The Traumatically Injured Patient - PowerPoint PPT Presentation

Loading...

PPT – The Traumatically Injured Patient PowerPoint presentation | free to download - id: 6c7566-YTczO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

The Traumatically Injured Patient

Description:

The Traumatically Injured Patient April 2014 CE Condell Medical Center EMS System Site Code: 107200E-1214 Prepared by: Sharon Hopkins, RN, BSN, EMT-P – PowerPoint PPT presentation

Number of Views:17
Avg rating:3.0/5.0
Date added: 27 August 2019
Slides: 97
Provided by: Informat78
Learn more at: http://www.advocatehealth.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: The Traumatically Injured Patient


1
The Traumatically Injured Patient
  • April 2014 CE
  • Condell Medical Center
  • EMS System
  • Site Code 107200E-1214
  • Prepared by Sharon Hopkins, RN, BSN, EMT-P
  • Rev 5.23.14

2
Objectives
  • Upon successful completion of this module, the
    EMS provider will be able to
  • 1. Describe the purposes of data collection in
    injury
  • prevention, trauma registry, and quality
    improvement.
  • 2. Describe the association between mechanism of
    injury and anticipated injury patterns.
  • 3. Describe trauma assessment process
  • 4. Describe trauma assessment priorities.
  • 5. Describe the capabilities of a Level I and
    Level II Trauma Centers.

3
Objectives contd
  • 6. Describe the procedure for instituting
    critical invasive interventions to the critically
    injured patient.
  • 7. Given a variety of scenarios, assign the
    appropriate trauma triage criteria to the patient
  • 8. Actively participate in review of selected
    Region X SOPs.
  • Actively participate in review of a variety of
    EKG rhythms and 12 lead EKGs.
  • Actively participate in case scenario discussion.

4
Objectives contd
  • 11. Actively participate in return demonstration
  • of insertion of IO, King airway, and Quick
  • Trach at the paramedic level.
  • 12. Actively participate in ventilating a patient
  • via a BVM at the EMT-Basic level.
  • 13. Review responsibilities of the preceptor
    role.
  • 14. Discuss the use of tourniquets and QuikClot
    tools in Region X.
  • 15. Successfully complete the post quiz with a
    score of 80 or better.

5
Data Collection
  • Processes used to identify problems/issues and
    remedy them
  • Process of gathering and measuring information
  • Accurate data is essential
  • Results drive decision making
  • Focus is on objective, not subjective information

6
Focus of Data Collection
  • Move from I think there is a problem to Data
    indicates the problem is
  • In past, medical practices have been based on
    medical knowledge, intuition, and judgment
  • Care provided needs to be best practice
    (evidenced based practice)
  • Based on best available clinical and scientific
    evidence available in literature

7
Data Collection Injury Prevention
  • Changes over the years driven by data
  • Restraints consisted of lap belt in the front
    seat only (early 1900s)
  • Now lap and shoulder belts are positioned
    through-out vehicle
  • Early air bags for driver only
  • Now air bags all around vehicle
  • Opposing roadways had no separation head on
    collisions more common
  • Hard to find a major roadway without some
    separation (i.e. concrete barrier, grass)

8
Data Collection State Trauma Registry
  • Hospitals submit data to the State of Illinois
    specifically for patients with traumatic injuries
  • Again, data drives change
  • Without specific, accurate data, evidence based
    changes difficult to formulate

9
Trauma Transports By The Numbers
  • Volume of trauma transports in Region X
  • Total transports reported to IDPH 2011 5914
  • Total transports reported to IDPH 2012 6084
  • Total transports reported to IDPH 2013 4454
  • Snapshot of CMC totals reported to IDPH
  • Total 2012 1361 (Cat I 208 Cat II 729)
  • Total 2013 1256 (Cat I 181 Cat II 792)
  • Dec 2013 total - 144 (Cat I - 12 Cat II - 54)
  • Patients included IF admitted or transferred
    out
  • First 3 quarters 2013 reported

10
Mechanism of Injury (MOI)
  • Refers to how a person was injured
  • Kinetics is the science of analyzing the MOI
  • Documentation describing the MOI is the data used
    to drive decisions
  • Needs to be detailed
  • i.e. Why and how patient fell
  • MOI can influence assessment and interventions
  • Changes to product design/structure and use can
    be generated after review of data

11
MOI
  • Due to collected data, energy patterns can be
    predicted and allow the rescuer to focus on
    probable and most likely injuries anticipated
  • Vehicle collisions
  • Falls
  • Penetrating trauma
  • Explosions

12
MOI
  • Falls most common but
  • Over 1/3 of deaths result from MVC
  • Best you could do for a patient???
  • Maintain a high index of suspicion

13
Trauma Assessment Process
  • Scene safety and size up
  • Primary or initial assessment
  • AVPU, ABCs and c-spine control
  • Transport decision
  • Rapid trauma assessment or focused exam
  • Detailed secondary assessment
  • Ongoing assessment

14
Trauma Assessment Process
  • Be methodical
  • Be repetitive
  • Perform the same steps on all calls
  • Can modify steps based on type of call
  • Builds muscle memory
  • If you always do something, youll never NOT do
    something

15
Trauma Intervention Priorities
  • Identify life threats in primary assessment
  • Continue to look for life threats with every
    additional assessment
  • Correct airway problems
  • Establish adequate oxygenation ventilation
  • Control external hemorrhage
  • Direct pressure, pressure points, tourniquets,
    hemostatic agents
  • Expedite transport to appropriate facility
  • Need to determine category trauma to make this
    decision

16
Category I Trauma Patient Unstable Vital Signs
  • GCS lt13 with blunt head injury
  • Trying to avoid categorizing all patients with
    altered level of consciousness NOT due to trauma
    (i.e. under the influence of ETOH and drugs
  • Respiratory rate lt10 or gt29

17
Category I Trauma Patient Anatomy of Injury
  • Penetrating injuries to head, neck, torso, groin
  • Combination trauma with burns gt20
  • 2 or more proximal long bone fractures
  • 2 or more body regions with potential life or
    limb threats
  • Unstable pelvis
  • Flail chest

18
Category I Trauma Patient Anatomy of Injury
contd
  • Limb paralysis and/or sensory deficits above
    wrist or ankle
  • Open or depressed skull fracture
  • Amputation proximal to wrist or ankle

19
Category II Trauma Patient Mechanism of Injury
  • Ejection from auto
  • 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 run over

20
Category II Trauma Patient Mechanism of Injury
contd
  • Auto vs pedestrian/bicyclist with gt 5mph impact
  • Extrication gt 20 minutes
  • High speed MVC
  • Speed gt40 mph
  • Intrusion gt12 inches
  • Major deformity gt20 inches
  • Basically, a very lucky patient with significant
    MOI which increases the risk of injury

21
Category II Trauma Patient Co-morbid Factors
  • Increased risk of morbidity or mortality related
    to co-existing factors
  • Age lt5 without car/booster seat
  • Bleeding disorders or on anticoagulants
  • Pregnancy gt20 weeks
  • Renal disease requiring dialysis

22
Anticoagulants
  • Why are these an issue with trauma?
  • Increases the risk of bleeding internal and
    external
  • Can you name the 6 more commonly used
    anticoagulant medications that can increase the
    risk of bleeding for trauma patients?
  • Coumadin / Warfarin
  • Xarelto
  • Pradaxa
  • Elaquis
  • Lovenox
  • (Note Plavix ASA are antiplatelets)

23
Transportation DestinationWho Goes Where???
  • Highest level Trauma Center within 25 minutes of
    transport time
  • Unstable systolic B/P on 2 consecutive readings
  • Adult lt 90 systolic
  • Peds lt 80 systolic
  • Category I trauma patient
  • Closest Trauma Center
  • Category II trauma patient
  • The lucky patient with a significant MOI!

24
Transport Destination contd
  • Closest appropriate comprehensive ED
  • Patient NOT categorized as I or II but who has
    suffered a traumatic injury
  • Closest comprehensive ED
  • The patient with NO airway
  • This includes GEC and Vistas Emergency Center in
    Lindenhurst

25
Level I and Level II Trauma Centers
  • IDPH has printed Administrative Code (i.e. Rules
    and Regulations) designating criteria to be met
    by hospitals
  • Staffing availability
  • By title, department, and hours available
  • Staff training
  • Equipment
  • Performance QI program
  • Operating Protocols

26
Trauma Center Operations
  • IDPH Rules and Regs require
  • Staffing availability requirements by specialty
  • Immediate, 30 minutes, 60 minutes response
  • Transfer agreements for unique cases (ie burns)
  • List of equipment per level trauma center
  • Minimum performance QI to be performed
  • Guidelines for contents of operating protocols
  • Including measures to avoid going on by-pass
  • Type of public education performed

27
IO Access
  • When there is a need to have access for
    medication administration and alternative
    peripheral sites have failed or are not available
  • Needle inserted into bone marrow cavity

28
Treatment Interventions - IO
  • Indications
  • Shock, arrest, or impending arrest
  • Unconscious/unresponsive or conscious critical
    patient without IV access
  • 2 unsuccessful IV attempts or 90 second duration
    or no visible sites

29
IO contd
  • Contraindications
  • Insertion into extremity with fracture
  • Infection at insertion site
  • Previous orthopedic procedure
  • Knee replacement, previous IO within 480
  • Pre-existing medical condition
  • Inability to locate landmarks
  • Significant edema

30
IO Sites
  • Primary site proximal tibia
  • Secondary site for adults proximal humerus
  • Not developed anatomically in children lt5,
    therefore not recommended lt 5y/o
  • If you are anticipating humeral site in the
    pediatric patient over 5 years-old, contact
    Medical Control for guidance

31
Proximal Tibia Insertion Site
  • Flat surface below growth plate and medial to
    tibial tuberosity
  • Palpate 2 fingers below patella to tibial
    tuberosity (approx. 2 cm)
  • Leg needs to be straight
  • Not always palpable in very young
  • Palpate 1 finger width medially
  • EZ IO to big toe

32
Humeral Insertion Site
  • Place patients hand over navel and elbow
    adducted to body (tucked back in line with spine)
  • Palpate with thumb moving up the humeral bone
  • Palpate to the most prominent rounded protrusion
    greater tubercule
  • Rotate fingers around site to confirm
  • Site is anterior to midline of arm

33
Humeral Site Alternate Methods to Identify
  • Keep hand over navel, elbow adducted
  • Using heel of your hand, strike at prominence top
    of arm
  • Site feels like golf ball
  • OR
  • Slide fingers down from top of shoulder
  • As soon as drop off palpated, come down 1 finger
    breadth and anterior 1 finger breadth

34
IO Sizing
  • Pink 15 mm 15 G
  • Blue 25 mm 15 G
  • Yellow 45 mm 15 G
  • 15 mm if you can feel bone just under skin
    generally for infants 3-39 kg (6.5-88)
  • 25 mm general population for tibial placement
  • 45 mm adult humeral site and obese leg

35
IO Equipment
  • IO needle package
  • IO needle
  • EZ-connect tubing
  • Florescent arm band
  • Driver
  • Syringe with NS for flushing
  • Primed normal saline (NS) IV bag
  • Material to cleanse site
  • Pressure bag
  • Material to secure needle

36
IO Needles
  • Whats with the black
    hash marks???
  • Purpose to validate appropriate length of
    needle for site chosen
  • Advance needle into site until bone touched
  • If you can see a black hash mark, you have enough
    needle left to be secured into bone
  • If no hash mark visible, withdraw needle from
    skin, move to next size needle and resume
    placement

37
Confirming IO Placement
  • Needle stands up by self
  • Flushes without resistance
  • No evidence of infiltration
  • Fluid flows with pressure bag
  • Can squeeze bag manually until pressure bag in
    place but may not be enough pressure

38
Pain Control For IO Infusion
  • What causes pain during fluid infusion?
  • Infusion of fluids into a non-expandable space
  • How do you fix it?
  • Lidocaine 50 / 60 / 60
  • 50 mg over 60 seconds wait 60 seconds
  • For peds 1mg/ kg up to 50 mg
  • Company recommended to inject Lidocaine before
    initial flush if anticipated
  • Infusion can be stopped any time to instill
    Lidocaine for pain control

39
Why Do IOs Fail???
  • Catheter not flushed following insertion
  • Pressure bag not in place
  • FYI - Manually squeezing IV bag may not produce
    high enough pressure
  • Wrong size needle chosen
  • Too short and not entered into bone
  • Drilled too deep and punctures through the bone

40
Treatment Interventions King Airway
  • Indications
  • Cardiac or respiratory arrest
  • Inability to place ETT in unresponsive patient
    without a gag reflex
  • Contraindications
  • Height less than 4 feet
  • Presence of gag reflex
  • Ingestion of caustic substance
  • Known esophageal disease

41
Gag Reflex
  • Purpose
  • Protects the airway
  • How to test for presence
  • Stroke eyelashes or tap space between eyes
    looking for blink reflex
  • Blink and gag reflexes are protective
  • Disappear at same time
  • Testing for one sheds light on other one
  • Note about 1/3 of adults have ? gag reflex

42
King Airway Sizing
  • Color coded sizes
  • Size 3 yellow
  • Size 4 red
  • Size 5 - purple
  • Based on patient's height
  • Yellow size 3 for 4 5 foot height
  • Red size 4 for 5 6 foot height
  • Purple size 5 for over 6 foot height

43
King Airway Equipment
  • King airway properly sized
  • Large syringe
  • Yellow size 3 initial balloon inflation 50 ml air
  • Red size 4 initial balloon inflation 70 ml air
  • Purple size 5 initial balloon inflation 80 ml air
  • Water soluble lubricant
  • Avoid smearing lubricant over distal air passages
    on airway

44
King Airway Confirmation
  • Begin by attempting to start ventilating patient
    you should meet resistance
  • Perform usual steps
  • Observe bilateral rise and fall of chest
  • 5 point auscultation
  • Absent epigastric sounds
  • Bilateral breath sounds
  • Capnography
  • Qualitative/colormetric - yellow
  • Note This is a blind insertion
  • You will not visualize vocal cords

45
Why do King Airways Fail???
  • Failure to choose correct size airway
  • Failure to initially insert airway deep enough
  • Failure to inflate cuff sufficiently
  • Failure to pull King airway out far enough

46
Treatment Interventions Quick Trach
  • Indications
  • All other conventional methods to ventilate
    patient have failed
  • Contraindications
  • Tracheal transection
  • Other less invasive techniques allows ventilation
    of patient (i.e. they are successful)

47
Quick Trach Sizing
  • Size 4.0 mm ID patients gt77 (35 kg)
  • Size 2.0 mm ID patients between 22 and 77
    (10 35 kg)
  • Needle cricothyrotomy patients lt 22 (10 kg)

48
Quick Trach Equipment
  • Contained in one kit
  • Size 4.0 or 2.0 pre-assembled cricothyrotomy unit
  • Attached 10 ml syringe
  • Connecting tubing
  • Padded neck strap
  • Add to kit
  • PPEs
  • Cleansing material
  • BVM

49
Quick Trach Landmark Identification
  • With patient supine, hyperextend neck if no neck
    injury suspected
  • Locate cricothyroid membrane
  • Located between thyroid cartilage (Adams apple)
    and cricoid cartilage
  • Start at sternal notch and run finger upward
  • First rigid landmark is cricoid cartilage
  • Cricothyroid membrane just above cartilage

50
Landmark Identification Alternative Method
  • Palpate prominence of Adams apple
  • Slowly palpate finger downward
  • Finger drops off into cricothyroid membrane

51
Quick Trach Confirmation
  • Audible escape of trapped air
  • Ability to aspirate air via syringe during
    insertion
  • Ability to ventilate Quick Trach 1 breath every
    6 8 seconds
  • Observation of bilateral rise and fall of chest

52
Why do Quick Trachs Fail???
  • Improper identification of landmarks
  • Blockage lower down/ more distal in airway system
  • Improper insertion of device
  • Not removing red stopper
  • Potential for barotrauma (i.e. subcutaneous
    emphysema or pneumothorax) if
    exhalation is inadequate and airway
    pressure is elevated

53
What Is Your Impression???
  • Review the following slides
  • Based on MOI and presenting signs and symptoms,
    determine your general impression
  • Discuss intervention priorities

54
What Would You Do???
  • Patient was unrestrained driver involved in
    head-on with tree
  • Patient is in shock
  • All peripheral veins are collapsed
  • What would be your alternative to inserting a
    peripheral IV???
  • Evaluate extremities for IO access
  • What would block use of this site?
  • Fracture of extremity or infection at intended
    site

55
What Would You Do???
  • Patient becomes unconscious and unresponsive
    while eating
  • You are unable to ventilate even after
    repositioning performing the Heimlich
  • What could be your next interaction?
  • Visualize the airway with blade and handle
  • Have Magill forceps available
  • For unrelieved obstruction, what device would be
    appropriate to use?
  • Prepare for insertion QuickTrach or needle
    cricothyrotomy

56
What Do You Think???
  • How do you find the cricothyroid membrane???
  • Start at notch and run finger up to first bony
    ring
  • Go to soft spot above the cricoid cartilage
  • OR
  • Palpate down to the Adams apple prominence
  • Slide finger over prominence into soft space

57
What Would You Do???
  • Your patient is in full arrest and in VF
  • CPR is ongoing following defibrillation
  • What is your next action IV access or insertion
    of advanced airway???
  • Gain IV access
  • You need a route for drug administration
  • You should already have airway secured via BVM
  • What are the sites for IO insertion if necessary?
  • First site of choice is proximal tibia
  • Back-up site is humeral head

58
What Do You Think???
  • How do you find the proximal tibial landmark???
  • Palpate the distal edge of the patella (knee cap)
  • Leg must be straight
  • Flexed knee alters the landmark
  • 2 fingers below patella palpate the tibial
    tuberosity prominence
  • Not always palpable in the young
  • Move 1 finger width medially

59
What Do You Think???
  • How do you find the humeral head landmark???
  • Patients elbow MUST be tucked back and adducted
    hand resting over navel
  • Landmark not prominent when arm moved forward
  • Palpate humeral head slightly forward from
    midline
  • Aim drill tip to space between sternum and spine

60
Heres the story
  • Your patient has shallow, slow respirations
  • They do not respond to a sternal rub
  • There is no change after Narcan administration
  • Blood glucose level is 72

61
What Do You Think???
  • What measures can be utilized to protect their
    airway???
  • Positioning
  • Easiest technique least often used
  • Suction ready
  • If used, limited to 10 seconds and suction
    applied during withdrawal
  • Placement of advanced airway
  • ETT attempted first
  • King airway placed if unable to place ETT

62
What Do You Think???
  • How do you size the King airway???
  • By patient height
  • How far down do you initially insert the King
    airway???
  • Until the colored hub is even with the teeth or
    lip line
  • When are the cuffs inflated on the King???
  • When the device is inserted up to the hub
  • Inflate with volume printed on side of tube and
    on packaging
  • Reposition tube by pulling it out until bagging
    is easy and you observe rise and fall of chest

63
Triage PracticeCategory I or Category II
  • Review the following slides
  • Determine if the patient is a Category I, II, or
    non-category trauma patient
  • Be prepared to explain your rationale

64
Triage Practice 1
  • You are with the patient who passed out at a
    local event found lying in the grass
  • Minor laceration right palm with broken bottle
    lying near patient
  • Definite evidence of excessive ETOH consumption
  • GCS (3, 2, 5) Total 10
  • Is this a Category I trauma patient due to GCS
    lt13?
  • No no evidence of blunt head injury

65
Triage Practice 2
  • Upon arrival, your patient is standing at the
    roadside
  • Patient was restrained driver in rollover self
    extricated
  • What category trauma is this?
  • Not Category I or II restrained in a rollover
  • Can this patient sign a refusal for
    transportation?
  • Yes, if they are alert and oriented x3 and
    understand the risks and benefits
  • But, due to MOI encourage transport
  • Requires a full, documented assessment

66
Triage Practice 3
  • Your patient was struck by a forklift and hit on
    the right chest wall
  • They are more comfortable with shallow
    respirations and not moving around
  • Your palpation indicates crepitations over
    multiple areas of the rib cage SpO2 94
  • Lung sounds are diminished but present
  • You suspect a flail chest
  • What category trauma is this???
  • Category I flail chest

67
Triage Practice 4
  • Your patient required extrication of 25 minutes
  • Respiratory rate of 32 and shallow
  • Unstable pelvis
  • Penetration of thigh
  • What meets criteria for a Category I patient?
  • Respiratory rate gt29 and unstable pelvis
  • What meets criteria for a Category II patient?
  • Extrication gt20 minutes

68
Triage Practice 5
  • Patient slipped in garage and hit head
  • GCS 15 alert and oriented
  • Med history Allopurinol, hydrochlorothiazide,
    Xarelto, Lipitor
  • Does this patient meet criteria for Category I,
    II, or non-category???
  • Category II co-morbidity on anticoagulant
    (Xarelto)
  • Increased risk for internal bleeding

69
Case Review
  • Review following cases
  • Decide general impression
  • Discuss interventions

70
Case Review 1
  • EMS at scene of a low speed MVC vs pole
  • 67 y/o unconscious driver GCS 11 (3, 3, 5)
  • Multiple facial lacerations
  • Obvious deformity to wrist
  • What is the rhythm strip implications???

Sinus brady with ST elevation obtain 12 lead EKG
71
Case Review 1
  • What are your suspicions???
  • Driver passed out due to low heart rate
  • Driver passed out due to AMI
  • Driver had AMI that caused MVC
  • Driver had MVC and then AMI
  • You are now caring for a trauma and acute medical
    patient
  • What Category trauma are they???
  • Category I GCS lt13 with evidence blunt head
    injury

72
Case Review 1 12 Lead EKGIs there ST
elevation?
  • ST elevation II, III, aVF Inf wall MI

73
Case Review 1
  • What are the implications to your care based on
    working diagnosis?
  • Patient needs routine trauma care
  • Patient also requires care for AMI
  • Can you give ASA if not alert?
  • Hold ASA document why in narrative
  • Does he need NTG?
  • No complaints of chest pain so usually held
  • FYI - Some cardiologists do tend to use it for
    decreasing pre-load even in absence of chest pain
  • Remember to screen for additional
    contraindications
  • B/P, Viagra use (already know inferior wall MI)

74
Case Review 2
  • EMS called for an adult patient that fell from a
    2nd floor balcony
  • Eyelids flutter to touch
  • Moaning and groaning
  • Flexes right arm, extends left arm
  • What is the GCS???
  • Eye opening 2
  • Verbal response 2
  • Motor response 3 (give best score possible)

75
Case Review 2
  • Injuries found after assessment
  • Scalp laceration
  • Forehead hematoma
  • Flail chest right
  • Deformed right humerus
  • Right tib/fib deformity
  • Left femur deformity

76
Case Review 2
  • VS B/P 82/56 P 124 R 24 shallow SpO2 91
  • What interventions does the patient require?
  • Manual c-spine control
  • Supplemental oxygen
  • IV access
  • Limited access to peripheral site
  • If IO, site choice limited to left humerus
  • Fluid challenge 200 ml increments
  • B/P goal 90 systolic as guideline

77
Case Review 2
  • What Category trauma is this patient and why?
  • Category I
  • GCS lt13 with blunt head injury
  • Flail chest
  • 2 or more long bone fractures
  • Anatomical injury and unstable vital signs are
    used to indicate a Category I trauma patient
  • MOI used to indicate a Category II trauma patient

78
Case Review 2
  • As a Category I trauma patient, where does this
    patient get transported to?
  • Highest level Trauma Center within 25 minutes
    transport time

79
Case Review 2
  • What is this rhythm?
  • Does this patient require Adenosine?
  • No!!! consider the cause and treat the cause

Sinus tachycardia
80
Case Review 2 - Discussion
  • When would you administer Adenosine?
  • Adult stable narrow complex SVT
  • Adult stable wide complex monomorphic VT
  • Assumed to be SVT with aberrancy until proven
    otherwise
  • Peds probable SVT with adequate and poor
    perfusion
  • Peds possible VT with adequate perfusion

81
Permissive Hypotension
  • Not a new concept evidenced-based research has
    been underway
  • Challenges the way weve always done it just
    because thats the way weve always done it
  • Currently researching what parameters SHOULD be
    used to evaluate circulatory status of patient to
    determine condition status
  • Currently use systolic blood pressure
  • Region X SOP uses systolic gt90 as guideline

82
Permissive Hypotension contd
  • What do we know?
  • Achieving a normal B/P increases the
    hemorrhaging volume and increases mortality rates
  • Infusing large amounts of crystalloid fluids
  • Dilutes circulating blood volume left
  • Dilutes/makes less effective remaining components
    (i.e. clotting mechanisms)
  • When B/P is normal, compensatory mechanisms of
    body not triggered to turn on

83
Permissive Hypotension contd
  • Why are we talking about this topic???
  • Informational
  • Want to share current research underway
  • Educational
  • Could explain a Medical Control order to restrict
    fluid resuscitation
  • Using critical thinking skills, could encourage
    dialogue with Medical Control regarding degree of
    fluid resuscitation in field for certain
    traumatically injured patients

84
Case Review 3
  • You are called for an adult who was
    clotheslined while riding their
    motorcycle
  • You find rider separated from motorcycle
  • Unresponsive struggling to breathe
  • You provide routine trauma care
  • Manual c-spine control
  • Initial/primary assessment
  • Determined to be rapid transport

85
Case Review 3
  • What are the progression of steps for securing
    the airway???
  • Attempt repositioning
  • Restrictions in place for this patient due to
    high suspicion for c-spine injury
  • Attempt BVM
  • Rate 1 breath every 5 6 seconds
  • Progress to ETT
  • Requires in-line technique for placement
  • Best performed with minimal 2 people

86
Case Review 3
  • If unable to pass ETT, then what???
  • Progress to King airway
  • Blind insertion technique
  • Sizing according to patient height
  • If unable to ventilate with BVM, then what???
  • Consider QuickTrach device
  • How is this device sized?
  • 4.0 for adults gt 77
  • 2.0 for peds 22 77

87
Reminder Ventilatory Rates via BVM
  • Infant and child
  • 1 breath every 3 5 seconds
  • For documentation that would be assisted rate of
    12 20 breaths per minute
  • 60 seconds (1 minute) ? 5 12
  • 60 seconds (1 minute) ? 3 20
  • Adult
  • 1 breath every 5 6 seconds
  • For documentation that would be assisted rate of
    10 12 breaths per minute

88
Reminder Ventilatory Rates via Advanced Airway
  • Infant, child and adult
  • Via ETT, King, combitube or any other advanced
    airway system
  • 1 breath every 6 -8 seconds
  • For documentation that would be assisted rate of
    8 10 breaths per minute
  • 60 seconds (1 minute) ? 8 8
  • 60 seconds (1 minute) ? 6 10

89
Future Developments in Region X
  • Use of tourniquets
  • Use of QuikClot
  • Information and educational material for these
    devices as methods for control of bleeding are
    being developed by the Region

90
Tourniquets
  • In general
  • Tourniquets used when other initial steps fail to
    control bleeding
  • Tourniquet chosen needs to be minimally 4? wide
    or commercial device
  • Needs to be placed just proximal to the wound but
    as distal as possible
  • Once placed, a tourniquet should not be removed

91
QuickClot
  • Hemostatic dressing used to promote clotting
  • Used after failure of conventional methods
  • ?Direct pressure
  • ?Pressure points
  • Works with physical action
  • Material placed over wound absorbs water
    molecules from blood to allow concentration of
    clotting factors
  • Note Elevation not found to be effective OR
    harmful if used would be in conjunction with
    direct pressure never alone

92
Use of QuickClot
  • Pilot study will be completed in Region X
    utilizing volunteer departments
  • Participating departments will complete training
  • Participating departments will report results via
    an evaluation form
  • Results of pilot study to be discussed at Region
    X Trauma/EMS meetings for adoption decision

93
Preceptor Role Peer Review
  • Often perform as a peer in this role
  • You are of the same rank as the person you are
    overseeing
  • Peer review based on current acceptable practices
  • Feedback is timely, routine and a continual
    expectation
  • Peer review fosters continuous learning
  • Feedback is given as a dialogue
  • Focuses on the level of the provider along the
    novice-to-expert continuum

94
Bibliography
  • Bledsoe, B., Porter, R., Cherry, R. Paramedic
    Care Principles Practices, 4th edition. Brady.
    2013.
  • Mistovich, J., Karren, K. Prehospital Emergency
    Care 9th Edition. Brady. 2010.
  • Region X SOPs IDPH Approved January 6, 2012.
  • IDPH Administrative Code Subpart H Trauma Centers
  • https//balancedscorecard.org/Portals/0/PDF/dataco
    ll.pdf
  • http//blog.esurance.com/seat-belt-history/

95
Bibliography contd
  • http//www.jems.com/article/intraosseous/pain-mana
    gement-use-io
  • http//www.narescue.com/media/NAR/guides/ISG-KingL
    TD.pdf
  • www.vidacare.com
  • www.youtube.com/watch?vsHib5EHbUEc
  • www.youtube.com/watch?vGYM3cUBBzls
  • www.youtube.com/watch?vca710sG4-ck
  • www.youtube.com/watch?vaGfDpXrxOk

96
Bibliography contd
  • www.savevid.com/video/rusch-quicktrach.html
  • http//www.youtube.com/watch?vxWERlDWNNm4
  • http//www.youtube.com//watch?vuyh-TDb2xkc
  • http//youtube.com/watch?vBELokurs5fU
  • http//www.jems.com/article/patient-care/permissiv
    e-hypotension-trauma-resuscitat
  • www.NARescue.com
  • www.z-medica.com/
About PowerShow.com