact Medical Control for direction
• Afib patients at increased risk for atrial
clots dislodging and migrating to the brain
and the patient having an ischemic stroke
Rhythm Strip Identification
• Strip #1 – Second degree Type I Wenckebach (“drops one”)
• Strip #2 – Normal sinus rhythm
• Strip #3 – Atrial fibrillation - controlled
#1 – Identify ST Elevation
#2 – Identify ST elevation
#3 – Identify ST Elevation
ST Elevation Answer Key
• EKG #1 – Leads V 1 - 4
• EKG #2 – Leads V 2 - 5
• EKG #3 – Leads II, III, aVF
Bibliography
• Bledsoe, B., Porter, R., Cherry, R. Paramedic
•
•
•
•
•
Care Principles & Practices 2nd Edition Brady.
2006.
ITLS Bulletin. Case Study: ITLS Patient ETCO2.
June 2008.
Region X SOP’s Eff date March 1, 2007; Revised
January
2008.
www.chems.alaska.gov/ems/document/GCS
www.merck.com
www.swsahs.nsw.gov.au/