Region VIII Continuing Education

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Amputations, Traumatic Arrests and Crush
Injuries Can You Handle the Pressure?

• Region VIII Continuing Education
• March 2009
• Content produced by the Loyola EMS System

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Objectives

• Describe the pathophysiology and treatment of
  crush injuries
• Review the care of amputations
• Discuss current trends of using tourniquets
• Review pathophysiology, epidemiology and common
  causes of traumatic arrests

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• Drug of the Month
• Sodium Bicarbonate
• SOP Review
• Initial Trauma Care
• Traumatic Arrest

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• EKG of the Month
• Sinus Rhythm with Peaked T waves
• Skills
• BLS-Traction Splint
• ALS-Adult In-Line Endotracheal Intubation

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Crush Injuries
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Case scenario 1

• Ambulance 41 please respond mutual aid to 1901
  W. Madison St in Chicago for a building collapse.
  Stage at the corner of Damen and Jackson. As
  you drive to the scene you prepare yourself for
  what you might see. Thats the United Center,
  isnt it? you say to your partner. You arrive
  at the staging area with countless other
  ambulances from Chicago and the surrounding
  suburbs. As you look towards the United Center,
  you only see a cloud of smoke and dust

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Case scenario continued

• After staging for 2 hours, you are assigned to
  care for 50-year-old male who was just pulled
  from the debris. Rescue crews removed a large
  cement wall that had been crushing the patients
  lower extremities. The patient was entrapped for
  close to 3 hours prior to extrication. No
  medical care has been given to this patient
  because rescue crews werent able to access the
  patient until now. What are your treatment
  priorities for this patient?

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History

• Early crush injuries were reported during World
  War I when soldiers were buried in trenches
• Rescued soldiers had a triad of symptoms of
  symptoms muscle pain, weakness and brown urine

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History

• 1955 earthquake in Kobe, Japan
• Hospitalized patients with crush injuries had
  twice the mortality rate compared to other trauma
  patients

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Crush Injury Pathophysiology

• Results from prolonged continuous pressure on
  large muscles
• Usually 4-6 hrs of compression but, possibly lt1
  hr
• Also call traumatic rhabdomyolysis
• Injuries may be exacerbated by hypovolemia
  secondary to hemorrhage

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Pathophysiology continued

• Skeletal muscles are the most prominent type of
  muscle in the body
• Its cell membrane is called the sarcolemma
• Maintains cells structure and homeostasis
• Sodium/calcium pumps
• Embedded in the cell membrane
• Use ATP as energy source for pumps
• Pumps sodium out of cell and calcium into cell

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Pathophysiology continued

• Myoglobin
• Protein found within the skeletal muscle cell
• High affinity for oxygen-draws O2 into the cell
• This oxygen is used for normal metabolism

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During compression

• Skeletal cell membrane is damaged
• Cells leak myoglobin, potassium, uric acid and
  phosphorus into interstitial fluid (eventually
  goes into systemic circulation)
• Calcium and sodium enter the cell
• Compressed tissue isnt perfused
• Cellular hypoxia
• Irreversible ischemia and muscle necrosis can
  occur after 2.5 hours
• Compartment syndrome
• Bleeding into intact muscle compartment
• Increases muscle fascia compartment pressure
• Worsens ischemia

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Removal of compressive force

• Blood flow to compressed tissue resumes
• Toxic substances circulate systemically
• Results in
• Systemic metabolic acidosis, vasodilation and
  hyperkalemia
• High potassium levels and low calcium levels
• Calcium is cardioprotective
• Ventricular tachycardia and ventricular
  fibrillation can result

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EKG changes

• Initially elevated T-waves (fig 2)
• Progresses to a widened QRS (fig 3)
• Ventricular fibrillation or tachycardia
• Usually see within the 1st hr after compression
  is removed

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Death from crush syndrome

• Initial death from crush syndrome is typically
  from cardiac arrhythmias
• Ventricular fibrillation or ventricular
  tachycardia
• Later death results from acute renal failure
• Due to renal ischemia and obstruction of renal
  blood flow from uric acid and myoglobin

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Assessment

• Scene size-up
• Make sure the scene is safe!!!!
• If prolonged extrication and transport is
  expected, consider requesting a specialty
  transport helicopter
• Conduct a rapid trauma assessment
• Maintain a high index of suspicion for anyone
  with a compressive mechanism of injury
• Symptoms typically develop 4-6 hrs after initial
  injury (can occur after one hr during severe
  injury)

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Treatment

• Assess and stabilize the patients Airway,
  Breathing and Circulation.
• Apply 100 oxygen via non-rebreather mask or a
  bag-valve mask if apneic
• Correct any life-threatening conditions as they
  are found
• Maintain cervical and full spinal immobilization
• Remove any restrictive clothing, jewelry

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Treatment

• Initiate two large-bore IVs. Administer Normal
  Saline fluid bolus while patient is entrapped.
  Continue fluid bolus when the muscle compression
  is released
• Early fluid resuscitation of the entrapped victim
  leads to increased survival
• For extended scene times, contact medical control
  for guidance on amount of fluid to administer
• Assess lungs for pulmonary edema (rales/crackles)

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Treatment

• If prolonged compression and entrapment exists,
  contact Medical Control to consider administering
  NaHCO3
• If extremity is severely entrapped and
  extrication appears unlikely, contact medical
  control to discuss having a hospital team
  dispatched to the scene for a field amputation
• After extrication, perform a rapid trauma
  assessment, correct life-threatening conditions
  and transport to the closest trauma center

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Case scenario 1 conclusion

• Your patient is alert and talking to you but
  confused to the events that just occurred. Your
  partner maintains C-Spine immobilization and you
  apply a cervical collar. The patients airway is
  patent, respiratory rate 26. Lungs are clear
  bilaterally. Your partner applies 100 oxygen
  via non-rebreather. You palpate a weak, rapid
  radial pulse at 138. You and your partner each
  establish 16-gauge IVs and start normal saline
  fluid boluses

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Case scenario conclusion

• Your rapid trauma assessment finds crepitus and
  pain in the right side of the pelvis and in the
  patients bilateral lower extremities. You are
  able to palpate weak pedal pulses and he is able
  to feel and move both feet. You secure the
  patient to the long back board and rapidly
  transport to the closest trauma center. The
  patient undergoes multiple surgeries to stabilize
  the fractured extremities. He is diagnosed with
  having Crush Syndrome, acute renal failure and
  temporarily has to be on dialysis.

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FYI - see 8 of handout for story

• Lt. John McLoughlin Crushed During World Trade
  Center Collapse Survives Because of Care Provided
  By Paramedic John Busching

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Amputations
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Amputations

• More than 30,000 traumatic amputations every year
• One out of every 200 individuals in the United
  States has had an amputation

Bledsoe-Paramedic Care, Principles Practice
Trauma Emergencies
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Amputations

• Amputations can involve any body part
• Arms, hands, fingers, legs, toes, ears, eyelids
  and genitalia
• Many different things can cause amputations
• Electrical saws, lawnmowers, garbage disposals,
  snow-blowers, industrial machinery, motor vehicle
  collisions, etc.

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Mechanism

• Crushing mechanisms
• Significant tissue and muscle damage
• Edges of amputated parts are shredded or rough
  appearing
• Reattachment of this type of amputation is less
  successful
• Guillotine mechanism
• Sharp cutting edge (knife, ax, etc.)
• Clean smooth edges
• Reattachment is more successful

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Complete vs. Partial

• Complete
• No tissue, ligaments, muscles or other anatomical
  structures connecting the amputated part to the
  body
• Partial
• Some anatomical structure connects the amputated
  part to the body
• Could be skin, muscle, bone, ligaments, tendons

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Treatment

• BLS/ALS
• Ensure BSI and scene safety
• Get additional help to depower machinery, trains,
  etc. Make sure you dont become a victim
  yourself!
• Consider the use of eye protection and gowns for
  injuries with excessive bleeding
• Attempt to locate amputated parts
• Assess and stabilize the patients Airway,
  Breathing and Circulation

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Treatment

• Complete Amputations - BLS/ALS
• Control bleeding by using a pressure dressing
• Cover the stump with a moist dressing to help
  preserve tissue for re-implantation
• Elevate and immobilize the stump
• Try to avoid excessive manipulation of the stump
• Cover the amputated part with moist dressing and
  place the part in a sealable plastic bag
• Place the bag in ice water
• Make sure to avoid direct contact between the
  body part and ice.

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Bledsoe, Porter, Cherry. Paramedic Care,
Principles Practice Trauma Emergencies
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Treatment

• Partial Amputations BLS/ALS
• Assess distal Circulation, Motor and Sensation
  (CMS or PMS-pulse, motor, sensation)
• All partial amputations should be splinted
• It should be assumed that all partial amputations
  could possibly be reattached.
• Saline-moistened sterile dressings can be placed
  over exposed tissue
• Bleeding should be controlled with direct
  pressure and press points

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(No Transcript)
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Treatment

• All Patients-ALS
• Obtain IV access to administer fluid bolus as
  needed to maintain blood pressure
• Consider administering IV morphine for pain
  control

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Tourniquets

• Should be used as a last resort as a life-saving
  measure
• Use commercial tourniquets if available
• A blood pressure cuff can be used if a commercial
  tourniquet isnt available
• Make sure that no sharp edges or clothing is
  between tourniquet and skin
• Apply tourniquet as close to the stump as
  possible
• Tighten the tourniquet enough to occlude arterial
  pressure
• Document the time that you applied the tourniquet

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Commercial Tourniquets
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FYI New Trends in Tourniquet Use

• There is new evidence from military and
  operating room use that suggests that tourniquets
  can be safely used as a life-saving procedure.
  Modern tourniquets have been demonstrated to
  rapidly and effectively stop extreme hemorrhage,
  minimizing blood loss. Immediate hemorrhage
  control allows you to be able to focus on airway,
  breathing, circulation and other injuries. Some
  new protocols allow paramedics to apply and then
  eventually remove tourniquets in the field after
  the patient has been stabilized and during long
  patient transports. Adverse effects are limited
  if tourniquet application is less than 2 hours.

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Traumatic Arrests
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Case scenario 2

• Ambulance 41, please respond to 6421 Ogden Ave.
  for one-car MVC. You are pulling out of the
  garage before you are fully awake. You look at
  your watch, 0236. As you arrive on scene, you
  see a red sedan that has hit a light pole on the
  side of the road. No other vehicles are around.
  There is significant front-end damage and
  starring of the windshield.

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Case scenario 2 continued

• The driver is the only person in the car. He
  looks to be in his 20s. He is unrestrained and
  partially laying in the front passenger seat. He
  is unresponsive. You grab c-spine as your
  partner sits the patient up. It is hard to tell
  if he is breathing because it is dark. Your
  partner tries to palpate a pulse, but cant find
  one. The patient has a deep laceration down his
  forehead. It is bleeding minimally. What are
  your treatment priorities for this patient?

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Traumatic arrests

• Common causes
• Exsanguination
• Injuries incompatible with life
• Severe brain or spinal cord injury
• Traumatic cardiopulmonary arrest
• Penetrating
• Higher chance of survival
• Blunt

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Withholding resuscitation

• For patients who are obviously dead
• Examples
• Incineration
• Decapitation
• Dependent lividity
• Rigor mortis
• Decomposition

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Causes of Cardiac Arrest in the Trauma Patient
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Case scenario conclusion

• You and your partner rapidly extricate the
  patient and place him in your ambulance. He
  continues to be unresponsive, apneic and
  pulseless. A fireman performs CPR while your
  partner established an IV and you intubate the
  patient. You are able to intubate the patient
  with an 8.0 ETT and your partner establishes a
  14g IV. Lungs are clear bilaterally with
  mechanical ventilation. You place the patient on
  the monitor which shows asystole

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Case scenario conclusion

• Your partner gives 1 mg Epinephrine IVP and 1 mg
  Atropine IVP as you continue to bag the patient
  and a fireman drives your ambulance to the
  closest trauma center. Enroute you expose the
  patient and find no obvious injuries except the
  head laceration. Pupils are 4/4 bilaterally. On
  arrival to the hospital the patient remains in
  asystole. The emergency department confirms the
  ETT placement and pronounces the patient at 0302.
  What injuries could have killed this patient?

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Standing Operating Procedure ReviewInitial
Trauma Care pg 55-56
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Standing Operating Procedure ReviewInitial
Trauma Care pg 55-56
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Standing Operating Procedure ReviewInitial
Trauma Care pg 55-56
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Standing Operating Procedure ReviewInitial
Trauma Care pg 55-56
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Standing Operating Procedure ReviewInitial
Trauma Care pg 55-56
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Standing Operating Procedure ReviewInitial
Trauma Care pg 55-56
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PEDIATRIC TRAUMA15 years of age
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PEDIATRIC TRAUMA15 years of age
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Traumatic Arrest pg 63
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Rhythm of the Month Sinus rhythm with peaked T
waves - The Hyperkalemic Patient

• Mild hyperkalemia
• NSR with tall, pointed, narrow T waves
• P wave height may be smaller than normal
• ST segment elevation or depression may be present
  
• 1st degree AV block may be seen
• Severe hyperkalemia
• Widening QRS complex with peaked T waves
• Can progress to AV blocks, V-tach, V-fib,
  Asystole

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Rhythm of the Month Sinus rhythm with peaked T
waves - The Hyperkalemic Patient
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Drug of the Month Sodium Bicarbonate

• Buffering agent against acidosis in the body
• Mechanism reacts with hydrogen ions to form
  water and carbon dioxide
• Indications Cyclic Antidepressant overdose,
  Chronic Renal Failure / Dialysis Patient
  Emergencies.
• Contraindications Respiratory alkalosis
• Precautions History of congestive heart failure,
  renal impairment, cirrhosis, hypertension
• Dose 1 mEq/kg of 8.4 solution IV/IO. In TCA
  overdose, consider additional dose for
  hypotension, altered mental status or cardiac
  arrhythmias
• Adverse Reactions hypotension, decreased cardiac
  output, metabolic alkalosis, hypernatremia, and
  cerebral edema. Tissue necrosis can occur from
  extravasation.

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Skills

• BLS - Traction Splint
• ALS - Adult In-Line Endotracheal Intubation

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References

• Campbell, J.E. (2008). International Trauma Life
  Support for Prehospital Care Providers (6th
  edition). Upper Saddle River, New Jersey
  Pearson.
• Gonzalez, D. (2005). Crush syndrome. Critical
  Care Medicine. 33(1), S34-S41.
• Kalish, J., Burke, P., Feldman, J., Agarwal, S.,
  Glantz, A., et al. (2008). The return of
  tourniquets Original research evaluates the
  effectiveness of prehospital tourniquets for
  civilian penetrating extremity injuries. Journal
  of Emergency Medical Services 33(8), 44-54.
• Murphy, P., Colwell, C., Pineda, G., Bryan, T.
  (2006). Traumatic amputations How EMS providers
  can manage amputations in the field. Emergency
  Medical Services. June, 2006.
• Raynovich, W. (2006). Crushed How proper
  treatment of Crush Syndrome saved police Sgt.
  John McLoughlin after 22 hours under WTC rubble.
  Journal of Emergency Medical Services. 31(9),
  58-65.
• Sever, M.S., Vanholder, R., Lameire, N. (2006).
  Management of crush-related injuries after
  disasters. New England Journal of Medicine.
  354(10), 1052-10.