2nd Trimester, June 2013 CMEPrepared by Leslie Livett RN, MSPresence St. Joseph Medical Center

ObjectivesUpon successful completion of this module, the EMS provider should be able to:Understand what the mechanism of injury is and the information it providesDescribe assessment and treatment appropriate for the patient with traumatic insultTension pneumothorax, sucking chest wound, flail chest, eviscerated organsSuccessfully identify the landmark and perform chest needle decompressionActively participate in trauma scenario discussion

DefinitionDamage to the body caused by an exchange of energy beyond the bodys resilience.

Epidemiology of TraumaLeading cause of death in ages 1-443rd leading cause of death for all ages100,000 deaths/year60 million injuries/year

Overall ApproachAnticipate the worstNever make any assumptionsHistory and Exam have to make senseDont take short cutsDocument frequentlyTEAMWORK

Dont get distracted with ugly injuries

Your Initial assessment findings will determine how you will proceed

Caveats in Elderly:Loss of Reserve FunctionAssume that every organ has some degree of lossImprove outcomes

Trauma SystemMortality is decreased when

The RIGHT patientGets toThe RIGHT hospitalIn the RIGHT AMOUNT of TIME

A B Cs of Trauma CareMany ways to interpret that

The original way A Airway with C-spine B Breathing C Circulation

The New Way A Airway

B Be Careful of the Airway

C Concentrate on the Airway

(An Amusing Variation)

A Antibiotics

B Blood Cultures

C Consults

A Always

B Bring

C Camera

Approach to TraumaChallengingSystematic Approach to Patient CareLogical & OrganizedMechanism of Injury

General Assessment PearlsWith restlessness and agitation, you must considerhypoxia, shock, influence of alcohol and/or drugsneed to assess for all reasons of restlessness.dont not just stop when you discovered one causethere may be more than one pathology going on at a time

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

Airway Assessment Maneuvers in TraumaInspectionColor, contour, symmetry, smell, audible abnormal sounds, obvious woundsPalpationTextures, moisture, pulsations, deformities, crepitus, masses, temperaturePercussionResonant = normalHyperresonant = more airDull = solid, fluidAuscultation

Focused History Physical ExamAs you approach: OBSERVELevel of ConsciousnessAppearanceRestlessnessDistress/PainHemorrhage/Gross DeformitiesUnusual odorsKinematics

Airway & C-Spine

AccessAssessMaintainCervical Spine Control

Airway CompromisedWhat are some etiologies of a compromised/ obstructed airway in trauma?

Airway CompromisedDiscuss: What are some causes of a compromised/ obstructed airway in trauma?

Airway AssessmentObserve for Respiratory effortSymmetryAccessory musclesAudible soundsWhat should ventilations sound like?Ability to talkImpaired laryngeal reflexes

Airway InterventionPosition Appropriately Reposition MandibleChin lift, jaw thrustDO NOT Hyperextend or Hyperflex Remove Debris/SuctionMaintain with Adjuncts

Airway Adjuncts

Nasopharyngeal if awakeOropharyngeal if unconscious/no gagRescue:BVM, Intubation,King LTS-D,

Airway AdjunctsLower AirwayNeedle CricothyrotomyQuick-trach

Need to secure your airway & always reassess!

Spine PrecautionsManual in-line stabilizationMaintain axial alignmentApply c-collarProvide lateral immobilization

Airway Caveats in special populationsObeseSleep apnea, elevate head of bed, difficult access to airway

ElderlySpine/arthritic changes Dental appliances

BreathingInspectExpose the chest

Palpate

Percussion

Auscultate

Breathing InspectRATE, PATTERN, DEPTH, EFFORTAppearanceSymmetrySigns of past traumaAccessory musclesSpeechJugular veinsCough

Breathing PalpatePain, point tendernessDeformityChest wall expansionMobilityCrepitusSkin temp/moistureSQ emphysemaTactile fremitusPosition of the trachea

Breathing Percussion

HyperresonancePneumothorax or emphysema

DullBlood from hemothorax

Breathing AuscultatePerform immediately if in distressAudible

ListenOminous sound = silenceTissue mismatch: reflects sound away

Breathing AuscultateWhere to listen?

Epigastrium (first after intubation)AnteriorLateralPosterior

Breathing CompromiseDyspneaBradypnea: weak/shallowTachypneaCoughDiminished or absent breath soundsSigns of chest traumaIncreased effort using accessory musclesSQ emphysemaUnequal pulmonary excursionHypoxia/cyanosisRestlessness

Breathing InterventionPulse OX (SpO2) Oxygen (NRB)

Breathing Life ThreatsTension PneumothoraxOpen PneumothoraxFlail ChestMassive Hemothorax

Needle DecompressionLandmarks anterior approach2nd intercostal space in the midline of the claviclesPlace prepared flutter valve needle over the top of the ribAvoids potential injury to vessels and nerves that run along the bottom of the rib

Quick Way to Find 2nd ICSFeel for the top of the sternumRoll your finger tip to the anterior surface at the top of the sternumFeel the little bump near the top of the sternumThis bump is the Angle of LouisFrom the Angle of Louis slide your fingers angled slightly downward toward the affected side following the rib spaceYou are automatically in the 2nd ICSIdentify the midline of the clavicleThe midline is more lateral than persons realize and usually runs in line with the nipple

Alternate Method to Find 2nd Intercostal Space Palpate the clavicle and find the midlineThe midline is farther out (more lateral) from the sternum than most persons realizeMove your finger tips under the clavicle into the 1st intercostal space1st rib is under the clavicle and is not palpatedSpaces identified for the numbered rib above the spaceFeel for the firm 2nd rib and palpate the soft space below the ribThis is the 2nd ICS

Needle DecompressionFind your own 2nd ICSNow find your neighbors 2nd ICSUse both methods to find the landmark and decide which is easiest for youDocumentationTo include signs and symptomsSize of needle used (length and gauge)Site needle inserted intoResponse from the patient

EquipmentLong needle (preferably 2-3 inch) and large bore needle (preferably 12-14G)Flutter valveNot required by system, but can be helpfulCommercial devices, or finger from a gloveCleanser to prepare skinMethod to secure needle in placeSkin will most likely be diaphoreticTape may not stickMay need to maintain manual control of needle

Skin PreparationMidline ofclavicle

Angle of Louis2nd ICS

Inserting the Needle

Remove proximal end cap from needleWill be able to hear trapped air escapingNeedle inserted over top of ribOnce hiss of air heard continue to advance catheter while withdrawing styletStabilize catheter as best as possiblePatient should symptomatically improveDo not expect to hear improved breath sounds; takes time for the lung to reexpand

Case Study #1EMS 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 leftVital signs: 98/62; HR 118; RR 32 and shallowYour impression & intervention plan?

Case Study #1Spontaneous tension pneumothoraxThey dont all develop from traumaBegin supplemental oxygen support via non-rebreather, cardiac monitor, preparation for IVBUTQuickly prepare for needle decompression while the above are being preparedPatients with a tension pneumothorax cant wait and will deteriorate without needle decompression

Sucking Chest WoundMost common with penetrating woundsFree 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 tracheaSize of trachea about the size of pts 5th fingerAir is drawn into the chest cavityAir replaces lung tissueLung collapses

Sucking Chest WoundSevere dyspneaOpen chest woundCheck anterior, posterior, axilla areasFrothy blood at wound openingSucking sound as air moves in and outTachycardia with hypovolemia

Treatment Sucking Chest WoundImmediate treatment is to seal the openingMay start by placing a gloved hand over the woundWhen able, place an occlusive dressing, taped on 3 sides, over the woundWound now converted to a closed pneumothoraxMonitor for signs of tension pneumothoraxMay need to lift a corner of the dressing to release trapped air via burping dressing

Flail Chest 3 or more adjacent ribs broken in 2 or more placesSegment becomes free with pardoxical chest wall motion during respirationsParadoxical movement more evident after the muscles splinting the flail segment fatigueUsually takes a tremendous amount of blunt trauma to cause a flail chestOften present will be associated severe underlying injury (ie: pulmonary contusion)Respiratory volume reduced and respiratory effort increased

Treatment Flail ChestPlace patient on the injured side (may not be possible to do this in the field based on mechanism of injury)High flow oxygen nonrebreather maskMonitor for need to assist ventilations via BVM to deliver positive pressure ventilationsEvidence of underlying pulmonary injuryEffort and fatiguePulse oximetryEKG monitoringTremendous amount of force is delivered to the chest wall and cardiac injury is highly likely as a result

Breathing CaveatsElderly:Pulmonary system is the leading cause of post-traumatic complicationsConsider the need to intubateCaution to over-correct patients with COPDBut Never withhold oxygen to any patient who needs it

Breathing CaveatsMorbidly Obese:Difficult assessmentSpO2 monitoring CO2 retention may occur oftenTension Pneumo might need 10g (longer than 14g)

Circulation AssessmentPulsesRadial: B/P 80-90 mm HgFemoral: B/P 70mm HgCarotid: B/P 60mm HgRapid, thready, >120 = probable shock

Circulation AssessmentPerfusionMental statusSkin color/temp of extremitiesBP/secondary surveyQuality of the peripheral pulse

Circulation AssessmentSkin Color, Temperature, & MoistureVasoconstriction = shockCap Refill < 2 secLevel of ConsciousnessIndicator of central perfusionBleedingLocation, type, amount, & rate

Circulation Life ThreatsPEACardiac TamponadeShockMassive Hemothorax > 1,500 ml

Circulation ResuscitationCPR, if neededControl bleedingIV access FluidsEKG monitoringMAST Pants/PASG no longer required on ambulance by IDPH

FLUIDSAdultsFill the TankNot always effective filling tank with water will not allow engine to runBut sometimes its all we haveBolus isotonic fluid to maintain effective systolic BPPediatrics20 cc/Kg then maintenance

Circulation CaveatsElderly & Morbidly ObeseFluid loading is poorly toleratedVascular access may be difficultECG changesPregnant patientsBlood supply increases significantly in a woman who is at full termMore information on that coming up toward the end of this presentation

DisabilityLevel of consciousnessBest indicator of central perfusion & deterioration of patient statusPupilsGlucose Level

Disability AssessmentGlasgow best responseEye openingVerbal responseMotor responseTotal 3-15There is no such thing as a GCS of zero. Even a rock has a GCS of at least 3.

GCS PearlsAcceptable noxious stimuliArmpit pinch or nailbed pressureSternal rub, pinching web space between fingers, pinching shoulder muscle (trapezius)Earlobe pinch is out of favorCan cause movement of head & neck in response to the pain

GCS PearlsThe change in the GCS is more important than the absolute scoreCheck for associated injuries Manage a head injury as a multiple injured patient until other injuries ruled outStabilize the neck for any head injuryDont assume the level of consciousness is altered just because of ETOH and/or drugsIs there an occult (hidden) injury present?Provide accurate, clear, detailed documentation

Disability AssessmentPossible causes of altered mental status: AEIOUTIPSAirwayEndocrineInsulinOverdoseUremiaTrauma/tumorsInfectionPsychosisShock/seizures

Disability CaveatsElderly:

Hearing, visual, cognition, memory, perception, communication, and motor deficits 65 with GCS 8 is poor prognosis 65 with RTS < 7 has 100% mortalityDont control all restlessness with sedation

Disability CaveatsMorbidly obese:

Supine position = decrease range of motionStrength may be difficult to determineLook for asymmetry for injury

Environment/ExposureFlip them (back)Strip them (wounds, burns)Keep warm

Caveats:Elderly: increase in hypothermiaMorbidly obese: pull back skin

Vital signsBP, HR, RR, TempManual BP Pulse pressureNarrowed = bleeding (50 mmHg)

PulseConscious palpate radialUnconscious palpate carotidNormal 60-100Bradycardia vs TachycardiaRhythmQualityLocation

Current & Past Health HistorySample:S: SymptomsA: AllergiesM: MedicationsP: Past medical historyL: Last oral intake, last LMP, last TDE: Events surrounding the incident

MOIMVCFallsStruck by blunt objectPenetrating woundsViolence/abuse

Caveats in Elderly

Pain is often undertreatedPolypharmacy they take a lot of meds already that affect their response to traumaIncreased sensitivity to side effects

Head to Toe ReviewInspectPalpateAnticipatePercussionAuscultate

Head to Toe ReviewHEENT Elderly: brain atrophies allows more blood to accumulate without showing signs of ICPNeckCervical fracturesChest/thorax/pulmonary system

Head to Toe ReviewAbdomen (inspect, listen, palpate, percuss)Kehrs signSeat belt signCullens sign Gray-Turners SignContourOld scarsVisible pulsations

Head to Toe ReviewGU/PelvisPalpateGentle Inward/outward pressureNo pelvic rock

Head to Toe ReviewExtremities (6 Ps of pain)Back/SpineLog rollSkin & soft tissueNeurologicalLOC/GCS/Motor exam/Sensory exam

Standard MonitoringCardiovascularPeripheral pulsesSkin color/temperature/moistureBPECGHeart soundsFluid volume (type and amount)Drainage from wounds

Standard MonitoringNeurologicalMental status (GCS)Content arousalPupilsMotor/sensory exam changesSeizure activity

Evaluation Pearls Low SaO2SaO2 reading may be inaccurate in the presence of:Hemorrhagic shock with delayed capillary refill HypothermiaLung damageEvaluate all parameters together to get the best overall picture in ventilated patientAre 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?

More Case Studies

Case Study #2Your 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 minimalWhat are your interventions?

Case Study #2 Make sure the scene is securedConsider need for spinal immobilizationDuring 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 axillaPrepare for the worst assume the patient will deteriorate before ED arrivalRepeat VS: B/P 80/; HR 140; RR 32, remains conscious and in painTransport to a Trauma Center

Case Study #2 - TreatmentRoutine trauma careQuestion is this an isolated abdominal wound or is it a combination abdominal/ chest wound?Need to treat patient for potential injuries of both body cavitiesEMS cannot determine in the field the angle of the trajectory Cover the wound and watch for eviscerationFluid resuscitation keep B/P normal; the higher the B/P the faster the patient bleeds out

Case Study #2 - DocumentationIf patient states anything, put it in quotesIf information available, add angle patient shot from (ie: above, below) and distance from weapon If known, list type of weapon usedInclude results of inspection, auscultation, palpationLocation of entrance and exit woundSize of wound(s)Assessment of the general area (ie: contusions, bleeding, swelling/distention, pain, powder marks)Preserve evidence as much as possible

Case Study #3Your 10 year-old patient has a penetrating injury to the right leg above the knee while playing in his backyardInitial VS: B/P 90/70; HR; 130; RR 32; no active bleedingField interventions?

Case Study #3 Next VS: B/P 92/64; HR 110; RR 20.Stabilize foreign body in placeObtain distal neurovascular statusDistal pulsesMovement can you wiggle your toes?Sensation close your eyes and tell me which toe I am touchingDocument distal neurovascular status and describe how the foreign object is stabilized in place

Case Study #4Your 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 24No active bleedingWhat interventions are appropriate?

Case Study #4 - InterventionsImmediately cover the woundNeed to minimize contaminationNeed to prevent more organs from protrudingNeed to prevent loss of fluidsPlace a saline moistened dressing over the exposed tissuePlace dry gauze over the saline dressingsCan place light manual control over the organs to prevent further evisceration especially during movement, coughing, sneezing, deep breaths

Case Study #521 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 dyspneaVS: B/P 90/62; HR 130; RR 34; GCS 15Breath sounds L > RLook at the injury what is your impression and what interventions are necessary?

MVC Into Metal Fencing

Case Study #5 An adequate dressing will be difficult to achieve with such an extensive woundA gloved hand just wont be enough to get startedThis patient may be a candidate for conscious sedation and intubation to provide positive pressure ventilationReassessment VS: B/P 80/56; HR 140; RR 36 GCS remains 15Transport

Case Study #5 - TreatmentOpen chest wounds need to be covered ASAP with a non-occlusive dressingCarefully monitor if the treatment of the open chest wound converts the injury into a tension pneumothoraxCarefully 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

Case Study #5 - DocumentationWhat cause of the injury (penetration, MVC, pedestrian, etc)When the injury occurredWhere by body locationquadrant refers to the abdomenChest injuries uses reference such as anterior/ posterior, nipple line, upper/lower chest wall How the injury occurredExpand and give detail description of the injury, treatment rendered, pt response

Case Study #6Your 45 year-old patient is a construction worker who was accidentally shot in the head with a nail gunUpon 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).

X-ray from ED

No deficitsnoted

Case Study #6 - TreatmentConsider any injury above the level of the clavicles to include a c-spine injury until proven otherwise and immobilize the patientControl bleedingThe face and scalp have such a rich blood supply small wounds tend to bleed heavilyProtect from further contaminationThe open wound may be in direct contact with the brainDocument neurological evaluation to establish baseline for comparison (AVPU, GCS, movement)

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

10 y/o run over by bus

Case Study #7 General impressionPotential problems to consider & addressMassive hemorrhage & control of hemorrhageSpinal injuryAdditional injuriesAirway control Equipment to fit a 10 year-oldFurther wound contamination

Lastly

DOCUMENTDOCUMENTDOCUMENT

Caveats in Pregnancy

General treat the mom to treat the fetusAirwayBreathingCirculationDisability

Anatomical and Physiological Changes in the Pregnant PatientCardiovascularHemodynamic-Increased HR 10-20 bpm, increased SV, increased blood volume by 45-50%, increased cardiac output by 30-50%, SVR decreasesHematologicIncreased WBC, decreased hemoglobin and hematocritHypercoagulation- excessive blood clottingShock ConsiderationsMay not see S & S until >30% circulating blood volume is lost!!!

Anatomical and Physiological Changes (cont)Respiratory Increased MR, O2 consumption, decreased CO2RenalBladder higher, kidneys dilated, increased vascularity, increased GFRGastrointestinalIntestines higher, liver & spleen enlarged, prolonged gastric emptying

ReproductiveBlood flow through uterus 500-750ml/min, 1/6 total maternal BV, 10-20% of CO, hypoperfusion of uterus may occur before signs of shockMusculoskeletalChanges in center of gravityEndocrineEnlarged thyroid

Strip O the MonthPEA Pulseless electrical activityPulseless 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).

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

Causes: Hs and TsThe Hs include:Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyper-/hypokalemia, Hypothermia.

The Ts include:Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary).

PEA Another Way to Remember the CausesPulmonary embolismAcidosisTension pneumothoraxCardiac tamponadeHypovolemia (most common cause)HypoxiaHeat/cold (hypothermia/hyperthermia)Hypokalemia/hyperkalemia (and other electrolytes)Myocardial infarction

Drug overdose/accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digoxin)PATCH-4-MD

PEA InterventionBegin CPRSearch aggressively for possible cause(s) of the situationOften finding the right H or T can solve PEA quicklyMost common cause: hypovolemiaPharm: Epinephrine 1:10,000 IV/IONo More Atropine!!!

Questions?Email afinkel@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

Mechanism: always be thinking of the mechanism in relation to other factors (age, gender, presentation, etc.)Many things can happen simultaneously. **Tongue, Fluids, teeth, debris, tissue, edema, malposition of the airway, compression of the chest*Tongue, Fluids, teeth, debris, tissue, edema, malposition of the airway, compression of the chest*JVD: tension pneumo/cardiac tamponadeCough: smoke inhalation

*Trachea remains mid-line until a severe mediastinal shiftTracheal deviation is a late sign

* Needle Decompression, chest tube 3-sided occlusive dressing, chest tube Pain management, PP ventilation if necessary

*Electronic VS are not an acceptable baselineLook, Feel*BP unreliable and the last to change*LOC: slight change, without head injury, with tachycardia and low BP = shock*PEA: Hs and Ts

Tamponade: Becks Triad: JVD, muffled heart tones, narrowed pulse pressure with hypotension Pericardiocentesis/ thoracotomyShock: what is the problem? Hemorrhagic vs Hypovolemic vs Cardiogenic, vs Neurogenic what happens hypodynamically when the body is in a shock state: hr>100, RR>20, mottled, cool skin, altered mental status, decrease UO

Commotio cortis: blow to the chest that cause cardiac arrest

*IV 2 large bore, central line, IO

PSAG Mast pants or Anti-shock pants*Elderly: higher risk for cerebral and myocardial infarcts due to atheroslerosis *Pupil constriction is controlled by Cranial nerve IIIIncreased ICP and hypoxia can alter pt responsiveness

Dilated pupils reactive to lightinjury is often reversible

One pupil dilated or oval pupil reactive to light earlier sign of ICP or herniation

Fixed and dilated pupils*Elderly impaired thermo-regulation*Reality: some of these interventions happen during the primary survey

Narrowed: decrease CO, Peripheral vascular constriction (compensatory mechanism) loss of volume (life threat)*Head, eyes, ears, nose, throatOdontoid (C2) most common*Kehrs: pain radiating to the left shoulder from free blood in the abd

Cullens sign periumbilical ecchymosis due to retroperitoneal bleeding

Gray: ecchymosis over flanks (renal trauma) *Pain, pallor, pulselessness, paresthesia, paralysis, and pressure**

PEA exists when organized electrical activity (other than VT) is observed on the cardiac monitor, but the patient is pulseless.*The causes of PEA are the same as those for asystole.*The treatment of PEA includes CPR, endotracheal intubation, IV access, an aggressive search for possible causes of the situation, and medications per current resuscitation guidelines.