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Paramedic Care: Principles & Practice Volume 4 Trauma Emergencies Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 12 Shock Trauma Resuscitation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Introduction to Shock Trauma Resuscitation Injury Prevention Trauma Assessment Shock Trauma Resuscitation Interaction with Other Care Providers Standard Precautions at the Trauma Scene Air Medical Transport Research and Trauma Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Shock Trauma Resuscitation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Shock Trauma Resuscitation EMS professionals must secure a future for prehospital emergency care and assure that our patients receive the best chances for survival – Promoting injury prevention – Assure that our practices are current and truly benefit those who receive our care – Function as an integrated component of the health care system Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Injury Prevention Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 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 Programs 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Injury Prevention Home Inspection Example Click here to view the injury prevention home inspection form. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Dispatch Information – Critical pre-arrival information: Nature of call Number of victims Mechanism of injury Safety of scene – 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Scene Size-up – Mechanism of Injury Analysis – Hazard Identification – Accounting for and Locating all Patients – Resource Needs Determination © Jeff Forster © Mark C. Ide Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Initial Assessment 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 – Noxious or painful stimuli Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Initial Assessment Airway – Open – Patent – Noisy Respirations Breathing – – – – High-Flow O2 Auscultation Assess injuries Ventilatory effort Circulation – Detect signs of shock Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Initial Assessment Concluding the initial assessment – Modify MOI analysis – Safety – Assessment considerations Rapid trauma Focused – Transport considerations Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Examination Techniques The rapid trauma assessment and the focused exam use basic techniques of assessment: – Patient questioning – Inspection – Palpation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Examination Techniques Questioning – Question the patient about any symptoms – Patient complaints are subjective Watch response to pain Note if easily distracted from pain – Note complaint in patients own words Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Examination Techniques Inspection – Look first to the skin color Initial coloration is a baseline when you examine injured regions of the body – Look for deformities Compare limb to limb or one side of the body to the other – Examination for disruption of the skin (wounds) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Examination Techniques Palpation – Gently touch the entire surface of the area being evaluated – Note any muscle spasm (guarding) or pain on palpation Observe for painful movement or rebound tenderness Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Examination Techniques Auscultation – Evaluate for the presence and quality of breath sounds – Compare side-toside and regional differences Percussion – Resonance Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Rapid Trauma Assessment – Scan the body looking for hemorrhage or evidence of significant injury – Examine the patient’s head, neck, chest, abdomen, pelvis, extremities, and back – Quick patient history and a set of vital signs Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Detailed Physical Exam – An organized and intensive evaluation of each body area: Head, neck, chest, abdomen, back, pelvis, and extremities – DCAP-BTLS may be useful in identifying potential injuries to each area Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Physical Exam 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Physical Exam 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 Flat Hypovolemia Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Physical Exam Chest – – – – – – 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Physical Exam Abdomen – Asymmetry – Pulsing masses – Contusion, erythema, and ecchymosis Pelvis – Firm pressure on iliac crests medially – Downward on pubis – Examine buttocks and inguinal area Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Physical Exam Extremities – – – – – 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Patient History AMPLE History – – – – – Allergies Medications Past medical history Last oral intake Events leading up to the incident Vital Signs – – – – Pulse rate and quality Respiratory rate and quality Blood pressure Skin temperature and condition Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Glasgow Coma Scale Determine your patient’s Glasgow Coma Scale score Best eye, verbal, and motor response Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Transport Decision – Rapid Transport Trauma triage criteria Revised Trauma Score Includes Glasgow score, pulse, and blood pressure – 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 Emergencies, 3rd. Ed. © 2009 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Assessment Ongoing Assessment – – – – 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Signs of Deterioration Pulse Mental Status – Increasing pulse – Decreasing pulse strength – Narrowing pulse pressure – Increasing capillary refill time – Decreasing mental status – Increasing anxiety or restlessness Skin – Changes in skin color or temperature Respirations – Increasing respiratory rate – Decreasing respiratory volume Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Shock trauma resuscitation is care to rapidly support the seriously injured trauma patient – Providing airway protection with endotracheal intubation or rapid sequence intubation – Assuring adequate oxygenation and ventilations – Providing appropriate fluid resuscitation – Performing pleural decompression Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Hypothermia – Due to sympathetic effects – Body begins to conserve energy – Prevention: Provide warm fluids during fluid resuscitation Maintain patient’s body temperature Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Body Splinting – Splinting must be effective and performed quickly – Best accomplished by aligning limbs and securing body on long spine board © Craig Jackson/In the Dark Photography Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Rapid Transport – Best way to reduce mortality 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Fight-or-Flight Response – Autonomic nervous system response Sympathetic nervous system stimulation Increase heart rate Increase stroke volume Increase respiratory rate and volume – Calm and reassure the patient to minimize effects Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Trauma Resuscitation Non-Critical Patients – – – – – 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Patients Pediatrics – Same basic anatomy and physiology as adults – Trauma greatest cause of death during first year of life Blunt trauma greatest cause Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pediatric Anatomical Differences Smaller size and weight – Larger ratio of body surface area to volume 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Patients: Pediatrics Compensatory Mechanisms – Vibrant cardiovascular system Greater compensation during shock 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Patients Geriatrics – Fastest growing population Healthier lifestyles and the advances of modern medicine are extending life – Trauma accounts for 25% of mortality Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Geriatric Patients Aging affects virtually every body system Preexisting diseases are more prevalent in the geriatric population Assessment of the geriatric patient is often difficult – Problem is often masked by other signs and symptoms of disease Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Patients Geriatric Care – Initiate shock care early Provide care conservatively Monitor for fluid overload – – – – – Consider smaller IV catheters Frequent chest auscultation Maintain warmth Monitor ECG Aggressive oxygenation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Interaction with Other Care Providers Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 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 SAMPLE history – Interventions Information must be clear and concise Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Standard Precautions at the Trauma Scene Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Standard Precautions at the Trauma Scene Handle contaminated materials while wearing PPE Dispose of contaminated linens, clothing, dressing, and equipment in properly labeled containers Dispose of sharps in puncture-resistant sharps container Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Standard Precautions at the Trauma Scene 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport Landing Zone Criteria – Free of debris and dust Consider wetting to reduce “dust out” – – – – As level as possible Free of power lines Charged fire hose Size of landing zone Small helicopter: 60’ x 60’ Medium helicopter: 75’ x 75’ Large helicopter or in doubt: 120’ x 120’ – Contact local helicopter agency for their specific landing zone criteria Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport Working around the Helicopter – – – – – – 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Considerations with Helicopters Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport Flight Considerations – Confined working area Perform crucial procedures prior to loading – Limited ability to perform procedures Fully immobilize patient prior to transport © Mark C. Ide Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Air Medical Transport Air Medical Patient Preparation – Assure maximal oxygenation – Assure maximal ventilation – Administer high-flow oxygen Consider intubation or RSI – Assess for pneumothorax Decompress prior to loading – Establish 2 large-bore IV lines – Provide flight crew with complete and abbreviated patient report Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Research and Trauma Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 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 Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Introduction to Shock Trauma Resuscitation Injury Prevention Trauma Assessment Shock Trauma Resuscitation Interaction with Other Care Providers Standard Precautions at the Trauma Scene Air Medical Transport Research and Trauma Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ