Trauma Patient Assessment Intubation Review Needle Decompression

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Trauma Patient AssessmentIntubation
ReviewNeedle Decompression

• Condell Medical Center EMS System
• October, 2007 CE
• Site Code 10-7200E1207
• Prepared by Sharon Hopkins RN, BSN, EMT-P

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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

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• 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

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7 Ways to Die in Trauma

• Hypovolemia
• Hypoxia
• Acidosis
• Obstructed airway
• Flail chest
• Cardiac tamponade
• Tension pneumothorax

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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

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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

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Normal Blood Volumes

• Neonate 85 ml/kg
• Infant 80 ml/kg
• Adult men 75 ml/kg
• Adult women 65 ml/kg

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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 65ml4420ml

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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

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• 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

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• 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

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• 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

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Categories of Shock orShock 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

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• Distributive shock
• vascular space too large for the amount of blood
  circulating
• problem distributing the blood volume to all the
  bodys 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

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• 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

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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?

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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!

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Hypoxia

• Hypoxemia
• decreased oxygen content of the arterial blood
• Hypoxia
• decreased oxygen content to the bodys cells and
  at the tissue level

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Causes of Hypoxia

• Reduction of oxygen in the system
• Inadequate oxygen transport
• Inability of tissues to use the oxygen delivered

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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)

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• 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

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• Chest wall abnormalities
• flail chest
• scoliosis
• full thickness burns with contractions
• Increased thickness of the respiratory membrane
• pulmonary edema
• interstitial fibrosis

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• 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

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• 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

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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

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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

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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

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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

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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?

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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

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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

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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

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Magill Forceps
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Needle Cricothyrotomy

• While patient supine, locate the cricothyroid
  membrane
• soft membrane between thyroid cartilage (Adams
  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

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Thyroid cartilage Cricothyroid
membrane Cricoid cartilage Thyroid gland
Thyroid cartilage (Adams apple) Cricothyroid
membrane Cricoid cartilage
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• 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

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Needle Cric

• Step 1 - needle advanced, confirmation by air
  being aspirated with the syringe

Step 2 - catheter advanced while the stylet is
removed
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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
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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

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Melker Cric Kit

• Department personnel recommended to review the CD
  from Cook Medical to review using the Melker
  Emergency Cricothyrotomy Catheter Set

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Case Scenario 3

• This patient has been impaled by a foreign object
• Do they need spinal immobilization for this
  
  injury?
• No

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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

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Flail Chest On Right Side
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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

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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

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Cardiac Tamponade

• Tears in the heart chamber walls with blood
  entering the pericardial space
• Occurs in lt2 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

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Cardiac Tamponade
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Signs Symptoms of Cardiac Tamponade

• Peripheral vasoconstriction (cool clammy)
• Tachycardia
• Narrowed pulse pressure (diastolic blood pressure
  rises more than systolic blood pressure)
• Becks Triad
• JVD (early sign)
• muffled heart tones
• hypotension (late sign)

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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

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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

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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

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Tension pneumothorax on the right side with
shifting to the left
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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

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Field Interventions For Tension Pneumothorax

• A true emergency requiring immediate
  identification and intervention
• Goal reduce the pressure in the pleural space
• emergency needle decompression

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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)

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Landmarks For Needle Decompression
Rib 1
Rib 2
2nd intercostal space mid-clavicular line
Rib 3
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Placement of Needle
Flutter valve attached
2nd rib
3rd rib
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Placement of Needle
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• 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 4x4s around base of the
  angiocath
• Monitor patient status watching for deterioration

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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
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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

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Case Scenario 4

• Patient interventions
• Full spinal immobilization
• CPR - IV - O2 support - monitor
• Consider the 6 Hs and 5 Ts as causes
• Perform bilateral chest decompressions
• Fluid challenges reevaluating every 200 ml
• Drugs - Epinephrine 1 mg every 3-5 minutes
• Rate is gt60 so Atropine not indicated
• Transport destination
• Traumatic arrest - to closest Trauma Center

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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

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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

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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

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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)

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• 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

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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

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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 patients
  head

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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
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Difficult Intubations
Neck and chest tissue fall over the airway
making intubation difficult
Better patient positioning allows for improved
chance of success in intubation
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Orotracheal Intubation
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Cricoid Pressure - Sellicks 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

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Lateral View of ETT Placement
Curved blade in vallecula
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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

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Opening Airway with Cervical Trauma - Jaw Thrust
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In-Line Intubation

• Intubator positioning
• Intubator may sit at the patients head and
  their legs straddle the patients shoulders and
  arms patients head is gripped with the
  intubators thighs
• Intubator may lie on their stomach facing the
  patients head
• A second rescuer stabilizes the patients head by
  gripping the head from the side and grasping
  along the jaw and lower face, spreading their
  fingers near the temple (ear) area

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In-Line Intubation

• Patient
• being
• stabilized
• Equipment
• being
• prepared
• Cricoid
• pressure
• being held

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Orotracheal Intubation

• Face-to-face procedure to intubate a patient when
  the provider cannot take a position above the
  patients 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)

80
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 patients mouth
• Follow the normal curvature of the tongue
• Visualize the vocal cords from above the
  patients mouth

81

• 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

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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

83
Cricoid Pressure
84

• 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

85

• 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

86
Case Scenario 5

• What airway significance could there be in this
  case and what needs to be monitored?

87
Case Scenario 5 - End Results

88
Region X SOPs

• Field Triage Criteria For Assessing Trauma
  Patients
• In-Field Spinal Clearance
• Routine Trauma Care
• Revised Trauma Score

89
Field Triage Criteria

• Transport to highest level Trauma Center within
  25 minutes if
• systolic blood pressure lt 90 x2 (peds lt
  80 x 2)

90
Field Triage Criteria

• Transport to highest level Trauma Center within
  25 minutes if patient is a Category I
• Vital signs unstable
• Glasgow Coma Scale lt10 or deteriorating mental
  status
• respiratory rate lt10 or gt29
• Revised Trauma Score lt11

91
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 gt20
• 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

92
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 gt20 mph or with separation of
  rider from bike
• Rollover (unrestrained)
• Falls gt20 feet (peds falls gt3x body length)
• Pedestrian thrown or runover

93

• Mechanism of injury (continued)
• Auto vs pedestrian/bicyclist with gt5mph impact
• Extrication gt 20 minutes
• High speed MVC
• Speed gt 40 mph
• Intrusion gt 12 inches
• Major deformity gt 20 inches
• Co-morbid factors
• Age lt 5 without car/booster seat
• Bleeding disorders or on anticoagulants
• Pregnancy gt 24 weeks

94
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

95
Field Triage Criteria

• Transport to the closest Trauma Center if
• traumatic arrest
• isolated burns gt 20 BSA
• Transport to closest Emergency Department if
• no airway can be established

96
Region X SOPs 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

97
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

98
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

99
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

100
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?

101
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 lt 2 seconds abdomen
  flat, non-tender pain over lower right chest

102
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 patients pulse rate not be higher
  if he lost so much blood?
• The patient was taking beta blockers for
  hypertension control

103
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

104
In-Field Spinal Clearance SOP

• Mechanism of injury
• High velocity MVC gt 40 mph
• Unrestrained occupant in MVC
• Passenger compartment intrusion gt 12 inches
• Ejection from vehicle
• Rollover MVC
• Motorcycle collision gt 20 mph
• Death in same vehicle
• Pedestrian struck by vehicle
• Falls gt 2 time patient height
• Diving injury

105
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

106
In-Field Spinal Clearance SOP

• Patient reliability
• Signs of intoxication
• Abnormal mental status
• Communication difficulty
• Abnormal stress reaction

107
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

108
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

109
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., OKeefe, M. Emergency
• Care 10th Edition. Brady. 2005.

110

• Region X Standard Operating Procedures. March 1,
  2007.
• Sanders, M. Mosbys Paramedic
• Textbook. Elsevier. 2007.

111
Name That Rhythm
SVT
112
Name That Rhythm
Second Degree Type II - Classical
113
Name That Rhythm
Atrial Fibrillation
114
Identify ST Elevation
ST elevation V1 - V4