paramedic update part 3

TOPIC

NeonatologyNeonatology

56

Objectives

• Identify incidence and morbidity/mortality in neonatal complications.

• Review leading causes of death in the <1 year bracket.

• Discuss the assessment format and interventions for a newborn child.

• Review a mnemonic to assist the paramedic in remembering steps and interventions on a neonate.

Introduction

• In utero, the fetus is totally dependent on the mother for survival.

• Once born, the neonate now needs to rely on his own body processes for survival.

• Many times, there are congenital or acquired anomalies that disturb the body's processes.

Epidemiology

• 2 percent to 5 percent of all live births have some type of congenital anomalies.

• 20 percent to 30 percent of perinatal deaths are the result of congenital anomalies.

Epidemiology

• 10 percent of births will need some medical help at birth to begin life.

• 1 percent will need aggressive resuscitation to survive the neonatal period.

Terminology

• Review of terminology related to newborns– Fetal or in utero– Gestational period– Premature– Term– Late term– Perinatal– Infancy

Transitioning

• Review the anatomic and physiologic changes from in utero to the extrauterine environment.

• The lungs must open and allow gas to be exchanged for the first time.

• Discuss how meconium aspiration, structural defects, and infection can affect the neonate.

ABCs ABCs “In That Order, Every “In That Order, Every Time”Time”

• Airway– Anatomical differences make positive

pressure ventilation challenging.– Do not place pressure on the trachea.– The insertion of an oropharyngeal

airway or a nasopharyngeal airway may help control the airway.

– The use of a bag-valve-mask does not require much force or strength.

To provide positive pressure ventilation, use a bag-valve mask. Maintain a good mask seal. Ventilate with just enough force to raise the infant’s chest.

Ventilate at a rate of 40–60 per minute for 30 seconds, then reassess

Pathophysiology

• Breathing– Rate of 40–60 per minute.• 30–40 for older neonate.

Pathophysiology

• Breathing– Tidal volumes• 15–25 mL for a newborn.• 25–50 for a neonate up to 1 month of age.• “Just enough to move the chest.”

– Use a manometer to keep airway pressure <30 cmH2O.

Pathophysiology

• Breathing– If adequate:• Rapid improvement in color and perfusion

will occur.• Heart rate will normalize.• Spontaneous respirations may return.• Use a blended mix of oxygen to achieve a

desired pulse oximetry level.

Pathophysiology

• Careful and efficient basic airway management is preferred over advanced techniques.

• Meconium aspiration should only be performed to distressed babies.

• Review the 2010 AHA Guidelines for achieving the desired SpO2 levels.

Pathophysiology

• Circulation– If persistently bradycardic (<60 bpm),

signs of poor perfusion after 1 minute of BVM with oxygen, start compressions.

– “Thumb technique” is recommended.– Compression: Breath ratio 3:1

To provide chest compressions, circle the torso with the fingers and place both thumbs on the lower third of the infant’s sternum. If the

infant is very small, you may need to overlap the thumbs. If the infant is very large, compress the sternum with the ring and middle

fingers placed one finger’s depth below the nipple line. In the newborn, compress the chest one-third the depth of the chest at the

rate of 120 per minute and a ratio of 3:1 compressions to ventilations.

Pathophysiology

• Circulation• Obtain intravenous access– Can be challenging.– Use intraosseous if needed.

• Consider 1:10,000 epinephrine if heart rate does not increase.

• Determination of poor perfusion

What is after ABC? DEFGWhat is after ABC? DEFG“Don't Ever Forget Glucose”“Don't Ever Forget Glucose”• Fuel stores in infants are quickly

exhausted.– Coordinating feeding and breathing is

exercise enough for a sick infant.– Ascertain feeding and sleeping patterns.– Always access a blood glucose level.– Glucose (D10W) administration in the

neonate. – 5-10ml/kg iv over 20 min.

H is for Hypothermia

• Hypothermia– Environmental temperature is important– The best resuscitation efforts will fail on

a cold neonate.– If the temperature in the back of the

ambulance is comfortable for you, then it is too cold for the neonate.

I is for Infection

• Infection–Major killer of neonates– ANY of the following requires physician

evaluation:• ANY history of fever, cyanosis, apnea, rapid

or shallow breathing.• ANY history of poor feeding, decreased urine

output, or vomiting.• ANY blood in stool, urine, or emesis.• ANY rash beyond “baby acne.”

Safe Transport of the Infant

• Transport in parent's arms is not acceptable.

• Transporting the neonate in an isolette is ideal.

• Use a commercially available age-appropriate car seat, or an integrated car seat.

Case Study

• You are called to care for a 3-week-old baby who has “stopped breathing.” Upon your arrival, you are met at the door by a frantic young mother holding a limp baby. The mother is crying and, through her sobs, you can barely understand her saying something about “sleeping,” “blue,” and “not breathing.”

Case Study (cont'd)

• What kinds of problems could this neonate have?

• What are your priorities?

Case Study (cont'd)

• Scene Size-Up– Standard Precautions taken.– Scene is safe, no entry or egress

problems.– 3-week-old male, about 6 or 7 pounds.– Patient found in mother's arms, limp.

Case Study (cont'd)

• Scene Size-Up–Mechanism of illness/nature of injury is

unresponsiveness. – First child, no prenatal care, minimal

hospital stay at birth.

Case Study (cont'd)

• Primary Assessment Findings– Patient unresponsive.– Airway looks clear with manual

technique.– Breathing slow and irregular. – Carotid pulse 98/min, peripheral pulse

absent.– Peripheral skin cool and blue.– Poor muscle tone, neonate is very limp.

Case Study (cont'd)

• Is this patient a high or low priority? Why?

• What are the patient's life threats, if any?

• What care should be administered immediately?

• Should endotracheal intubation be initiated immediately?

Case Study (cont'd)

• Medical History– Born 1 week early, recent diagnosis of

upper respiratory infection.

• Medications– Nebulized med for upper respiratory

infection.

• Allergies–Mother does not think infant has any.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils sluggish to respond to light.– Airway patent, patient being ventilated

at 30/min.– Central pulse present now only

60/minute.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Skin is still cool, cyanosis has resolved

some.– Pulse oximetry only 90 percent with PPV

and supplemental oxygen.– Patient still limp, no response to

interventions.

Case Study (cont'd)

• Is the infant improving or deteriorating?

• Is there any additional treatment or change in treatment required?

• What is the likely underlying cause for the emergency?

Case Study (cont'd)

• Care provided:– Patient positioned supine, secured for

transport.– Ongoing PPV with oxygen.– Compressions administered when heart

rate dropped below 60/min with poor perfusion.

Case Study (cont'd)

• Care provided:– Temperature maintained with

ambulance heater and warm blankets.– Rapid transport with paramedic

intercept.

Case Study (cont'd)

• What signs and symptoms would indicate that the patient’s condition is still deteriorating?.

• What additional interventions will you provide?

Case Study (cont'd)

• Additional care provided:– Peripheral IV access or IO access.• Fluid administration with use of buretrol.

– Administration of epinephrine.– Reassess and monitor the patient.

Summary

• Neonatal emergencies are stressful for the parent as well as EMS providers.

• Remember the mnemonics for assessing and managing neonates:– ABCs “In that order every time”– DEFG “Don't ever forget glucose”– H is for hypothermia – I is for infection

Summary

• Also ensure proper and secure transport to hospital in ambulance.

• Paramedics must remember that good basic interventions are preferred when managing for this age group, but they must be competent in providing advanced interventions when needed.

TOPIC

Obstetrics (Antepartum Obstetrics (Antepartum Complications)Complications)

55

Objectives

• Review rates for complications seen during pregnancy.

• Discuss specific pathology related to obstetric emergencies.

• Review specific questions to ask when obtaining an obstetric history.

• Review assessment parameters and current treatment standards for a patient with antepartum complications.

Introduction

• Antepartum refers to the period of pregnancy prior to the onset of labor.

• Emergencies that occur during this time may be benign or even life threatening.

• The goal of the paramedic is to differentiate between these and provide safe, and occasionally lifesaving, treatment to these patients.

Epidemiology

• 4 percent of all pregnancies develop third trimester complications.– 22 percent are placenta previa cases.– 31 percent are abruptio placentae cases.

Pathophysiology

• Placenta Previa– Placenta implants over the internal

cervical os.– Types include complete, marginal, and

partial.– Cervical effacement can lead to

hemorrhage at the implantation site.

Placenta previa.

Pathophysiology

• Abruptio Placentae– Placental lining separates from the

uterus.– The expanding collection of blood

continues to force the placenta away, which increases bleeding.

– Complete and partial abruption occurs.

Abruptio placentae.

Pathophysiology

• Ectopic Pregnancy– Pregnancy in which the ovum implants

outside the uterine cavity.– Still the leading cause of pregnancy-

related deaths in the first trimester.– Almost 100 percent result in fetal death.

Ectopic pregnancy.

Pathophysiology• Preeclampsia and Eclampsia – Preeclampsia has hypertension, edema, protein

in the urine, visual disturbances, and headaches.

– Eclampsia is all the above, but in addition the patient has now developed generalized tonic-clonic seizures.

– Preeclampsia is the third leading cause of pregnancy-related death.

• New hypertension >140/90 mmHg• Previous history of hypertension > 30/15 mmHg

above norm

Pathophysiology

• Spontaneous Abortion– Loss of pregnancy before the age of

viability.– Spontaneous means abortion was

unintentional, involuntary, and due to some natural cause.

– Patient will commonly have abdominal cramping, discharge, and expulsion of tissues of conception.

Types of Abortion

Assessment

• Physical exam should follow the standard primary and secondary assessments.

• Assessment techniques should be the same as those for a non-pregnant patient.

Assessment

• Patient interview should include a focus on:–When was last menstrual period?– Have you been pregnant before?– Are you experiencing any pain or

discomfort?– Are you having any vaginal discharge?– Any prenatal care? –When is your due date?

Antepartum Complications and Associated Signs and Symptoms

Emergency Medical Care

• Consider spinal immobilization.• Assess and maintain the airway.• Determine breathing adequacy.– Provide oxygen if adequately breathing.– Provide high-flow oxygen via positive

pressure ventilation if inadequately breathing.

Emergency Medical Care

• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.– Suspect internal hemorrhage

Emergency Medical Care

• Position patient left lateral recumbent tilted to the left side.

• Provide aggressive care for seizures.–Magnesium sulfate– Benozdiazapines

• Initiate IV access and administer fluids based on presentation.

• Expedite transport to facility.• Reassess and reassure while en

route.

Case Study

• At about 0230 hours, your EMS unit is dispatched to a local battered women's shelter in the downtown area. Upon your arrival, you find a 19-year-old female, 8½ months pregnant. She has bruises and cuts on her face, and dried blood on her shirt. She states her boyfriend beat her up and kicked her in the stomach. She now has abdominal pain and bleeding.

Case Study (cont'd)

• What kinds of injuries could this patient have?

Case Study (cont'd)

• Scene Size-Up– Standard Precautions taken.– Scene is safe, no entry or egress

problems.– 19-year-old pregnant female, 160

pounds.

Case Study (cont'd)

• Scene Size-Up– Patient found in sitting position.–Mechanism of injury is physical

altercation.– The police have been summoned but not

on scene yet.– First pregnancy with no prenatal care.

Case Study (cont'd)

• Primary Assessment Findings– Patient responsive.– Airway appears open.– Breathing fast but adequate.– Carotid and radial pulses present.– Peripheral skin cool and slightly

diaphoretic.– Pants soaked with blood from vaginal

bleeding.

Case Study (cont'd)

• Is this patient a high or low priority? Why?

• What are the patient's life threats, if any?

Case Study (cont'd)

• Medical History– None other than pregnancy.

• Medications– She takes OTC multivitamin.

• Allergies– Patient denies any.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils reactive to light bilaterally.– Airway patent, patient’s breathing is

rapid.– Central and peripheral pulses present.– Pulse oximeter reading 99 percent on

oxygen.– Soft tissue injuries to face are minor.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– BP 100/60, heart rate 122, respirations

22.– Painful dark red blood escaping from the

vagina.– Abdomen is tense to the touch, tender

also.

Case Study (cont'd)

• What is the patient's para and gravida status?

• What do you think is the patient's primary problem?

• Why is the abdomen tense?• What complications could the patient

have as a result of this condition?• What care will you provide?

Summary

• Antepartum emergencies can be the reason for the EMS call, or a consequence of some other trauma or medical problem.

• In many instances, there are two lives at stake—the mother and the unborn child.

• The paramedic must properly assess, treat, and transport these patients.

TOPIC

Trauma in Special Trauma in Special Populations: GeriatricsPopulations: Geriatrics

51

Objectives

• Discuss statistical rates pertinent to the aging population.

• Discuss incidence rates for geriatric trauma and death.

• Identify pathophysiologic changes that accompany injuries in geriatrics.

Objectives

• Differentiate early from late assessment findings.

• Review current treatment strategies for the geriatric patient suffering from trauma.

Introduction

• In trauma, age is one of the most important determinants.

• Elderly patients do not survive trauma, and concurrent chronic diseases make survival even more unlikely.

• It is important to reconsider the assessment and management of the geriatric trauma patient

Epidemiology

• Over 40 million geriatric people in the United States

• Geriatric patients use a disproportionate amount of EMS and health care services.

• Geriatric patients account for 75 percent of fall-related deaths.

Epidemiology

• The elderly drive fewer miles, but have a three times higher death rate in motor vehicle crashes.

Pathophysiology

• Head and Brain Trauma– Brain atrophy increases injury.– Higher risks of blood occupying lesions.• Findings may be delayed.

– Patient or family may not remember injury.

– Pupillary findings may not be reliable.

Pathophysiology

• Neck Trauma– Perception of pain is diminished.– C1 and C2 fractures common with

minimal traumatic mechanisms.– Immobilization concerns

Pathophysiology

• Spinal Trauma– Degenerative bone disorders are more

common.– Presence of kyphosis or scoliosis

increases injury risks.– Anterior cord syndrome is almost

exclusively a geriatric emergency.

Neck injuries are common in patients with a history of either head or chest

wall trauma.

Pathophysiology

• Thoracic Trauma– Ribs become brittle.– Disease states of lung tissue decrease

function.– Compensatory mechanisms are unable

to recover when a thoracic injury occurs.

Pathophysiology

• Abdominal Trauma– Liver and spleen are more exposed to

injury.– Internal bleeding can be masked by

what is thought to be a “normal” systolic pressure.

Pathophysiology

• Musculoskeletal Trauma– Bones are more at risk of injury due to

decrease adipose tissue, weakening cartilaginous support, and underlying disease.

– Osteoporosis contributes to bone weakness and fractures.

– Isolated fractures can become life threatening.

Pathophysiology

• Burn Trauma– Fourth leading cause of death in

geriatrics.– Changes in the skin make burns more

severe.– Burn shock occurs more readily as does

airway occlusion due to burns.– Linear increase in mortality of a burn

injury based on age alone.

Common Manifestations of Trauma in Geriatric Patients

Common Manifestations of Trauma in Geriatric Patients

Common Manifestations of Trauma in Geriatric Patients

Emergency Medical Care

• Spinal immobilization considerations– Allow for cervical/spinal curvature.

• Assess and maintain the airway.• Assess and manage circulatory

components.

Emergency Medical Care

• Determine breathing adequacy.– Apply high-flow oxygen via

nonrebreather to maintain a normal oxygen saturation with adequate breathing.

– Provide positive pressure with high-flow oxygen if inadequately breathing.

Emergency Medical Care

• Provide full immobilization.• Initiate transport to an appropriate

trauma facility.• Consider establishing IV access to

keep systolic blood pressure >90 mmHg.

• Treat any minor injuries, time allowing.

• Frequently reassess for rapid deterioration.

Case Study

• You are called to a residential address where an elderly male was trying to retrieve Christmas ornaments from his attic, when he slipped and fell down the attic steps. Upon your arrival, the patient is at the bottom of the steps, moaning, with blood coming from a temporal laceration. His right ankle looks angulated.

Case Study (cont'd)

• Scene Size-Up– Standard Precautions taken.– Scene is safe, no entry or egress

problems.– 82-year-old male, 160 lbs.– Patient found in lateral fetal position.–Mechanism of injury is fall down 10–12

wooden steps.– No additional resources needed at this

time.

Case Study (cont'd)

• What kinds of injuries could this patient have?

• What will be your assessment approach to him?

• What is your first priority?

Case Study (cont'd)

• Primary Assessment Findings– Patient moaning, but responsive to

yes/no questions only.– Airway open, breathing adequate, rate

fast.– Carotid and radial pulses present,

tachycardic.

Case Study (cont'd)

• Primary Assessment Findings– Peripheral skin cool and slightly

diaphoretic.– Bleed to right temporal region.– No other major bleeding noted.

Case Study (cont'd)

• Is this patient a high or low priority? Why?

• What interventions should be provided at this time?

Case Study (cont'd)

• Medical History– Hypertension, myocardial infarction,

COPD, constipation, hemorrhoids

• Medications– Coumadin, Nitro PRN, Proventil, Colace,

Preparation H

• Allergies–Morphine

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils equal and reactive, membranes

hydrated.– Airway patent, minute volume

adequate, breath sounds diminished.– Central and peripheral pulses present.– Pulse oximeter reading 94 percent on

ambient air.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Patient is becoming more unresponsive.– BP 180/90, heart rate 108, respirations

28.– Right ankle angulated with swelling,

pain, and tenderness noted.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Physical assessment reveals no other

skeletal trauma.– No other findings are contributory to

this report.

Case Study (cont'd)

• Provide two different explanations for his change in mental status.

• What else about this patient's medical history could make managing him more difficult?

Case Study (cont'd)

• Will his age or his medical history make you alter your treatment any?

• If the patient starts to improve, what would be the expected findings for:–Mental status– Heart rate–Muscle tone

Case Study (cont'd)

• Care provided:– Patient cervical spine manually

immobilized.– High-flow oxygen via mask initially, PPV

with supplemental oxygen after patient is in respiratory failure.

– Patient carefully immobilized to supine.– Patient loaded and transported to

appropriate trauma center.

Case Study (cont'd)

• Care provided:– Intravenous access should be

established and fluids should be administered only to maintain SBP of 90 mmHg.

– Patient reassessed and reassured during transport without change in condition.

– Treat laceration and ankle en route if possible.

Summary

• Although they are adults, approaching a geriatric patient should be given the same consideration as approaching the pediatric patient.

• Many times the paramedic will need to anticipate deterioration, modify treatment to fit the patient, and not expect all care to have the same effect as it would on a younger patient.

TOPIC

Complete and Incomplete Complete and Incomplete Spine and Spinal Cord InjuriesSpine and Spinal Cord Injuries

49

Objectives

• Discuss the predisposition, incidence, and mechanism of spinal cord injuries.

• Review normal spinal cord anatomy.• Discuss the pathophysiology of spinal

cord injuries.• Review motor and sensory findings

for incomplete spinal cord injuries.

Objectives

• Review assessment tests that ascertain spinal cord involvement.

• Review current treatment standards for cord injuries.

Introduction

• Cord injuries in the traumatized patient may be subtle or obvious.

• The paramedic must keep a high index of suspicion for possible spinal cord damage.

• Failure to manage, or the mismanagement of, a cord injury can have permanent, if not fatal, outcomes.

Epidemiology

• 11,000 new cases of spinal cord injury per year in the United States

• About 80 percent occur to men, average age 38 years.

• Incidence of elderly spinal cord injury is on the rise.

Illustration of the spinal nerves (a) laterally and (b) posteriorly. The

ganglia are detailed as well.

Cross section of spinal cord showing corticospinal, spinothalamic, and

posterior columns.

Ligaments and intervertebral disks of the spine. Lateral view of the spinal column

(anterior to the right). The lower vertebrae have been cut sagittally to reveal the spinal

canal and some of the ligaments.

Pathophysiology

• Injury to the spinal cord– Flexion, rotation, compression,

hyperextension, lateral bending, distraction, penetration

– Primary cord injury (structural damage)– Secondary cord injury (ongoing damage

from swelling or ischemia/necrosis)

Pathophysiology

• Complete spinal cord injury– Total loss of motor and sensory

function.– Fairly easy to detect.– Can be mimicked by spinal shock.–Management still remains the same.

Pathophysiology

• Incomplete spinal cord injury– A portion of the spinal cord is injured– Partial neurologic function– Requires immobilization– Specific presentations of incomplete

spinal injury include:• Central cord syndrome• Brown-Séquard syndrome• Anterior cord syndrome

Cross sections of the spinal cord, showing the H-shaped gray matter surrounded by white matter. Illustrated here are the three most common types of incomplete spinal cord injury (the areas of the injury are highlighted in red): (a) Central cord

syndrome results from injury to the central cord. (b) Brown-Séquard syndrome results from injury to the right or left half of the cord. (c) Anterior cord syndrome results from injury to the anterior cord.

Incomplete Spinal Cord Injury Syndrome Assessment Findings

Pathophysiology

• Spinal shock– Loss of neurologic function and

autonomic tone distal to injury site.– Neurogenic hypotension, hypothermia,

bradycardia may result.

Differential Assessment Findings: Hypovolemic Shock Versus Neurogenic

Shock

Assessment Findings

• Dispatch information may provide a clue.

• Assess spinal tracts by testing for pain, light touch, and motor function.

• Goal is to assess the cord at multiple levels to ensure presence/absence of injury.

Spinal Cord Motor Assessment and Level of Loss of Function

Level of Spinal Cord Injury Correlated to Loss of Sensory

Function

Emergency Medical Care

• The following patients should always be immobilized– Significant mechanism of injury.– Patient has an altered mental status.– Patient has pain or tenderness to

vertebral column.– Patient is unreliable.– Any sensory or motor dysfunction is

found.

Emergency Medical Care

• Manual cervical spine considerations• Assess and maintain the airway.• Determine breathing adequacy.

– Administer oxygen to maintain SpO2 above 94 percent

– Provide positive pressure ventilation with high flow oxygen if inadequate

Emergency Medical Care

• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.

• Initiate transport to an appropriate facility and reassess patient’s ABC’s and neurologic function en route.

Emergency Medical Care

• Initiate intravenous access with a large-bore catheter.– Administer IV fluids to keep systolic

blood pressure >90 mmHg.– If hypoglycemic (blood glucose level

<60 mg/dL), administer 25 g of 50% dextrose in water.

– Consider vasoactive agents in severe cases of spinal shock.

Case Study

• You have a 31-year-old construction worker who fell from a scaffolding onto a pile of waste material from about 20 feet. Bystanders state he landed on his back and was unresponsive for about 15 seconds. Upon your arrival, the patient can speak to you, but is not sure what happened.

Case Study (cont'd)

• Scene Size-Up– Standard Precautions taken.– Scene is safe, workers have cleared

area of debris.– 31-year-old male patient, 180 lbs.– Mechanism of injury appears to be a fall– Additional resources are not requested

at this time

Case Study (cont'd)

• Scene Size-Up– Patient found supine, no gross

hemorrhages.– Patient entry made, egress not

problematic.– No additional resources needed at this

time.

Case Study (cont'd)

• Primary Assessment Findings– Patient responsive, but amnestic to fall.– Airway open, breathing adequate, no

dyspnea.– Carotid and radial pulses present,

normal rate.

Case Study (cont'd)

• Primary Assessment Findings– Peripheral skin warm and slightly

diaphoretic.– No major bleeds noted to body.– Patient keeps telling you that he cannot

move his arms.

Case Study (cont'd)

• Is this patient a high or low priority? Why?

• What interventions should be provided at this time?

Case Study (cont'd)

• Medical History– Asthma

• Medications– Proventil inhaler PRN

• Allergies– No drug allergies

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils equal and reactive, membranes

hydrated.– Airway patent, good minute ventilation.– Central and peripheral pulse and

perfusion good.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pulse oximeter reading 98 percent on

ambient air.– Patient has normal lower extremity

motor tone; however, he cannot move his arms.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– He can feel light touch in all extremities,

but not painful stimuli to arms.– Deformity and abrasion to base of neck

noted.– B/P 104/80, heart rate 70, respirations

12.– BGL is 120 mg/dL

Case Study (cont'd)

• Do you suspect a spinal cord injury? If so, what type?

• Explain the reason for the conflicting assessment findings.

• What spinal nerve tract is injured on this patient?

• What treatments would you provide to this patient?

Case Study (cont'd)

• Care provided:– Patient’s cervical spine manually

immobilized.– Administer oxygen to maintain SpO2

above 94 percent.– Patient carefully immobilized.– Transported to an appropriate facility.– Initiated intravenous access and provide

fluids to maintain SBP >90 mmHg.

Summary

• As mentioned, the traditional method for assessing motor, sensory, and perfusion is not sufficient for incomplete spinal injuries.

• Incomplete SCI need immobilization as well to prevent the incomplete from progressing to complete.

TOPIC

Traumatic Brain InjuryTraumatic Brain Injury

48

Objectives

• Discuss the predisposition, incidence, and death rates for brain injuries.

• Review the pathophysiology behind the types of brain injuries.

• Define assessment considerations and findings for patients with brain injuries.

• Review current treatment parameters for patients with herniating and non-herniating brain injuries.

Introduction

• Brain injuries may manifest themselves now, or weeks later.

• The physiology of the brain and surrounding structures leaves itself open to certain types of brain injuries.

• Understanding the pathophysiology of brain injuries will allow the paramedic to provide optimal treatment.

Epidemiology

• 1.5 million head injuries occur per year in the United States

• It is the leading cause of death in accident victims younger than 45.

• 50,000 people die each year from brain injury.

Pathophysiology

• Intracerebral hemorrhage– Extraaxial hemorrhage

• Epidural, subdural, subarachnoid

– Intraaxial hemorrhage• Occurs within brain tissue itself• Intracerebral hemorrhage

– Intraparenchymal hemorrhage– Intraventricular hemorrhage

Pathophysiology

• Diffuse axonal injury (DAI)– Most devastating of traumatic brain

injuries– Acceleration-deceleration mechanism– Frequent outcome is coma– Stretching and swelling of axons

Pathophysiology

• Diffuse axonal injury– Concussion

• Mild DAI• GCS 13-15

– Epidural hematoma• Serious complication of head injury• Bleeding between dura and skull

Pathophysiology

• The rise in ICP causes a cascade of signs and symptoms, including:• Decreased mental status • Severe headache • Fixed and dilated pupils • Vomiting• Altered or absent breathing • Posturing • Systolic hypertension with associated

bradycardia (Cushing reflex, a late finding)

Figure 48–1 Epidural hematoma.

Pt. will suffer a loss of consciousness and then a period of responsiveness. Shortly thereafter, his level of consciousness will deteriorate rapidly.Result from low velocity impact skull Fx is common occurring in 90% of pt.

Pathophysiology

• Diffuse axonal injury– Subdural hematoma

• Bleeding between arachnoid and dura• Low-pressure bleed• Phases include acute, subacute, and chronic

Pathophysiology

• Acute phase—Signs and symptoms begin immediately

• Subacute phase—begins three to seven days after the injury

• Chronic phase—begins two to three weeks later• Subdural hematoma is seen in child abuse cases

and incidents involving shaken baby syndrome.• typical mortality rate around 60 percent.

Pathophysiology

• Signs and symptoms of acute subdural hematoma include:

• Declining level of consciousness • Abnormal or absent respirations • Dilation of one pupil • Weakness or paralysis to one side of the body• Vomiting• Seizures • Increasing systolic blood pressure• Decreasing heart rate

Figure 48–2 Subdural hematoma.

Pathophysiology

• Diffuse axonal injury– Subarachnoid hemorrhage

• Brain tissue becomes ischemic• Severe headache common• May rapidly progress to seizures and cardiac

arrest

Assessment Findings

• Dispatch information – Seizures, headache, trauma, etc.

• Soft tissue injuries to skull• Closed or open skull injuries• Alteration in mental status• Possible loss of airway patency• Breathing may be irregular and slow• Changes to vitals (Cushing response)

Assessment Findings

• Response to painful stimuli– Purposeful vs. nonpurposeful– Decorticate vs. decerebrate

• Assess and reassess mental status.– Compute Glasgow Coma Score, look for

trends.

• Assess vital signs– Trends of vitals may also help identify

brain injury.

Nonpurposeful responses to painful stimuli include (a) flexion (decorticate) posturing and (b)extension

(decerebrate) posturing.

Glasgow Coma Scale

Implications of Changes in Vital Signs with Head Injuries

Emergency Medical Care

• Manual cervical spine considerations• Assess and maintain the airway.• Determine breathing adequacy.

– Administer oxygen to maintain SpO2 above 94 percent.

– Positive pressure ventilation with high flow oxygen if inadequate.

– Consider hyperventilation (at no more than 20/min) with brain herniation.

Emergency Medical Care

• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.

• Transport immediately to an appropriate medical facility.

Emergency Medical Care

• Initiate a large-bore intravenous catheter.– Administer fluids to keep systolic blood

pressure >90 mmHg.– Do not cause hypertension with IV

fluids.

Emergency Medical Care

• Be prepared to manage seizure activity.

• Constantly monitor airway, breathing, and circulation.

• Mental status changes are key to determining improvement or deterioration.

Case Study

• You are called to a motorcycle accident where a rider who was not wearing a helmet lost control of his cycle on a turn and hit a tree. When you arrive, the patient is lying supine, blood covering his face and shirt, and the patient is actively seizing. The police are already on scene and you can hear the wail of the fire department sirens approaching.

Case Study (cont'd)

• Scene Size-Up– Standard precautions taken.– Scene is safe, police stopped traffic – 43-year-old male patient, 200 lbs.– Patient supine, blood on face and shirt.– MOI- motorcycle accident– Entry made, egress not problematic.– PD on scene, FD pulling up.– Additional resources requested

Case Study (cont'd)

• Based on the information provided and the scene size-up, what differential diagnosis might you suspect?

• What types of additional resources may you consider requesting?

• What are your priorities at this time?• Would you consider this a high-

priority patient? Why?

Case Study (cont'd)

• Primary Assessment Findings– Patient unresponsive, active tonic-clonic

seizures.– Mouth clenched shut, blood on face,

sonorous breath sounds with gurgling.– Breathing is ineffective due to seizure

activity.

Case Study (cont'd)

• Primary Assessment Findings– Carotid and radial pulses present.– Peripheral skin warm and sweaty.– No major bleeds noted to body.

Case Study (cont'd)

• What interventions should be provided at this time?

• How would you manage the airway of this patient?

• What could be the cause of his seizure activity?

Case Study (cont'd)

• Medical History– Unknown

• Medications– Unknown

• Allergies– Unknown

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils unequal, sluggish to light.– Airway patent, spontaneous breathing

still ineffective.– Patient is still unresponsive and seizing.– Pulse oximeter reading 82 percent

initially with attempts at PPV. 93 percent on high-flow oxygen.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– B/P 198/90, heart rate 56, spontaneous

respirations 4 and irregular.– Crepitus noted to posterior vertebrae.– Depressed right frontal skull fracture

noted.– Sinus bradycardia on monitor– Blood glucose level 65 mg/dL

Case Study (cont'd)

• What type of brain injury would you suspect?

• Is this patient displaying any indications of herniation? Why?

• What interventions might you provide at this time?

Case Study (cont'd)

• Care provided:– Stabilize cervical spine– Considering hyperventilation based on

protocol– Maintain airway, oxygenation, and

ventilation

Case Study (cont'd)

• Care provided:– IV initiation and fluid therapy– Stop seizures (based on protocol)– Full spinal immobilization– Rapid transport to appropriate facility

Summary

• Brain injuries are a common cause of death and disability following traumatic events.

• Prehospital recognition and proper management can help reduce the long-term effects of brain injuries.

• As with any trauma, focus first on supporting lost function.

TOPIC

Soft Tissue Injuries: Crush Injury Soft Tissue Injuries: Crush Injury and Compartment Syndromeand Compartment Syndrome

45

Objectives

• Review the occurrences and mechanisms of soft tissue trauma.

• Discuss pathophysiological changes at the cellular level of crush and compartment syndrome injuries.

• Review assessment findings and current treatment interventions for these types of injuries.

Introduction

• Crush injury is a mechanism of blunt trauma, whereas compartment syndrome is an injury pattern.

• Crush injuries are caused by excessive compressive forces on the body.

• Can occur to small localized areas (thumb), or to large regions (thorax).

Epidemiology

• A broad definition of soft tissue injury accounts for the vast majority of traumatic injuries.

• Crush injuries are a small portion of this category.

• Crush injuries result from a wide range of mechanisms.

Mechanism

• Direct force– Tissue destruction from compressive

forces

• Entrapment/Weight-based compression– Compression caused by patient's

position

• Internal compression– Internal swelling causing compartment

syndrome

Direct force can cause crush injuries, some resulting in open wounds.

A stroke patient who has fallen and trapped her right leg beneath her body

weight.

Pathophysiology

• Direct compression destroys tissue cells.

• Pressure can also inhibit normal blood flow to tissues, worsening tissue damage.

• Compression > four hours may result in muscle breakdown with toxin release.– Can have devastating systemic effects.

Pathophysiology

• Compartment syndrome– Compression from the opposite

direction.– Swelling or bleeding in muscle occurs.– Fascia enveloping muscle is

nondistensible.– Pressure builds, causing changes to

blood flow.

Assessment Findings

• Common findings– Pain to traumatized area– Possible entrapment of extremity– Bruising, tenderness, ecchymosis– Deformity, loss of function– Diminished or absent distal circulation,

motor, or sensory findings– Internal hemorrhage, shock

Assessment Findings

• Specific compartment syndrome findings– Pain, discomfort, burning sensation– Pain that continues after immobilization– Tenderness, unusual firmness at injury

site– Altered CMS distal to the injury–Weakness or paralysis of muscle

Assess circulation in an extremity following a crush injury.

Emergency Medical Care

• Spinal immobilization considerations• Assess and maintain the airway.• Determine breathing adequacy.–Maintain adequate oxygenation.– Positive pressure ventilation with high

flow oxygen if inadequate.

• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.

Emergency Medical Care

• Relieve any compression pressure if possible.– Cellular waste products may be released

into the blood stream.–May result in massive internal bleeding.

• Initiate intravenous therapy.• Consider the administration of

medications.

Emergency Medical Care

• Prepare for cardiac arrest.• Treat any minor injuries, time

allowing.• Consider full spinal immobilization.• Transport to appropriate facility.

Emergency Medical Care

• Preventing and treating compartment syndrome.– Elevate extremities.– Beware of constricting immobilization.– Apply cold.–Monitor distal CMS.

Case Study

• You are called to a remote area of your response district where a man was injured while cutting down trees. The man was reportedly trapped by a fallen tree for hours prior to being found missing by his family. When you arrive, the patient's abdomen and legs are still entrapped, and the fire department is extricating him. The patient is able to respond to you.

Case Study (cont'd)

• Scene Size-Up– Standard Precautions taken.– Scene is safe, no further fear of pinning.– Adult male, 40 years old, 230 lbs.– Patient found supine, large tree stump

across his abdomen and legs.

Case Study (cont'd)

• Scene Size-Up– Patient entry made, egress problematic

due to woods and distance to carry.– Additional resources of FD on scene

already.

Case Study (cont'd)

• Primary Assessment Findings– Patient responsive, seems lethargic

though.– Airway open and maintained by self.– Breathing is rapid, alveolar sounds

present.

Case Study (cont'd)

• Primary Assessment Findings– Carotid and radial pulses present,

cannot assess lower extremities.– Peripheral skin cool, pale, sweaty.– You see some evidence of bleeding from

legs, but nothing current.

Case Study (cont'd)

• Is this patient a high or low priority? Why?

• What interventions should be provided at this time?

• What type of injuries do you expect from this mechanism?

• Describe how this mechanism could cause compartment syndrome.

Case Study (cont'd)

• Medical History– High cholesterol.

• Medications– Patient denies any, watches his diet.

• Allergies– “Some antibiotics,” he states.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils dilated but reactive, membranes

pale.– Airway patent, breathing tachypneic.– Peripheral perfusion diminishing to

arms.– Breath sounds present bilaterally.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Patient's mental status still continuing to

deteriorate.– Pulse oximeter reading 98 percent on

high flow.– BP 100/82, heart rate 114, respirations

20.– Unable to assess lower extremities or

abdomen.

Case Study (cont'd)

• The fire department reports that it will take them at least 10 minutes to lift the tree stump off of the patient.

• They ask you if you need anything else ready or set up. What would be your response?

• What additional emergency medical care might you consider while waiting for extrication?

Case Study (cont'd)

• After lifting the tree from the patient, he arrests about 30 seconds later. Explain why this may have happened.

• What emergency care will you provide?

Case Study (cont'd)

• Care provided:– Patient immobilized.– Open and maintain airway.– PPV with oxygen due to apnea.– Cardiopulmonary resuscitation initiated

upon arrest.

Case Study (cont'd)

• Care provided:– Advanced cardiovascular life support

provided accordingly.– All lower extremity fractures managed

by immobilization to backboard.– Rapid transport.

Summary

• Crush injuries are a rare, but potentially fatal mechanism for soft tissue trauma, since the injury pattern could be so widely dispersed.

• The paramedic should indentify and treat life threats before managing the soft tissue trauma and compartment syndrome issues.

TOPIC

Chest TraumaChest Trauma

43

Objectives

• Review annual injury and death rates for chest trauma victims.

• Understand pathophysiologic changes that occur with chest trauma.

• Discuss common clinical findings of chest trauma.

• Identify the importance of mechanism of injury in determining presence of chest trauma.

Introduction

• Chest injuries can be obvious and dramatic, or small and easy to miss.

• The assessment of the chest must be comprehensive in order to find all injuries.

• The paramedic must understand the physiology of the chest wall and its response to trauma.

Epidemiology

• 20 percent to 25 percent of trauma deaths each year are due to thoracic trauma.

• The most common mechanism is motor vehicle collision.

Epidemiology

• Immediate deaths are due to myocardial or aorta rupture.

• Early deaths are due to tension and open pneumothorax, tamponade, flail segments, and hemothorax.

Pathophysiology

• Chest trauma distorts the normal thoracic anatomy.

• Distortion injures body system and causes a change in physiology.

• V/Q ratio disturbances, hypoxemia, and hypercapnea ensue.

• Ultimately, cellular death occurs.

Pathophysiology

• Tension pneumothorax– Disruption of visceral pleura– Accumulation of intrathoracic air– Collapse of lung tissue– Shifting of mediastinum– Changes in hemodynamics– Assessment• Early findings• Late findings

In a tension pneumothorax, air continuously fills the pleural space, the lung collapses, pressure rises, and the trapped air compresses the heart and the other

lung.

Pathophysiology

• Open pneumothorax– Disruption of parietal pleura from hole in

chest– Accumulation of intrathoracic air– Collapse of lung tissue– Injury may turn into tension

pneumothorax– Assessment findings

In an open pneumothorax, air enters the chest cavity through an open chest wound or leaks from a

lacerated lung. The lung then cannot expand.

Pathophysiology

• Flail chest– Fractured ribs (2 or more in 2 places)– Creates “free floating” segment of chest– Paradoxical motion inhibits adequate

ventilation– Resulting pulmonary contusion– Assessment findings

Flail chest occurs when blunt trauma causes the fracture of two or more ribs, each in two or more

places.

With a flail chest, (a) the flail segment is drawn inward as the rest of the lung expands with

inhalation; (b) the flail segment is pushed outward as the rest of the lung contracts with exhalation.

Pathophysiology

• Hemothorax– Similar to pneumothorax– Pleural cavity fills with blood (chest

trauma)– Collapse of lung tissue creates

hypoventilation–May also cause hypovolemia– Assessment findings

In a hemothorax, blood leaks into the chest cavity from lacerated vessels or the lung itself,

and the lung compresses.

Pathophysiology

• Acute pericardial tamponade– Injury to heart causes blood to collect in

pericardial sac– Pericardial sac nondistendable– Collapsed ventricles, poor stroke volume– Assessment findings

In pericardial tamponade, accumulating blood compresses the heart inward.

Assessment Findings

• Inspection– Any open chest injuries– Any structural abnormalities

• Auscultation– Type, quality, location of breath sounds

• Palpation– Structural abnormalities– Subcutaneous emphysema

Differential Field Diagnosis of Chest Injury

Emergency Medical Care

• Spinal immobilization considerations• Assess and maintain the airway.• Determine breathing adequacy.– Provide positive pressure ventilation

with high-flow oxygen @ 10-12/min if inadequately breathing.

– Occlude any punctures to chest wall.– Decompress a tension pneumothorax.

Emergency Medical Care

• Assess circulatory components– Check pulse, skin characteristics– Control major bleeds

• Provide full immobilization• Initiate safe and expeditious

transport• Establish a large bore IV en route.– Avoid aggressive fluid administration

• Consider pain medication

Case Study

• Your EMS unit is summoned for a patient who was injured while hunting. Upon your arrival, you find a male patient holding his hand over his right thorax. Some blood is seeping past his fingers, and the breathing looks labored. Friends report he was accidently shot with an arrow.

Case Study (cont'd)

• Scene Size-Up– Standard Precautions taken.– Scene is safe, no sign of struggle.– Young male, 18 years old.– Patient found sitting along edge of road.– No patient entry nor egress problems.– No additional resources needed

presently.

Case Study (cont'd)

• Primary Assessment Findings– Patient responsive.– Airway open and maintained by self.– Breathing is rapid, patient is dyspneic.– Breath sounds diminished on the right.– Carotid and radial pulses present but

radial gets weaker with inhalation.– Peripheral skin cool, pale, sweaty.– No other major bleeds or concerns.

Case Study (cont'd)

• Is this patient a high or low priority? Why?

• What interventions should be provided at this time?

Case Study (cont'd)

• What are your differentials thus far that the patient could be suffering from?

• Do you think that this patient will have a problem with the ventilation or perfusion side of the V/Q ratio? Why?

Case Study (cont'd)

• Medical History– Patient states he has attention deficit

hyperactivity disorder and Tourette syndrome

• Medications– Patient states he takes Vyvance, Tenex,

and Albilify

• Allergies– Patient states he is allergic to penicillin

Case Study (cont'd)

• Pertinent Secondary Assessment Findings– Pupils dilated but reactive, membranes

pale.– Airway patent, breathing tachypneic.– Peripheral perfusion diminishing.– Absent breath sounds to right thorax.– Patient's mental status still continuing to

deteriorate.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings – No jugular venous distention noted– No tracheal deviation noted– Penetration injury fourth intercostal

space, right anterior chest.– Pulse oximeter reading 98 percent with

supplemental O2.

Case Study (cont'd)

• Pertinent Secondary Assessment Findings – Occlusive dressing “burped.”– B/P 82/palp, heart rate 114,

respirations 20.– Pulsus paradoxus noted

Case Study (cont'd)

• What would be key clinical indications the patient is deteriorating despite treatment?

• What advantage does “burping” the occlusive dressing have?

• Why would PPV possibly be detrimental to the patient?

Case Study (cont'd)

• Based on the assessment findings, what is your differential diagnosis?

• What additional treatments would you perform?

• How would the patient benefit from your interventions?

Case Study (cont'd)

• Care provided:– Patient immobilized.– High-flow oxygen via nonrebreather

mask, switched to PPV due to failing ventilations.

– Occlusive dressing to chest injury which is burped.

Case Study (cont'd)

• Care provided:– Needle decompression.– Transport to trauma hospital initiated.– Established intravenous access to

maintain systolic BP of 90 mmHg.

Summary

• Chest wall injuries can result in significant disturbances to the V/Q ratio.

• Although these injury typically require surgery, the paramedic can provide treatments that will support lost function.