Transcript Document

First Responder Workshop
2010
Jim Holliman, M.D., F.A.C.E.P.
Program Manager, Afghanistan Healthcare Sector
Reconstruction Project
Center for Disaster and Humanitarian Assistance
Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland, U.S.A.
Goals of This Workshop
Using
a case - based format for 20 of the
common types of cases seen by first
responders :
Present critical actions that should be
done for each case
Review pitfalls to avoid on each case
Have a two - way discussion of other
aspects of each case
Cases to be Presented in this
Workshop
Cardiac
arrest
Burns
Electrocution
Chest
pain
Stroke
Dyspnea
Insecticide poisoning
Medication overdose
Multiple trauma
Pediatric trauma
Precipitous
Heat
childbirth
illness
Acute psychosis
Obvious fatality
Snakebite
Coma
Shock
Near-drowning
Allergic reaction
Seizure
Case 1
Cardiac Arrest
65
year old male
Family called because he had chest pain
Lying in bed in home
Apneic, cyanotic, no pulse
Has history of "heart problems" and
"colon cancer 12 years ago" according to
the family
Cardiac Arrest
Critical Actions
Verify
presence of cardiac arrest
Quickly start CPR
Find out quickly if the patient has a "Do not
attempt resuscitation status" certified by their
doctor
Move quickly to ambulance
Contact advanced medical help (doctor or
ambulance with defibrillator if available)
Rapid transport to closest hospital
Cardiac Arrest
Pitfalls to Avoid
Not
checking the resuscitation status of the
patient
Taking a detailed history before starting
resuscitation efforts
Not considering hypothermia
Not checking for signs of injury
Not notifying the receiving medical facility as
early as possible
Expecting a high success rate
Case 2
Burns
28
year old male
Was cleaning motor with gasoline when it
exploded
The table and curtain in the room also caught
fire ; the room is smoky
Second and third degree burns of face, neck,
chest, and arms
Awake and alert but coughing frequently
Pulse 120, resps. 20, BP 136 / 88
Burns
Critical Actions
Protect
yourself if the fire is still burning
Remove patient from smoky environment quickly
Airway / breathing / circulation ("ABC") assessment
Get all burned clothes off the patient
Cover with clean dry sheets
Start oxygen if any potential airway problem or smoke
inhalation
Copious irrigation with water if a chemical burn
Rapid transport to appropriate hospital
Burns
Pitfalls to Avoid
Not
removing all potentially smoldering clothes
& stopping the burning process
Continued soaking of a large burn area thus
making the patient hypothermic
Mis-estimating the extent of the burn
Not recognizing the potential for airway
compromise
Not recognizing other associated traumatic
injuries
Case 3
Electrocution
24
year old male
Was working on a roof 4 meters high when he touched
an overhead electric power line, was shocked, and fell
off the roof
Was initially unconscious, now is awake but confused
Has entrance burns on one hand and his sandals are
smoldering
Complains of limb and back pain
Pulse 96, resps. 20, BP 94 / 64
Electrocution
Critical Actions
Turn
off the electric power or push the patient off
the electric source with an object that does not
conduct electricity
ABC assessment
Determine if high voltage (> 1000 volts)
Assess for other associated injuries
Rapid transport to hospital (may require very large
amounts of intravenous fluid)
Fairly good chance of success even if prolonged
CPR required
Electrocution
Pitfalls to Avoid
Not
checking for associated trauma such as
spinal injury, joint dislocations, etc., and not
performing appropriate spinal
immobilization or splinting
Not appreciating that there may be large
amounts of muscle damage beneath
unburned skin
Not checking for exit wounds
Case 4
Chest Pain
48
year old female
Complains of anterior chest pain with radiation to
the neck for 2 hours
No previous history of heart disease
Awake and alert, diaphoretic
Also complains of shortness of breath
No allergies
Husband is reluctant for her to go to hospital
Pulse 76, resps. 20, BP 130 / 90
Chest Pain
Critical Actions
Assume
a life - threatening cause is present until
definitively proven otherwise
ABC assessment
Start oxygen if available
Give an aspirin (80 to 500 milligrams) if not allergic to
aspirin or nonsteroidals, and cardiac ischemia is
suspected
Rapid transport to a hospital with cardiology
capabilities
Chest Pain
Pitfalls to Avoid
Not
suspecting cardiac ischemia in younger or
female patients
Not considering cardiac ischemia in elderly patients
with vague symptoms (remember many elderly
patients with acute myocardial infarction will NOT
have chest pain)
Taking the patient to a medical facility that does not
have advanced cardiac care
Not starting oxygen or giving aspirin
Case 5
Stroke
60
year old male
Suddenly developed weaknes of the left side
and "garbled speech" according to the
family 30 minutes ago
The family does not know what medicines
he takes
He is sleepy but arousable, and his speech
is difficult to understand
Pulse 55, resps. 14, BP 190 / 116
Stroke
Critical Actions
ABC
assessment, may need airway management if
level of consciousness is depressed
Check fingerstick blood sugar
Check pulse oximetry if available
Start oxygen if available
Determine time of onset of symptoms
Rapid transport to a hospital with a computed
tomography scanner
Repeat the neurological exam at frequent intervals
Stroke
Pitfalls to Avoid
Not
checking for hypoxia or hypoglycemia early
Not protecting the patient's airway if they have a
depressed level of consciousness
Not checking for associated injury (the patient may
fall down from sudden weakness)
Overtreating elevated blood pressure
Not repeating the neurologic exam to see if there is
worsening or improvement of the patient's
symptoms and signs
Case 6
Dyspnea
44
year old male
Long history of smoking cigarettes
Also history of asthma and pneumonia
No allergies
Uses salbutamol inhaler as needed
Complains of progressive shortness of breath and
frequent cough for the past several days ; no
chest pain
Pulse is 112, resp. rate 32, BP 155 / 100
Dyspnea
Critical Actions
ABC
assessment ; check and record pulse oximetry
if available
Start oxygen
If the patient is wheezing, have him use his metered
dose inhaler meds if available (this is safe even if
the dyspnea has a cardiac cause)
If not hypotensive, don't force the patient to lie flat
Rapid transport to an appropriate medical facility
Dyspnea
Pitfalls to Avoid
Not
starting oxygen for fear of
"suppressing respiratory drive"
Not considering a cardiac cause
Dismissing hyperventilation as just due to
anxiety
Not providing aggressive airway
management for patients with a depressed
mental status
Case 7
Insecticide (Organophosphate) Poisoning
30
year old female
Ingested liquid insecticide in a suicide
attempt
Actively vomiting, diaphoretic, drooling,
complaining of shortness of breath
Vomitus all over the patient's clothes
Pulse 90, resp. rate 36, BP 100 / 60
Insecticide Poisoning
Critical Actions
Protect
yourself ; remember the patient's clothes may be
contaminated and all the patient's body fluids (sputum,
emesis, etc.) may contain the insecticide ; use universal
precautions
Make sure the ambulance is well ventilated (to prevent
your exposure to "off-gassing")
ABC assessment ; start oxygen
Remove all the patient's clothes and footwear and bag
these in plastic ; decontaminate the skin by irrigation with
water if the skin was exposed to powder or liquid
Rapid transport to appropriate medical facility
Insecticide Poisoning
Pitfalls to Avoid
Getting
yourself poisoned by skin exposure to
contaminated clothes or vomitus or breathing offgassed vapors
Failing to decontaminate the patient prior to
entering the ambulance
Not assessing for other exposures or ingestants
Not providing supportive care (oxygen, suction of
airway secretions, etc.)
Not properly disposing of contaminated clothes or
footwear
Case 8
Medication Overdose
18
year old female
History of depression and prior suicide
attempts
Taking several antidepressant meds but
family does not know the names
Took "a large number" of multiple pills
about one hour ago
Now drowsy but arousable
Pulse 120, resp. rate 14, BP 104 / 55
Medication Overdose
Critical Actions
ABC
assessment
Try to identify what meds and how many the
patient took and the time of ingestion ; collect all
pill bottles in the home and bring these to the
hospital
Monitor the patient closely ; sudden deterioration
may occur
Try to determine if the ingestion was accidental or
suicidal
Medication Overdose
Pitfalls to Avoid
Trying
to make the patient vomit (just predisposes
to aspiration)
Not identifying all co-ingestants
Not preventing the patient from accessing other
items to use in another suicide attempt ; not
closely monitoring the patient at all times
Not evaluating the airway or providing oxygen if
the patient has a depressed mental status
Case 9
Multiple Trauma
30
year old male truck driver
Truck ran off road at high speed and rolled over
Patient was thrown 5 meters from the vehicle
Unconscious, several scalp lacerations actively
bleeding, abrasions over chest and abdomen,
deformity of left thigh and ankle
Pulse 130, resp. rate 8, BP 80 / 40
Multiple Trauma
Critical Actions
If
motor vehicle crash, assess scene for rescuer
safety (is there need for water or foam to cover
spilled gasoline or hot engine, etc.)
ABC assessment ; start oxygen
Control external bleeding with direct pressure
Immobilize spine and apply limb splints
Limit on-scene time as much as possible
Make sure someone checks the scene for other
"hidden" victims
Rapid transport to trauma center
Multiple Trauma
Pitfalls to Avoid
Not
prioritizing the "ABC's"
Being inefficient and taking too much time at the
scene ; performing actions at the scene that could
wait until the patient is in the ambulance
Not having someone search the scene for other
victims
Not notifying the receiving medical facility early
Not taking measures to prevent hypothermia
Not frequently reassessing the patient
Case 10
Pediatric Trauma
5
year old male
Walking across road and hit by car at high speed
Thrown 6 meters by the impact
Reported initial loss of consciousness
Now sceaming
Bleeding lacerations of scalp, right arm, and left
flank, deformity left thigh
Pulse 145, resp. rate 28, BP 94 / 56
Pediatric Trauma
Critical Actions
Scene
safety and ABC assessment ; oxygen
Stop external bleeding with direct pressure
dressings
Try to notify the parents if they are not at the scene
and find out the patient's medical history, allergies,
and current meds
Limit on-scene time as much as possible however
Reassure
and try to verbally calm the child
Rapid transport to (pediatric) trauma center
Pediatric Trauma
Pitfalls to Avoid
Not
prioritizing the "ABC's"
Focusing on one obvious injury and not performing
a complete assessment
Not taking measures to prevent hypothermia
Not providing reassurance to the child
Using terminology the child does not understand
Taking the child to a facility not capable of pediatric
care
Case 11
Precipitous Childbirth
30
year old female
5 prior pregnancies with vaginal deliveries
Started having strong contractions 2 hours ago,
now every 2 minutes
"Water broke" one hour ago
Pulse 110, resp. rate 24, BP 110 / 60
Now says she feels as if she must use the toilet
Precipitous Childbirth
Critical Actions
ABC
assessment
Start oxygen if possible fetal distress (prolapsed
cord, breech crowning, etc.)
Position mother so if baby is suddenly delivered,
the baby will not fall or be injured
Don't insert anything in the vagina (could stir up
bleeding)
Expose the perineum if any possibility of
crowning
Rapid transport to obstetric facility
Precipitous Childbirth
Pitfalls to Avoid
Not
safely positioning the mother
Not recognizing urge to void or defecate as a
sign of imminent delivery
Not starting oxygen if any possibility of fetal
distress
Not providing reassurance to the mother and
family
Not notifying the receiving facility early
Case 12
Heat Illness
68
year old male
Found unconscious in very hot poorly ventilated
upstairs room in an apartment buliding
Outside air temperature > 40 degrees Centigrade for
the past 5 days
Responds only to painful stimuli
Skin dry and very warm
Pulse 112, Resps. 22, BP 90 / 60
Heat Illness
Critical Actions
Recognition
ABC
assessment
Measure temperature if thermometer available
Check fingerstick blood sugar if abnormal mental
status
Start cooling measures early
Scalp, axillary, and groin ice packs
Water mist and fan
Try to avoid causing shivering
Rapid
transport to medical facility
Heat Illness
Pitfalls to Avoid
Attributing
altered mental status from hyperthermia
to something else such as alcohol intoxication
Not starting cooling measures as part of initial
resuscitation
Excessive fluid treatment for classic heatstroke
Not anticipating multiorgan dysfunction
Causing excess shivering from cooling measures
(shivering may make the patient's temperature go
even higher)
Case 13
Acute Psychosis
32
year old male
Found running in circles in the street
Yelling loudly "the spiders are after me ! "
Previous history of "psychiatric problems"
No allergies according to family
Stopped taking his haloperidol recently
Pulse 120, Resps. 24, BP 160 / 100
Acute Psychosis
Critical Actions
Protect
yourself from injury if the patient is
potentially combative
ABC assessment
May require physical restraints for both patient safety
and rescuer safety
Check for hypoxia and hypoglycemia
Determine
if alcohol or illicit drug ingestion may be
contributing
Make sure the patient is not hyperthermic (this can
accompany amphetamine or cocaine use)
Acute Psychosis
Pitfalls to Avoid
Not
assessing for "reversible" or medical causes of
the psychosis
Not restraining the patient safely
Safest approach to the combative patient is to wait
until 4 or 5 first responders are available before
closely approaching the patient
Trying
to verbally reason with the patient
Not searching the restrained patient for weapons
Case 14
Obvious Fatality
85
year old male
Last seen by family over 12 hours ago
Found by family unresponsive in bed
History of metastatic cancer and
advanced cardiac disease
No pulse or resps.
Dependent lividity noted
Obvious Fatality
Critical Actions
Don't
start any resuscitation if death criteria clearly
present (dependent lividity, rigor mortis, initial
decomposition, major dismemberment or open head
injury incompatible with life, etc.)
Notify appropriate local authorities
Counsel the family
Cover the body from public view and treat the body with
cultural respect
Don't leave the family until responsibilty for the body
has been transferred to local authorities or a funeral
director
Obvious Fatality
Pitfalls to Avoid
Overlooking
resuscitatable hypothermia
Moving the body or altering the scene if any
possibility of homicide
Leaving the family before arrangements for
management of the body are verified
Not notifying the local authorities or the patient's
regular doctor
Continuing resuscitation attempts when started by
others but when clearly inappropriate
Case 15
Snakebite
18
year old male
Was walking through tall grass when
bitten by a large black snake on the right
leg about one half hour ago
Did not see what kind of snake it was
Now complaining of nausea and vomiting
and feeling weak
Pulse 120, resps. 12, BP 88 / 50
Snakebite
Critical Actions
Move
patient a safe distance from the
snake if it is still in the vicinity
ABC assessment
Try to identify the snake type but don't
take any risk to do so
Apply "lymphatic" tourniquet above the
bite site (snug but not too tight)
Rapid transport to a medical facility that
has antivenin
Snakebite
Pitfalls to Avoid
Trying
to capture the snake and bring it
also to the hospital
Excessive ice treatment of the bite site
Can cause tissue damage like frostbite
Incising
the bite site to try to release
venom
Not recognizing signs of systemic
envenomation
Case 16
Coma
35
year old male
Found by coworkers lying on the floor in a
garage, last seen by them two hours ago
No histroy of alcohol or illicit drug use
Unconscious, responds to pain only by limb
withdrawl
Pulse 60, resps. 12 and snoring, BP 166 / 100
Coma
Critical Actions
ABC
assessment
May benefit from nasal airway
Start oxygen routinely
Neck
and spine immobilization if any
possibility of trauma
Check for hypoxia and hypoglycemia
Consider also carbon monoxide
intoxication, and hypothermia or
hyperthermia
Rapid
transport to medical facility
Coma
Pitfalls to Avoid
Failure
to consider possibility of spine injury and
provide spine immobilization
Failure to check for hypoxia or hypoglycemia
Attributing coma just to alcohol intoxication
Taking the patient to a medical facility without a
computed tomography (CT) scanner
Case 17
Shock
20
year old female
Called ambulance because of severe
lower abdominal pain
Last menstrual period 7 weeks ago
No prior abdominal problems
No current meds or allergies
Pulse 92, resps. 22, BP 60 / 30
Skin pale and diaphoretic
Shock
Critical Actions
ABC
assessment
Start oxygen routinely
Stop any external blood loss with
pressure dressings
Elevate legs
Rapid transport to medical facility
Shock
Pitfalls to Avoid
Not
diagnosing shock just because the
patient has a near normal blood pressure
or pulse
Not starting oxygen
Not rechecking the patient's vital signs
frequently
Not notifying the receiving facility early
Case 18
Near-drowning
12
year old male
Fell off bridge into lake
Was submerged 5 to 10 minutes
Was unconscious when pulled from the
water
Now drowsy but arousable, coughing
frequently
Pulse 70, resps. 20, BP 100 / 64
Near-drowning
Critical Actions
ABC
assessment
May need to suction upper airway
Even prolonged CPR may be successful
(particularly in cold water near-drownings)
Start
oxygen if patient still symptomatic
Don't induce vomiting
Assess for associated trauma
Check for hypoxia and hypoglycemia if altered
mental status
Rapid
transport to medical facility
Near-drowning
Pitfalls to Avoid
Doing
CPR with the patient's head higher than the
chest (after rescue from the water, position patient
parallel to shore line so head and heart are at same
level)
Not checking for associated trauma (such as neck
injury from diving)
Performing the Heimlich maneuver routinely (it just
predisposes to vomiting and aspiration ; most
patients do not have any removable fluid in their
airway)
Case 19
Allergic Reaction
29
year old male
Stung by wasp on left hand 15 minutes
ago
Now complaining of throat tightness,
difficulty breathing, and diffuse itchy
rash
Skin shows diffuse hives
Left hand is very swollen and red
Pulse 124, resps. 22, BP 92 / 64
Allergic Reaction
Critical Actions
ABC
assessment
Start oxygen if in shock
Remove stinger or insect if still imbedded
Administer injectable epinephrine if patient has a
self-treatment kit
Administer oral antihistamine med if available
Administer aerosol treatment if wheezing
Ice pack to sting site
Rapid transport to medical facility
Allergic Reaction
Pitfalls to Avoid
Not
recognizing risk for airway
obstruction
Not stopping further exposure of the
patient to the allergen
Not rechecking the patient's vital signs
frequently
Case 20
Seizure
18
year old male
Was in a store when he was seen to fall
to the floor and started having a tonicclonic gran mal seizure which lasted
about 5 minutes
No other history available
Now very drowsy with snoring
respirations
Pulse 110, resps. 14, BP 140 / 78
Seizure
Critical Actions
ABC
assessment
May benefit from nasal airway
Assess for associated trauma (such as tongue lacerations)
and immobilize neck and spine if possible injury from fall
Check for hypoxia and hypoglycemia
Position the patient to prevent injury if seizure recurs
Determine if any prior history of seizures or drug or
alcohol use
Transport to medical facility if patient not quickly back to
normal mental status or if new onset seizure
Seizure
Pitfalls to Avoid
Not
checking for associated trauma
Not starting oxygen if potentially hypoxic
Not determining what medications or
drugs the patient may have taken
Failing to position the patient so he will
not injure himself if the seizure recurs
Overly aggressive use of a bite block
thus damaging the teeth
First Responder Workshop
Summary
Always
consider scene safety first
Then always perform an "ABC" pattern patient
assessment
Try to quickly gather all relevant information about
the patient at the scene ; consider searching the
scene for medication bottles to bring along
Decide on the medical facility destination based on
its capabilities to manage the patient
Notify the receiving facility early