Title: Trauma Patient Assessment Intubation Review Needle Decompression
1Trauma Patient AssessmentIntubation
ReviewNeedle Decompression
- Condell Medical Center EMS System
- October, 2007 CE
- Site Code 10-7200E1207
- Prepared by Sharon Hopkins RN, BSN, EMT-P
2Objectives
- Upon successful completion of this module, the
EMS provider should be able to - identify life threatening trauma to the adult
population - describe the Region X interventions that apply to
traumatically injured patients - actively participate in return demonstration of
the use of the BVM
3- actively participate in return demonstration in
use of emergency equipment to secure an airway
via intubation including in-line technique - actively participate in return demonstration of
needle decompression - review a variety of EKG rhythms
- successfully complete the quiz with a score of
80 or better
47 Ways to Die in Trauma
- Hypovolemia
- Hypoxia
- Acidosis
- Obstructed airway
- Flail chest
- Cardiac tamponade
- Tension pneumothorax
5Perfusion
- Circulation is the movement of blood through the
heart and blood vessels - Adequate circulation dependent on
- functioning pump
- intact blood vessels
- adequate volume of blood
- Adequate perfusion
- enough blood with an adequate supply of oxygen
nutrients delivered to organs tissues and the
removal of waste products
6Hypoperfusion
- Inadequate perfusion also known as shock
- Shock - a life threatening condition of
inadequate blood flow to body cells that could
result in death of cells
7Normal Blood Volumes
- Neonate 85 ml/kg
- Infant 80 ml/kg
- Adult men 75 ml/kg
- Adult women 65 ml/kg
8Typical Total Blood Volumes
- Neonate (7) - 3 kg x 85 ml 255 ml
- 1 y/o infant (24) - 11 kg x 80 ml 880 ml
- Adult man (180) - 82 kg x 75 ml 6150 ml
- (200) - 91 kg x 75 ml 6825
ml - Adult woman (150) - 68 kg x 65ml4420ml
9Stages of Blood Loss
- Stage 1 - compensated
- blood loss up to 15 of circulating blood vol
- 154 person (70 kg) is 500-750 ml loss
- at a typical blood drive you donate 500 ml and
over a period of 15-20 minutes - early compensation
- nervousness
- slight paleness
- slightly cool skin
- slight elevation of pulse rate
10- Stage 2 blood loss - compensated
- blood loss at 15 - 25 of circulating volume
- 750 - 1250 ml of blood volume is lost
- Additional compensatory measures in place (?
in catecholamine release) - tachycardia definitely noted with normal blood
pressure - pulse strength lessened
- pulse pressure narrowed (diastolic systolic
values closer together) - peripheral vasoconstriction noted as cool, clammy
skin - patient is anxious thirsty
11- Stage 3 blood loss - decompensated
- 25 - 35 loss of circulating blood volume
- 1250 - 1750 ml of blood is lost
- compensatory mechanisms failing
- classic signs of shock evident
- rapid tachycardia with falling blood pressure
- narrowed pulse pressure with barely palpable
pulse - tachypnea, air hunger
- anxious, restless, severe thirst
- decreased level of consciousness
- pale, cool, diaphoretic
12- Stage 4 blood loss
- Blood loss greater than 35 total circulating
blood volume - patient very lethargic, confused, or unconscious
- barely palpable central pulses
- rapid, shallow, ineffective breathing
- skin very cool, clammy, extremely pale
- High mortality rate
- even with aggressive identification and
intervention
13Categories of Shock orShock Syndromes
- Low-volume shock - absolute hypovolemia
- Number one cause of preventable deaths
- Absolute loss of circulating blood volume
- trauma
- dehydration
- diarrhea
- vomiting
- poor intake
- fever
14- Distributive shock
- vascular space too large for the amount of blood
circulating - problem distributing the blood volume to all the
bodys cells - sepsis
- drug overdoses - including alcohol and anything
that dilates blood vessels (ie nitroglycerin,
calcium channel blockers) - neurogenic shock (spinal shock) - injury to the
spinal cord - anaphylactic shock
15- Mechanical (obstructive) shock
- anything that slows or prevents the venous return
of blood or obstructs the flow of blood to or
through the heart can lower cardiac output and
cause shock - tension pneumothorax
- cardiac tamponade
- myocardial contusion
16Case Scenario 1
- Your adult patient has fallen 30 feet off a
ladder - They are confused
- The abdomen is tender and rigid
- The left femur is deformed and the thigh is
increasing in diameter - The patient is pale, cool, and clammy. The pulse
is tachycardic and the patient is tachypnic. B/P
remains 88/60. - What is your impression?
17Case Scenario 1
- The patient is in hypovolemic shock
- The patient meets criteria for a Category I
trauma patient - The patient requires transportation to the
highest level Trauma Center within 25 minutes - Does this patient require a blood glucose level
in addition to all the trauma care they are
receiving? - Yes - they are confused!
18Hypoxia
- Hypoxemia
- decreased oxygen content of the arterial blood
- Hypoxia
- decreased oxygen content to the bodys cells and
at the tissue level
19Causes of Hypoxia
- Reduction of oxygen in the system
- Inadequate oxygen transport
- Inability of tissues to use the oxygen delivered
20Conditions That Can Affect Blood Oxygenation
- Depressed respiratory drive
- head injury
- central nervous system depressants
- narcotics, sedatives
- Paralysis of respiratory muscles
- spinal injury
- inhalation injury
- neuromuscular diseases
- (ie ALS, muscular dystrophy, polio)
21- Increased resistance in the airways
- asthma
- chronic bronchitis, emphysema
- congestion
- Decreased compliance of lungs and thoracic wall
- interstitial lung disease from inhaling toxic
material - infection
- lung cancer
- connective tissue diseases
- chronic pulmonary hypertension
22- Chest wall abnormalities
- flail chest
- scoliosis
- full thickness burns with contractions
- Increased thickness of the respiratory membrane
- pulmonary edema
- interstitial fibrosis
23- Decreased surface area for gas exchange
- emphysema
- tuberculosis
- pneumonia
- pulmonary edema
- atelectasis
- Reduced capacity of blood to transport oxygen
- anemias
- hemoglobin abnormalities
- carbon monoxide poisoning
- methahemoglobinemia
24- Ventilation and perfusion mismatching (ventilated
alveoli are not perfused or perfused alveoli are
not ventilated) - asthma
- pneumonia
- pulmonary embolus
- pulmonary edema
- myocardial infarction
- respiratory distress syndrome
- shock
25Respiratory Acidosis
- Primarily a problem with inadequate elimination
of carbon dioxide (CO2) from the lungs (or
increased CO2 retention) - respiratory depression or arrest
- neuromuscular impairment (ie ALS, muscular
dystrophy, polio) - sedative, hypnotic medications
- chest wall injury
- flail chest, pneumothorax
- pulmonary disorders
- airway obstruction, COPD, pulmonary edema
26Acidosis
- When a patient is not ventilating/breathing
effectively, they will develop respiratory
acidosis. This is often followed by the
development of metabolic acidosis - Many medications administered in critical
situations are not effective when given in an
acidotic environment
27Hypoxia and Acidosis
- If the patient needs or you suspect that they
need O2, you must supply the patient with
supplemental oxygen - Do not withhold oxygen therapy to the patient
with COPD - Adequately ventilating and oxygenating the
patient will prevent/treat/reverse hypoxia and/or
acidosis
28Oxygenation Ventilation
- Oxygen therapy for patients in the field
- nasal cannula at 2 - 6 l/min
- delivers 24 - 44 O2
- non-rebreather oxygen mask at enough flow to keep
the reservoir inflated during inhalation
(typically 12-15 l/min) - delivers 90 plus O2
- Ventilation rates
- patient with a heart rate buts needs ventilation
support - ventilate 1 breath every 5 - 6 seconds - once intubated, ventilate 1 breath every
6-8 seconds
29Case Scenario 2
- Your 56 year-old patient has been involved in a
head-on crash into a tree. Upon your arrival, you
note a dusky, cyanotic appearing patient with a
rapid respiratory rate who is struggling to
breathe. The patient is so anxious they are
uncooperative. - Breath sounds indicate bilateral wheezing with
very diminished breath sounds. - What is your first impression?
30Case Scenario 2
- This patient was on their way to the ED for
treatment of an asthma attack - While trying to reach for their inhaler, they
lost control of the vehicle and struck the tree - EMS approach is to treat them as a trauma patient
with a medical emergency - this patient requires trauma care while an
albuterol nebulizer treatment is simultaneously
started
31Obstructed Airway
- Foreign bodies
- food, foreign material, blood
- swollen tissues
- Patient is unable to speak, cough, or cough is
weak highpitched - Patient is becoming dusky or cyanotic
- Totally obstructed airways will cut off oxygen
supply - You have 4-6 minutes to reopen an airway to
minimize negative consequences
32Adult Airway Obstruction
- Conscious patient who is unable to speak
- continuous abdominal thrusts
- chest compressions for pregnant or obese patients
- Unconscious patient
- open airway attempt to ventilate
- reposition head and repeat attempt once
- perform direct visualization of the airway and
attempt removal with the magill forceps - if obstruction unrelieved, begin CPR steps
- during ventilation steps, attempt ventilations
twice, reposition between the 2 attempts - consider cricothyrotomy
33Magill Forceps
34Needle Cricothyrotomy
- While patient supine, locate the cricothyroid
membrane - soft membrane between thyroid cartilage (Adams
apple) and cricoid cartilage - Stabilize larynx with thumb middle finger of
one hand - Prep the area of the cricothyroid membrane
- Insert 14 G or larger angiocath, with syringe
attached, into trachea at 450 angle - Aspirate air with the syringe
35Thyroid cartilage Cricothyroid
membrane Cricoid cartilage Thyroid gland
Thyroid cartilage (Adams apple) Cricothyroid
membrane Cricoid cartilage
36- Air should return easily if in the trachea
- Advance the catheter while withdrawing the stylet
(like starting an IV) - Attach a 3.0 mm ETT adapter (the colored proximal
tip of the ETT the BVM attaches to) to the needle
hub - Ventilate assessing for breath sounds
- Secure the angiocath
- Continue to ventilate
- May need to allow for longer exhalation time than
inhalation time
37Needle Cric
- Step 1 - needle advanced, confirmation by air
being aspirated with the syringe
Step 2 - catheter advanced while the stylet is
removed
38 Step 3 - the 3.0 mm adapter removed from the
proximal end of a 3.0 mm ETT
Step 4 - the 3.0 mm ETT adapter will be attached
to the needle hub of the IV catheter when the
stylet is removed
Step 5 - patient can be ventilated assess for
breath sounds, allowing adequate time for
exhalation
39Cricothyrotomy
- Indications
- contraindication for placement of an endotracheal
tube - endotracheal tube placement not possible
- attempt to place an endotracheal tube fails
- to relieve upper airway obstruction
- emergency access with severe facial trauma
40Melker Cric Kit
- Department personnel recommended to review the CD
from Cook Medical to review using the Melker
Emergency Cricothyrotomy Catheter Set
41Case Scenario 3
- This patient has been impaled by a foreign object
- Do they need spinal immobilization for this
injury? - No
42Flail Chest
- Fracture of 3 or more adjacent ribs in 2 or more
locations - Chest wall segment becomes unstable
- Mortality rate is 20 - 40 due to associated
injuries - Secondary lung contusion is often associated with
flail chest - Development of hypoxia is common
43Flail Chest On Right Side
44Signs Symptoms Flail Chest
- History of chest wall injury
- Tenderness bony crepitus on palpation
- Tachypnea (? respiratory rate)
- Tachycardia
- Decreased pulse oximetry
- Late sign is paradoxical motion
- muscle spasms may hide the paradoxical motion for
the first few hours
45Field Interventions For Flail Chest
- Supportive oxygenation
- non-rebreather oxygen mask
- possibly BVM if ventilations need to be supported
(1 breath every 5-6 seconds) - intubation (probably in-line technique) if
necessary - Fluid replacement for co-existing injuries
- Do not tape chest wall for support
46Cardiac Tamponade
- Tears in the heart chamber walls with blood
entering the pericardial space - Occurs in lt2 of patients with chest trauma
- A result of penetrating trauma, blunt trauma, and
occasionally, spontaneous - Increase in pericardial pressure
- Heart is prevented from expanding and refilling
with blood - Stroke volume and cardiac output decreases
47Cardiac Tamponade
48Signs Symptoms of Cardiac Tamponade
- Peripheral vasoconstriction (cool clammy)
- Tachycardia
- Narrowed pulse pressure (diastolic blood pressure
rises more than systolic blood pressure) - Becks Triad
- JVD (early sign)
- muffled heart tones
- hypotension (late sign)
49Is It Tamponade or Hypovolemic Shock?
- JVD is present in cardiac tamponade
- compression of the heart chambers causing a
decrease in filling which creates a backup of
fluid noted as JVD - JVD is not present in hemorrhagic shock
- there is a total decrease in blood volume
throughout the entire circulatory system so there
is nothing to be backing up
50Field Interventions For Cardiac Tamponade
- Cardiac monitoring
- Oxygen support
- IV fluid replacement if shock present
- 20 ml/kg
- reevaluate every 200 ml
- Rapid transport with high index of suspicion
- Removal of blood from the pericardial sac will be
performed at the hospital
51Tension Pneumothorax
- Trapping of air in the pleural space
- Increase in pleural pressure producing a shift in
the mediastinum - Compression of
- the lung on the unaffected side
- vena cava reducing blood flow return to the heart
with a decrease in cardiac output
52Tension pneumothorax on the right side with
shifting to the left
53Signs Symptoms of Tension Pneumothorax
- Anxiety
- Cyanosis
- Increasing dyspnea
- Tachycardia
- Hypotension or unexplained signs of shock
- Diminished or absent breath sounds on affected
side with profound hypoventilation - Distended neck veins (JVD)
- Subcutaneous emphysema
54Field Interventions For Tension Pneumothorax
- A true emergency requiring immediate
identification and intervention - Goal reduce the pressure in the pleural space
- emergency needle decompression
55Needle Decompression
- Prepare equipment
- 2-3 long catheter 12- 14 G
- skin surface prep material(ie alcohol prep pad)
- flutter valve attached to IV catheter
- Identify landmarks
- 2nd intercostal space, mid-clavicular line
- Clean site
- Insert needle, bevel up, over the top of the 3rd
rib (into the 2nd intercostal space)
56Landmarks For Needle Decompression
Rib 1
Rib 2
2nd intercostal space mid-clavicular line
Rib 3
57Placement of Needle
Flutter valve attached
2nd rib
3rd rib
58Placement of Needle
59- As air is released, clinically the patient should
show improvement - less distress less anxiety
- greater ease in breathing/ventilating
- rise in pulse ox saturation level
- Secure angiocath and flutter valve
- place opened, loosened 4x4s around base of the
angiocath - Monitor patient status watching for deterioration
60Case Scenario 4
- Your patient was a pedestrian struck by a vehicle
at a high rate of speed. Upon your arrival you
initially felt a faint pulse but now there is
none. The patient is not breathing and bagging is
difficult due to the resistance felt. - What is this rhythm and how is it treated?
6 second strip - there is no pulse
61Case Scenario 4
- The rhythm is PEA (with a rapid rate)
- The patient is treated as an arrested trauma with
suspicions of chest injuries (difficulty bagging) - Any airway maneuvers need to provide
immobilization of the airway - opening airway using jaw thrust maneuver
- intubation would be the in-line technique
62Case Scenario 4
- Patient interventions
- Full spinal immobilization
- CPR - IV - O2 support - monitor
- Consider the 6 Hs and 5 Ts as causes
- Perform bilateral chest decompressions
- Fluid challenges reevaluating every 200 ml
- Drugs - Epinephrine 1 mg every 3-5 minutes
- Rate is gt60 so Atropine not indicated
- Transport destination
- Traumatic arrest - to closest Trauma Center
63Intubation
- Preferred advanced airway for controlling the
airway in patients who are unable to maintain an
open airway - Indications
- unable to ventilate an unconscious patient
- patient cannot protect their own airway
- prolonged ventilation is required
64Intubation
- Advantages
- airway is isolated preventing aspiration
- ventilation (breathing) and oxygenation is easier
to accomplish - suctioning of the trachea is easier
- gastric insufflation of air during inhalation is
prevented
65Intubation
- Disadvantages
- inadvertent placement in the esophagus with lack
of recognition of improper placement - ineffective ventilation volumes
- use enough volume to gently make the chest rise
- inappropriate ventilation rate
- patient with a pulse, breath once every 5-6
seconds - during CPR with intubated patient, ventilate once
every 6-8 seconds while chest compressions
continue uninterrupted
66Intubation Equipment
- BVM connected to oxygen source
- Handle and blade
- bulb bright and tight
- straight blade lifts epiglottis up
- preferred for infant intubations
- curved blade fits into the vallecular space
- ETT (generally size 7-8 for men and size 7
for women no cuff under age 8)
67- Stylet
- does not protrude beyond distal end of ETT
- reform tube into curved position after straight
stylet passed into position - Syringe
- do not leave attached to cuff once ETT is in
place air will be pulled out of the cuff - Tape or commercial tube holder to secure tube
- Cervical collar
- tube positions are better maintained when head
movement is minimized
68Patient Preparation
- Pre-oxygenate the patient with 100 O2 for 15 -
30 seconds before the intubation attempt - Consider medications for conscious sedation
- Lidocaine 1.5 mg /kg, if head insult is present,
to eliminate the cough reflex - Versed 5 mg initially 2 mg every minute until
sedated 1 mg every 5 minutes to maintain
sedation post intubation - Morphine 2 mg every 3 minutes to relieve pain,
reduce anxiety, potentiate the effects of Versed - Benzocaine 2 second spray to eliminate the
gag reflex, if present
69Patient Positioning - Non-Trauma
- Non-trauma patient - sniffing position
- neck is flexed
allowing the
best alignment
of anatomical
landmarks - place a few
towels under
the patients
head
70Influence of Positioning
Landmarks not in alignment intubation more
difficult for the practitioner and with
increased risk of injury to patient
Anatomical landmarks lined up intubation is
easier on the medical personnel and the patient
71Difficult Intubations
Neck and chest tissue fall over the airway
making intubation difficult
Better patient positioning allows for improved
chance of success in intubation
72Orotracheal Intubation
73Cricoid Pressure - Sellicks Maneuver
- Helps prevent gastric distention when bagging the
patient using the mouth-to-mask technique - Helps prevent passive regurgitation with
aspiration while bagging the patient or
attempting intubation - With pressure applied over the cricoid cartilage,
the esophagus becomes occluded - Can improve the view of the vocal cords for the
intubator - Can help stabilize the trachea
74Lateral View of ETT Placement
Curved blade in vallecula
75In-line Intubation Techniques
- Indication
- when spinal precautions need to be observed
- Equipment
- identical to normal intubation procedures
- Manual cervical spine control
- stabilization must be constantly maintained in a
neutral position during the procedure - head is securely controlled post-procedure
76Opening Airway with Cervical Trauma - Jaw Thrust
77In-Line Intubation
- Intubator positioning
- Intubator may sit at the patients head and
their legs straddle the patients shoulders and
arms patients head is gripped with the
intubators thighs - Intubator may lie on their stomach facing the
patients head - A second rescuer stabilizes the patients head by
gripping the head from the side and grasping
along the jaw and lower face, spreading their
fingers near the temple (ear) area
78In-Line Intubation
- Patient
- being
- stabilized
- Equipment
- being
- prepared
- Cricoid
- pressure
- being held
79Orotracheal Intubation
- Face-to-face procedure to intubate a patient when
the provider cannot take a position above the
patients head (ie patient in the sitting
position) - Manual stabilization must be maintained by a
second rescuer at all times (often from behind if
there is room for the provider behind the
patient)
80Orotracheal Intubation Procedure
- Primary rescuer takes a position facing the
patient - Open the mouth with the left hand
- Hold the laryngoscope in the right hand
- Insert the blade into the patients mouth
- Follow the normal curvature of the tongue
- Visualize the vocal cords from above the
patients mouth
81- With the left hand, pass the ETT between the
cords - Remove the stylet, if used
- Begin to ventilate the patient with the BVM
- Inflate the cuff and remove the syringe
- Confirm proper ETT placement
82Confirming Placement and Securing ETT
- Direct visualization
- cricoid pressure can be helpful
- stabilizes the trachea
- may drop the trachea into view
- with enough pressure, can stop vomitus coming
back up - once cricoid pressure is applied for blocking
vomitus, pressure is maintained until the cuff is
inflated
83Cricoid Pressure
84- Bilateral equal rise and fall of the chest
- 5 point auscultation
- listen over the epigastrium (expect to hear
nothing) - listen 4 points over the lungs
- listen anteriorly just under the clavicles on
either side of the sternum - listen in the axillary line approximately 5th
intercostal space - ETCO2 detector
- after 6 breaths should see maintain the yellow
color to indicate exhaled CO2 being
detected
85- EDD bulb
- back-up tool to the ETCO2 detector
- need to interrupt ventilation to use
- when bulb is depressed and placed on the end of
the ETT tube, will reinflate rapidly if ETT is
placed in the trachea
86Case Scenario 5
- What airway significance could there be in this
case and what needs to be monitored?
87Case Scenario 5 - End Results
88Region X SOPs
- Field Triage Criteria For Assessing Trauma
Patients - In-Field Spinal Clearance
- Routine Trauma Care
- Revised Trauma Score
89Field Triage Criteria
- Transport to highest level Trauma Center within
25 minutes if - systolic blood pressure lt 90 x2 (peds lt
80 x 2)
90Field Triage Criteria
- Transport to highest level Trauma Center within
25 minutes if patient is a Category I - Vital signs unstable
- Glasgow Coma Scale lt10 or deteriorating mental
status - respiratory rate lt10 or gt29
- Revised Trauma Score lt11
91Field Triage Criteria
- Transport to highest level Trauma Center within
25 minutes if patient is a Category I - Based on anatomy of injury
- Penetrating injuries to head, neck, torso, groin
- Combination trauma with burns gt20
- Two or more proximal long bone fractures
- Unstable pelvis
- Flail chest
- Limb paralysis and/or sensory deficits above the
wrist or ankle - Open and depressed skull fractures
- Amputation proximal to wrist or ankle
92Field Triage Criteria
- Transport to closest Trauma Center if the patient
is a Category II trauma patient - Mechanism of injury
- Ejection from automobile
- Death in same passenger compartment
- Motorcycle crash gt20 mph or with separation of
rider from bike - Rollover (unrestrained)
- Falls gt20 feet (peds falls gt3x body length)
- Pedestrian thrown or runover
93- Mechanism of injury (continued)
- Auto vs pedestrian/bicyclist with gt5mph impact
- Extrication gt 20 minutes
- High speed MVC
- Speed gt 40 mph
- Intrusion gt 12 inches
- Major deformity gt 20 inches
- Co-morbid factors
- Age lt 5 without car/booster seat
- Bleeding disorders or on anticoagulants
- Pregnancy gt 24 weeks
94Field Triage Criteria
- If patient is not a Category I trauma patient
(based on unstable vital signs or anatomy of the
injury) - and
- patient is not a Category II trauma patient
(based on mechanism of injury or co-morbid
factors) - then
- provide routine trauma care and transport to the
closest Trauma Center
95Field Triage Criteria
- Transport to the closest Trauma Center if
- traumatic arrest
- isolated burns gt 20 BSA
- Transport to closest Emergency Department if
- no airway can be established
96Region X SOPs Routine Trauma Care
- Scene size-up
- Initial assessment
- Airway / spinal precaution
- Breathing
- Circulation
- Disability - AVPU and GCS
- (alert responds to verbal responds to pain
unresponsive) - General impression
97Routine Trauma Care
- Identify priority of transport
- Begin rapid transport (treatment enroute)
- Based on mechanism of injury or patient complaint
- Begin treatment and initiate transport
- Treatment
- Airway control - oxygen support
- IV (200 ml if fluid challenge required)
- Detailed exam as time permits
- Ongoing assessment - on all patients
- Every 5 minutes if patient is a rapid transport
98Case Scenario 6
- Your patient is a 63 year-old male involved in a
head-on MVC on a road with posted speed of 55 mph - Scene size-up
- head-on car vs truck
- restrained driver
- heavy front-end damage
- airbag deployed
- back of seat broken
99Case Scenario 6 - Assessment
- By-standers state patient was initially
unresponsive - Upon your arrival the patient is awake, alert,
and cooperative - GCS 15
- 136/88 P - 68 R - 20 SaO2 98 NSR breath
sounds clear bilaterally - Complaints soreness over multiple abrasions of
chest, abdomen, and extremities blood in the
nostrils tenderness with mild rigidity over the
left abdominal wall where abrasions are noted
100Case Scenario 6
- What initial care is to be established?
- What Category Trauma does this patient meet for
transport decisions? - What are the potential injuries you need to
consider this patient receiving?
101Case Scenario 6
- Patient meets criteria for a Category II Trauma
- Stable vital signs
- No anatomical injuries meeting criteria
- High speed MVC with major deformity
- Vitals condition on arrival to ED
- 104/82 P - 64 R - 18 SaO2 - 100 NSR
- Patient now cool, pale, diaphoretic, clear breath
sounds capillary refill lt 2 seconds abdomen
flat, non-tender pain over lower right chest
102Case Scenario 6
- Follow-up
- Patient became hypotensive in the ED (B/P -
65/34 P-50 R - 18) - The patient went to OR and was found to have 2
liver lacerations and multiple liters of free
blood in the abdominal cavity - The patient went to ICCU after OR
- Why would this patients pulse rate not be higher
if he lost so much blood? - The patient was taking beta blockers for
hypertension control
103In-Field Spinal Clearance SOP
- A reliable patient without signs or symptoms of
neck or spine injury and a negative mechanism of
injury does not require full spinal
immobilization - When in doubt, fully immobilize patient
104In-Field Spinal Clearance SOP
- Mechanism of injury
- High velocity MVC gt 40 mph
- Unrestrained occupant in MVC
- Passenger compartment intrusion gt 12 inches
- Ejection from vehicle
- Rollover MVC
- Motorcycle collision gt 20 mph
- Death in same vehicle
- Pedestrian struck by vehicle
- Falls gt 2 time patient height
- Diving injury
105In-Field Spinal Clearance SOP
- Signs and symptoms
- Pain in neck or spine
- Tenderness/deformity of neck or spine upon
palpation - Paralysis or abnormal motor exam
- Paresthesia in extremities
- Abnormal response to painful stimuli
106In-Field Spinal Clearance SOP
- Patient reliability
- Signs of intoxication
- Abnormal mental status
- Communication difficulty
- Abnormal stress reaction
107In-Field Spinal Clearance SOP
- If the patient meets the criteria of need for
spinal immobilization based on mechanism of
injury, and/or signs symptoms, and/or
reliability, then patient intervention includes - routine trauma care
- full spinal immobilization
- transport
108Revised Trauma Score - RTS
- Points scored are based on
- Respiratory rate
- Systolic blood pressure
- Glasgow Coma Scale (scale 3-15 and points
converted for RTS) - eye opening
- verbal response
- motor response
- Revised Trauma Score scale is 0 - 12
- Provide the ECRN with the components and they can
score pt
109Bibliography
- Bledsoe, B., Porter, R., Cherry, R.
- Essential of Paramedic Care. 2nd
- Edition. Brady. 2007.
- Campbell, J. Basic Trauma Life support
- 5th Edition. Brady. 2004.
- Caroline, N. Emergency Care In The Streets. 6th
Edition. AAOS. 2008. - Limmer, D., OKeefe, M. Emergency
- Care 10th Edition. Brady. 2005.
110- Region X Standard Operating Procedures. March 1,
2007. - Sanders, M. Mosbys Paramedic
- Textbook. Elsevier. 2007.
111Name That Rhythm
SVT
112Name That Rhythm
Second Degree Type II - Classical
113Name That Rhythm
Atrial Fibrillation
114Identify ST Elevation
ST elevation V1 - V4