ECRN: Assessment Based Management Thoracic

1
ECRNAssessment Based Management Thoracic
Abdominal Trauma Neurological Considerations

• Condell Medical Center EMS System
• 2006
• Site Code 10-7214-E-1206
• Revised by Sharon Hopkins, RN, BSN

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Objectives

• Upon successful completion of this module, the
  ECRN should be able to
• 1. Understand the factors that affect patient
  assessment and decision making capabilities.
• 2. Describe the steps of patient assessment based
  on ITLS guidelines.
• 3. Identify mechanisms of injury that can lead to
  thoracic and abdominal traumatic injuries.
• 4. Understand EMS interventions appropriate for
  thoracic and abdominal injuries.

3
Objectives contd

• 5. Describe a variety of degenerative
  neurological diseases.
• 6. Review case scenarios.
• 7. Successfully complete the quiz with a score of
  80 or better.

4
ASSESSMENT BASED MANAGEMENT

• Involves the use of
• critical thinking skills
• problem solving abilities
• clinical decision making
• Includes avoiding
• tunnel vision (can create distractions)
• patient labeling or jumping to conclusions based
  on preconceived ideas
• the drunk the frequent flyer the whiner

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Goals of Our Profession

• Provide competent,
• compassionate care
• for each and every
• patient interaction
• You need a strong
  knowledge base and
  excellent
  assessment skills to care for patients

6
Factors Affecting Assessment and Decision-Making

• Attitude needs to be non-judgmental
• May short circuit" information gathering leading
  to insufficient information gathering
• May leap to conclusions before gathering a
  thorough assessment
• Garbage in garbage out
• Patients depend on us for medical assessment/
  management and not determination of social
  standing or "likability"

7
Factors Affecting Assessment and Decision-Making

• Uncooperative Patients
• Perception of intoxication - drugs or alcohol
• In all uncooperative, restless, belligerent
  patients consider other possible causes
• hypoxia
• hypovolemia
• hypoglycemia
• head injury

8
Factors Affecting Assessment and Decision-Making

• Patient compliance influenced by
• Patient confidence in the medical team
• Prior experiences of the patient and their family
• Cultural and ethnic barriers

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Factors Affecting Assessment and Decision-Making

• Distracting injuries
• can divert attention from more serious problems
• Need to resist the temptation of forming an
  initial diagnosis too early
• Gut instincts may lead to snap judgements
• Systematic approach to patient care
• helps prioritize avoid being swayed by the
  wrong impression

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Factors Affecting Assessment and Decision-Making

• Distractors in the environment
• Scene chaos
• Violent dangerous situations
• Crowds of bystanders
• High noise levels
• Crowds of responders
• enough help is crucial
  but they must be used wisely

11
General Approach to Patient Assessment in The
Field The ED

• Size-up the situation
• Identify need for body substance isolation (BSI)
• gloves, gown, mask, eye protection as needed
• Evaluate scene safety
• hazards to yourself, the team, the patient
• Identify mechanism of injury or nature of illness
• can help determine severity of situation

12
Patient Assessment

• Initial assessment
• To identify life-threatening conditions
• Mental status (AVPU)
• A - awake, not necessarily oriented
• V - responding to verbal stimulation
• P - responding only after touch or lite pain
  applied
• U - unresponsive (absolutely no response)
• Airway assessment
• Breathing assessment
• Circulation status
• pulses present?
• obvious bleeding to be controlled?

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Initial assessment contd

• Forming a general impression
• What do you think is going on?
• These answers drive the care you want to start
  providing.
• Which protocol will you follow?

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Patient Assessment

• Focused history and physical exam performed based
  on chief complaint and information gathered so
  far
• trauma patient with significant mechanism of
  injury or altered mental status
• needs rapid head-to-toe
• trauma patient with isolated injury (ie ankle
  sprain)
• focus on body systems related to complaint
• medical patient (responsive) - focus exam on c/o
• medical patient (unresponsive)
• needs rapid assessment with head-to-toe exam when
  patient input not available

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Patient Assessment

• Vital signs
• CMC ED policy take and record vital signs
  minimally every 2 hours or more often as needed
• SAMPLE history - reminds you to obtain
• symptoms
• allergies
• medications
• pertinent past medical history
• last oral intake food or liquids including water
• events leading up to the incident
• Check for medic alert bracelet, necklace

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Blood Pressure

• A measurement of the force of blood against the
  walls of the blood vessels
• Reassessment over time gives most accurate
  reflection of patient state
• Changes in B/P can be very significant
• Is last vital sign to change in decompensation
• Cuff should cover 2/3rds of the upper arm
• Cuff should not be placed over clothing
• Arm should be maintained at heart level
• Obese arm? Wrap cuff around forearm place
  stethoscope over radial pulse area

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Tips, Tricks Pearls on Blood Pressure Pulses

• B/P by palpation can only determine a systolic
  reading
• As cuff is deflated, palpate over the radially
  area until the pulse returns
• Record as 90/systolic
• Guidelines suggest that palpated pulses equate
  with systolic blood pressures
• carotid pulse felt means B/P at least 60/systolic
• radial pulse felt means B/P at least 80/systolic
• No peripheral pulse? Think circulatory collapse
• B/P should always be attempted documented

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Patient Assessment

• Detailed physical exam
• a more detailed slower head-to-toe exam than
  the initial one performed
• clinical experience and patient condition often
  dictate how if a detailed exam is done in the
  field if there is time before ED arrival
• Ongoing Assessment - always done
• used to detect trends, determine changes in
  patient condition, and assess effectiveness of
  interventions
• mental status, ABCs, vital signs (pulse,
  respirations, B/P, SaO2, pain level), EKG

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Assessment Techniques

• Inspection
• observation looking beyond the obvious
• Palpation
• use your sense of touch to gather information
• pads of fingers more sensitive than tips for
  touch
• back of hand is better for sense of temperature
• Percussion - not often done in the field
• Auscultation
• listening for sounds (lungs, heart, intestines)
• for lung sounds, note abnormal sounds, location,
  timing during inspiration or expiration

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Accurate Decision Making

• Relies on
• Patient history obtained
• Physical, hands-on exam performed
• Recognizing a pattern
• comparing information gathered with what you
  already know (existing knowledge base)
• Impression or field diagnosis made
• the first diagnosis is based on the most probable
  cause of the patients complaint based on the
  information gathered during the assessment
• used to formulate a plan of action based on the
  patients condition and the environment

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Use of Protocols SOPs

• Protocol - policies and procedures of all
  components of the EMS system
• Standard operating procedures (SOPs) -
  preauthorized treatment procedures
• Exercise judgement when following protocol and
  SOPs
• know which protocol/SOP to choose
• know when and how to follow protocol/SOPs
• recognize when you must deviate from the stated
  protocol/SOP - allergies, abnormal vital signs
  (ie hypotension)

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SOPs/Protocols The ECRN

• An ECRN, by the restriction of their license,
  cannot give a medical order the ECRN is only
  authorized to give an order if it is printed in
  the SOP/protocol
• The ECRN must consult with the ED MD to give an
  order to EMS that is not listed in the SOP (ie
  lidocaine drip after bolus given for stable
  ventricular tachycardia)

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Difficulty Establishing An Airway In The Field

• If EMS cannot establish an airway on any patient
  in the field, EMS is to transport the patient to
  the closest Comprehensive Emergency Department
  even if they are on by-pass
• A Comprehensive Emergency Department is one that
  is open 24 hours, 7 days a week and has a
  physician on duty as well as other support
  services

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Communication

• Hospital reports are best when they
• Are given in less than one minute
• Are clear and concise
• Avoid use of unfamiliar or unclear medical or
  technical terms including 10 codes
• Follow a basic format
• Include both pertinent findings and pertinent
  negatives (findings that would be expected but
  are not present)
• Conclude with specific actions, requests, or
  questions related to the plan

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Transmission of Patient Information

• Provider identified by name and vehicle number
• Age, sex, and approximate weight of patient
• Level of consciousness
• Chief complaint and degree of distress
• Vital signs, EKG, pulse oximetry, blood glucose
  if obtained
• If indicated, lung sounds, pupils, skin condition
  and color, GCS, pain assessment
• Treatment rendered and patient response
• Patient history
• ETA and destination

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Calling Report on Trauma Patients

• Important for EMS to include information the
  hospital can use to categorize the trauma level
  for this patient as well as determine which
  members of the trauma team that need to be
  activated
• mechanism of injury
• destruction to vehicle/surroundings
• injuries noted or suspected
• vital signs, GCS
• Restlessness first think hypoxia shock

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THORACIC TRAUMA
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Anatomy Physiology of the Thorax

• Thoracic cage responsible for moving air in and
  out
• Place where carbon dioxide and oxygen exchange
  takes place to support metabolism
• Includes thoracic skeleton, diaphragm, and
  supporting musculature
• Location of major organs and vessels
• heart, aorta, trachea, lungs, mediastinum

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Thoracic Trauma

• Classifying thoracic injuries
• Blunt trauma - closed
  injury from kinetic
  energy transmitted through
  tissue
• blasts
• deceleration
• compression/crush
• Penetrating trauma - open wound direct or
  indirect trauma transmitted via kinetic energy

dart
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Blunt Trauma From Blast Injuries

• Blast injury - explosion caused by dust, fumes,
  natural gas, explosive compounds
• Confined space blast/shock wave
• pressure wave debris cannot dissipate as far
  so maintains higher energy level longer
• danger of structural collapse flying debris
• extremely deadly overpressures created

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Thoracic Injuries

• Thoracic cage - ribs sternal fx, flail segment
• Cardiovascular - contusion, tamponade
• Pleural and pulmonary- contusions, pneumos
• Mediastinal - pneumomediastinum

• Diaphragm - tear, laceration, rupture
• Esophageal - laceration
• Penetrating cardiac trauma - laceration aorta,
  vena cava, pulmonary arteries/veins
• Spinal cord injuries

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Flail Chest

• Definition
• 3 or more adjacent ribs broken in 2 or more
  places
• Most common mechanism of injury - blunt trauma
• falls, MVC, industrial injuries, assaults
• Risks to the patient
• reduces tidal volume (air moving in and out)
• increases respiratory effort
• usually accompanied by pulmonary and possibly
  cardiac contusions

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Flail Chest

• Signs and symptoms
• paradoxical motion of the chest wall
• asymmetrical chest wall movement flail segment
  moves in opposite direction from the rest of the
  chest
• increased respiratory effort and rate
• decreased pulse oximetry readings
• increased amount of pain to the chest wall
• Treatment
• support respiratory effort - supplemental O2 via
  nonrebreather mask BVM as needed
• support fractured section manually - no taping of
  the chest or sandbags/IVs placed on chest
• EKG monitoring

34
Sucking Chest Wound

• Definition
• open wound of the chest with air passage into the
  pleural space
• Risks to the patient
• collapse of the lung on the affected side
• uninjured lung unable to fully expand
• change in intrathoracic pressures negatively
  affect venous return to the heart
• if the chest wall opening is at least 2/3 the
  diameter of the trachea (normally the size of the
  patients little finger), air will move in out
  thru the chest wall defect not thru the trachea

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Sucking Chest Wound

• Signs and symptoms
• open wound to the thorax frothy blood noted
  around the chest wall defect
• gurgling sound heard near the chest wound
• severe dyspnea
• possible hypovolemia - associated injury
  hemorrhage
• increased pulse rate respiratory rate
  decreased blood pressure
• evidence of air hunger if, with each breath, more
  air enters thru the chest wall defect than thru
  the trachea

36
Sucking Chest Wound

• Treatment
• Immediately seal the chest wound (gloved hand to
  start with if necessary) eventually with
  occlusive dressing taped on 3 sides
• Open pneumothorax now converted to closed
  pneumothorax - watch for increased respiratory
  distress leading to tension pneumothorax
• if needed, burp dressing by lifting one corner
  during exhalation
• O2 via nonrebreather mask
• Monitor vital signs, pulse ox, EKG

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Tension Pneumothorax

• Definition
• An open or simple pneumothorax that generates and
  maintains a greater pressure than atmospheric
  pressure within the thorax via a created one-way
  valve
• Risks to the patient
• Air is trapped in the pleural space and puts
  pressure on the affected lung, the structures in
  the mediastinum, the opposite lung

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Tension Pneumothorax
(JVD)
Dyspnea, SOB
(rare late sign not often appreciated)
tachycardia
Low pulse ox, narrowed pulse pressure
decreased B/P
PEA
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Needle Decompression

• Treatment
• Provide supplemental oxygenation (nonrebreather
  mask) or BVM
• Initially perform needle decompression
• identify site 2nd intercostal space in
  midclavicular line above the rib
• prep the site
• prepare a flutter valve on a 3? large gauged
  needle
• insert 3? needle largest gauge available (12-14g)
  straight into the chest wall over the top of a
  rib
• can take the plug off the catheter end and attach
  a syringe
• upon feeling a pop or noting air return in
  syringe, advance catheter remove needle secure
  catheter

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Needle Decompression
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Hemothorax

• Definition
• an accumulation of blood in the pleural space due
  to internal hemorrhage
• more of a blood loss problem than an airway issue
• each side of the thorax may hold up to 3000 ml of
  blood
• Risks to the patient
• hypovolemic shock
• reduction of tidal volume efficiency of
  ventilations

42
Hemothorax Signs Symptoms
History blunt or penetrating trauma
decreased blood pressure
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Hemothorax

• Treatment
• support the patient with supplemental oxygenation
  (nonrebreather mask) and potentially BVM
• IV access for fluid resuscitation
• 20 ml/kg normal saline (Routine Trauma Care
  Protocol)
• carefully administer fluids to avoid worsening
  the edema and congestion of pulmonary contusions
• Note
• Hemothorax is primarily a blood loss problem more
  than a respiratory one

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Cardiac Tamponade

• Definition
• A restriction to cardiac filling caused by blood
  or fluid in the pericardial sac
• Most common mechanism of injury
• penetrating trauma (could be medical problem)
• Risks to the patient
• accumulating blood exerts pressure on the heart
• pressure limits cardiac filling restricting
  venous return to the heart
• cardiac output is diminished

45
Cardiac Tamponade
agitation
(JVD)
PEA
Muffled heart tones
Diaphoretic, ashen or cyanotic
46
Cardiac Tamponade

• Treatment
• keep high index of suspicion
• field care limited to supportive oxygenation
  (nonrebreather mask or BVM),IV fluids, and rapid
  transport
• definitive care must be provided in-hospital
• removal of some of the accumulated fluid from the
  pericardial sac in the ED and then patient needs
  to go to the OR

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ABDOMINAL TRAUMA
A high degree of suspicion must be exercised
based on mechanism of injury and kinematics.
48
Abdominal Anatomy and Physiology

• Boundaries
• superiorly the diaphragm
• inferiorly the pelvis
• posteriorly the vertebral column, posterior
  inferior ribs, back muscles
• laterally the flank muscles
• anteriorly the abdominal muscles

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Abdominal Anatomy and Physiology

• The 3 abdominal spaces
• peritoneal space
• organs or portions of organs covered by abdominal
  (peritoneal) lining
• retroperitoneal space
• organs posterior to the peritoneal lining
• pelvic space
• organs contained within the pelvis

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Abdominal Quadrants

• RUQ
• gallbladder, right kidney, most of the liver,
  some small bowel, portion of ascending
  transverse colon, small portion of pancreas
• LUQ
• stomach, spleen, left kidney, most of pancreas,
  portion of liver, small bowel, transverse
  descending colon
• RLQ
• appendix, portions urinary bladder, small bowel,
  ascending colon, rectum, female genitalia
• LLQ - sigmoid colon, portion urinary bladder,
  small bowel, descending colon, rectum, female
  genitalia

51
Blunt Abdominal Trauma

• Produces least visible signs of injury
• Responsible for 40 of splenic injuries
• Responsible for 20 or liver injuries
• Bowel and kidneys next most frequently injured
  organs
• Injuries must be anticipated by evaluating
  mechanism of injury with force direction of
  impact
• Maintain high index of suspicion based on
  mechanism of injury

52
Blunt Mechanisms

• Compression forces
• Shear forces
• Deceleration forces
• Motor vehicle crashes
• Motorcycle collisions

• Pedestrian injuries
• Falls
• Assault
• Blast injuries

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Penetrating Abdominal Trauma

• Low velocity - injury limited to the direct area
• Knife, ice pik
• Medium velocity
• Handgun shotgun wounds
• High velocity
• High power hunting rifles
• Military weapons
• Ballistics - study of projectiles in motion
• Trajectory - path a projectile follows
• Distance traveled a consideration

54
Evisceration of the bowel caused by a knife wound
Cover eviscerated area with sterile, moistened
dressing Minimize patient movement, coughing
55
Hollow Organ Injury

• Hollow organs
• Stomach, small bowel, large bowel, rectum,
  urinary bladder, gallbladder, pregnant uterus
• Anticipated injuries
• May rupture due to forces especially if the organ
  is full and distended
• Can cause hemorrhage and spillage of the contents
  into the peritoneal, retroperitoneal or pelvic
  spaces
• Contents spilled may have high bacterial counts,
  contain irritating chemicals, have high acid
  counts, or contain digestive enzymes

56
Solid Organ Injury

• Solid organs
• spleen, liver, pancreas, kidneys
• Anticipated injuries
• Prone to contuse resulting in organ damage
  bleeding often minimal if organ intact and
  contained within the organ but could be severe
• If organ torn or lacerated may cause
  life-threatening hemorrhage

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Patient Assessment

• Maintain high index of suspicion
• Serious trauma to the abdomen is often a surgical
  problem and requires prompt and rapid transport
  with frequent reassessment
• Identify additional causative forces of injury
• seatbelt worn above the iliac crest
• no seatbelt restraint used, steering wheel
  deformity
• type of weapon used in penetrating trauma

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Patient Assessment For Abdominal Trauma

• Early signs of serious or continuing internal
  hemorrhage
• diminishing level of consciousness
• increasing anxiety or restlessness
• thirst
• increasing pulse rate
• decreasing pulse pressure - systolic and
  diastolic numbers moving closer together
• increasing capillary refill time (gt2 seconds)
• increasing abdominal distention, bruising

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Abdominal Assessment

• Inspection
• Redness, ecchymosis, contusions, open wounds,
  distention
• May hold up to 1.5 L of blood before distended
• Palpation
• Gently palpate each quadrant individually with
  tips of fingers
• Quadrants with pain or injury are palpated last
• Distention, tenderness, crepitus, instability,
  guarding, pulsations
• Auscultation - Not often done in field in trauma
  - too much time and need for quieter environment

60
Initial Abdominal Trauma Treatment

• Timely, thorough assessment repeated often
• Critical findings rigid or distended abdomen or
  guarding presence of shock shock out of
  proportion to findings (maybe havent found all
  the sources of bleeding yet)
• Supportive oxygenation (nonrebreather mask)
• IV access
• EKG monitoring

61
Neurological Emergencies

• The human bodys ability to maintain a state of
  homeostasis results primarily from the nervous
  systems regulatory and coordinating activities
• A disruption in the nervous system affects the
  functioning of the body and can be in a variety
  of forms from simple to severe

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Headache

• Common ailment
• Described as a symptom rather than a disorder
• Can accompany many disorders
• Can be brought on by emotional
  events
• Recurring headaches may be an
  early sign of a more serious disease
• Most are caused by vasodilatation
  in tissues surrounding the brain
• 
  

63
Headache

• Immediate attention is needed if
• Severe and sudden in onset
• Other neurological impairments such as visual
  disturbances, confusion, motor dysfunction or
  sensory loss also occur
• Accompanied by fever
  or stiff neck
• Patient states the
  worse headache in
  my life

64
Types of Headache

• Migraine
• Usually one sided and accompanied by nausea
• Personal or environmental triggers
• Dietary substances or medication triggers
• Cluster
• Unilateral intense pain over and behind the eye
• Lasts about an hour and occur in clusters
  (bunches)
• Tension
• Prolonged overwork or stress
• Usually occipital region

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Headache

• Treatment in general
• Medications based on individual history, symptoms
  and needs
• Analgesics may or may not be effective
• Mild diuretics may be effective at times
• Dark environment
• Rest
• Determine trigger and
  use avoidance
• Accurate diagnosis
  necessary in case of
  more severe problem!

66
Neoplasms - Tumor

• Any abnormal growth of cells
• May be benign or malignant
• Cell multiplication is fast and uncontrolled
• Classified by origin
• Treatment - depends on type, location age of
  tumor
• Observation
• Chemotherapy
• Radiation therapy
• Surgical removal
• 
  

67
Malignant Neoplasms

• Cancerous tumor
• Embryonic or poorly
  differentiated cells
• Grow in a disorganized manner
• Necrosis and ulceration is common sign
• Invasion of surrounding tissue for nutritional
  needs
• Metastatic in nature (i.e. Initiates growth of
  like tumors in other areas)
• 
  

68
Benign Neoplasms

• Usually not dangerous to life unless they occur
  in a vital organ
• Slow growth
• Do not invade tissue for nutrition
• Usually encapsulated
• Do not form secondary tumors in other organs

69
Assessment of Neoplasms

• Some are painful yet some have no pain at all
• External presentation
• Irregular borders
• Rough texture
• Brown/black in color
• Capsule formation under the skin
• Ulceration of overlying skin
• Dependant on the organ or organ system affected
• 
  

70
Neoplasm

• When to be concerned
• Change in bowel or bladder habits
• A sore throat that does not heal
• Unusual bleeding or discharge
• Thickening on breast or other soft tissue
• Indigestion or difficulty swallowing
• Obvious change in a wart or mole
• Nagging cough or hoarseness

71
Neoplasm Treatment

• Chemotherapy
• Intravenous pharmacological therapy to slow
  growth or kill tumors
• Cytotoxic to all cells of the body even though
  target is cancerous cells
• Can cause lethargy, hair loss, unsteady gait,
  weakness and nausea

72
Neoplasm Treatment

• Radiation therapy
• Ionizing radiation
• Dose of particulate or electromagnetic radiation
  to a specific area of the organ or body
• Can come from outside the body or inside the body
  (implanted radiotherapy)
• More effective and less harmful than when first
  introduced

73
Neoplasm Treatment

• Surgical intervention
• Dependant on type and amount of tissue
  involvement with the tumor
• Can be radical or precise
• Can be used in conjunction with other therapy
  methods
• Can cause self esteem issues

74
Neoplasms

• Prevention strategies to include in patient
  teaching
• Self breast exams
• Mammograms
• PAP smears
• Yearly physical exams
• Self testicular exams
• Prostate screening
• PSA
• Digital inspection
• Seek medical evaluation early after abnormal
  finding
• 
  

75
Bells Palsy

• Seventh cranial nerve inflammation or trauma
• Temporary weakness or
  paralysis in facial muscles
• Can reoccur
• Good to complete recovery
  with nerve regeneration
• Conditions that compromise
  the immune system increase
  odds of disease
• Lyme disease, herpes viruses,
  mumps and HIV infections

76
Degenerative Neurological Disorders

• Muscular fatigue usually attributed to
  interruption in the ability of the axon to
  communicate with the muscular endplate for
  various reasons
• Symptoms can be mild to severe depending on
  manifestation and advancement of the disease
  process can come and go can be localized or
  systemic
• Chronic conditions can be debilitating and affect
  quality of life
• 
  

77
Degenerative Neurological Disorders

• Pathophysiology is variable and dependant on the
  specific disease
• Some are caused by an autoimmune type response to
  a toxic invader
• Example Multiple sclerosis
• Some are the muscles inability to use the
  proteins provided by the body as fuel
• Example Muscular dystrophy
• Some are actual nerve tissue breakdown
• Example Parkinsons disease
• 
  

78
Degenerative Neurological Disorders

• Partial facial paralysis
• Example Bells Palsy
• Degeneration of the cell bodies in the gray
  matter of the anterior spinal cord, brain stem
  and pyramidal tract
• Example Amyotrophic Lateral Sclerosis (ALS)
• Contraction of muscles or muscle groups that can
  contribute to convulsive disorders
• Example Myoclonus

79
Degenerative Neurological Disorders

• An abnormal closing of the protective bony
  casement for the spinal cord. Nervous meninges
  may or may not be exposed
• Example Spina bifida
• Non-inflammatory lesions that affect the
  peripheral nervous system
• Example Peripheral neuropathy

80
Degenerative Neurological Disorders

• General disease manifestations
• Weakness
• General body aches
• Partial paralysis that comes and goes
• Parasthesia - pins needles sensation
• Peripheral sensory impairment
• Respiratory insufficiency (chronic stages)
• Immunosuppression - more vulnerable to contract
  communicable diseases
• Multiple medication interactions
• 
  

81
Degenerative Neurological Disorders

• Pharmacological interventions range from
  anti-inflammatory drugs to experimental protein
  altering medications
• Medication usage depends on the organ system
  involved and the severity of symptom
• Environmental changes (living in a cool area) can
  help some diseases
• Decreased exercise or production of muscular heat
  can decrease symptoms

82
Degenerative Neurological Disorders

• Caring for the patient in crisis must include
  maintaining ABCs
• Endotracheal intubation or bagging the patient
  through an in-place tracheostomy may be necessary
• Supportive care for hypotension
• Patients may need total lift assistance to move
• 
  

83
Muscular Dystrophy

• Inherited through DNA degeneration of muscle
  fibers
• Early recognition in children who are slow to sit
  and walk
• Calf muscles become bulky as wasted
  muscle turns to fat
• Pulmonary infections and heart
  failure are frequent causes of
  death

84
Multiple Sclerosis

• Myelin in the brain and spinal cord are
  destroyed. Autoimmune system sees myelin as
  foreign material.
• Experience numbness to paralysis
• Damage to white matter causes fatigue, vertigo,
  unsteady gait, slurred speech,
  pain
• Some disable at onset others degenerative over
  many years

85
Structure of the Neuron and Multiple Sclerosis

• The myelin sheath is a membranous extension of
  specialized cells called oligodendrocytes. These
  form an insulating substance. Non-myelinated
  axons (not insulated) conduct impulses very slowly

86
Parkinsons Disease

• Degeneration of nerve cell in basal ganglia in
  the brain
• Lack of dopamine inhibits basal ganglia from
  modifying nerve pathways that control muscle
  contraction
• Tremors, joint rigidity
• Leading cause of neuro disability
  in those over 60
  years old

87
Lou Gehrigs Disease - ALS

• Progressive motor neuron disease
• Types
• Spinal muscular atrophy
• Bulbar palsy
• Primary lateral sclerosis
• Pseudobulbar palsy

88
Amyotrophic Lateral Sclerosis
(ALS)Upper motor neurons affected in the central
nervous system lower motor neurons affected in
the peripheral muscles
89
Amyotrophic Lateral Sclerosis (ALS)

• More common men over 50
• Weakness, quivering (fasciculations)
• Unable to speak, swallow, move, breath on
  own
• Intellect and awareness maintained
• Become ventilator dependent
• Aspiration pneumonia constant threat
• Starvation, failure to thrive

90
Trigeminal Neuralgia

• Trigeminal nerve 5th cranial
  nerve with opthalmic, maxillary and
  mandibular functions
• Affects skin of upper eye, side
  of nose, half of scalp
• Affects mucous
  membranes of nose,
  forehead, upper lip
• Affects lower teeth and tongue

91
Peripheral Neuropathy

• Axon or myelin sheath in peripheral nervous
  system damaged/irritated causing blockage of
  electrical signals
• Can affect
• muscle activity
• sensation
• reflexes
• internal organ function
• Can be caused locally - trauma, compression
  (tight casts, tourniquet use), carpal tunnel,
  infections
• Can be demyelination or degeneration of
  peripheral nerves - diabetes, Guillain-Barre
  syndrome

92
Myoclonus

• Temporary, involuntary rapid, uncontrolled
  muscular contractions (jerking) or twitching of a
  group of muscles
• Generally considered a symptom more than a
  diagnosis
• Can occur at rest or during movement
• Can distort normal movement and interfere with
  the ability to eat, walk, and talk

93
Spina Bifida

• Defect of neural tube closure
• Portion of vertebra fails to develop leaving a
  portion of the spinal cord unprotected
• Lower back most affected
• Nerve damage is permanent
• Long term effects
• physical mobility limitations
• loss of bowel bladder control
• most have some form of a
  learning disability

94
Spina Bifida
95
Degenerative Neurological Diseases

• Make treating the chief complaint a priority
• Do not overlook the underlying history but do not
  allow it to cloud judgement for a more serious
  issue
• Management Plan
• History
• Acute or chronic complaint for today?
• General health?
• Previous medical conditions?
• Medications?

96
Degenerative Neurological Diseases

• Management
• Oxygen
• Position of comfort
• Venous access
• Pharmacological interventions
• Check for hypoglycemia in setting of altered
  level of consciousness
• Antihistamine - benadryl for dystonic reactions
  (impairment of muscle tone (peculiar posturing
  difficulty speaking) after exposure usually to
  certain meds)
• Psychological support

97
Degenerative Neurological Diseases

• Treatment concerns
• mobility often limited
• communication often difficult - hearing, speech
  unclear
• respiratory compromise - especially exacerbations
  of underlying problems
• anxiety - coping with debilitating disease
  difficult on patient and family stress and
  anxiety levels can run high

98
Case Study 1

• 32 year old male unrestrained in head-on MVC at
  55 mph
• Awake oriented, increased respiratory rate,
  weak rapid radial pulse
• Major complaint is pain to the left side of the
  chest with evident redness, crepitation felt on
  palpation
• Vital signs B/P 102/50 P - 108 R - 24 pulse ox
  94 EKG - sinus tachycardia
• Breath sounds - decreased left side

99
Case Study 1

• General impression (what are possibilities)?
• Cardiac contusions
• Lung contusions
• Pneumothorax
• The patient is becoming more restless with
  increased anxiety pulse ox dropping to 84
  respiratory rate climbing to 38 and now shallow
  with increasing dyspnea
• Whats going on now?

100
Case Study 1

• Reassess ABCs
• Airway still open
• Breathing getting more difficult
• Breath sounds absent on the left
• Pulse more rapid and thready and barely palpable
  radially
• Impression
• Tension pneumothorax
• Treatment
• Initially needle decompression

101
Case Study 1

• Landmarks for needle decompression?
• 2nd intercostal space in the midclavicular line
• Be above the rib (avoid vessels nerves that run
  under the rib)
• Equipment used in the field
• Largest gauge longest needle available
• 12-14 G and 3 inches long
• Flutter valve prepared
• Skin prepped
• Needle must be secured in place

102
Case Study 2

• 55 year old extremely obese female unrestrained
  rear seat passenger of taxi cab involved in 60
  mph MVC
• Patient is agitated, complaining of pain all over
  (was thrown around back of cab)
• Patient is pale, slightly diaphoretic (apologizes
  because she says she is always somewhat sweaty),
  unable to feel radial pulse because of fat
  wrists

103
Case Study 2

• If unable to take a blood pressure in the upper
  arm, what are alternatives?
• Place the cuff around the forearm and place the
  stethoscope over the radial pulse area.
• Not acceptable to not attempt any kind of blood
  pressure.
• Why is this patient so restless?
• Dont be fooled by the obvious and dont dismiss
  her concerns to her weight

104
Case Study 2

• What can cause restlessness?
• Hypoxia
• Hypovolemia
• Internal injury
• Hypoglycemia
• Pain
• Anxiety being scared
• Being uncomfortable (pain, positioning, full
  bladder)

105
Acknowledgement

• NIMSCA contribution for packet by
• Kathy Wexelberg RN, Advocate Christ
• Marlene Blacklaw, RN, Advocate Christ
• Lonnie Polhemus, EMT-P, Silver Cross
• Additions made by
• Sharon Hopkins, RN, BSN,
• Condell Medical Center
• Region X SOPs, Effective March 2005