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Chapter 12
Shock Trauma Resuscitation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Shock Trauma Resuscitation
Injury Prevention
Trauma Assessment
Trauma Patient History
Shock Trauma Resuscitation
Interaction with Other Care Providers
Body Substance Isolation at the Trauma
Scene
Air Medical Transport
Research and Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction
In the mid 1960s trauma was identified as
“the neglected disease of modern society.”
– Resulted in establishment of growth of EMS
Current research shows that often the skills
of EMS professionals worsen the outcome
of the trauma patient.
– Must ensure that our practices are current and
BENEFIT our patients
– Must function as part of an integrated health
care delivery team
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Injury Prevention
Prevention is the GREATEST key to reduce
injury.
– Injury prevention is the future of EMS.
“Let’s not meet by accident”
Bicycle rodeo clinics
MADD
Home safety inspections
In conjunction with fire service
Workplace standards for safety
Improved motor vehicle safety
Focus on at-risk populations
Males 13–35
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (1 of 2)
Dispatch Information
– Critical pre-arrival information:
Nature of call
Number of victims
Mechanism of injury
Safety of scene
Law enforcement required
Specialized rescue
Fire department
Hazardous materials
– Anticipate and prepare for injuries:
Equipment to be brought to the patient
Procedures to be performed
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (2 of 2)
Scene Size-up
– Mechanism of Injury Analysis
– Hazard Identification
US DOT Hazardous Materials: The Emergency
Response Guidebook
Presence and mood of bystanders and family
members
– Body Substance Isolation
– Accounting for and Locating all Patients
Search for evidence of other occupants, etc.
– Resource Needs Determination
Fire, Police, Rescue, Additional EMS, Hazardous
Materials, Animal Control, etc.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Initial Assessment (1 of 2)
Spinal Precautions
– Provide spinal restriction after appropriate
assessment of neck and back.
General Impression
Mental Status
– AVPU
– A&O x 4
Time, place, event, and person
Orientation diminishes in this order
– Posturing
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Initial Assessment (2 of 2)
Airway
– Open
– Patent
– Noisy Respirations
Breathing
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High-Flow O2
Auscultation
Needle decompression
BVM if Rs <12
Circulation
– Detect signs of shock
Concluding the Initial Assessment
– Re-evaluate MOI
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (1 of 5)
When to Employ Spinal Precautions
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MOI suggests possible spinal injury
Blunt forces, or excessive movement of the neck
Reduced mental status
Significant injury above shoulders
Complaint of pain along spinal column
Complaint of numbness or tingling in any
extremity
– Unusual distal neurological sign
– IF YOU ARE IN DOUBT
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (2 of 5)
General Examination Techniques
– Questioning
SAMPLE
OPQRST
Pain evaluation
– Inspecting
Skin color
Deformities
Skin disruption
– Palpation
– Auscultation
– Percussion
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (3 of 5)
Rapid Trauma Assessment
– Suspect serious injury to body
– Rapid transport criteria
– Order
Head
Neck
Chest
Abdomen
Pelvis
Extremities
Distal function: pulse, motor, and sensation
Back
– Quick history and vitals
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (4 of 5)
Focused Exam and History
– Performed if limited injuries
– Direct exam to location of patient
complaints
– Use examination criteria for detailed
examination
– Patient history
– Vitals
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment (5 of 5)
Detailed Physical Exam
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Head
Neck
Chest
Abdomen
Pelvis
Extremities
Back
D-Deformity
C-Contusions
A-Abrasions
P-Penetrations
S-Swelling
B-Burns
T-Tenderness
L-Lacerations
S-Symmetry
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Detailed Physical Exam (1 of 5)
Head
– Inspect and Palpate
– Evaluate
Eyes
Pupillary response
H-Pattern evaluation
Ears
Fluid
Nose and Mouth
Fluid and obstructions
Face
Battle’s sign and raccoon’s eyes
Le Fort fractures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Detailed Physical Exam (2 of 5)
Neck
– Signs of injury
– Position of trachea
Displacement indicative of tension pneumothorax
– Status of jugular veins
Normal
Distended in supine position
Flatten as head raised above 45o
Abnormal
Distended
Tension pneumothorax
Pericardial tamponade
Traumatic asphyxia
Flat
Hypovolemia
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Detailed Physical Exam (3 of 5)
Chest
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Retractions
Sucking wounds
Paradoxical chest movement
Erythema
Auscultate all lung fields
Palpate
Crepitus
Gentle pressure on rib cage
Subcutaneous emphysema
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Detailed Physical Exam (4 of 5)
Abdomen
– Asymmetry
– Pulsing masses
– Contusion, erythema, and ecchymosis
Pelvis
– Firm pressure on iliac crests
DO NOT COMPRESS IF OBVIOUS FX.
– Examine buttocks and inguinal area
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Detailed Physical Exam (5 of 5)
Extremities
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Muscle tone
Distal pulse
Temperature
Color
Capillary refill
Back
– Evaluate during log roll
– Maintain proper spinal restriction procedures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Patient History
AMPLE History
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Allergies
Medications
Past medical history
Last oral intake
Events leading up to the incident
Vital Signs
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Pulse rate and quality
Respiratory rate and quality
Blood pressure
Skin temperature and condition
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Transport Decision
– Rapid Transport
Trauma triage criteria
– Revised Trauma Score
– Treat and Transport
No significant MOI and non-urgent injuries
– Treat and Release
Minor and isolated injuries
– Patient Care Refusals
Provide the patient with information
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Steps to Follow for
Patient Refusals
Strongly suggest that patient receives
assessment, care, and transport.
Warn patient of the dangers of refusing
assessment, care, and transport.
Suggest that the patient see a family
physician for follow-up.
Encourage the patient to contact EMS
if the problem persists or worsens.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Trauma Assessment
Ongoing Assessment
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To monitor and guide care
Critical: every 5 minutes
Non-critical: every 15 minutes
Components
Vitals
Recheck interventions
Mental status
Skin condition
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs of Deterioration
Pulse
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Increasing pulse
Decreasing pulse strength
Narrowing pulse pressure
Increasing capillary refill time
Respirations
– Increasing respiratory rate
– Decreasing respiratory volume
Mental Status
– Decreasing mental status
– Increasing anxiety or restlessness
Skin
– Changes in skin color or temperature
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Hypovolemia/Hypotension/Hypoperfusion
– Describes status of cardiovascular system
– Hypovolemia
Reduced volume in cardiovascular system
– Hypotension
Reduction in blood pressure caused by cardiac,
vascular, neurogenic, or volume problems
– Hypoperfusion
Low or inadequate distribution of blood to body organs
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Steps of Shock Trauma
Resuscitation
Airway Protection
– Intubation
– RSI
Assure adequate oxygenation and
ventilation
– <12 or >30 breaths/minute  BVM
Provide rapid fluid resuscitation
– 2 large-bore IVs
– Isotonic fluids
Maximum 3 L
Chest Decompression
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
(1 of 5)
Hypothermia
– Due to sympathetic effects.
– Body begins to conserve energy.
Redirects blood supply to internal organs.
Slows temperature regulation activities.
– Prevention:
Provide warm fluids during fluid resuscitation.
Maintain patient’s body temperature.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
(2 of 5)
Body Splinting
– Splinting must be effective and performed
quickly.
– Best accomplished by aligning limbs and
securing body on long spine board.
Limits movement of all extremities and spine.
Movement and immobilization must be
coordinated.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
(3 of 5)
Rapid Transport
– Best way to reduce mortality.
– Meeting objective:
Rapid packaging.
Reduce time on scene.
Limit scene time to 10 minutes.
Perform procedures en route to hospital.
IV and PASG while immobilizing spine.
Other critical procedures en route unless delayed
on scene time due to prolonged extrication.
Consider using air medical transport.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
(4 of 5)
Fight-or-Flight Response
– Autonomic nervous system response
Sympathetic nervous system stimulation
Increase heart rate
Increase stroke volume
Increase respiratory rate and volume
Release of:
Glucose
Insulin
Epinephrine
Norepinephrine
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
(5 of 5)
Non-Critical Patients
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Account for 80% of trauma patients
Receive focused exam
Receive focused care
Monitor interventions
Monitor for deterioration
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Pediatrics (1 of 6)
Same basic anatomy and physiology
as adults
Trauma greatest cause of death during
first year of life
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Blunt trauma greatest cause
Falls
Abuse
Penetrating injuries
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Pediatrics (2 of 6)
Anatomical Differences
– Smaller size and weight
Larger ratio of body surface area to volume
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Organs closer together
Limbs proportionally shorter
Heads proportionally larger
Tongues more likely to obstruct airway
Obligatory nose breathers
Trachea shorter and more delicate
Bones softer and more pliable
Energy of trauma distributes better to organs
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Pediatrics (3 of 6)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Pediatrics (4 of 6)
Compensatory Mechanisms
– Vibrant cardiovascular system
Greater compensation during shock
>25% of blood volume before signs develop
>50% of blood volume before compensation fails
Rapid deterioration once compensation fails
Rapid progression to irreversible shock
Loss of vital signs
– Respiratory system has less reserves
Less able to tolerate stressors
Muscles tire quickly due to faster respirations
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Pediatrics (5 of 6)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Pediatrics (6 of 6)
Pediatric Care
– Maintain airway in neutral position.
Pad under shoulders.
– Insert oral airways using tongue blade.
– Keep nasal passage clear in children under 6
months of age.
– Use uncuffed endotracheal tube.
Approximate size of little finger.
– IV access same as adult.
Consider IO in children <6 yrs.
Fluid bolus: 20 mL/kg:
Administer sooner than in adults.
Can repeat to up to 60 mL/kg.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Geriatrics (1 of 3)
Fastest growing population
Trauma accounts for 25% of mortality
Concerns
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Multiple co-existing diseases or illnesses
Prone to fractures
Body system deterioration
Loss of brain mass
More prone to overhydration
Less able to respond to hypovolemia
Reduced pulmonary functioning
Higher pain tolerance
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Geriatrics (2 of 3)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Trauma Resuscitation
Special Patients: Geriatrics (3 of 3)
Geriatric Care
– Initiate shock care early.
Provide care conservatively.
Monitor for fluid overload.
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Consider smaller IV catheters.
Frequent chest auscultation.
Maintain warmth.
Monitor ECG.
Aggressive oxygenation.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Interaction with Other
Care Providers
Providing information to other health care
providers:
– Mechanism of injury
– Results of assessment
Injuries
Normal or abnormal history
Vital signs and trends
Patient age, sex, and weight
AMPLE history
– Interventions
Information must be clear and concise.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Body Substance Isolation
at the Trauma Scene (1 of 2)
Handle contaminated materials while
wearing PPE.
Dispose of contaminated linens,
clothing, dressing, and equipment in
properly labeled containers.
Dispose of sharps in punctureresistant sharps container.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Body Substance Isolation
at the Trauma Scene (2 of 2)
DO NOT recap sharps.
DO NOT stick sharps into mattresses.
Scan the scene prior to departure to
ensure that contaminated material has
been collected.
Contact Infection Control Officer if
personnel become contaminated.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (1 of 7)
Indications for air transport
– Ground versus air transport
If ground transport time exceeds 20 minutes,
helicopter transport may be warranted.
Air transport equates to 1 min/2 miles.
Consider rendezvous with helicopter.
– Consider placing helicopter on standby.
Limitations for air transport
– Weather
– Dispatched to another call
– Down time for maintenance
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (2 of 7)
Landing Zone Criteria
– Free of debris and dust
Consider wetting to reduce “dust out”
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As level as possible
Free of power lines
Charged fire hose
Size of landing zone
Small helicopter: 60’x60’
Medium helicopter: 75’x75’
Large helicopter or in doubt: 120’x120’
– Contact local helicopter agency for their specific
landing zone criteria.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (3 of 7)
Working around the Helicopter
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Approach ONLY after pilot signals.
Approach from front at direction of flight crew.
Allow flight crew to load and unload patient.
Keep head down.
Secure hats and glasses.
Secure sheets and items that can be drawn up
into rotors.
– FOLLOW FLIGHT CREW INSTRUCTIONS.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (4 of 7)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (5 of 7)
Flight Physiology
– Higher altitude = less pressure on patient
Internally trapped air exerts more pressure.
Conditions that can worsen:
Asthma
COPD
Tension pneumothorax
Interventions that can worsen:
PASG can increase in pressure exerted.
Cuffed ET tubes expand.
Pressure infusing bags exert more pressure.
Air splints exert more pressure.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (6 of 7)
Flight Considerations
– Confined working area.
– Limited ability to perform procedures.
Intubation
Chest decompression
CPR
Application of PASG
– Fully immobilize patient prior to transport.
– Ensure that any ALS interventions are
patent and secured.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport (7 of 7)
Air Medical Patient Preparation
– Assure maximal oxygenation.
– Assure maximal ventilation.
– Administer high-flow oxygen.
Consider intubation or RSI.
If patient airway status is marginal or deteriorating.
– Assess for pneumothorax.
Decompress prior to loading.
– Establish 2 large-bore Ivs.
– Provide flight crew with complete and
abbreviated patient report.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Research and Trauma
Research must occur to assure that
EMS uses procedures beneficial to
patient outcomes.
– Outcomes include discharge from
hospital.
NOT delivering a “live” patient to the hospital.
All EMS personnel must participate to
ensure optimal patient care.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Shock Trauma Resuscitation
Injury Prevention
Trauma Assessment
Trauma Patient History
Shock Trauma Resuscitation
Interaction with Other Care Providers
Body Substance Isolation at the Trauma
Scene
Air Medical Transport
Research and Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ