lesson 11

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Golden Principles of Golden Principles of Prehospital Trauma CarePrehospital Trauma Care

Lesson 11

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2

You are dispatched to the scene of a pedestrian You are dispatched to the scene of a pedestrian struck by a vehicle. Law enforcement and the struck by a vehicle. Law enforcement and the fire department are en route. It is an overcast fire department are en route. It is an overcast spring day with a temperature of 50° F (10° C). spring day with a temperature of 50° F (10° C).

Scenario


What are your initial concerns as you arrive on What are your initial concerns as you arrive on scene?scene?

ScenarioScenario


Ensure the safety of the prehospital care Ensure the safety of the prehospital care providers and the patientproviders and the patient What are the safety concerns with this scene?What are the safety concerns with this scene?

Scene Size-upScene Size-up


Assess the scene situation to determine the Assess the scene situation to determine the need for additional resourcesneed for additional resources What additional resources may be needed?What additional resources may be needed?

Scene Size-upScene Size-up


Recognize the Recognize the kinematics that kinematics that produced produced the injuriesthe injuries What are the What are the

factors relating factors relating to kinematics to kinematics implied here?implied here?

KinematicsKinematics


Use the primary survey approach to identify Use the primary survey approach to identify life-threatening conditionslife-threatening conditions What are the key concepts of the primary survey?What are the key concepts of the primary survey?

Breathing

Airway

Kinematics

Circulation

Disability

Expose/Environment

Primary SurveyPrimary Survey


Provide appropriate management while Provide appropriate management while maintaining cervical spine stabilizationmaintaining cervical spine stabilization The patient has noisy ventilations and blood is The patient has noisy ventilations and blood is

draining from the oropharynxdraining from the oropharynx What should be considered when managing this What should be considered when managing this

airway?airway?

ScenarioScenario


The patient’s ventilatory rate is 6 and is shallow. The patient’s ventilatory rate is 6 and is shallow. Cyanosis is visible on the patient’s face and Cyanosis is visible on the patient’s face and fingers. There is bruising across the chest and fingers. There is bruising across the chest and decreased breath sounds are heard on the left. decreased breath sounds are heard on the left. GCS score is 7 (E-2, V-1, M-4). Support ventilation GCS score is 7 (E-2, V-1, M-4). Support ventilation and deliver oxygen to maintain SpOand deliver oxygen to maintain SpO22 of 95% or of 95% or

more.more.

How can this be accomplished?How can this be accomplished?

ScenarioScenario


• Control any significant external hemorrhage

ScenarioScenario


Direct pressure controls the external hemorrhage Direct pressure controls the external hemorrhage from the right arm. The radial pulse is weak and from the right arm. The radial pulse is weak and rapid at about 140 beats/min. The patient is pale, rapid at about 140 beats/min. The patient is pale, cold, and clammy. There is crepitus and tenderness cold, and clammy. There is crepitus and tenderness on palpation of the pelvis and a left thigh deformity on palpation of the pelvis and a left thigh deformity consistent with a left midshaft femur fracture.consistent with a left midshaft femur fracture.

How would you manage these findings?How would you manage these findings?

ScenarioScenario


Provide basic shock therapy, including restoring Provide basic shock therapy, including restoring and maintaining normal body temperature and and maintaining normal body temperature and appropriately splinting musculoskeletal injuries appropriately splinting musculoskeletal injuries

Consider the use of the PASG for patients with Consider the use of the PASG for patients with decompensated shock (SBP less than 90 mm Hg) decompensated shock (SBP less than 90 mm Hg) and suspected pelvic, intraperitoneal, or and suspected pelvic, intraperitoneal, or retroperitoneal hemorrhage; and in patients with retroperitoneal hemorrhage; and in patients with profound hypotension (SBP less than 60 mm Hg)profound hypotension (SBP less than 60 mm Hg)

ShockShock


Maintain manual spinal Maintain manual spinal stabilization until the stabilization until the patient is immobilized patient is immobilized onto a long backboardonto a long backboard

When is spinal When is spinal immobilization immobilization indicated? indicated?

ImmobilizationImmobilization


For critically injured patients, initiate transport to the For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival closest appropriate facility within 10 minutes of arrival on sceneon scene

10

Platinum10 minutesGolden

Period

TransportTransport


Field Triage Decision Scheme Step 1: Vital Signs & LOCStep 1: Vital Signs & LOC

GCS <14 or SBP <90 or RR <10 or >29 GCS <14 or SBP <90 or RR <10 or >29 (<20 in infants <1 yr)(<20 in infants <1 yr)

Step 2: Anatomy of InjuryStep 2: Anatomy of Injury Penetrating injuries of head, neck, torso, Penetrating injuries of head, neck, torso,

or proximal extremitiesor proximal extremities

Flail chestFlail chest

2 or more proximal long-bone fractures2 or more proximal long-bone fractures

Crush or degloving extremity injuryCrush or degloving extremity injury

Amputation proximal to wrist or ankleAmputation proximal to wrist or ankle

Pelvic fracturePelvic fracture

Open or depressed skull fractureOpen or depressed skull fracture

ParalysisParalysis

If yes to any: transport to highest level of If yes to any: transport to highest level of trauma care in systemtrauma care in system

Step 3: Mechanism of InjuryStep 3: Mechanism of Injury Falls (adult) >20 ft (2 stories)Falls (adult) >20 ft (2 stories) Falls (child) >10 ft or > 2-3 x ht.Falls (child) >10 ft or > 2-3 x ht. Auto crash:Auto crash:

• Intrusion >12” occupant site, >18” any siteIntrusion >12” occupant site, >18” any site• Ejection, partial or completeEjection, partial or complete• Death in same vehicleDeath in same vehicle• Vehicle telemetry data indicates riskVehicle telemetry data indicates risk

Auto vs. pedestrian or bicyclist thrown, run over Auto vs. pedestrian or bicyclist thrown, run over or >20 mph impactor >20 mph impact

Motorcycle crash >20 mphMotorcycle crash >20 mph Step 4: Other FactorsStep 4: Other Factors

Pediatric or >55 yearsPediatric or >55 years CoagulopathyCoagulopathy BurnsBurns Time-sensitive extremity injuryTime-sensitive extremity injury DialysisDialysis Pregnancy >20 weeksPregnancy >20 weeks Provider judgmentProvider judgment

If yes to any: contact medical control and transport to If yes to any: contact medical control and transport to closest appropriate trauma center or specific closest appropriate trauma center or specific

resource hospitalresource hospital


Initiate warmed Initiate warmed intravenous fluid intravenous fluid replacement en route replacement en route to the receiving facilityto the receiving facility

What are the considerations with What are the considerations with prehospital fluid therapy?prehospital fluid therapy?

Fluid TherapyFluid Therapy


Ascertain the patient’s medical history and Ascertain the patient’s medical history and perform a secondary survey when life-perform a secondary survey when life-threatening problems have been satisfactorily threatening problems have been satisfactorily managed or have been ruled out.managed or have been ruled out.

ScenarioScenario


Decision MakingDecision MakingTrauma-related incident

Scene assessment

Primary survey

Life threatening or multisystem injuries

NoYes

Initiate rapid transport

Reassess

Secondary survey

Secondary survey

Reassess

Manage injuries as appropriate

Initiate transport


Above all, Above all,

do no further harm.do no further harm.


Fundamental PrinciplesFundamental Principles

Rapid assessmentRapid assessment Key field interventionsKey field interventions Rapid transport to the closest appropriate Rapid transport to the closest appropriate

facilityfacility


PHTLS Works!PHTLS Works!


QUESTIONS?QUESTIONS?

lesson 11

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