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Trauma Patient Assessment Intubation Review Needle Decompression

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Title: Trauma Patient Assessment Intubation Review Needle Decompression


1
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

2
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

3
  • 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

4
7 Ways to Die in Trauma
  • Hypovolemia
  • Hypoxia
  • Acidosis
  • Obstructed airway
  • Flail chest
  • Cardiac tamponade
  • Tension pneumothorax

5
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

6
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

7
Normal Blood Volumes
  • Neonate 85 ml/kg
  • Infant 80 ml/kg
  • Adult men 75 ml/kg
  • Adult women 65 ml/kg

8
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

9
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

10
  • 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

11
  • 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

12
  • 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

13
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

14
  • 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

15
  • 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

16
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?

17
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!

18
Hypoxia
  • Hypoxemia
  • decreased oxygen content of the arterial blood
  • Hypoxia
  • decreased oxygen content to the bodys cells and
    at the tissue level

19
Causes of Hypoxia
  • Reduction of oxygen in the system
  • Inadequate oxygen transport
  • Inability of tissues to use the oxygen delivered

20
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)

21
  • 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

22
  • Chest wall abnormalities
  • flail chest
  • scoliosis
  • full thickness burns with contractions
  • Increased thickness of the respiratory membrane
  • pulmonary edema
  • interstitial fibrosis

23
  • 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

24
  • 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

25
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

26
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

27
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

28
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

29
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?

30
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

31
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

32
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

33
Magill Forceps
34
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

35
Thyroid cartilage Cricothyroid
membrane Cricoid cartilage Thyroid gland
Thyroid cartilage (Adams apple) Cricothyroid
membrane Cricoid cartilage
36
  • 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

37
Needle Cric
  • Step 1 - needle advanced, confirmation by air
    being aspirated with the syringe

Step 2 - catheter advanced while the stylet is
removed
38

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
39
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

40
Melker Cric Kit
  • Department personnel recommended to review the CD
    from Cook Medical to review using the Melker
    Emergency Cricothyrotomy Catheter Set

41
Case Scenario 3
  • This patient has been impaled by a foreign object
  • Do they need spinal immobilization for this

    injury?
  • No

42
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

43
Flail Chest On Right Side
44
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

45
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

46
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

47
Cardiac Tamponade
48
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)

49
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

50
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

51
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

52
Tension pneumothorax on the right side with
shifting to the left
53
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

54
Field Interventions For Tension Pneumothorax
  • A true emergency requiring immediate
    identification and intervention
  • Goal reduce the pressure in the pleural space
  • emergency needle decompression

55
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)

56
Landmarks For Needle Decompression
Rib 1
Rib 2
2nd intercostal space mid-clavicular line
Rib 3
57
Placement of Needle
Flutter valve attached
2nd rib
3rd rib
58
Placement of Needle
59
  • 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

60
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
61
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

62
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

63
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

64
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

65
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

66
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)

67
  • 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

68
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

69
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

70
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
71
Difficult Intubations
Neck and chest tissue fall over the airway
making intubation difficult
Better patient positioning allows for improved
chance of success in intubation
72
Orotracheal Intubation
73
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

74
Lateral View of ETT Placement
Curved blade in vallecula
75
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

76
Opening Airway with Cervical Trauma - Jaw Thrust
77
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

78
In-Line Intubation
  • Patient
  • being
  • stabilized
  • Equipment
  • being
  • prepared
  • Cricoid
  • pressure
  • being held

79
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

82
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
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