2nd Trimester, June 2013 CMEPrepared by Leslie Livett RN, MS

Presence St. Joseph Medical Center

Objectives

• Upon successful completion of this module, the EMS provider should be able to:– Understand what the mechanism of injury is and the

information it provides– Describe assessment and treatment appropriate for the

patient with traumatic insult• Tension pneumothorax, sucking chest wound, flail chest,

eviscerated organs– Successfully identify the landmark and perform chest

needle decompression– Actively participate in trauma scenario discussion

Definition

• Damage to the body caused by an exchange of energy beyond the body’s resilience.

Epidemiology of Trauma

• Leading cause of death in ages 1-44• 3rd leading cause of death for all ages• 100,000 deaths/year• 60 million injuries/year

Overall Approach

• Anticipate the worst• Never make any assumptions• History and Exam have to make sense• Don’t take short cuts• Document frequently• TEAMWORK

Don’t get distracted with “ugly injuries”

Your Initial assessment findings will determine how you will proceed

• Caveats in Elderly:– Loss of Reserve Function– Assume that every organ has some degree of loss– Improve outcomes

Trauma System

Mortality is decreased when

The RIGHT patientGets to

The RIGHT hospitalIn the

RIGHT AMOUNT of TIME

A B C’s of Trauma Care

• Many ways to interpret that

• The original way A Airway with C-spine B Breathing C Circulation

The New Way

A Airway

B Be Careful of the Airway

C Concentrate on the Airway

(An Amusing Variation)

• A Antibiotics

• B Blood Cultures

• C Consults

• A Always

• B Bring

• C Camera

Approach to Trauma

• Challenging• Systematic Approach to Patient Care• Logical & Organized• Mechanism of Injury

General Assessment Pearls

• With restlessness and agitation, you must consider– hypoxia, – shock, – influence of alcohol and/or drugs– need to assess for all reasons of

restlessness.– don’t not just stop when you discovered one cause– there may be more than one pathology going on at a

time

AIRWAY

• Way back in 1983, studies showed us that NO Airway or a DELAYED airway was the single most important cause of mortality in trauma

If you THINK you need an airway ….

YOU DO

Airway Assessment Maneuvers in Trauma

• Inspection– Color, contour, symmetry, smell, audible abnormal sounds, obvious

wounds• Palpation

– Textures, moisture, pulsations, deformities, crepitus, masses, temperature

• Percussion– Resonant = normal– Hyperresonant = more air– Dull = solid, fluid

• Auscultation

Focused History Physical Exam

• As you approach: OBSERVE– Level of Consciousness– Appearance– Restlessness– Distress/Pain– Hemorrhage/Gross Deformities– Unusual odors– Kinematics

Airway & C-Spine

• Access• Assess• Maintain• Cervical Spine Control

Airway Compromised

• What are some etiologies of a compromised/ obstructed airway in trauma?

Airway Compromised

• Discuss: What are some causes of a compromised/ obstructed airway in trauma?

Airway Assessment

• Observe for Respiratory effort• Symmetry• Accessory muscles• Audible sounds

– What should ventilations sound like?

• Ability to talk• Impaired laryngeal reflexes

Airway Intervention

• Position Appropriately • Reposition Mandible

– Chin lift, jaw thrust– DO NOT

• Hyperextend or Hyperflex

• Remove Debris/Suction• Maintain with Adjuncts

Airway Adjuncts

• Nasopharyngeal if awake• Oropharyngeal if unconscious/no gag• Rescue:

– BVM, Intubation,King LTS-D,

Airway Adjuncts

• Lower Airway– Needle Cricothyrotomy– Quick-trach

Need to secure your airway & always reassess!

Spine Precautions

• Manual in-line stabilization– Maintain axial alignment

• Apply c-collar• Provide lateral immobilization

Airway Caveats in special populations

• Obese– Sleep apnea, elevate head of bed, difficult access

to airway

• Elderly– Spine/arthritic changes – Dental appliances

Breathing

• Inspect– Expose the chest

• Palpate

• Percussion

• Auscultate

Breathing Inspect

RATE, PATTERN, DEPTH, EFFORT• Appearance• Symmetry• Signs of past trauma• Accessory muscles• Speech• Jugular veins• Cough

Breathing Palpate

• Pain, point tenderness• Deformity• Chest wall expansion• Mobility• Crepitus• Skin temp/moisture• SQ emphysema• Tactile fremitus• Position of the trachea

Breathing Percussion

• Hyperresonance– Pneumothorax or emphysema

• Dull– Blood from hemothorax

Breathing Auscultate

• Perform immediately if in distress– Audible

– Listen• Ominous sound = silence• Tissue mismatch: reflects sound away

Breathing Auscultate

• Where to listen?

– Epigastrium (first after intubation)– Anterior– Lateral– Posterior

Breathing Compromise

• Dyspnea• Bradypnea: weak/shallow• Tachypnea• Cough• Diminished or absent breath sounds• Signs of chest trauma• Increased effort using accessory muscles• SQ emphysema• Unequal pulmonary excursion• Hypoxia/cyanosis• Restlessness

Breathing Intervention

• Pulse OX (SpO2) • Oxygen (NRB)

Breathing Life Threats

• Tension Pneumothorax• Open Pneumothorax• Flail Chest• Massive Hemothorax

Needle Decompression

• Landmarks anterior approach– 2nd intercostal space in the midline of the

clavicles– Place prepared flutter valve needle over

the top of the rib• Avoids potential injury to vessels and

nerves that run along the bottom of the rib

Quick Way to Find 2nd ICS• Feel for the top of the sternum• Roll your finger tip to the anterior surface at the top

of the sternum• Feel the little bump near the top of the sternum

– This bump is the Angle of Louis

• From the Angle of Louis slide your fingers angled slightly downward toward the affected side following the rib space– You are automatically in the 2nd ICS

• Identify the midline of the clavicle– The midline is more lateral than persons realize and

usually runs in line with the nipple

Alternate Method to Find 2nd Intercostal Space

• Palpate the clavicle and find the midline– The midline is farther out (more lateral) from the sternum

than most persons realize

• Move your finger tips under the clavicle into the 1st intercostal space– 1st rib is under the clavicle and is not palpated– Spaces identified for the numbered rib above the space

• Feel for the firm 2nd rib and palpate the soft space below the rib– This is the 2nd ICS

Needle Decompression

• Find your own 2nd ICS• Now find your neighbor’s 2nd ICS

– Use both methods to find the landmark and decide which is easiest for you

• Documentation– To include signs and symptoms– Size of needle used (length and gauge)– Site needle inserted into– Response from the patient

Equipment

• Long needle (preferably 2-3 inch) and large bore needle (preferably 12-14G)

• Flutter valve– Not required by system, but can be helpful– Commercial devices, or finger from a glove

• Cleanser to prepare skin• Method to secure needle in place

– Skin will most likely be diaphoretic– Tape may not stick– May need to maintain manual control of needle

Skin Preparation

Midline ofclavicle

Angle of Louis

2nd ICS

Inserting the Needle

• Remove proximal end cap from needle– Will be able to hear trapped air escaping

• Needle inserted over top of rib– Once hiss of air heard continue to advance

catheter while withdrawing stylet• Stabilize catheter as best as possible• Patient should symptomatically improve

– Do not expect to hear improved breath sounds; takes time for the lung to reexpand

Case Study #1

• EMS is called to the scene for a 52 year-old male with c/o sudden onset dyspnea with pain between his shoulder blades while watching TV at home. The patient is agitated, short of breath, with increased respiratory rate and SaO2 of 89%.

• Further assessment reveals decreased breath sounds on the right and clear on the left

• Vital signs: 98/62; HR 118; RR 32 and shallow• Your impression & intervention plan?

Case Study #1

• Spontaneous tension pneumothorax– They don’t all develop from trauma

• Begin supplemental oxygen support via non-rebreather, cardiac monitor, preparation for IV

BUT• Quickly prepare for needle decompression while the

above are being prepared– Patients with a tension pneumothorax can’t wait and will

deteriorate without needle decompression

Sucking Chest Wound

• Most common with penetrating wounds• Free passage of air between the atmosphere

and pleural space if the open wound is at least 2/3

rd the size of the diameter of the trachea– Size of trachea about the size of pt’s 5th finger

• Air is drawn into the chest cavity• Air replaces lung tissue• Lung collapses

Sucking Chest Wound

• Severe dyspnea• Open chest wound

– Check anterior, posterior, axilla areas

• Frothy blood at wound opening• Sucking sound as air moves in and out• Tachycardia with hypovolemia

Treatment Sucking Chest Wound• Immediate treatment is to seal the opening

– May start by placing a gloved hand over the wound

– When able, place an occlusive dressing, taped on 3 sides, over the wound

• Wound now converted to a closed pneumothorax

• Monitor for signs of tension pneumothorax– May need to lift a corner of the dressing to release

trapped air via burping dressing

Flail Chest • 3 or more adjacent ribs broken in 2 or more places

– Segment becomes free with pardoxical chest wall motion during respirations

– Paradoxical movement more evident after the muscles splinting the flail segment fatigue

• Usually takes a tremendous amount of blunt trauma to cause a flail chest

• Often present will be associated severe underlying injury (ie: pulmonary contusion)

• Respiratory volume reduced and respiratory effort increased

Treatment Flail Chest• Place patient on the injured side (may not be possible to

do this in the field based on mechanism of injury)• High flow oxygen – nonrebreather mask

– Monitor for need to assist ventilations via BVM to deliver positive pressure ventilations• Evidence of underlying pulmonary injury• Effort and fatigue• Pulse oximetry

• EKG monitoring– Tremendous amount of force is delivered to the

chest wall and cardiac injury is highly likely as a result

Breathing Caveats

• Elderly:– Pulmonary system is the leading cause of post-

traumatic complications– Consider the need to intubate– Caution to over-correct patients with COPD

– But Never withhold oxygen to any patient who needs it

Breathing Caveats

• Morbidly Obese:– Difficult assessment– SpO2 monitoring – CO2 retention may occur often– Tension Pneumo might need 10g (longer than 14g)

Circulation Assessment

• Pulses– Radial: B/P 80-90 mm Hg– Femoral: B/P 70mm Hg– Carotid: B/P 60mm Hg– Rapid, thready, >120 = probable shock

Circulation Assessment

• Perfusion– Mental status– Skin color/temp of extremities– BP/secondary survey– Quality of the peripheral pulse

Circulation Assessment

• Skin Color, Temperature, & Moisture– Vasoconstriction = shock

• Cap Refill < 2 sec• Level of Consciousness

– Indicator of central perfusion

• Bleeding– Location, type, amount, & rate

Circulation Life Threats

• PEA• Cardiac Tamponade• Shock• Massive Hemothorax > 1,500 ml

Circulation Resuscitation

• CPR, if needed• Control bleeding• IV access • Fluids• EKG monitoring• MAST Pants/PASG no longer required on

ambulance by IDPH

FLUIDS

• Adults– “Fill the Tank”

– Not always effective… filling tank with water will not allow engine to run

– But sometimes it’s all we have

– Bolus isotonic fluid to maintain effective systolic BP

• Pediatrics– 20 cc/Kg then maintenance

Circulation Caveats

• Elderly & Morbidly Obese– Fluid loading is poorly tolerated– Vascular access may be difficult– ECG changes

• Pregnant patients– Blood supply increases significantly in a woman who is

at full term– More information on that coming up toward the end

of this presentation

Disability

• Level of consciousness– Best indicator of central perfusion & deterioration

of patient status

• Pupils• Glucose Level

Disability Assessment

• Glasgow “best” response– Eye opening– Verbal response– Motor response

• Total 3-15• There is no such thing as a GCS of “zero”. Even a

rock has a GCS of at least 3.

GCS Pearls

• Acceptable noxious stimuli– Armpit pinch or nailbed pressure– Sternal rub, pinching web space between

fingers, pinching shoulder muscle (trapezius)

– Earlobe pinch is out of favor• Can cause movement of head & neck in

response to the pain

GCS Pearls• The change in the GCS is more important than the

absolute score• Check for associated injuries

– Manage a head injury as a multiple injured patient until other injuries ruled out

• Stabilize the neck for any head injury• Don’t assume the level of consciousness is altered

just because of ETOH and/or drugs– Is there an occult (hidden) injury present?

• Provide accurate, clear, detailed documentation

Disability Assessment

• Possible causes of altered mental status: AEIOUTIPS– Airway– Endocrine– Insulin– Overdose– Uremia– Trauma/tumors– Infection– Psychosis– Shock/seizures

Disability Caveats

• Elderly:

– Hearing, visual, cognition, memory, perception, communication, and motor deficits

– ≥ 65 with GCS ≤ 8 is poor prognosis– ≥ 65 with RTS < 7 has 100% mortality– Don’t control all restlessness with sedation

Disability Caveats

• Morbidly obese:

– Supine position = decrease range of motion– Strength may be difficult to determine– Look for asymmetry for injury

Environment/Exposure

• Flip them (back)• Strip them (wounds, burns)• Keep warm

• Caveats:– Elderly: increase in hypothermia– Morbidly obese: pull back skin

• Vital signs– BP, HR, RR, Temp

• Manual BP • Pulse pressure

– Narrowed = bleeding (<30 mmHg)– Widened = increase ICP (>50 mmHg)

• Pulse– Conscious palpate radial– Unconscious palpate carotid– Normal 60-100– Bradycardia vs Tachycardia– Rhythm– Quality– Location

• Current & Past Health History• Sample:

– S: Symptoms– A: Allergies– M: Medications– P: Past medical history– L: Last oral intake, last LMP, last TD– E: Events surrounding the incident

• MOI– MVC– Falls– Struck by blunt object– Penetrating wounds– Violence/abuse

Caveats in Elderly

• Pain is often undertreated• Polypharmacy – they take a lot of meds

already that affect their response to trauma• Increased sensitivity to side effects

• Head to Toe Review– Inspect– Palpate– Anticipate– Percussion– Auscultate

• Head to Toe Review– HEENT

• Elderly: – brain atrophies allows more blood to accumulate without

showing signs of ICP

– Neck• Cervical fractures

– Chest/thorax/pulmonary system

• Head to Toe Review– Abdomen (inspect, listen, palpate, percuss)

• Kehr’s sign• Seat belt sign• Cullen’s sign • Gray-Turner’s Sign• Contour• Old scars• Visible pulsations

• Head to Toe Review• GU/Pelvis

– Palpate• Gentle Inward/outward pressure• No pelvic rock

• Head to Toe Review– Extremities (6 P’s of pain)– Back/Spine

• Log roll

– Skin & soft tissue– Neurological

• LOC/GCS/Motor exam/Sensory exam

Standard Monitoring

• Cardiovascular– Peripheral pulses– Skin color/temperature/moisture– BP– ECG– Heart sounds– Fluid volume (type and amount)– Drainage from wounds

Standard Monitoring

• Neurological– Mental status (GCS)– Content arousal– Pupils– Motor/sensory exam changes– Seizure activity

Evaluation Pearls – Low SaO2

• SaO2 reading may be inaccurate in the presence of:– Hemorrhagic shock with delayed capillary refill – Hypothermia– Lung damage

• Evaluate all parameters together to get the best overall picture in ventilated patient– Are you able to ventilate the patient?– Are there extenuating circumstances where the

circulation is affected and would affect the pulse ox reading like those listed above?

More Case

Studies

Case Study #2• Your 34 year-old patient

received a GSW to the right upper abdomen.

• They are conscious and alert; B/P 90/62; HR 120; RR 28; bleeding is minimal

• What are your interventions?

Case Study #2 • Make sure the scene is secured• Consider need for spinal immobilization• During assessment of wound, consider thoracic injury

in addition to abdominal injury depending on the angle of the GSW.

• Examine for an exit wound – Check the back and the axilla

• Prepare for the worst – assume the patient will deteriorate before ED arrival

• Repeat VS: B/P 80/; HR 140; RR 32, remains conscious and in pain

• Transport to a Trauma Center

Case Study #2 - Treatment• Routine trauma care• Question – is this an isolated abdominal wound or is it

a combination abdominal/ chest wound?– Need to treat patient for potential injuries of both

body cavities– EMS cannot determine in the field the angle of the

trajectory • Cover the wound and watch for evisceration• Fluid resuscitation – keep B/P normal; the higher the

B/P the faster the patient bleeds out

Case Study #2 - Documentation• If patient states anything, put it in quotes• If information available, add angle patient shot from (ie:

above, below) and distance from weapon • If known, list type of weapon used• Include results of inspection, auscultation, palpation

– Location of entrance and exit wound– Size of wound(s)– Assessment of the general area (ie: contusions, bleeding,

swelling/distention, pain, powder marks)

• Preserve evidence as much as possible

Case Study #3• Your 10 year-old patient

has a penetrating injury to the right leg above the knee while playing in his backyard

• Initial VS: B/P 90/70; HR; 130; RR 32; no active bleeding

• Field interventions?

Case Study #3

• Next VS: B/P 92/64; HR 110; RR 20.• Stabilize foreign body in place• Obtain distal neurovascular status

– Distal pulses– Movement – “can you wiggle your toes?”– Sensation – “close your eyes and tell me which toe

I am touching”• Document distal neurovascular status and

describe how the foreign object is stabilized in place

Case Study #4• Your 62 year-old

patient had abdominal surgery 1 week ago. Today at home he sneezed hard and felt a tearing sensation in his abdomen and called EMS.

• VS: B/P 100/60; HR 110; RR 24

• No active bleeding

• What interventions are appropriate?

Case Study #4 - Interventions

• Immediately cover the wound– Need to minimize contamination– Need to prevent more organs from protruding– Need to prevent loss of fluids

• Place a saline moistened dressing over the exposed tissue

• Place dry gauze over the saline dressings• Can place light manual control over the organs to

prevent further evisceration especially during movement, coughing, sneezing, deep breaths

Case Study #5

• 21 year-old drove into a metal fence. Upon EMS arrival, there is obvious external chest injury with bleeding. Coming closer to the patient, EMS can hear a sucking sound from the chest wound.

• Patient is alert, in pain, severe dyspnea• VS: B/P 90/62; HR 130; RR 34; GCS 15• Breath sounds L > R• Look at the injury – what is your impression and

what interventions are necessary?

MVC Into Metal Fencing

Case Study #5 • An adequate dressing will be difficult to

achieve with such an extensive wound– A gloved hand just won’t be enough to get started

• This patient may be a candidate for conscious sedation and intubation to provide positive pressure ventilation

• Reassessment VS: B/P 80/56; HR 140; RR 36 GCS remains 15

• Transport

Case Study #5 - Treatment

• Open chest wounds need to be covered ASAP with a non-occlusive dressing

• Carefully monitor if the treatment of the open chest wound converts the injury into a tension pneumothorax

• Carefully monitor the patient for the need for more aggressive airway control (ie: supportive ventilation via BVM or intubation)– Initially can start O2 therapy with a non-rebreather

mask

Case Study #5 - Documentation

• What – cause of the injury (penetration, MVC, pedestrian, etc)

• When – the injury occurred• Where – by body location

– “quadrant” refers to the abdomen– Chest injuries uses reference such as anterior/

posterior, nipple line, upper/lower chest wall • How – the injury occurred• Expand and give detail description of the

injury, treatment rendered, pt response

Case Study #6

• Your 45 year-old patient is a construction worker who was accidentally shot in the head with a nail gun

• Upon arrival, the patient is awake, alert, talking (GCS 15)

• VS: B/P 132/78; HR 96; RR 20; complains of a minor headache; minimal bleeding at a few puncture wounds noted on the occipital area of the scalp (patient has thick hair).

X-ray from ED

No deficitsnoted

Case Study #6 - Treatment• Consider any injury above the level of the clavicles to

include a c-spine injury until proven otherwise and immobilize the patient

• Control bleeding– The face and scalp have such a rich blood supply small wounds

tend to bleed heavily

• Protect from further contamination– The open wound may be in direct contact with the brain

• Document neurological evaluation to establish baseline for comparison (AVPU, GCS, movement)

Case Study #7

• You are called to the scene for a 10 year-old female who has been run over by a bus

• As patient exited bus, she bent down to tie her shoe and was caught under the wheels of the bus

• Upon your arrival, you note a large amount of avulsed tissue with bleeding from the left hip, left buttock, and left upper thigh area

• The patient is screaming in pain• VS: B/P 110/70; HR 110; RR 26 GCS 15• What is your impression?

10 y/o run over by bus

Case Study #7 – • General impression• Potential problems to consider & address

– Massive hemorrhage & control of hemorrhage– Spinal injury– Additional injuries– Airway control – Equipment to fit a 10 year-old– Further wound contamination

Lastly

DOCUMENT

DOCUMENT

DOCUMENT

Caveats in Pregnancy• General – treat the mom to treat the fetus• Airway• Breathing• Circulation• Disability

Anatomical and Physiological Changes in the Pregnant Patient

• Cardiovascular– Hemodynamic-

• Increased HR 10-20 bpm, increased SV, increased blood volume by 45-50%, increased cardiac output by 30-50%, SVR decreases

– Hematologic• Increased WBC, decreased hemoglobin and hematocrit

– Hypercoagulation- excessive blood clotting– Shock Considerations

• May not see S & S until >30% circulating blood volume is lost!!!

Anatomical and Physiological Changes (con’t)

• Respiratory – Increased MR, O2

consumption, decreased CO2• Renal

– Bladder higher, kidneys dilated, increased vascularity, increased GFR

• Gastrointestinal– Intestines higher, liver &

spleen enlarged, prolonged gastric emptying

• Reproductive– Blood flow through uterus

500-750ml/min, 1/6 total maternal BV, 10-20% of CO, hypoperfusion of uterus may occur before signs of shock

• Musculoskeletal– Changes in center of gravity

• Endocrine– Enlarged thyroid

Strip O’ the Month• PEA – Pulseless electrical activity

– Pulseless electrical activity is a clinical situation, not a specific dysrhythmia

– Formerly called electromechanical dissociation (EMD)

• One of the more common “death rhythms” in traumatic arrest.– So common, “trauma” used to be included in the

possible causes (H’s and T’s)… but the most recent ACLS algorhythm gets a little more specific than that (hypovolemia, tension pneumo, etc).

Pulseless Electrical Activity

• PEA exists when organized electrical activity (other than VT) is present on the cardiac monitor, but the patient is pulseless

Causes: H’s and T’s

• The H’s include:– Hypovolemia, Hypoxia, Hydrogen ion (acidosis),

Hyper-/hypokalemia, Hypothermia.

• The T’s include:– Toxins, Tamponade(cardiac),Tension

pneumothorax, Thrombosis (coronary and pulmonary).

PEA – Another Way to Remember the Causes

• Pulmonary embolism• Acidosis• Tension pneumothorax• Cardiac tamponade• Hypovolemia (most common cause)• Hypoxia• Heat/cold (hypothermia/hyperthermia)• Hypokalemia/hyperkalemia (and other electrolytes)• Myocardial infarction

• Drug overdose/accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digoxin)

PATCH-4-MD

PEA – Intervention

• Begin CPR

• Search aggressively for possible cause(s) of the

situation

– Often finding the right “H” or “T” can solve PEA quickly

– Most common cause: hypovolemia

• Pharm: Epinephrine 1:10,000 IV/IO

• No More Atropine!!!

Questions?Email afinkel@silvercross.org or call 815-300-7425 (or type into text box if watching live).

Thank You for Your Attention And a special thank you to Dr Wendy Marshall, Courtney McKibben RN MSN and Sharon Hopkins RN MS for the use of some of their material