Transcript October 2007 CE - Advocatehealth.com

Trauma Patient Assessment
Intubation Review
Needle Decompression
Condell Medical Center EMS System
October, 2007 CE
Site Code #10-7200E1207
Prepared by: Sharon Hopkins RN, BSN, EMT-P
Objectives
Upon successful completion of this module,
the EMS provider should be able to:
• identify life threatening trauma to the adult
population
• describe the Region X interventions that
apply to traumatically injured patients
• actively participate in return demonstration
of the use of the BVM
• actively participate in return
demonstration in use of emergency
equipment to secure an airway via
intubation including in-line technique
• actively participate in return
demonstration of needle decompression
• review a variety of EKG rhythms
• successfully complete the quiz with a
score of 80% or better
7 Ways to Die in Trauma
•
•
•
•
•
•
•
Hypovolemia
Hypoxia
Acidosis
Obstructed airway
Flail chest
Cardiac tamponade
Tension pneumothorax
Perfusion
• Circulation is the movement of blood
through the heart and blood vessels
• Adequate circulation dependent on:
– functioning pump
– intact blood vessels
– adequate volume of blood
• Adequate perfusion
– enough blood with an adequate supply of
oxygen & nutrients delivered to organs &
tissues and the removal of waste
products
Hypoperfusion
• Inadequate perfusion also known as
shock
• Shock - a life threatening condition of
inadequate blood flow to body cells
that could result in death of cells
Normal Blood Volumes
•
•
•
•
Neonate 85 ml/kg
Infant 80 ml/kg
Adult men 75 ml/kg
Adult women 65 ml/kg
Typical Total Blood Volumes
•
•
•
•
•
Neonate (7#) - 3 kg x 85 ml = 255 ml
1 y/o infant (24#) - 11 kg x 80 ml = 880 ml
Adult man (180#) - 82 kg x 75 ml = 6150 ml
(200#) - 91 kg x 75 ml = 6825 ml
Adult woman (150#) - 68 kg x 65ml=4420ml
Stages of Blood Loss
• Stage 1 - compensated
– blood loss up to 15% of circulating blood vol
– 154# person (70 kg) is 500-750 ml loss
• at a typical blood drive you donate 500 ml
and over a period of 15-20 minutes
– early compensation
• nervousness
• slight paleness
• slightly cool skin
• slight elevation of pulse rate
• Stage 2 blood loss - compensated
– blood loss at 15 - 25% of circulating volume
– 750 - 1250 ml of blood volume is lost
– Additional compensatory measures in place
( in catecholamine release)
• tachycardia definitely noted with normal
blood pressure
• pulse strength lessened
• pulse pressure narrowed (diastolic &
systolic values closer together)
• peripheral vasoconstriction noted as cool,
clammy skin
• patient is anxious & thirsty
• Stage 3 blood loss - decompensated
–
–
–
–
25 - 35% loss of circulating blood volume
1250 - 1750 ml of blood is lost
compensatory mechanisms failing
classic signs of shock evident
• rapid tachycardia with falling blood
pressure
• narrowed pulse pressure with barely
palpable pulse
• tachypnea, air hunger
• anxious, restless, severe thirst
• decreased level of consciousness
• pale, cool, diaphoretic
• Stage 4 blood loss
– Blood loss greater than 35% total
circulating blood volume
– patient very lethargic, confused, or
unconscious
– barely palpable central pulses
– rapid, shallow, ineffective breathing
– skin very cool, clammy, extremely pale
• High mortality rate
– even with aggressive identification and
intervention
Categories of Shock or
Shock Syndromes
Low-volume shock - absolute
hypovolemia
• Number one cause of preventable deaths
• Absolute loss of circulating blood volume
– trauma
– dehydration
• diarrhea
• vomiting
• poor intake
• fever
Distributive shock
– vascular space too large for the amount of
blood circulating
– problem distributing the blood volume to all
the body’s cells
• sepsis
• drug overdoses - including alcohol and
anything that dilates blood vessels (ie:
nitroglycerin, calcium channel blockers)
• neurogenic shock (spinal shock) - injury to
the spinal cord
• anaphylactic shock
Mechanical (obstructive) shock
– anything that slows or prevents the venous
return of blood or obstructs the flow of
blood to or through the heart can lower
cardiac output and cause shock
– tension pneumothorax
– cardiac tamponade
– myocardial contusion
Case Scenario #1
• Your adult patient has fallen 30 feet off
a ladder
• They are confused
• The abdomen is tender and rigid
• The left femur is deformed and the
thigh is increasing in diameter
• The patient is pale, cool, and clammy.
The pulse is tachycardic and the patient
is tachypnic. B/P remains 88/60.
• What is your impression?
Case Scenario #1
• The patient is in hypovolemic shock
• The patient meets criteria for a
Category I trauma patient
• The patient requires transportation to
the highest level Trauma Center within
25 minutes
• Does this patient require a blood
glucose level in addition to all the
trauma care they are receiving?
– Yes - they are confused!
Hypoxia
• Hypoxemia
– decreased oxygen content of the
arterial blood
• Hypoxia
– decreased oxygen content to the
body’s cells and at the tissue level
Causes of Hypoxia
 Reduction of oxygen in the system
 Inadequate oxygen transport
 Inability of tissues to use the oxygen
delivered
Conditions That Can Affect
Blood Oxygenation
 Depressed respiratory drive
– head injury
– central nervous system depressants
• narcotics, sedatives
 Paralysis of respiratory muscles
– spinal injury
– inhalation injury
– neuromuscular diseases
(ie: ALS, muscular dystrophy, polio)
 Increased resistance in the airways
– asthma
– chronic bronchitis, emphysema
– congestion
 Decreased compliance of lungs and
thoracic wall
– interstitial lung disease from inhaling
toxic material
– infection
– lung cancer
– connective tissue diseases
– chronic pulmonary hypertension
 Chest wall abnormalities
– flail chest
– scoliosis
– full thickness burns with contractions
 Increased thickness of the respiratory
membrane
– pulmonary edema
– interstitial fibrosis
 Decreased surface area for gas exchange
–
–
–
–
–
emphysema
tuberculosis
pneumonia
pulmonary edema
atelectasis
 Reduced capacity of blood to transport
oxygen
–
–
–
–
anemias
hemoglobin abnormalities
carbon monoxide poisoning
methahemoglobinemia
 Ventilation and perfusion mismatching
(ventilated alveoli are not perfused or
perfused alveoli are not ventilated)
–
–
–
–
–
–
–
asthma
pneumonia
pulmonary embolus
pulmonary edema
myocardial infarction
respiratory distress syndrome
shock
Respiratory Acidosis
• Primarily a problem with inadequate
elimination of carbon dioxide (CO2) from the
lungs (or increased CO2 retention)
– respiratory depression or arrest
– neuromuscular impairment (ie: ALS, muscular
dystrophy, polio)
– sedative, hypnotic medications
– chest wall injury
• flail chest, pneumothorax
– pulmonary disorders
• airway obstruction, COPD, pulmonary
edema
Acidosis
• When a patient is not
ventilating/breathing effectively, they
will develop respiratory acidosis. This
is often followed by the development
of metabolic acidosis
• Many medications administered in
critical situations are not effective
when given in an acidotic environment
Hypoxia and Acidosis
• If the patient needs or you suspect that
they need O2, you must supply the
patient with supplemental oxygen
• Do not withhold oxygen therapy to the
patient with COPD
• Adequately ventilating and
oxygenating the patient will
prevent/treat/reverse hypoxia and/or
acidosis
Oxygenation & Ventilation
• Oxygen therapy for patients in the field
– nasal cannula at 2 - 6 l/min
• delivers 24% - 44% O2
– non-rebreather oxygen mask at enough flow to
keep the reservoir inflated during inhalation
(typically 12-15 l/min)
• delivers 90% plus O2
• Ventilation rates
– patient with a heart rate buts needs ventilation
support - ventilate 1 breath every 5 - 6 seconds
– once intubated, ventilate 1 breath every
6-8 seconds
Case Scenario #2
• Your 56 year-old patient has been
involved in a head-on crash into a tree.
Upon your arrival, you note a dusky,
cyanotic appearing patient with a rapid
respiratory rate who is struggling to
breathe. The patient is so anxious they
are uncooperative.
• Breath sounds indicate bilateral
wheezing with very diminished breath
sounds.
• What is your first impression?
Case Scenario #2
• This patient was on their way to the ED
for treatment of an asthma attack
• While trying to reach for their inhaler,
they lost control of the vehicle and
struck the tree
• EMS approach is to treat them as a
trauma patient with a medical
emergency
– this patient requires trauma care
while an albuterol nebulizer
treatment is simultaneously started
Obstructed Airway
• Foreign bodies
– food, foreign material, blood
– swollen tissues
• Patient is unable to speak, cough, or cough
is weak & highpitched
• Patient is becoming dusky or cyanotic
• Totally obstructed airways will cut off
oxygen supply
• You have 4-6 minutes to reopen an airway
to minimize negative consequences
Adult Airway Obstruction
• Conscious patient who is unable to speak
– continuous abdominal thrusts
• chest compressions for pregnant or obese patients
• Unconscious patient
– open airway & attempt to ventilate
– reposition head and repeat attempt once
– perform direct visualization of the airway and
attempt removal with the magill forceps
– if obstruction unrelieved, begin CPR steps
– during ventilation steps, attempt ventilations
twice, reposition between the 2 attempts
– consider cricothyrotomy
Magill Forceps
Needle Cricothyrotomy
• While patient supine, locate the cricothyroid
membrane
– soft membrane between thyroid cartilage
(Adam’s apple) and cricoid cartilage
• Stabilize larynx with thumb & middle finger
of one hand
• Prep the area of the cricothyroid membrane
• Insert 14 G or larger angiocath, with syringe
attached, into trachea at 450 angle
• Aspirate air with the syringe
Thyroid cartilage
Cricothyroid
membrane
Cricoid cartilage
Thyroid gland
Thyroid cartilage (Adam’s apple)
Cricothyroid membrane
Cricoid cartilage
• Air should return easily if in the trachea
• Advance the catheter while withdrawing
the stylet (like starting an IV)
• Attach a 3.0 mm ETT adapter (the colored
proximal tip of the ETT the BVM attaches
to) to the needle hub
• Ventilate assessing for breath sounds
• Secure the angiocath
• Continue to ventilate
• May need to allow for longer exhalation
time than inhalation time
Needle Cric
Step #1 - needle
advanced, confirmation
by air being aspirated
with the syringe
Step #2 - catheter
advanced while the
stylet is removed
Step #3 - the 3.0 mm
adapter removed from
the proximal end of a
3.0 mm ETT
Step #4 - the 3.0 mm ETT
adapter will be attached to
the needle hub of the IV
catheter when the stylet is
removed
Step #5 - patient can be ventilated;
assess for breath sounds, allowing
adequate time for exhalation
Cricothyrotomy
• Indications
– contraindication for placement of an
endotracheal tube
– endotracheal tube placement not
possible
– attempt to place an endotracheal tube
fails
– to relieve upper airway obstruction
– emergency access with severe facial
trauma
Melker Cric Kit
• Department personnel recommended to
review the CD from Cook Medical to
review using the Melker Emergency
Cricothyrotomy Catheter Set
Case Scenario #3
• This patient has been impaled by a
foreign object
• Do they need spinal immobilization for
this
injury?
• No
Flail Chest
• Fracture of 3 or more adjacent ribs in 2
or more locations
• Chest wall segment becomes unstable
• Mortality rate is 20 - 40% due to
associated injuries
• Secondary lung contusion is often
associated with flail chest
• Development of hypoxia is common
Flail Chest On Right Side
Signs & Symptoms Flail Chest
• History of chest wall injury
• Tenderness & bony crepitus on
palpation
• Tachypnea ( respiratory rate)
• Tachycardia
• Decreased pulse oximetry
• Late sign is paradoxical motion
– muscle spasms may hide the paradoxical
motion for the first few hours
Field Interventions For Flail
Chest
• Supportive oxygenation
– non-rebreather oxygen mask
– possibly BVM if ventilations need to be
supported (1 breath every 5-6 seconds)
– intubation (probably in-line technique) if
necessary
• Fluid replacement for co-existing
injuries
• Do not “tape” chest wall for support
Cardiac Tamponade
• Tears in the heart chamber walls with blood
entering the pericardial space
• Occurs in <2% of patients with chest trauma
• A result of penetrating trauma, blunt
trauma, and occasionally, spontaneous
• Increase in pericardial pressure
• Heart is prevented from expanding and
refilling with blood
• Stroke volume and cardiac output decreases
Cardiac Tamponade
Signs & Symptoms of Cardiac
Tamponade
• Peripheral vasoconstriction (cool & clammy)
• Tachycardia
• Narrowed pulse pressure (diastolic blood
pressure rises more than systolic blood
pressure)
• Beck’s Triad
JVD (early sign)
muffled heart tones
hypotension (late sign)
Is It Tamponade or
Hypovolemic Shock?
• JVD is present in cardiac tamponade
– compression of the heart chambers
causing a decrease in filling which creates
a backup of fluid noted as JVD
• JVD is not present in hemorrhagic
shock
– there is a total decrease in blood volume
throughout the entire circulatory system
so there is nothing to be backing up
Field Interventions For Cardiac
Tamponade
• Cardiac monitoring
• Oxygen support
• IV fluid replacement if shock present
– 20 ml/kg
– reevaluate every 200 ml
• Rapid transport with high index of
suspicion
• Removal of blood from the pericardial
sac will be performed at the hospital
Tension Pneumothorax
• Trapping of air in the pleural space
• Increase in pleural pressure producing
a shift in the mediastinum
• Compression of:
– the lung on the unaffected side
– vena cava reducing blood flow return to
the heart with a decrease in cardiac output
Tension
pneumothorax
on the right
side with
shifting to the
left
Signs & Symptoms of Tension
Pneumothorax
•
•
•
•
•
•
Anxiety
Cyanosis
Increasing dyspnea
Tachycardia
Hypotension or unexplained signs of shock
Diminished or absent breath sounds on
affected side with profound hypoventilation
• Distended neck veins (JVD)
• Subcutaneous emphysema
Field Interventions For Tension
Pneumothorax
• A true emergency requiring immediate
identification and intervention
• Goal: reduce the pressure in the pleural
space
– emergency needle decompression
Needle Decompression
• Prepare equipment
– 2-3” long catheter 12- 14 G
– skin surface prep material(ie: alcohol prep pad)
– flutter valve attached to IV catheter
• Identify landmarks
– 2nd intercostal space, mid-clavicular line
• Clean site
• Insert needle, bevel up, over the top of the
3rd rib (into the 2nd intercostal space)
Landmarks For Needle
Decompression
Rib #1
Rib #2
2nd intercostal
space
mid-clavicular
line
Rib #3
Placement of Needle
Flutter valve attached
3rd rib
2nd rib
Placement of Needle
• As air is released, clinically the patient
should show improvement
– less distress; less anxiety
– greater ease in breathing/ventilating
– rise in pulse ox saturation level
• Secure angiocath and flutter valve
– place opened, loosened 4x4’s around
base of the angiocath
• Monitor patient status watching for
deterioration
Case Scenario #4
• Your patient was a pedestrian struck by a
vehicle at a high rate of speed. Upon your
arrival you initially felt a faint pulse but now
there is none. The patient is not breathing and
bagging is difficult due to the resistance felt.
• What is this rhythm and how is it treated?
6 second strip - there is no pulse
Case Scenario #4
• The rhythm is PEA (with a rapid rate)
• The patient is treated as an arrested
trauma with suspicions of chest injuries
(difficulty bagging)
– Any airway maneuvers need to
provide immobilization of the airway
• opening airway using jaw thrust
maneuver
• intubation would be the in-line
technique
Case Scenario #4
• Patient interventions
–
–
–
–
–
–
Full spinal immobilization
CPR - IV - O2 support - monitor
Consider the 6 H’s and 5 T’s as causes
Perform bilateral chest decompressions
Fluid challenges reevaluating every 200 ml
Drugs - Epinephrine 1 mg every 3-5 minutes
• Rate is >60 so Atropine not indicated
• Transport destination
– Traumatic arrest - to closest Trauma Center
Intubation
• Preferred advanced airway for
controlling the airway in patients who
are unable to maintain an open airway
• Indications
– unable to ventilate an unconscious
patient
– patient cannot protect their own
airway
– prolonged ventilation is required
Intubation
• Advantages
– airway is isolated preventing
aspiration
– ventilation (breathing) and
oxygenation is easier to accomplish
– suctioning of the trachea is easier
– gastric insufflation of air during
inhalation is prevented
Intubation
• Disadvantages
– inadvertent placement in the esophagus with lack
of recognition of improper placement
– ineffective ventilation volumes
• use enough volume to gently make the chest
rise
– inappropriate ventilation rate
• patient with a pulse, breath once every 5-6
seconds
• during CPR with intubated patient, ventilate
once every 6-8 seconds while chest
compressions continue uninterrupted
Intubation Equipment
• BVM connected to oxygen source
• Handle and blade
– bulb bright and tight
– straight blade lifts epiglottis up
• preferred for infant intubations
– curved blade fits into the vallecular
space
• ETT (generally size 7-8 for men and
size 7 for women; no cuff under age 8)
• Stylet
– does not protrude beyond distal end of ETT
– reform tube into curved position after
straight stylet passed into position
• Syringe
– do not leave attached to cuff once ETT is in
place; air will be pulled out of the cuff
• Tape or commercial tube holder to secure
tube
• Cervical collar
– tube positions are better maintained when
head movement is minimized
Patient Preparation
• Pre-oxygenate the patient with 100% O2 for
15 - 30 seconds before the intubation attempt
• Consider medications for conscious sedation
– Lidocaine 1.5 mg /kg, if head insult is present, to
eliminate the cough reflex
– Versed 5 mg initially; 2 mg every minute until
sedated; 1 mg every 5 minutes to maintain
sedation post intubation
– Morphine 2 mg every 3 minutes to relieve pain,
reduce anxiety, potentiate the effects of Versed
– Benzocaine 2 second spray to eliminate the
gag reflex, if present
Patient Positioning - Non-Trauma
• Non-trauma patient - sniffing position
– neck is flexed
allowing the
best alignment
of anatomical
landmarks
– place a few
towels under
the patient’s
head
Influence of Positioning
Landmarks not in alignment;
intubation more difficult for the
practitioner and with increased
risk of injury to patient
Anatomical landmarks lined
up; intubation is easier on the
medical personnel and the
patient
Difficult Intubations
Neck and chest tissue fall
over the airway making
intubation difficult
Better patient
positioning allows
for improved chance
of success in intubation
Orotracheal Intubation
Cricoid Pressure Sellick’s Maneuver
• Helps prevent gastric distention when bagging
the patient using the mouth-to-mask technique
• Helps prevent passive regurgitation with
aspiration while bagging the patient or
attempting intubation
• With pressure applied over the cricoid
cartilage, the esophagus becomes occluded
• Can improve the view of the vocal cords for
the intubator
• Can help stabilize the trachea
Lateral View of ETT Placement
Curved blade in
vallecula
In-line Intubation Techniques
• Indication
– when spinal precautions need to be
observed
• Equipment
– identical to normal intubation procedures
• Manual cervical spine control
– stabilization must be constantly
maintained in a neutral position during the
procedure
– head is securely controlled post-procedure
Opening Airway with Cervical
Trauma - Jaw Thrust
In-Line Intubation
• Intubator positioning
 Intubator may sit at the patient’s head and
their legs straddle the patient’s shoulders and
arms; patient’s head is gripped with the
intubator’s thighs
 Intubator may lie on their stomach facing the
patient’s head
• A second rescuer stabilizes the patient’s
head by gripping the head from the side and
grasping along the jaw and lower face,
spreading their fingers near the temple
(ear) area
In-Line Intubation
•Patient
being
stabilized
•Equipment
being
prepared
•Cricoid
pressure
being held
Orotracheal Intubation
• Face-to-face procedure to intubate a
patient when the provider cannot take a
position above the patient’s head (ie:
patient in the sitting position)
• Manual stabilization must be
maintained by a second rescuer at all
times (often from behind if there is
room for the provider behind the
patient)
Orotracheal Intubation Procedure
• Primary rescuer takes a position facing
the patient
• Open the mouth with the left hand
• Hold the laryngoscope in the right hand
• Insert the blade into the patient’s mouth
• Follow the normal curvature of the
tongue
• Visualize the vocal cords from above the
patient’s mouth
• With the left hand, pass the ETT
between the cords
• Remove the stylet, if used
• Begin to ventilate the patient with the
BVM
• Inflate the cuff and remove the syringe
• Confirm proper ETT placement
Confirming Placement and
Securing ETT
Direct visualization
– cricoid pressure can be helpful
• stabilizes the trachea
• may “drop” the trachea into view
• with enough pressure, can stop vomitus
coming back up
– once cricoid pressure is applied for
blocking vomitus, pressure is maintained
until the cuff is inflated
Cricoid Pressure
Bilateral & equal rise and fall of the chest
5 point auscultation
– listen over the epigastrium (expect to hear
nothing)
– listen 4 points over the lungs
• listen anteriorly just under the clavicles on
either side of the sternum
• listen in the axillary line approximately 5th
intercostal space
ETCO2 detector
– after 6 breaths should see & maintain the
yellow color to indicate exhaled CO2
being
detected
• EDD bulb
– back-up tool to the ETCO2 detector
– need to interrupt ventilation to use
– when bulb is depressed and placed on the
end of the ETT tube, will reinflate rapidly
if ETT is placed in the trachea
Case Scenario #5
• What airway significance could there be in
this case and what needs to be monitored?
Case Scenario #5 - End Results
Region X SOP’s
• Field Triage Criteria For Assessing
Trauma Patients
• In-Field Spinal Clearance
• Routine Trauma Care
• Revised Trauma Score
Field Triage Criteria
• Transport to highest level Trauma
Center within 25 minutes if:
– systolic blood pressure < 90 x2
(peds < 80 x 2)
Field Triage Criteria
• Transport to highest level Trauma Center
within 25 minutes if patient is a Category I
– Vital signs unstable
• Glasgow Coma Scale <10 or
deteriorating mental status
• respiratory rate <10 or >29
• Revised Trauma Score <11
Field Triage Criteria
• Transport to highest level Trauma Center
within 25 minutes if patient is a Category I
– Based on anatomy of injury
•
•
•
•
•
•
Penetrating injuries to head, neck, torso, groin
Combination trauma with burns >20%
Two or more proximal long bone fractures
Unstable pelvis
Flail chest
Limb paralysis and/or sensory deficits above the
wrist or ankle
• Open and depressed skull fractures
• Amputation proximal to wrist or ankle
Field Triage Criteria
• Transport to closest Trauma Center if the
patient is a Category II trauma patient
– Mechanism of injury
• Ejection from automobile
• Death in same passenger compartment
• Motorcycle crash >20 mph or with
separation of rider from bike
• Rollover (unrestrained)
• Falls >20 feet (peds falls >3x body length)
• Pedestrian thrown or runover
– Mechanism of injury (continued)
• Auto vs pedestrian/bicyclist with >5mph
impact
• Extrication > 20 minutes
• High speed MVC
– Speed > 40 mph
– Intrusion > 12 inches
– Major deformity > 20 inches
– Co-morbid factors
• Age < 5 without car/booster seat
• Bleeding disorders or on anticoagulants
• Pregnancy > 24 weeks
Field Triage Criteria
• If patient is not a Category I trauma
patient (based on unstable vital signs or
anatomy of the injury)
and
• patient is not a Category II trauma
patient (based on mechanism of injury
or co-morbid factors)
then
• provide routine trauma care and
transport to the closest Trauma Center
Field Triage Criteria
• Transport to the closest Trauma Center if:
traumatic arrest
isolated burns > 20% BSA
• Transport to closest Emergency Department
if:
no airway can be established
Region X SOP’s
Routine Trauma Care
• Scene size-up
• Initial assessment
– Airway / spinal precaution
– Breathing
– Circulation
– Disability - AVPU and GCS
• (alert; responds to verbal; responds to pain;
unresponsive)
– General impression
Routine Trauma Care
• Identify priority of transport
Begin rapid transport (treatment enroute)
• Based on mechanism of injury or patient complaint
Begin treatment and initiate transport
• Treatment
– Airway control - oxygen support
– IV (200 ml if fluid challenge required)
• Detailed exam as time permits
• Ongoing assessment - on all patients
– Every 5 minutes if patient is a rapid transport
Case Scenario #6
• Your patient is a 63 year-old male involved
in a head-on MVC on a road with posted
speed of 55 mph
• Scene size-up
–
–
–
–
–
head-on car vs truck
restrained driver
heavy front-end damage
airbag deployed
back of seat broken
Case Scenario #6 - Assessment
– By-standers state patient was initially
unresponsive
– Upon your arrival the patient is awake, alert,
and cooperative
– GCS 15
– 136/88; P - 68; R - 20; SaO2 98%; NSR; breath
sounds clear bilaterally
– Complaints: soreness over multiple abrasions of
chest, abdomen, and extremities; blood in the
nostrils; tenderness with mild rigidity over the
left abdominal wall where abrasions are noted
Case Scenario #6
What initial care is to be established?
What Category Trauma does this
patient meet for transport decisions?
What are the potential injuries you
need to consider this patient receiving?
Case Scenario #6
• Patient meets criteria for a Category II Trauma
– Stable vital signs
– No anatomical injuries meeting criteria
– High speed MVC with major deformity
• Vitals & condition on arrival to ED
– 104/82; P - 64; R - 18; SaO2 - 100%; NSR
– Patient now cool, pale, diaphoretic, clear breath
sounds; capillary refill < 2 seconds; abdomen flat,
non-tender; pain over lower right chest
Case Scenario #6
• Follow-up
– Patient became hypotensive in the ED
(B/P - 65/34; P-50; R - 18)
– The patient went to OR and was found to
have 2 liver lacerations and multiple liters
of free blood in the abdominal cavity
– The patient went to ICCU after OR
• Why would this patient’s pulse rate not
be higher if he lost so much blood?
– The patient was taking beta blockers for
hypertension control
In-Field Spinal Clearance SOP
• A reliable patient without signs or
symptoms of neck or spine injury and a
negative mechanism of injury does not
require full spinal immobilization
• When in doubt, fully immobilize
patient
In-Field Spinal Clearance SOP
Mechanism of injury
–
–
–
–
–
–
–
–
–
–
High velocity MVC > 40 mph
Unrestrained occupant in MVC
Passenger compartment intrusion > 12 inches
Ejection from vehicle
Rollover MVC
Motorcycle collision > 20 mph
Death in same vehicle
Pedestrian struck by vehicle
Falls > 2 time patient height
Diving injury
In-Field Spinal Clearance SOP
Signs and symptoms
– Pain in neck or spine
– Tenderness/deformity of neck or spine
upon palpation
– Paralysis or abnormal motor exam
– Paresthesia in extremities
– Abnormal response to painful stimuli
In-Field Spinal Clearance SOP
Patient reliability
–
–
–
–
Signs of intoxication
Abnormal mental status
Communication difficulty
Abnormal stress reaction
In-Field Spinal Clearance SOP
• If the patient meets the criteria of need
for spinal immobilization based on
mechanism of injury, and/or signs &
symptoms, and/or reliability, then
patient intervention includes:
routine trauma care
full spinal immobilization
transport
Revised Trauma Score - RTS
• Points scored are based on:
– Respiratory rate
– Systolic blood pressure
– Glasgow Coma Scale (scale 3-15 and points
converted for RTS)
• eye opening
• verbal response
• motor response
• Revised Trauma Score scale is 0 - 12
• Provide the ECRN with the
components and they can score pt
Bibliography
• Bledsoe, B., Porter, R., Cherry, R.
Essential of Paramedic Care. 2nd
Edition. Brady. 2007.
• Campbell, J. Basic Trauma Life support
5th Edition. Brady. 2004.
• Caroline, N. Emergency Care In The
Streets. 6th Edition. AAOS. 2008.
• Limmer, D., O’Keefe, M. Emergency
Care 10th Edition. Brady. 2005.
• Region X Standard Operating
Procedures. March 1, 2007.
• Sanders, M. Mosby’s Paramedic
Textbook. Elsevier. 2007.
Name That Rhythm
SVT
Name That Rhythm
Second Degree Type II - Classical
Name That Rhythm
Atrial Fibrillation
Identify ST Elevation
ST elevation V1 - V4