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Assessment of the Trauma Patient

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Title: Assessment of the Trauma Patient Author: Courtney McKibben Last modified by: Marilynm Created Date: 1/27/2012 10:36:44 PM Document presentation format – PowerPoint PPT presentation

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Title: Assessment of the Trauma Patient


1
Assessment of the Trauma Patient
  • 2nd Trimester, June 2013 CME
  • Prepared by Leslie Livett RN, MS
  • Presence St. Joseph Medical Center

2
Objectives
  • Upon successful completion of this module, the
    EMS provider should be able to
  • Understand what the mechanism of injury is and
    the information it provides
  • Describe assessment and treatment appropriate for
    the patient with traumatic insult
  • Tension pneumothorax, sucking chest wound, flail
    chest, eviscerated organs
  • Successfully identify the landmark and perform
    chest needle decompression
  • Actively participate in trauma scenario
    discussion

3
Definition
  • Damage to the body caused by an exchange of
    energy beyond the bodys resilience.

4
Epidemiology of Trauma
  • Leading cause of death in ages 1-44
  • 3rd leading cause of death for all ages
  • 100,000 deaths/year
  • 60 million injuries/year

5
Overall Approach
  • Anticipate the worst
  • Never make any assumptions
  • History and Exam have to make sense
  • Dont take short cuts
  • Document frequently
  • TEAMWORK

6
Dont get distracted with ugly injuries
7
  • Your Initial assessment findings will determine
    how you will proceed
  • Caveats in Elderly
  • Loss of Reserve Function
  • Assume that every organ has some degree of loss
  • Improve outcomes

8
Trauma System
  • Mortality is decreased when
  • The RIGHT patient
  • Gets to
  • The RIGHT hospital
  • In the
  • RIGHT AMOUNT of TIME

9
A B Cs of Trauma Care
  • Many ways to interpret that
  • The original way
  • A Airway with C-spine
  • B Breathing
  • C Circulation

10
The New Way
  • A Airway
  • B Be Careful of the Airway
  • C Concentrate on the Airway

11
(An Amusing Variation)
  • A Antibiotics
  • B Blood Cultures
  • C Consults
  • A Always
  • B Bring
  • C Camera

12
Approach to Trauma
  • Challenging
  • Systematic Approach to Patient Care
  • Logical Organized
  • Mechanism of Injury

13
General Assessment Pearls
  • With restlessness and agitation, you must
    consider
  • hypoxia,
  • shock,
  • influence of alcohol and/or drugs
  • need to assess for all reasons of restlessness.
  • dont not just stop when you discovered one cause
  • there may be more than one pathology going on at
    a time

14
AIRWAY
  • Way back in 1983, studies showed us that NO
    Airway or a DELAYED airway was the single most
    important cause of mortality in trauma
  • If you THINK you need an airway .
  • YOU DO

15
Airway Assessment Maneuvers in Trauma
  • Inspection
  • Color, contour, symmetry, smell, audible abnormal
    sounds, obvious wounds
  • Palpation
  • Textures, moisture, pulsations, deformities,
    crepitus, masses, temperature
  • Percussion
  • Resonant normal
  • Hyperresonant more air
  • Dull solid, fluid
  • Auscultation

16
Focused History Physical Exam
  • As you approach OBSERVE
  • Level of Consciousness
  • Appearance
  • Restlessness
  • Distress/Pain
  • Hemorrhage/Gross Deformities
  • Unusual odors
  • Kinematics

17
Airway C-Spine
  • Access
  • Assess
  • Maintain
  • Cervical Spine Control

18
Airway Compromised
  • What are some etiologies of a compromised/
    obstructed airway in trauma?

19
Airway Compromised
  • Discuss What are some causes of a compromised/
    obstructed airway in trauma?

20
Airway Assessment
  • Observe for Respiratory effort
  • Symmetry
  • Accessory muscles
  • Audible sounds
  • What should ventilations
  • sound like?
  • Ability to talk
  • Impaired laryngeal reflexes

21
Airway Intervention
  • Position Appropriately
  • Reposition Mandible
  • Chin lift, jaw thrust
  • DO NOT
  • Hyperextend or Hyperflex
  • Remove Debris/Suction
  • Maintain with Adjuncts

22
Airway Adjuncts
  • Nasopharyngeal if awake
  • Oropharyngeal if unconscious/no gag
  • Rescue
  • BVM, Intubation,King LTS-D,

23
Airway Adjuncts
  • Lower Airway
  • Needle Cricothyrotomy
  • Quick-trach
  • Need to secure
  • your airway
  • always reassess!

24
Spine Precautions
  • Manual in-line stabilization
  • Maintain axial alignment
  • Apply c-collar
  • Provide lateral immobilization

25
Airway Caveats in special populations
  • Obese
  • Sleep apnea, elevate head of bed, difficult
    access to airway
  • Elderly
  • Spine/arthritic changes
  • Dental appliances

26
Breathing
  • Inspect
  • Expose the chest
  • Palpate
  • Percussion
  • Auscultate

27
Breathing Inspect
  • RATE, PATTERN, DEPTH, EFFORT
  • Appearance
  • Symmetry
  • Signs of past trauma
  • Accessory muscles
  • Speech
  • Jugular veins
  • Cough

28
Breathing Palpate
  • Pain, point tenderness
  • Deformity
  • Chest wall expansion
  • Mobility
  • Crepitus
  • Skin temp/moisture
  • SQ emphysema
  • Tactile fremitus
  • Position of the trachea

29
Breathing Percussion
  • Hyperresonance
  • Pneumothorax or emphysema
  • Dull
  • Blood from hemothorax

30
Breathing Auscultate
  • Perform immediately if in distress
  • Audible
  • Listen
  • Ominous sound silence
  • Tissue mismatch reflects sound away

31
Breathing Auscultate
  • Where to listen?
  • Epigastrium (first after intubation)
  • Anterior
  • Lateral
  • Posterior

32
Breathing Compromise
  • Dyspnea
  • Bradypnea weak/shallow
  • Tachypnea
  • Cough
  • Diminished or absent breath sounds
  • Signs of chest trauma
  • Increased effort using accessory muscles
  • SQ emphysema
  • Unequal pulmonary excursion
  • Hypoxia/cyanosis
  • Restlessness

33
Breathing Intervention
  • Pulse OX (SpO2)
  • Oxygen (NRB)

34
Breathing Life Threats
  • Tension Pneumothorax
  • Open Pneumothorax
  • Flail Chest
  • Massive Hemothorax

35
(No Transcript)
36
Needle Decompression
  • Landmarks anterior approach
  • 2nd intercostal space in the midline of the
    clavicles
  • Place prepared flutter valve needle over the top
    of the rib
  • Avoids potential injury to vessels and nerves
    that run along the bottom of the rib

37
Quick Way to Find 2nd ICS
  • Feel for the top of the sternum
  • Roll your finger tip to the anterior surface at
    the top of the sternum
  • Feel the little bump near the top of the sternum
  • This bump is the Angle of Louis
  • From the Angle of Louis slide your fingers angled
    slightly downward toward the affected side
    following the rib space
  • You are automatically in the 2nd ICS
  • Identify the midline of the clavicle
  • The midline is more lateral than persons realize
    and usually runs in line with the nipple

38
Alternate Method to Find 2nd Intercostal Space
  • Palpate the clavicle and find the midline
  • The midline is farther out (more lateral) from
    the sternum than most persons realize
  • Move your finger tips under the clavicle into the
    1st intercostal space
  • 1st rib is under the clavicle and is not palpated
  • Spaces identified for the numbered rib above the
    space
  • Feel for the firm 2nd rib and palpate the soft
    space below the rib
  • This is the 2nd ICS

39
Needle Decompression
  • Find your own 2nd ICS
  • Now find your neighbors 2nd ICS
  • Use both methods to find the landmark and decide
    which is easiest for you
  • Documentation
  • To include signs and symptoms
  • Size of needle used (length and gauge)
  • Site needle inserted into
  • Response from the patient

40
Equipment
  • Long needle (preferably 2-3 inch) and large bore
    needle (preferably 12-14G)
  • Flutter valve
  • Not required by system, but can be helpful
  • Commercial devices, or finger from a glove
  • Cleanser to prepare skin
  • Method to secure needle in place
  • Skin will most likely be diaphoretic
  • Tape may not stick
  • May need to maintain manual control of needle

41
Skin Preparation
Midline of clavicle
2nd ICS
Angle of Louis
42
Inserting the Needle
  • Remove proximal end cap
    from needle
  • Will be able to hear trapped air escaping
  • Needle inserted over top of rib
  • Once hiss of air heard continue to advance
    catheter while withdrawing stylet
  • Stabilize catheter as best as possible
  • Patient should symptomatically improve
  • Do not expect to hear improved breath sounds
    takes time for the lung to reexpand

43
Case Study 1
  • EMS is called to the scene for a 52 year-old male
    with c/o sudden onset dyspnea with pain between
    his shoulder blades while watching TV at home.
    The patient is agitated, short of breath, with
    increased respiratory rate and SaO2 of 89.
  • Further assessment reveals decreased breath
    sounds on the right and clear on the left
  • Vital signs 98/62 HR 118 RR 32 and shallow
  • Your impression intervention plan?

44
Case Study 1
  • Spontaneous tension pneumothorax
  • They dont all develop from trauma
  • Begin supplemental oxygen support via
    non-rebreather, cardiac monitor, preparation for
    IV
  • BUT
  • Quickly prepare for needle decompression while
    the above are being prepared
  • Patients with a tension pneumothorax cant wait
    and will deteriorate without needle decompression

45
Sucking Chest Wound
  • Most common with penetrating wounds
  • Free passage of air between the atmosphere and
    pleural space if the open wound is at least 2/3rd
    the size of the diameter of the trachea
  • Size of trachea about the size of pts 5th finger
  • Air is drawn into the chest cavity
  • Air replaces lung tissue
  • Lung collapses

46
Sucking Chest Wound
  • Severe dyspnea
  • Open chest wound
  • Check anterior, posterior, axilla areas
  • Frothy blood at wound opening
  • Sucking sound as air moves in and out
  • Tachycardia with hypovolemia

47
Treatment Sucking Chest Wound
  • Immediate treatment is to seal the opening
  • May start by placing a gloved hand over the wound
  • When able, place an occlusive dressing, taped on
    3 sides, over the wound
  • Wound now converted to a closed pneumothorax
  • Monitor for signs of tension pneumothorax
  • May need to lift a corner of the dressing to
    release trapped air via burping dressing

48
Flail Chest
  • 3 or more adjacent ribs broken in 2 or more
    places
  • Segment becomes free with pardoxical chest wall
    motion during respirations
  • Paradoxical movement more evident after the
    muscles splinting the flail segment fatigue
  • Usually takes a tremendous amount of blunt trauma
    to cause a flail chest
  • Often present will be associated severe
    underlying injury (ie pulmonary contusion)
  • Respiratory volume reduced and respiratory effort
    increased

49
Treatment Flail Chest
  • Place patient on the injured side (may not be
    possible to do this in the field based on
    mechanism of injury)
  • High flow oxygen nonrebreather mask
  • Monitor for need to assist ventilations via BVM
    to deliver positive pressure ventilations
  • Evidence of underlying pulmonary injury
  • Effort and fatigue
  • Pulse oximetry
  • EKG monitoring
  • Tremendous amount of force is delivered to the
    chest wall and cardiac injury is highly likely as
    a result

50
Breathing Caveats
  • Elderly
  • Pulmonary system is the leading cause of
    post-traumatic complications
  • Consider the need to intubate
  • Caution to over-correct patients with COPD
  • But Never withhold oxygen to any patient who
    needs it

51
Breathing Caveats
  • Morbidly Obese
  • Difficult assessment
  • SpO2 monitoring
  • CO2 retention may occur often
  • Tension Pneumo might need 10g (longer than 14g)

52
Circulation Assessment
  • Pulses
  • Radial B/P 80-90 mm Hg
  • Femoral B/P 70mm Hg
  • Carotid B/P 60mm Hg
  • Rapid, thready, gt120 probable shock

53
Circulation Assessment
  • Perfusion
  • Mental status
  • Skin color/temp of extremities
  • BP/secondary survey
  • Quality of the peripheral pulse

54
Circulation Assessment
  • Skin Color, Temperature, Moisture
  • Vasoconstriction shock
  • Cap Refill lt 2 sec
  • Level of Consciousness
  • Indicator of central perfusion
  • Bleeding
  • Location, type, amount, rate

55
Circulation Life Threats
  • PEA
  • Cardiac Tamponade
  • Shock
  • Massive Hemothorax gt 1,500 ml

56
Circulation Resuscitation
  • CPR, if needed
  • Control bleeding
  • IV access
  • Fluids
  • EKG monitoring
  • MAST Pants/PASG no longer required on ambulance
    by IDPH

57
FLUIDS
  • Adults
  • Fill the Tank
  • Not always effective filling tank with water
    will not allow engine to run
  • But sometimes its all we have
  • Bolus isotonic fluid to maintain effective
    systolic BP
  • Pediatrics
  • 20 cc/Kg then maintenance

58
Circulation Caveats
  • Elderly Morbidly Obese
  • Fluid loading is poorly tolerated
  • Vascular access may be difficult
  • ECG changes
  • Pregnant patients
  • Blood supply increases significantly in a woman
    who is at full term
  • More information on that coming up toward the end
    of this presentation

59
Disability
  • Level of consciousness
  • Best indicator of central perfusion
    deterioration of patient status
  • Pupils
  • Glucose Level

60
Disability Assessment
  • Glasgow best response
  • Eye opening
  • Verbal response
  • Motor response
  • Total 3-15
  • There is no such thing as a GCS of zero. Even
    a rock has a GCS of at least 3.

61
GCS Pearls
  • Acceptable noxious stimuli
  • Armpit pinch or nailbed pressure
  • Sternal rub, pinching web space between fingers,
    pinching shoulder muscle (trapezius)
  • Earlobe pinch is out of favor
  • Can cause movement of head neck in response to
    the pain

62
GCS Pearls
  • The change in the GCS is more important than the
    absolute score
  • Check for associated injuries
  • Manage a head injury as a multiple injured
    patient until other injuries ruled out
  • Stabilize the neck for any head injury
  • Dont assume the level of consciousness is
    altered just because of ETOH and/or drugs
  • Is there an occult (hidden) injury present?
  • Provide accurate, clear, detailed documentation

63
Disability Assessment
  • Possible causes of altered mental status
    AEIOUTIPS
  • Airway
  • Endocrine
  • Insulin
  • Overdose
  • Uremia
  • Trauma/tumors
  • Infection
  • Psychosis
  • Shock/seizures

64
Disability Caveats
  • Elderly
  • Hearing, visual, cognition, memory, perception,
    communication, and motor deficits
  • 65 with GCS 8 is poor prognosis
  • 65 with RTS lt 7 has 100 mortality
  • Dont control all restlessness with sedation

65
Disability Caveats
  • Morbidly obese
  • Supine position decrease range of motion
  • Strength may be difficult to determine
  • Look for asymmetry for injury

66
Environment/Exposure
  • Flip them (back)
  • Strip them (wounds, burns)
  • Keep warm
  • Caveats
  • Elderly increase in hypothermia
  • Morbidly obese pull back skin

67
(No Transcript)
68
  • Vital signs
  • BP, HR, RR, Temp
  • Manual BP
  • Pulse pressure
  • Narrowed bleeding (lt30 mmHg)
  • Widened increase ICP (gt50 mmHg)

69
  • Pulse
  • Conscious palpate radial
  • Unconscious palpate carotid
  • Normal 60-100
  • Bradycardia vs Tachycardia
  • Rhythm
  • Quality
  • Location

70
  • Current Past Health History
  • Sample
  • S Symptoms
  • A Allergies
  • M Medications
  • P Past medical history
  • L Last oral intake, last LMP, last TD
  • E Events surrounding the incident

71
  • MOI
  • MVC
  • Falls
  • Struck by blunt object
  • Penetrating wounds
  • Violence/abuse

72
Caveats in Elderly
  • Pain is often undertreated
  • Polypharmacy they take a lot of meds already
    that affect their response to trauma
  • Increased sensitivity to side effects

73
  • Head to Toe Review
  • Inspect
  • Palpate
  • Anticipate
  • Percussion
  • Auscultate

74
  • Head to Toe Review
  • HEENT
  • Elderly
  • brain atrophies allows more blood to accumulate
    without showing signs of ICP
  • Neck
  • Cervical fractures
  • Chest/thorax/pulmonary system

75
  • Head to Toe Review
  • Abdomen (inspect, listen, palpate, percuss)
  • Kehrs sign
  • Seat belt sign
  • Cullens sign
  • Gray-Turners Sign
  • Contour
  • Old scars
  • Visible pulsations

76
  • Head to Toe Review
  • GU/Pelvis
  • Palpate
  • Gentle Inward/outward pressure
  • No pelvic rock

77
  • Head to Toe Review
  • Extremities (6 Ps of pain)
  • Back/Spine
  • Log roll
  • Skin soft tissue
  • Neurological
  • LOC/GCS/Motor exam/Sensory exam

78
Standard Monitoring
  • Cardiovascular
  • Peripheral pulses
  • Skin color/temperature/moisture
  • BP
  • ECG
  • Heart sounds
  • Fluid volume (type and amount)
  • Drainage from wounds

79
Standard Monitoring
  • Neurological
  • Mental status (GCS)
  • Content arousal
  • Pupils
  • Motor/sensory exam changes
  • Seizure activity

80
Evaluation Pearls Low SaO2
  • SaO2 reading may be inaccurate in the presence
    of
  • Hemorrhagic shock with delayed capillary refill
  • Hypothermia
  • Lung damage
  • Evaluate all parameters together to get the best
    overall picture in ventilated patient
  • Are you able to ventilate the patient?
  • Are there extenuating circumstances where the
    circulation is affected and would affect the
    pulse ox reading like those listed above?

81
More Case Studies
82
Case Study 2
  • Your 34 year-old patient received a GSW to the
    right upper abdomen.
  • They are conscious and alert B/P 90/62 HR 120
    RR 28 bleeding is minimal
  • What are your interventions?

83
Case Study 2
  • Make sure the scene is secured
  • Consider need for spinal immobilization
  • During assessment of wound, consider thoracic
    injury in addition to abdominal injury depending
    on the angle of the GSW.
  • Examine for an exit wound
  • Check the back and the axilla
  • Prepare for the worst assume the patient will
    deteriorate before ED arrival
  • Repeat VS B/P 80/ HR 140 RR 32, remains
    conscious and in pain
  • Transport to a Trauma Center

84
Case Study 2 - Treatment
  • Routine trauma care
  • Question is this an isolated abdominal wound or
    is it a combination abdominal/ chest wound?
  • Need to treat patient for potential injuries of
    both body cavities
  • EMS cannot determine in the field the angle of
    the trajectory
  • Cover the wound and watch for evisceration
  • Fluid resuscitation keep B/P normal the higher
    the B/P the faster the patient bleeds out

85
Case Study 2 - Documentation
  • If patient states anything, put it in quotes
  • If information available, add angle patient shot
    from (ie above, below) and distance from weapon
  • If known, list type of weapon used
  • Include results of inspection, auscultation,
    palpation
  • Location of entrance and exit wound
  • Size of wound(s)
  • Assessment of the general area (ie contusions,
    bleeding, swelling/distention, pain, powder
    marks)
  • Preserve evidence as much as possible

86
Case Study 3
  • Your 10 year-old patient has a penetrating injury
    to the right leg above the knee while playing in
    his backyard
  • Initial VS B/P 90/70 HR 130 RR 32 no active
    bleeding
  • Field interventions?

87
Case Study 3
  • Next VS B/P 92/64 HR 110 RR 20.
  • Stabilize foreign body in place
  • Obtain distal neurovascular status
  • Distal pulses
  • Movement can you wiggle your toes?
  • Sensation close your eyes and tell me which
    toe I am touching
  • Document distal neurovascular status and describe
    how the foreign object is stabilized in place

88
Case Study 4
  • Your 62 year-old patient had abdominal surgery 1
    week ago. Today at home he sneezed hard and felt
    a tearing sensation in his abdomen and
    called EMS.
  • VS B/P 100/60
    HR 110 RR 24
  • No active
    bleeding
  • What
    interventions
    are appropriate?

89
Case Study 4 - Interventions
  • Immediately cover the wound
  • Need to minimize contamination
  • Need to prevent more organs from protruding
  • Need to prevent loss of fluids
  • Place a saline moistened dressing over the
    exposed tissue
  • Place dry gauze over the saline dressings
  • Can place light manual control over the organs to
    prevent further evisceration especially during
    movement, coughing, sneezing, deep breaths

90
Case Study 5
  • 21 year-old drove into a metal fence. Upon EMS
    arrival, there is obvious external chest injury
    with bleeding. Coming closer to the patient, EMS
    can hear a sucking sound from the chest wound.
  • Patient is alert, in pain, severe dyspnea
  • VS B/P 90/62 HR 130 RR 34 GCS 15
  • Breath sounds L gt R
  • Look at the injury what is your impression and
    what interventions are necessary?

91
MVC Into Metal Fencing
92
Case Study 5
  • An adequate dressing will be difficult to achieve
    with such an extensive wound
  • A gloved hand just wont be enough to get started
  • This patient may be a candidate for conscious
    sedation and intubation to provide positive
    pressure ventilation
  • Reassessment VS B/P 80/56 HR 140 RR 36 GCS
    remains 15
  • Transport

93
Case Study 5 - Treatment
  • Open chest wounds need to be covered ASAP with a
    non-occlusive dressing
  • Carefully monitor if the treatment of the open
    chest wound converts the injury into a tension
    pneumothorax
  • Carefully monitor the patient for the need for
    more aggressive airway control (ie supportive
    ventilation via BVM or intubation)
  • Initially can start O2 therapy with a
    non-rebreather mask

94
Case Study 5 - Documentation
  • What cause of the injury (penetration, MVC,
    pedestrian, etc)
  • When the injury occurred
  • Where by body location
  • quadrant refers to the abdomen
  • Chest injuries uses reference such as anterior/
    posterior, nipple line, upper/lower chest wall
  • How the injury occurred
  • Expand and give detail description of the injury,
    treatment rendered, pt response

95
Case Study 6
  • Your 45 year-old patient is a construction worker
    who was accidentally shot in the head with a nail
    gun
  • Upon arrival, the patient is awake, alert,
    talking (GCS 15)
  • VS B/P 132/78 HR 96 RR 20 complains of a
    minor headache minimal bleeding at a few
    puncture wounds noted on the occipital area of
    the scalp (patient has thick hair).

96
X-ray from EDNo deficitsnoted
97
Case Study 6 - Treatment
  • Consider any injury above the level of the
    clavicles to include a c-spine injury until
    proven otherwise and immobilize the patient
  • Control bleeding
  • The face and scalp have such a rich blood supply
    small wounds tend to bleed heavily
  • Protect from further contamination
  • The open wound may be in direct contact with the
    brain
  • Document neurological evaluation to establish
    baseline for comparison (AVPU, GCS, movement)

98
Case Study 7
  • You are called to the scene for a 10 year-old
    female who has been run over by a bus
  • As patient exited bus, she bent down to tie her
    shoe and was caught under the wheels of the bus
  • Upon your arrival, you note a large amount of
    avulsed tissue with bleeding from the left hip,
    left buttock, and left upper thigh area
  • The patient is screaming in pain
  • VS B/P 110/70 HR 110 RR 26 GCS 15
  • What is your impression?

99
10 y/o run over by bus
100
Case Study 7
  • General impression
  • Potential problems to consider address
  • Massive hemorrhage control of hemorrhage
  • Spinal injury
  • Additional injuries
  • Airway control
  • Equipment to fit a 10 year-old
  • Further wound contamination

101
Lastly
  • DOCUMENT
  • DOCUMENT
  • DOCUMENT

102
Caveats in Pregnancy
  • General treat the mom to treat the fetus
  • Airway
  • Breathing
  • Circulation
  • Disability

103
Anatomical and Physiological Changes in the
Pregnant Patient
  • Cardiovascular
  • Hemodynamic-
  • Increased HR 10-20 bpm, increased SV, increased
    blood volume by 45-50, increased cardiac output
    by 30-50, SVR decreases
  • Hematologic
  • Increased WBC, decreased hemoglobin and
    hematocrit
  • Hypercoagulation- excessive blood clotting
  • Shock Considerations
  • May not see S S until gt30 circulating blood
    volume is lost!!!

104
Anatomical and Physiological Changes (cont)
  • Respiratory
  • Increased MR, O2 consumption, decreased CO2
  • Renal
  • Bladder higher, kidneys dilated, increased
    vascularity, increased GFR
  • Gastrointestinal
  • Intestines higher, liver spleen enlarged,
    prolonged gastric emptying
  • Reproductive
  • Blood flow through uterus 500-750ml/min, 1/6
    total maternal BV, 10-20 of CO, hypoperfusion of
    uterus may occur before signs of shock
  • Musculoskeletal
  • Changes in center of gravity
  • Endocrine
  • Enlarged thyroid

105
Strip O the Month
  • PEA Pulseless electrical activity
  • Pulseless electrical activity is a clinical
    situation, not a specific dysrhythmia
  • Formerly called electromechanical dissociation
    (EMD)
  • One of the more common death rhythms in
    traumatic arrest.
  • So common, trauma used to be included in the
    possible causes (Hs and Ts) but the most
    recent ACLS algorhythm gets a little more
    specific than that (hypovolemia, tension pneumo,
    etc).

106
Pulseless Electrical Activity
  • PEA exists when organized electrical activity
    (other than VT) is present on the cardiac
    monitor, but the patient is pulseless

107
Causes Hs and Ts
  • The Hs include
  • Hypovolemia, Hypoxia, Hydrogen ion (acidosis),
    Hyper-/hypokalemia, Hypothermia.
  • The Ts include
  • Toxins, Tamponade(cardiac),Tension pneumothorax,
    Thrombosis (coronary and pulmonary).

108
PEA Another Way to Remember the Causes
  • Pulmonary embolism
  • Acidosis
  • Tension pneumothorax
  • Cardiac tamponade
  • Hypovolemia (most common cause)
  • Hypoxia
  • Heat/cold (hypothermia/hyperthermia)
  • Hypokalemia/hyperkalemia (and other electrolytes)
  • Myocardial infarction
  • Drug overdose/accidents (cyclic antidepressants,
    calcium channel blockers, beta-blockers, digoxin)

PATCH-4-MD
109
PEA Intervention
  • Begin CPR
  • Search aggressively for possible cause(s) of the
    situation
  • Often finding the right H or T can solve PEA
    quickly
  • Most common cause hypovolemia
  • Pharm Epinephrine 110,000 IV/IO
  • No More Atropine!!!

110
Questions? Email afinkel_at_silvercross.org or call
815-300-7425 (or type into text box if watching
live). Thank You for Your Attention And a
special thank you to Dr Wendy Marshall, Courtney
McKibben RN MSN and Sharon Hopkins RN MS for the
use of some of their material
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