Transcript September 2012 - Advocate Health Care

Trauma Morbidity and
Mortality
Mod III 2012 ECRN CE
Condell Medical Center
EMS System
Site Code: 107200E -1212
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
Upon successful completion of this module, the ECRN will
be able to:
 1. Identify by mechanism of injury and signs and
symptoms major causes of increased risk of
morbidity & mortality related to a traumatic injury
(airway obstruction, flail chest, open pneumothorax,
tension pneumothorax, cardiac tamponade, aortic
tear).
 2. Identify the significance and signs and symptoms of
crush injuries and compartment syndrome.
 3. Describe field treatment based on injury presented.
2
Objectives cont’d
 4. Identify transport destination decision per
Region X SOP.
 5. Review case scenarios presented.
 6. Review the skills of needle decompression,
cricothyrotomy, and QuickTrach
 7. Successfully complete the post quiz
with a score of 80% or better.
3
Thoracic Trauma
 Responsible for 20-25% of all trauma
related deaths
 Purpose of primary assessment
 Determine the presence of any
LIFE THREATS!!!
What’s going to kill the patient the
fastest??
Hypoxia
Hemorrhage
4
Trauma Stats
 Deaths at the scene are usually due to
injury of the heart and/or great vessels
 Deaths delayed by hours are usually due
to airway obstruction, tension
pneumothorax, hemorrhage, and
tamponade
 Note: only a small portion of patients with
traumatic injuries to the chest need OR
5
Tissue Hypoxia
 Inadequate delivery of oxygen to tissues
can be caused by a variety of mechanisms
 Start patient assessments with primary
assessment
 Any change in the patient condition and
you should repeat the primary assessment
A–B-C
6
Causes of Tissue Hypoxia
 Hypovolemia from loss of blood volume
 Ventilation/perfusion mismatch due to
injury of lung tissue
 Compromise to ventilations and or
circulation due to a tension pneumothorax
 Pump failure from severe myocardial injury
or pericardial tamponade
7
Thoracic Cage
 A skeletal protection to many organs
 Lungs
 Heart
 Great vessels
 Spinal cord
 Liver
 Stomach
 Spleen
 Pancreas
 Kidneys
 Transverse colon
 Trauma to the protective rib cage may also
cause some injuries
8
Diaphragm
 Position: lies at the level following the curve of
the lower 6 ribs and connected to the xyphoid
process
 Main function: respirations
 Descends/flattens on inspiration
 Rises on exhalation
 Innervation: phrenic nerve which begins C3 to
C5 level
 Injury above C3 patient unable to breathe
 Injury below C5 patient can still initiate breathes
9
Diaphragm
10
Diaphragm – A Moving Target
 Palpate and place your finger tips at the lower
edge of your rib cage
 Keep your fingers in contact with your skin
 Take a deep breath
 Feel your rib cage flare out
 Diaphragm drawn downward moving lungs and
abdominal organs downward to accommodate lung
expansion
 Now exhale
 Feel your rib cage decrease in size
 Your diaphragm rises as lung capacity decreases
11
Anatomy – Chest Contents
 Contents above the diaphragm
Lungs
Lower trachea
Main stem bronchi
Heart and great vessels
Esophagus
 These organs sit above the diaphragm
12
Anatomy – Chest Contents
 Contents in the lower chest cavity in upper
abdominal region
Stomach
Spleen
Liver
Kidneys
Pancreas
 These organs are separated from the
upper chest by the diaphragm
 If diaphragm ruptures, abdominal organs
can migrate into chest cavity
13
Is the injury thoracic or
abdominal???
 Trauma below
the nipples (T4 or
4th intercostal
space (ICS) can
cause both
intrathoracic and
intra-abdominal
injuries
14
Did you know???
 The adult thoracic cavity can hold up to
3 L of blood for each side
 What is the average adult blood volume?
 5.5 – 6.5 liters (or quarts)
 1 liter = 1 quart
 Approximately 1.3 gallons
 Formula: 0.07 x weight in kg=liters of blood
 Ex: adult 0.07 x 80kg = 5.6 L
 Ex: newborn 0.07 x 3kg = 0.2 L (200ml)
15
Pleural Space
 A small area between 2 layers of pleura
 Normally filled with minimal fluid
 Can potentially expand if filled with air or
blood
 Expansion is at the sacrifice of other organs in
the area
 Visceral pleura
 Directly lines lungs
 Parietal pleura
 Inner lining of the chest wall
16
Mediastinum
 Midline area of the thoracic cavity
 Contains
Heart
Aorta and pulmonary artery
Superior and inferior vena cavas
Trachea
Major bronchi
Esophagus
17
Mechanisms of Injury
 Thoracic cage injuries can result from a
variety of sources
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MVC
Motorcycle incidents
Falls
Crush
Blunt
Penetrating – firearms, knives
18
MOI
 Blunt trauma
 Injuries more predictable
 Penetrating injuries
 Unpredictable organ injury
 Path of destruction can vary widely
19
Major Signs/Symptoms of Chest
Injuries
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Shortness of breath
Chest pain
Contusions
Open wounds
Sub Q emphysema
Hemoptysis
Distended neck veins
Tracheal deviation

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Cyanosis
Shock
Tenderness
Instability
Crepitation
Altered breath sounds
Asymmetrical chest
movement including
paradoxical motion
20
Patient Assessment
 Starts with scene size-up – safety a concern
 Primary assessment performed
Remember: ABC assessment repeated any time
there is a change in patient condition
 Moves into history taking with secondary
assessment
 EMS patients rarely have just one isolated
injury with traumatic MOI
 Signs and symptoms blur when injuries are
mixed together
21
Airway Obstruction
 Results in hypoxia
 Tissue insult occurs quickly
 Once cells die, they are gone
 Primary assessment starts with the
question:
 Is the airway open and do I need to
apply manual c-spine control???
 If the airway is not open, what do I need
to do to open it???
22
Opening a Blocked Airway
 If traumatic injury is suspected
Modified jaw thrust
 In absence of trauma
Head tilt/chin lift
 Are secretions present?
Limit suctioning generally to <10 seconds
 Are adjuncts required?
Is there a gag reflex?
 If necessary, stroke eyelashes to check for blink
reflex- if absent, then gag reflex is absent
23
Airway Maneuvers
 Modified jaw thrust
 Used in presence
of suspected or
known trauma
 Head tilt/chin lift
 Used when no
trauma suspected
24
Interventions for Obstructed
Airways Used by EMS
 Cricothyroid membrane - Need to know
landmarks now – patient can’t wait for you to look
them up!
25
QuickTrach
 Device sized for
adult (4.0 mm) or
peds (2.0 mm)
 Kit contains items
noted to the right
 Need to add skin
prep material and
BVM
26
Adjuncts for Obstructed Airway
 QuickTrach – emergency cricothyrotomy
 1 person assembles equipment
 1 person locates and palpates cricothyroid
membrane
 Runs finger up from sternal notch
 Cricoid cartilage first rigid ring palpated
 Membrane is above the cricoid cartilage
 Skin prepped
 Needle inserted at 90 degree angle
 Air aspirated to confirm needle entry into trachea
27
Quicktrach cont’d
 Angle of insertion changed to 600 sliding catheter
sheath forward until red stopper is flush with skin
 Red stopper removed
 Needle & syringe held firmly and plastic cannula
slid forward til hub of catheter snug to skin
 Needle and syringe removed
 Patient ventilated via BVM – equipment held
securely
 Placement assessed – BS, chest rise & fall
 Catheter secured with ties provided
28
Needle Cricothyrotomy
 Provides emergency access to an
otherwise blocked airway
29
Needle Cricothyrotomy
 Cricothyroid membrane located
 Site prepped
 Large gauge catheter with syringe attached


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


inserted into trachea – midline 450 angle
Aspiration of air with syringe confirms placement
Catheter advanced while withdrawing stylet
3.0 mm ETT hub attached to needle
Ventilated with BVM via the 3.0 mm ETT hub
Assessed for BS and chest rise
Catheter secured
Note: Will need to allow extra time for exhalation
30
Flail Chest
 Fracture of 3 or more (2 or more in some
sources) adjacent ribs in 2 or more places each
 Section becomes free floating
 Be suspicious for the presence of pulmonary
contusions
 It takes tremendous force to break that many ribs
 Organs under the rib cage most likely traumatized
 Compromise to normal diffusion of O2 and CO2 is
usually present
 Flail chest does NOT automatically equal the
presence of a tension pneumothorax
31
Flail Chest
 Can be suspicious of condition during the
primary assessment
 Patient states “I can’t breathe”
 The rib fractures cause significant pain as the
patient tries to take any breaths
 Patient is anxious
 May see paradoxical motion on visual
inspection
 This is often a later sign due to initial
splinting
32
Flail Chest and Primary
Assessment
 Primary assessment DOES NOT stop
 Note made to go back to address why there is
respiratory distress
 Remember: the only 2 times to interrupt a
primary assessment is to (1) correct an
obstructed/closed airway or to (2) control
major hemorrhage
33
Flail Chest
 Tremendous force
to fracture this
many ribs
 Notice how lateral
the clavicular
midline really is!!!
 Landmark
essential IF patient
develops a tension
pneumothorax
34
Flail Chest Key Signs /Symptoms
 Paradoxical motion on visual inspection
 Potential bruising or other marks on chest
wall
 Crepitation and tenderness on palpation
 Decreased breath sound depending on
degree of injury, splinting and presence of
pneumothorax
35
Flail Chest
36
Flail Chest Treatment
 Supplemental oxygen therapy
 Non-rebreather O2 if intubation not needed
 Cardiac monitoring
 Potential high for cardiac contusion
 Stabilizing the chest wall is controversial
 Chest wall no longer taped for support
 Providing positive pressure ventilation (i.e.:
intubation on a ventilator) is the preferred
method of support which can be done in the
ED if not necessary in the field)
37
Open/Sucking Chest Wound
 Air allowed to enter the thoracic space due
to an opening in the chest wall
 Results from penetrating trauma
 Air drawn into pleural space
 Air will enter via the largest opening
 The hole created in the chest wall versus the
glottic opening
 Air entering the pleural space does not reach
the alveoli
38
Open/Sucking Chest Wound
 Visual inspection reveals a wound
 May hear a sucking or bubbling sound
 May feel subcutaneous emphysema
around the area
 Lightly palpate the area and feel a crackling
sensation under your finger tips
 Noticed skin “puffed up”
39
Open/Sucking Chest Wound
 Immediate treatment as soon as the
wound is found is to cover the wound with
a gloved hand
 Then place an occlusive dressing over the
site
 Secure occlusive dressing on 3 sides
 Leaves a means of escape of air on the 4th
side to avoid the potential of converting the
injury to a tension pneumothorax
 If wound is large, try defib pad over wound
40
Open/Sucking Chest Wound
 Question
 If the patient develops a tension
pneumothorax after a sucking chest wound is
sealed with an occlusive dressing, do you
need to perform a needle decompression?
 NO!!! – not usually
 There is already a BIG hole in the chest wall that
air can escape from
 Just lift a corner of the dressing during exhalation
for air to escape
 If there is no improvement, you might have to
decompress with a needle
41
You Evaluate…
 What’s right?
 Wound immediately
covered with hand
 What’s wrong?
 The care provider has no
gloves on
42
Tension Pneumothorax
 A pneumothorax that generates and
maintains pressures greater than
atmospheric pressure in the thorax
 A one way valve is created and air flows into
the pleural space and cannot escape
 Most often associated with a traumatic
event but can be spontaneous
 Can be a complication of treatment of an
open/sucking chest wound
43
Tension Pneumothorax –
Cascade of Events
A
 Air enters pleural space
  intrapleural pressure collapses lung, intercostal





bulging occurs, pressure exerted against
mediastinum
Uninjured lung becomes compressed
Vena cava compression  venous return
Cardiac output (CO)  causing  pulse;  B/P
JVD present, narrowed pulse pressure
Tracheal shift is a late but rare sign (hard to view)
44
X-ray - Tension Pneumothorax
 What’s wrong with this
x-ray?
 It should never have
been taken!
 Diagnosis is clinical
 Arrow points to
completely collapsed
lung
 Dark filled images
indicate air filled
spaces
 Note tracheal shift to
the right
45
Tension Pneumothorax
 Typical signs and symptoms

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Severe dyspnea
Hyperinflation of affected side
Diminished, then absent breath sound
Hyperresonance of affected side
Diaphoresis
Cyanosis
JVD
Tachycardia
Altered mental status
Eventual hypotension
46
Simple
Pneumothorax
 There is a difference
 These patient DO NOT require needle
decompression
 May not even auscultate decreased breath
sounds if collapse is small
 There is a clinical difference in presentation
(i.e.: vital signs) from a simple to a tension
pneumothorax
47
Jugular Vein Distention - JVD
 JVD present when venous pressures are high
and blood cannot easily drain into the right
atrium
 Typically seen with tension pneumothorax, cardiac
tamponade, right sided heart failure and volume
overload
 Most appropriately measured with patient sitting
at 450 angle and evaluating right side of neck
 May not be possible with traumatic injury to  HOB
 Note: Lack of JVD in supine position with
physical findings may indicate hypovolemic
shock
48
JVD
 Jugular vein is prominent if distended at a
point slightly higher than 1 inch above right
clavicle
49
Tension Pneumothorax Treatment
 Rapid recognition is key!!!
 Severe dyspnea
 Distinct signs and symptoms
 Needle decompression to relieve
intrapleural pressures
 Administer supplemental O2 via NRB
 Equipment
 Longest and largest needle you have – 3 inch
long and 12-14 gauge
 Skin prep material
50
Needle Decompression Landmarks
 Finding
the Angle
of Louis is
an easier
landmark
than
counting
down rib
spaces
Angle of Louis
2nd ICS
51
Tension Pneumothorax Treatment
 Needle decompression
 Identify 2nd intercostal space (ICS)
 Find Angle of Louis
 Hang a Louis and slide into the 2nd ICS
 From Angle of Louis, slide finger tips
toward armpit crease OR
 Palpate down from MIDDLE of clavicle to
2nd ICS
 Middle of clavicle more lateral than most
people identify; is male nipple line
 Insert needle over top of rib
52
Landmarks for Needle Decompression
If needle placed too low and
too close to sternum, tip may
end up placed in the heart
53
Needle Decompression
 Goal of needle decompression:
 Provide a “relief valve” for air under tension
 Do NOT need to make a flutter valve on
needle
 Air will enter the path of least resistance
(i.e.: the larger pathway)
 Diameter of trachea larger than a 14 G needle
so air will enter via trachea into the lungs and
not through a 14G needle into the pleural
space
54
You Evaluate…
 What’s wrong?
 Too medial
 Too low, tip may be
in the heart
 Needle should have
been here
X
 What’s right?
 Catheter secured
55
Pericardial/Cardiac Tamponade
 Blood or fluid fills the pericardial sac
surrounding the heart
 Sac does not expand but compresses into the
heart limiting flow into the heart
 Penetrating trauma most frequent MOI
 High mortality rate due to potential for
rapid hemorrhage
56
Pericardial/Cardiac Tamponade

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Agitation
Tachycardia
Diaphoretic
 pulse strength & rate
Muffled heart tones
Beck’s triad (next slide)
Pulsus paradoxus
 Systolic B/P drops by 10 mmHg on inspiration
 Pulsus alternans
 Alteration between strong and weak pulses
 PEA
57
Beck’s Triad
 Indicative of pericardial tamponade
(IF present)
 This may be a LATE sign!
 A grouping of 3 clinical signs
JVD
Muffled/distant heart tones
Hypotension
58
Pericardial/Cardiac Tamponade
 It takes as little as 150-300 ml to exert pressure
to impede contractile function on the heart
 Removing as little as 20 ml may improve the
contractile force to improve the patient’s condition
 EMS goal: RAPID IDENTIFICATION
 Then rapid transport
 There won’t be much intervention in the field
that will save the patient’s life; they rapid
need transport
59
Aortic Tear
 Most commonly from blunt trauma
 MOI usually high speed MVC - especially
lateral impact - and falls from great heights
 High mortality rate – 85 - 95%
 GOAL:
 Rapid recognition of those patients that
survive the initial impact
 Transportation to a Level I trauma center (if
within 25 minutes of transport)
60
Aortic Tear
 Aorta fixed at 3 points in the thoracic
cavity
 Shearing forces can separate the arterial
layers of this large, high-pressured vessel
 Due to high pressures, aortic lining becomes
a false space
 Rupture can occur without surgical repair
 Death from rupture is usually quick;
dissection progresses more slowly
61
Aortic Tear
 Most commonly tear
just past the arch of
the aorta
 Less often at aortic
root (annulus) where
the aorta joins the
heart and the area
where aorta exits the
chest at the
diaphragm
62
Aortic Tear
 Typically patient complains of a severe
tearing chest pain
 Pain may radiate to the back
 Reduced pulse strength in lower extremities
 Mark pulse spots if palpated
 Pulse deficit between left & right upper
extremities
 If suspected, palpate to compare both radial
pulses
63
NEW!!! Permissive Hypotension in
Trauma
 Restrictive fluid therapy new concept
 At least until hemorrhage is controlled
 Highly suggested for aortic problems
 Not recommended in the patient without a pulse
 Aggressive fluid replacement tends to increase
total volume of blood loss
 EMS may call Medical Control for guidelines if
they feel patient may benefit from restricted fluid
resuscitation
 May order trendelenberg positioning
64
Region X SOP’s - Fluid Challenge
 Fluid given in 200 ml INCREMENTS
 You assess as you go
 For medical calls patient more likely will tolerate and
need the 20 ml/kg replacement formula
 Every body holds a different amount of blood
volume
 Adult average 5.2 – 6 liters (5.5 – 6.5 quarts or 10-12
pints)
 FYI - Average blood donation is 450 ml
 This is less than 1 pint
 Child average 2 liters
 Infant average is 85 ml/kg or <300 ml
65
Blood Volume by Age
 Do not judge the significance of the
volume you see lying in a pool until you
know whose blood it is
66
How Low Can You Go?
 Classes of shock




Class I - <15% (<750 in the adult)
Class II – 15-30% (750 – 1500ml in the adult)
Class III – 30-40% (1500-2000ml in the adult)
Class IV - >40% (>2000ml in the adult)
 Compensated shock in Class I & II
 Decompensated shock by Class III
 Blood pressure falling is the key
 Blood pressure falling is also a LATE sign
67
Complications Related to Traumatic
Injuries
 Goal – Do no further harm
 Sometimes, doing our best just isn’t
enough
 Secondary injuries may develop based on
what we do or don’t do at first patient
contact
 It’s simple – do the right thing at the right
time and document accurately
68
Complications: Crush Injuries
 Traumatic insults of severe compressive
forces
 Crush injury – an injury compressing a body part
 If short duration, local injury confined to injured part
 Crush syndrome – systemic effects of
entrapment if entrapment longer than 4 hours
 A potentially life-threatening event
 Limitation of effective & healthy circulation
 Think cave-in’s, equipment entrapment
69
Crush Syndrome
 Pressure remains imposed for long period
of time (usually >4 hours)
 Traumatic rhabdomyolysis develops
 Crushed skeletal muscle disintegrates
 Release of metabolic by-products restricted to
the compressed area for as long as area
remains compressed
 Myoglobin – a muscle protein
 Phosphate & potassium (K+) – from cell death
 Lactic acid – from anaerobic metabolism
70
Crush Syndrome
 When pressure released, metabolic
by-products enter the central circulation
 Cause severe metabolic acidosis
 Toxic to heart and kidneys
 Myoglobin plugs kidney’s filtering system
 Sodium, chloride and water flood into
damaged tissue creating hypovolemia
 Hyperkalemia reduces cardiac muscle
response to electrical stimuli  dysrhythmias
 Aerobic process resumed producing more uric
acid increasing cellular acidity and injury
71
EMS/Field Care of Crush Injuries
 Potential patient needs to be identified prior
to extrication
 Scene safety is the fist priority
 Goal of EMS:




Rapid transport
Adequate fluid resuscitation
Diuresis – keep kidneys flushed and working
Possibly systemic alkalinization
 Corrects acidosis, hyperkalemia, prevents renal failure
 Hospital may need to send a team with meds like
72
sodium bicarbonate
EMS Care cont’d
 Cardiac monitoring
 Influence of potassium and lactate traveling to
heart may cause dysrhythmias
 Tenting or peaking of T wave
 Prolonged PR interval
 ST segment depression
 Widening QRS (high levels of K+)
 Note: Cardiac monitor should be applied prior
to releasing the crushed area from entrapment
 Rapid onset of shock after release from
entrapment may develop
73
Tall, Peaked T wave
 Indicates excess potassium circulating in the
bloodstream
 Normal potassium levels 3.5 – 5 meq/L
 Hyperkalemia (>5.5 meq/L) is a cardiac irritant
74
Compartment Syndrome
 Complication most commonly associated with
closed injuries to the extremities
Think of the patient who has fallen and is in
one position for a period of time before a wellbeing check finds them
 Major muscle groups contained in compartments
 Swelling of muscles will impede blood flow to
nerves, blood vessels and other structures
 Most common site are lower extremities
75
Compartment Syndrome
 Six P’s

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



Pain out of proportion – key finding!!!
Pallor
Paralysis
Paresthesia – pins & needles tingling
Pressure – feeling tension in extremity
Pulses – diminished or absent
 Signs & symptoms not dependable
76
Compartment Syndrome
 Difficult to assess
 Motor and sensory usually intact
 Distal pulses often present
 Capillary refill with little to no change
 More likely to develop beyond 6-8 hours
post-injury or even later
 Key: patient complaining of pain out of
proportion
 Don’t assume they are a wimp
77
EMS/Field Care of Compartment
Syndrome
 Maintain high index of suspicion
 Elevation single most important tool for EMS
 Reduces edema
 Increases venous return
 Lowers compartment pressure
 Helps prevent ischemia
 Cold pack applied to severe contusions
 Hospital care includes measuring pressures
 Normal pressure near zero
 Pressure >30mmHg restricts capillary flow
 Irreversible ischemic changes after 10 hours
78
Hospital Intervention Compartment
Syndrome
 Fasciotomy is surgical intervention to open
fascia to allow for swelling without restrictive
pressures
 When pressures go down, patient taken back
to surgery to close the wound left open
79
Transport Criteria
 Highest level Trauma Center within 25 minutes
 Unstable per vital signs
 Anatomy of injury – life threatening injury
 Closest Trauma Center
 Based on mechanism of injury with higher potential for
traumatic injury or traumatic arrest
 Patient is stable
 Patient may have co-morbidity increasing their risk level
with the insult
 Closest appropriate comprehensive ED
 Do not meet any of the above criteria or EMS unable to
80
establish an airway
Case Scenarios
 Review the following cases
 What is your general impression?
 Review steps of the primary assessment
 Is there a life threatening condition?
 What are appropriate EMS interventions
and when are they performed?
 Where does this patient get transported to?
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Case Scenario #1
 EMS responds to a call
for MVC – 2 vehicles
 One patient is a 16 y/o
female restrained
driver hit head-on
approximately 45 mph
by a Suburban
 This is seen as EMS
approaches the scene
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Case Scenario #1
 + seatbelt
 Airbag deployed
 Small staring at base of windshield
 Driver’s side window shattered; unable to
open door
 A & O x3; hysterical teenager
 Active bleeding from nose
 Multiple lacerations to face and extremities
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Case Scenario #1
 Primary assessment





Mental – Patient awake, A & O x3, hysterical
Airway – open
C-spine – manual control taken
Breathing – rapid, without effort
Circulation – bleeding from nose; pulse rapid and
regular
 Life threats identified?
 None
 So EMS keeps moving on the survey and keeps
looking for injuries
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Case Scenario #1
 If this patient had chest injuries, what clues
would indicate:
 Flail chest
Multiple rib fractures found on palpation
Pain with breathing
 Pneumothorax
Pain with breathing
Decreased or absent breath sounds
 Tension pneumothorax
Agitation, tachycardia, hypotension, absent BS
85
Case Scenario #1 – EMS Care –
What Intervention Would Be Done?
 Flail chest
 Supplemental O2
 BVM for positive pressure ventilation if severe
 Pneumothorax
 Supplemental O2
 Observed for development of tension pneumothorax
 Tension pneumothorax
 Needle decompression 2nd ICS
 Needle placed above the rib
 Avoids nerves and blood vessels that run on inferior surface
86
Scenario #2
 EMS has been called to the scene of a MVC
 No witnesses
 Passer-by noticed MVC and called it in
 Patient has an altered level of consciousness
 What are the components of a primary
assessment?
 Mental status
 ABC’s with c-spine
 Identification of life threats
 These can be applied to the walk-in to the ED!
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Scenario #2
 The scene is safe
 The patient is in




the red car
They are looking
around upon your
arrival
They do not follow
commands
They are confused
Immediate control of the c-spine is taken
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Scenario #2
 Patient is wearing a seat belt
 Witnesses state the patient did not slow down
but just ran into the car in front of them
 Airway – open
 Breathing – rapid, regular
 Circulation – clammy, pale, pulse regular
and fast
 No obvious bleeding
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Scenario #2
 No life threats are found
 Why would the patient be confused???
 Head injury?
 Alcohol, drugs?
 Hypoglycemia?
 Blood sugar checked – 35
 Treatment indicated?
 IV access established
 D50 administered
90
Scenario #2
 IV infiltrates while pushing D50
 Now what???




Infusion stopped
IV line D/C’d
Event documented
Verbal report given to ED
91
Extravasation of IVP Dextrose
 Carefully monitor the site as medication is
given IVP
92
Case Scenario #3
 Female driver in small car had tree fall on
her car during a rain storm
 Patient impaled with branch of tree
 Are these chest or abdominal wounds?
 Could be both
depending on
inhalation or
exhalation at time of
injury and path of FB
93
Case Scenario #3
 How does EMS care for the open wound
in the field?
 Moist sterile saline dressing over the open
tissue
 Covered with dry
dressings
 Avoid poking anything
into the wound
 Observe for
evisceration
94
Case Scenario #3 – Pain
Management per Region X SOP
 Fentanyl 0.5 mcg/kg IVP/IN/IO
 May repeat in 5 minutes with same dose
 Max total 200 mcg
 Same formula for adult and peds
 Less cardiovascular changes than
morphine
 Less nausea from the medication
 As a synthetic narcotic, still watch for
respiratory depression
95
Case Scenario #3
 Tree branch removed from patient
96
Case Scenario
#4
 Patient fell onto bicycle
 Patient agitated,
complains of inability to breath
  breath sounds unilaterally
 Patient is dyspneic, tachycardiac,
becoming cyanotic, with JVD increasing
 Blood pressure falling (radial pulse harder
to palpate)
 What’s your impression?
 Tension pneumothorax
97
Case Scenario #4
 What intervention is necessary?
 Immediate needle decompression
 What are the landmarks?
 2nd ICS
 Midclavicular line
 Stay more lateral than you think
98
Needle Decompression
 2nd ICS, midclavicular
line – “X” marks the
spot
 When needle
inserted, listen for
hiss of released air
 Should have
immediate
improvement in
patient
X
99
Steps for Needle
Decompression
 Find the Angle of Louis
 Fingers slid toward the armpit
crease
 Stop at the midpoint of the
clavicle
 This is in-line (vertical) with the male nipple
 The male nipple horizontally lies in the 4th ICS
 Needle inserted above the rib, advance and
begin to separate needle from catheter
 Secure in place
100
Needle Decompression
 Needle inserted above the rib
 Avoids puncturing the vessels or nerves
 Takes time for lungs to
re-expand
 Do not expect
instantaneous breath
sounds to reappear
101
Bibliography
 Region X Advanced Life Support Standard Operating






Procedures February 1, 2012
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices Fourth Edition. Brady. 2013.
Campbell, J. International Trauma Life Support for
Emergency Care Providers. 7th edition. Pearson. 2012.
Caroline, N., Emergency Care in the Streets. 7th Edition.
AAOS. 2013.
Limmer, D., O’Keefe, M. Emergency Care 12th Edition.
Brady. 2012.
http://en.wikipedia.org/wiki/Beck's_triad_(cardiology)
http://docpods.com/compartment-syndrome-in-the-lowerleg
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