trauma unleashed outreach module pp

Trauma Unleashed!Trauma Unleashed!

Case Studies from the FieldCase Studies from the Field

Air Evac EMS, Inc.Air Evac EMS, Inc.

Outreach Education ModuleOutreach Education Module

You receive a call for an You receive a call for an elderly male that was found elderly male that was found unresponsive in the hot tubunresponsive in the hot tub

Case StudyCase Study

• What does this have to do What does this have to do with trauma?with trauma?

• Is he sick, is he injured, is Is he sick, is he injured, is he sick he sick andand injured? injured?

• Need more INFORMATION!Need more INFORMATION!


• What questions do you have?What questions do you have?• How long has he been in the hot How long has he been in the hot

tub? tub? • How hot is the water? How hot is the water? • How old is he? How old is he? • Any medical Hx? Any medical Hx?


• When you arrive you find an 85 yr old male When you arrive you find an 85 yr old male sitting in the hot tub with agonal breathing and a sitting in the hot tub with agonal breathing and a weak pulseweak pulse• GCS is 3GCS is 3• He has a history of a CVAHe has a history of a CVA• He has lost control of his bowel and bladder He has lost control of his bowel and bladder • Hot tub water is 105 degreesHot tub water is 105 degrees• The pt was last seen, last night with no complaintsThe pt was last seen, last night with no complaints

WHAT DO YOU DO?WHAT DO YOU DO?WHAT IS YOUR DX?WHAT IS YOUR DX?


• What is your initial Diagnosis?What is your initial Diagnosis?• Unconscious patient due to???Unconscious patient due to???

• CVA?CVA?• MI?MI?• Heat stroke/exposure?Heat stroke/exposure?• Drug ingestion?Drug ingestion?• ETOH intoxication?ETOH intoxication?


• Could be any one of the Could be any one of the aforementioned diagnoses or aforementioned diagnoses or a combination of two or a combination of two or more…BUT a more pressing more…BUT a more pressing matter would be matter would be

Case StudyCase Study• The patient is extricated from the hot tubThe patient is extricated from the hot tub• Agonal respirations at 6-8 Agonal respirations at 6-8

• IntubatedIntubated• Large bore IV’s are started and 2 liters of NS are rapidly Large bore IV’s are started and 2 liters of NS are rapidly

infusedinfused• Vital signs Vital signs

• BP is 60PBP is 60P• HR 140HR 140

• His skin is hot and shriveledHis skin is hot and shriveled• He has pressure ulcers on his heelsHe has pressure ulcers on his heels• Crackles are auscultated in all lung fieldsCrackles are auscultated in all lung fields• Pupils are 2mm and sluggishPupils are 2mm and sluggish

Any Thoughts? What to do next?Any Thoughts? What to do next?


• While en route to the hospital the While en route to the hospital the patient remained hypotensivepatient remained hypotensive• Dopamine gtt initiatedDopamine gtt initiated

• Patient weight is 180 lbsPatient weight is 180 lbs• What is the dose for Dopamine? What is the dose for Dopamine? • How much should you give?How much should you give?


• 10mcg/kg/min of Dopamine initiated10mcg/kg/min of Dopamine initiated

• SBP increased to 80SBP increased to 80• The quick down and dirty method to calculate The quick down and dirty method to calculate

DopamineDopamine• Take the wt - 180Take the wt - 180• Drop the 0 and subtract 2Drop the 0 and subtract 2• Now you have 16Now you have 16• That is your cc/hr for 5 mcg/kg/minThat is your cc/hr for 5 mcg/kg/min• Administer 32 cc/hr for 10mcg/kg/minAdminister 32 cc/hr for 10mcg/kg/min


• Why is the patient hypotensive?Why is the patient hypotensive?• Is the patient in Shock?Is the patient in Shock?

• Distributive?Distributive?• Hypovolemic?Hypovolemic?• Obstructive?Obstructive?• Cardiogenic?Cardiogenic?


Distributive ShockDistributive Shock Decreased systemic vasomotor tone which Decreased systemic vasomotor tone which

can result in end-organ dysfunctioncan result in end-organ dysfunction CausesCauses

SepsisSepsis AnaphylaxisAnaphylaxis Drug reactionsDrug reactions Neurogenic (Brain or Spinal Cord)Neurogenic (Brain or Spinal Cord)


Hypovolemic ShockHypovolemic Shock Decreased systemic vascular resistance Decreased systemic vascular resistance

which can result in end-organ dysfunctionwhich can result in end-organ dysfunction CausesCauses

Blood lossBlood loss Severe burnsSevere burns

Third spacing and loss of plasmaThird spacing and loss of plasma

DehydrationDehydration


Obstructive ShockObstructive Shock Decreased systemic vascular resistance Decreased systemic vascular resistance

which can result in end-organ dysfunctionwhich can result in end-organ dysfunction CausesCauses

Cardiac TamponadeCardiac Tamponade Tension PneumothoraxTension Pneumothorax


Cardiogenic ShockCardiogenic Shock The heart is unable to pump enough blood The heart is unable to pump enough blood

(both force and volume) for the needs of the (both force and volume) for the needs of the bodybody

CausesCauses Massive MIMassive MI Heart Failure Heart Failure

Left or right sided**Left or right sided**


What type of shock do you think our What type of shock do you think our patient is in?patient is in? Distributive?Distributive? Hypovolemic?Hypovolemic? Obstructive?Obstructive? Cardiogenic?Cardiogenic?

Case StudyCase Study• Pt arrives in the ED Pt arrives in the ED

• GCS remains 3GCS remains 3• Systolic pressure at 80Systolic pressure at 80• HR remains in the 140’s HR remains in the 140’s • Rectal temp is 107Rectal temp is 107• Placed on the ventilatorPlaced on the ventilator• Additional tests and treatmentsAdditional tests and treatments

• CT of the head CT of the head • CXRCXR• EKG EKG • ABG’sABG’s• A cooling blanket is appliedA cooling blanket is applied

What are your thoughts?What are your thoughts?


• CT of the head revealed a lacunar CT of the head revealed a lacunar nonhemorrhagic infarct (age unknown)nonhemorrhagic infarct (age unknown)

• EKG reveals ST depression in all of the lateral EKG reveals ST depression in all of the lateral leadsleads

• ABG’s ABG’s • ph 7.3ph 7.3• pC02 25.1pC02 25.1• HCO3 12.8HCO3 12.8• BE -11.5BE -11.5

• CXR – LLL infiltratesCXR – LLL infiltratesNow what do you think? What to do next?Now what do you think? What to do next?


• Levophed initiated to increase BP (15mcg/Levophed initiated to increase BP (15mcg/min) min) • Pressure not responsivePressure not responsive

• He received 3 liters of NS when we got the He received 3 liters of NS when we got the call to transfer this pt to a higher level of call to transfer this pt to a higher level of carecare

Why is the pt still hypotensive?Why is the pt still hypotensive?

Have we missed anything?Have we missed anything?


• Remember the ABGRemember the ABG• ph 7.3 and BE-11.5ph 7.3 and BE-11.5

• Acidotic patients Acidotic patients DO NOTDO NOT respond well to respond well to vasopressorsvasopressors• Given 1 amp of bicarbGiven 1 amp of bicarb• Another liter of NSAnother liter of NS• Temperature reduced with a cooling blanket to 99.1Temperature reduced with a cooling blanket to 99.1• 6000 unit heparin bolus and a gtt was initiated at 1500 6000 unit heparin bolus and a gtt was initiated at 1500

units/hrunits/hr


Arrival at the tertiary care facility Arrival at the tertiary care facility BP was 122/49BP was 122/49 RR via the ventilator was increased from 12 to RR via the ventilator was increased from 12 to

16 to keep his C02 in the low 30’s16 to keep his C02 in the low 30’s The pt was admitted to the ICUThe pt was admitted to the ICU

DiscussionDiscussion

Admitting DiagnosisAdmitting Diagnosis MIMI CVACVA Hyperthermia Hyperthermia

Due to heat exposureDue to heat exposure

DehydrationDehydration Secondary to heat exposureSecondary to heat exposure

Acute Renal FailureAcute Renal Failure

QuestionsQuestions

Ready for Another??Ready for Another??

Truck vs Car BROADSIDETruck vs Car BROADSIDE

Your Patient is the Driver of the Your Patient is the Driver of the TruckTruck

Extrication CompletedExtrication Completed

Patient has full spinal restrictionPatient has full spinal restriction What do you do?What do you do? What further information do you want?What further information do you want?

Report from First RespondersReport from First Responders

75 yr old male (driver) 75 yr old male (driver) + Seatbelt+ Seatbelt Airbag deployedAirbag deployed Trapped with prolonged extricationTrapped with prolonged extrication Pt c/o CPPt c/o CP No surface trauma observedNo surface trauma observed GCS is 10GCS is 10

Eyes open to painEyes open to pain Withdraws to painWithdraws to pain Disoriented and conversantDisoriented and conversant

NOW WHAT?NOW WHAT?

ABC’sABC’s

AirwayAirway Open and clearOpen and clear

BreathingBreathing Respirations are 16 and shallowRespirations are 16 and shallow

CirculationCirculation Skin is paleSkin is pale DiaphoreticDiaphoretic Capillary refill is at 5 secCapillary refill is at 5 sec Pulses are thready and slowPulses are thready and slow

Vital SignsVital Signs

BP: 70/30BP: 70/30HR: 30’sHR: 30’sPulse Ox was 94% but now does Pulse Ox was 94% but now does

not readnot readGCS is now 8 and pt becomes GCS is now 8 and pt becomes

combativecombative

Pre-hospital CoursePre-hospital Course

Airway management with DAI Airway management with DAI Ventilated with 100% 02Ventilated with 100% 02 2 IV’s were established with 2800 ml IV bolus2 IV’s were established with 2800 ml IV bolus 25 grams of Albumin was infused25 grams of Albumin was infused Gastric tube was passed for decompressionGastric tube was passed for decompression 3 mgs of Atropine3 mgs of Atropine

Without effectWithout effect Two Epi injections (0.5mg)Two Epi injections (0.5mg)

Increase HR and BP achievedIncrease HR and BP achieved

In Hospital CourseIn Hospital Course

VS on arrival were: VS on arrival were: BP 93/38BP 93/38 HR 115HR 115 EtCO2 30EtCO2 30 GCS 3 (DAI)GCS 3 (DAI)

Trauma protocol startedTrauma protocol started CXRCXR Pelvis Xray done (fractured pelvis seen)Pelvis Xray done (fractured pelvis seen) Blood transfusion startedBlood transfusion started Foley inserted with gross bloody urine returnedFoley inserted with gross bloody urine returned

OutcomeOutcome

Patient’s BP and HR steadily declined Patient’s BP and HR steadily declined Patient coded in spite of all resuscitation Patient coded in spite of all resuscitation

effortsefforts Continued resuscitation was not successfulContinued resuscitation was not successful

DiagnosisDiagnosis Blunt Chest TraumaBlunt Chest Trauma Cardiac and pulmonary contusionsCardiac and pulmonary contusions Pelvic FracturesPelvic Fractures

DiscussionDiscussion

Last but not leastLast but not least

The Trauma Call The Trauma Call

Call is received for a single vehicle accident (MV Call is received for a single vehicle accident (MV vs Tree) vs Tree)

There are multiple patients and reports of people There are multiple patients and reports of people trapped in the vehicletrapped in the vehicle

2 EMS units and Fire/Rescue are dispatched2 EMS units and Fire/Rescue are dispatched You are one of the medics enrouteYou are one of the medics enroute

What are you thinking? What are you thinking? What are you preparing for?What are you preparing for?

First to ArriveFirst to Arrive

You find a total of 4 patients, with 1 You find a total of 4 patients, with 1 trappedtrapped

You are 1 and ½ hours from the closest You are 1 and ½ hours from the closest trauma centertrauma center

What do you do?What do you do?

What do you want?What do you want?

TriageTriage

You find 1 patient trapped and 3 outside You find 1 patient trapped and 3 outside the vehiclethe vehicle

You classify 2 major and 2 minorYou classify 2 major and 2 minor

WHO YA GONNA CALL?WHO YA GONNA CALL?

ABC’sABC’s

You call for 2 EMS helicopters for the 2 You call for 2 EMS helicopters for the 2 majors majors Further assessment reveals one of the Further assessment reveals one of the

patients has a severe head injury patients has a severe head injury The patient that is trapped c/o severe CP and The patient that is trapped c/o severe CP and

SOB SOB Treatment and stabilization is initiated by the Treatment and stabilization is initiated by the

ground unitsground units

The SceneThe Scene

The Scene The Scene

The SceneThe Scene

BIG PICTURE BIG PICTURE ⇒⇒ Focused Focused assessmentassessment

The pt with the severe head injury is flown The pt with the severe head injury is flown to the closest trauma centerto the closest trauma center

The 2 minor trauma pt’s are ground The 2 minor trauma pt’s are ground transported to the closest appropriate transported to the closest appropriate facilityfacility

The 4The 4thth pt that remains trapped inside of pt that remains trapped inside of the vehicle becomes our focusthe vehicle becomes our focus

Trauma AssessmentTrauma Assessment

Our PatientOur Patient 36 yr old male who is awake, talking and c/36 yr old male who is awake, talking and c/

o severe CP, back pain and SOBo severe CP, back pain and SOB Remains in the vehicle on his side with his Remains in the vehicle on his side with his

lower extremities trappedlower extremities trapped

Primary AssessmentPrimary Assessment

AIRWAYAIRWAY Patient is vocalizingPatient is vocalizing

BREATHINGBREATHING Spontaneous breathing Spontaneous breathing

RR 36 and laboredRR 36 and labored Grunting respirations. Grunting respirations. Course rhonchi to all lung fieldsCourse rhonchi to all lung fields Skin is paleSkin is pale


Is breathing effective?Is breathing effective? What interventions are required?What interventions are required?


CIRCULATION CIRCULATION Central and peripheral pulses are presentCentral and peripheral pulses are present HR 88HR 88 Skin remains pale and clammySkin remains pale and clammy No uncontrolled bleeding is observedNo uncontrolled bleeding is observed

Intervention: 18g IV started with bolusIntervention: 18g IV started with bolus


DISABILITYDISABILITY A0x4A0x4 GCS 15GCS 15 Pupils - PERLPupils - PERL

Secondary AssessmentSecondary Assessment

Extrication is complete Extrication is complete Patient is secured on a backboard with a C-Collar and Patient is secured on a backboard with a C-Collar and

headblocks are in placeheadblocks are in place Abdomen soft and nontenderAbdomen soft and nontender Pelvis stable and nontenderPelvis stable and nontender MAE well with 4 point pulsesMAE well with 4 point pulses Surface trauma observed Surface trauma observed

Full thickness lower lip laceration with bleeding Full thickness lower lip laceration with bleeding controlledcontrolled

Secondary AssessmentSecondary Assessment

Vital SignsVital Signs HR is 88HR is 88 RR at 36-40 laboredRR at 36-40 labored SpO2 at 80% on 02 NRBSpO2 at 80% on 02 NRB BP not available at this timeBP not available at this time Patient is agitated and restlessPatient is agitated and restless

Do you continue with your secondary?Do you continue with your secondary?

InterventionsInterventions

Breathing continues to be ineffective?Breathing continues to be ineffective? Airway management with DAI is performed after Airway management with DAI is performed after

the patient has been moved to the aircraft the patient has been moved to the aircraft Prior to lift offPrior to lift off

Unsuccessful after three attemptsUnsuccessful after three attempts Failed airwayFailed airway

Combitube rescue device used to successfully secure Combitube rescue device used to successfully secure the airwaythe airway

In FlightIn Flight

Patient had expulsion of gastric contents via the Patient had expulsion of gastric contents via the combitubecombitube Suctioning performedSuctioning performed

During BV ventilation we observed bloody During BV ventilation we observed bloody pulmonary secretionspulmonary secretions Suctioning performedSuctioning performed

Patient’s EtCO2 started at 63 Patient’s EtCO2 started at 63 Down to 39 by arrival to the ED with hyperventilationDown to 39 by arrival to the ED with hyperventilation

In FlightIn Flight

The pt remained normotensive The pt remained normotensive Sp02 increased to 99%Sp02 increased to 99% Remained sedated and chemically Remained sedated and chemically

paralyzed paralyzed Received 800cc bolus while enroute to the Received 800cc bolus while enroute to the

EDED

DiagnosisDiagnosis

Why are the pt’s pulmonary secretions Why are the pt’s pulmonary secretions bloody?bloody?

Why was the pt’s breathing ineffective?Why was the pt’s breathing ineffective? Pneumothorax?Pneumothorax? Hemothorax?Hemothorax? Pulmonary Contusions?Pulmonary Contusions? Rib Fractures?Rib Fractures?

Trauma RoomTrauma Room Intubation/ Combitube removalIntubation/ Combitube removal FoleyFoley Gastric tubeGastric tube Trauma protocol Trauma protocol EKGEKG ABG’sABG’s CXRCXR CT’sCT’s

HeadHead NeckNeck ChestChest Abdomen and PelvisAbdomen and Pelvis

ABG ResultsABG Results Ph 7.30,PC02 46, P02 198 HC03 22.6Ph 7.30,PC02 46, P02 198 HC03 22.6

Vent SettingsVent Settings Fi02 100%, Vt 700, AC@12, No PEEPFi02 100%, Vt 700, AC@12, No PEEP

ABG’sABG’s

Vent settings were changed toVent settings were changed to Fi02 55%Fi02 55% Vt 700Vt 700 AC@14AC@14 PEEP of 5PEEP of 5

4 hour ABG results4 hour ABG results Ph 7.40Ph 7.40 PC02 38PC02 38 P02 147P02 147 HCO3 23.5HCO3 23.5

Predicted InjuriesPredicted Injuries

MOI suggests MOI suggests Blunt TraumaBlunt Trauma

Primary Survey suggestsPrimary Survey suggests Blunt Chest TraumaBlunt Chest Trauma

Predicted InjuriesPredicted Injuries

Possible injuries with blunt chest traumaPossible injuries with blunt chest trauma Pneumothorax/ Tension PneumothoraxPneumothorax/ Tension Pneumothorax HemothoraxHemothorax Aortic InjuriesAortic Injuries Cardiac TamponadeCardiac Tamponade Rib FracturesRib Fractures Myocardial and Pulmonary ContusionsMyocardial and Pulmonary Contusions Flail segmentsFlail segments Scapular FracturesScapular Fractures Sternal FracturesSternal Fractures

Our PatientOur Patient

Subdural hematomaSubdural hematoma Pulmonary ContusionsPulmonary Contusions Left sided rib fracturesLeft sided rib fractures

Ribs three – sevenRibs three – seven

Left PneumothoraxLeft Pneumothorax Right Scapular FractureRight Scapular Fracture Splenic lacerationSplenic laceration

Hospital CourseHospital Course

Admitted to the trauma ICU Admitted to the trauma ICU A chest tube was placed for his A chest tube was placed for his

pneumothoraxpneumothorax Pulmonology consult for respiratory failure Pulmonology consult for respiratory failure

Due to massive pulmonary contusionsDue to massive pulmonary contusions Bronchoscopy to remove a mucous plugBronchoscopy to remove a mucous plug

Patient OutcomePatient Outcome

Significant improvement over the next 3 Significant improvement over the next 3 days days

Discharged to home on the 3Discharged to home on the 3rdrd day with a day with a PT and OT consultPT and OT consult

QUESTIONS??QUESTIONS??

Thank You!Thank You!

Please ensure that you have signed the Please ensure that you have signed the roster and submitted your evaluation to roster and submitted your evaluation to the instructor!the instructor!

trauma unleashed outreach module pp

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