1 Trauma Morbidity and Mortality September 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

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Trauma Morbidity and Trauma Morbidity and MortalityMortality

September 2012 CESeptember 2012 CECondell Medical Center Condell Medical Center

EMS SystemEMS SystemSite Code: 107200E -1212Site Code: 107200E -1212

Prepared by: Sharon Hopkins, RN, BSN, EMT-PPrepared by: Sharon Hopkins, RN, BSN, EMT-PRev 9.19.12Rev 9.19.12

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ObjectivesObjectives

Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS provider will be able to:provider will be able to:

1. Identify by mechanism of injury and signs and1. Identify by mechanism of injury and signs and symptoms of major causes of increased risk ofsymptoms of major causes of increased risk of morbidity & mortality related to a traumatic injurymorbidity & mortality related to a traumatic injury (airway obstruction, flail chest, open pneumothorax,(airway obstruction, flail chest, open pneumothorax, tension pneumothorax, cardiac tamponade, aortictension pneumothorax, cardiac tamponade, aortic tear).tear). 2. Identify the significance and signs and symptoms of2. Identify the significance and signs and symptoms of crush injuries and compartment syndrome.crush injuries and compartment syndrome. 3. Describe treatment based on injury presented.3. Describe treatment based on injury presented.

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Objectives cont’dObjectives cont’d

4. Identify transport destination decision.4. Identify transport destination decision. 5. Actively participate in case scenario reviews.5. Actively participate in case scenario reviews. 6. Perform the skills of needle decompression,6. Perform the skills of needle decompression,

cricothyrotomy, and QuickTrachcricothyrotomy, and QuickTrach 7. Successfully complete the post quiz7. Successfully complete the post quiz

with a score of 80% or better.with a score of 80% or better.

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Thoracic TraumaThoracic Trauma

Responsible for 20-25% of all trauma Responsible for 20-25% of all trauma related deathsrelated deaths

Purpose of primary assessmentPurpose of primary assessment Determine the presence of any Determine the presence of any LIFE THREATSLIFE THREATS!!!!!!

What’s going to kill the patient the What’s going to kill the patient the fastest??fastest??

HypoxiaHypoxia HemorrhageHemorrhage

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Trauma StatsTrauma Stats

Deaths at the scene are usually due to Deaths at the scene are usually due to injury of the heart and/or great vesselsinjury of the heart and/or great vessels

Deaths delayed by hours are usually due Deaths delayed by hours are usually due to airway obstruction, tension to airway obstruction, tension pneumothorax, hemorrhage, and pneumothorax, hemorrhage, and tamponadetamponade

Note: only a small portion of patients with Note: only a small portion of patients with traumatic injuries to the chest need ORtraumatic injuries to the chest need OR

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Tissue HypoxiaTissue Hypoxia

Inadequate delivery of oxygen to tissues Inadequate delivery of oxygen to tissues can be caused by a variety of mechanismscan be caused by a variety of mechanisms

Start patient assessments with primary Start patient assessments with primary assessmentassessment

Any change in the patient condition and Any change in the patient condition and you should repeat the primary assessmentyou should repeat the primary assessment

A – B - C A – B - C

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Causes of Tissue HypoxiaCauses of Tissue Hypoxia

Hypovolemia from loss of blood volumeHypovolemia from loss of blood volume Ventilation/perfusion mismatch due to Ventilation/perfusion mismatch due to

injury of lung tissueinjury of lung tissue Compromise to ventilations and or Compromise to ventilations and or

circulation due to a tension pneumothoraxcirculation due to a tension pneumothorax Pump failure from severe myocardial injury Pump failure from severe myocardial injury

or pericardial tamponadeor pericardial tamponade

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Thoracic CageThoracic Cage

A skeletal protection to many organsA skeletal protection to many organs

LungsLungsHeartHeartGreat vesselsGreat vesselsSpinal cordSpinal cordLiverLiver

Trauma to the protective rib cage may also Trauma to the protective rib cage may also cause some injuriescause some injuries

StomachStomachSpleenSpleenPancreasPancreasKidneysKidneysTransverse colonTransverse colon

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DiaphragmDiaphragm

Position: lies at the level following the curve of Position: lies at the level following the curve of the lower 6 ribs and connected to the xyphoid the lower 6 ribs and connected to the xyphoid processprocess

Main function: respirationsMain function: respirationsDescends/flattens on inspirationDescends/flattens on inspirationRises on exhalationRises on exhalation

Innervation: phrenic nerve which begins C3 to Innervation: phrenic nerve which begins C3 to C5 levelC5 level Injury above C3 unable to breatheInjury above C3 unable to breathe Injury below C5 can still breatheInjury below C5 can still breathe

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DiaphragmDiaphragm

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Diaphragm – A Moving TargetDiaphragm – A Moving Target

Palpate and place your finger tips at the lower Palpate and place your finger tips at the lower edge of your rib cageedge of your rib cage Keep your fingers in contact with your skin Keep your fingers in contact with your skin

Take a deep breathTake a deep breath Feel your rib cage flare outFeel your rib cage flare out Diaphragm drawn downward moving lungs and Diaphragm drawn downward moving lungs and

abdominal organs downward to accommodate lung abdominal organs downward to accommodate lung expansionexpansion

Now exhale Now exhale Feel your rib cage decrease in sizeFeel your rib cage decrease in size Your diaphragm rises as lung capacity decreasesYour diaphragm rises as lung capacity decreases

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Anatomy – Chest ContentsAnatomy – Chest Contents

Contents above the diaphragmContents above the diaphragmLungsLungsLower tracheaLower tracheaMain stem bronchiMain stem bronchiHeart and great vesselsHeart and great vesselsEsophagusEsophagus

These organs sit above the diaphragmThese organs sit above the diaphragm

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Anatomy – Chest ContentsAnatomy – Chest Contents

Contents in the lower chest cavity in upper Contents in the lower chest cavity in upper abdominal regionabdominal regionStomach Stomach KidneysKidneysSpleen Spleen PancreasPancreasLiverLiver

These organs are separated from the These organs are separated from the upper chest by the diaphragmupper chest by the diaphragm

If diaphragm ruptures, abdominal organs If diaphragm ruptures, abdominal organs can migrate into chest cavitycan migrate into chest cavity

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Is the injury thoracic or Is the injury thoracic or abdominal???abdominal???

Trauma below Trauma below the nipples (T4 or the nipples (T4 or 44thth intercostal intercostal space (ICS) can space (ICS) can cause both cause both intrathoracic and intrathoracic and intra-abdominal intra-abdominal injuriesinjuries

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Did you know???Did you know???

The adult thoracic cavity can hold up to The adult thoracic cavity can hold up to 3 L of blood for each side3 L of blood for each side What is the average adult blood volume?What is the average adult blood volume?

5.5 – 6.5 liters5.5 – 6.5 liters5.5 – 6.5 quarts5.5 – 6.5 quarts

1 liter = 1 quart1 liter = 1 quartApproximately 1.3 gallonsApproximately 1.3 gallons

Formula: 0.07 x weight in kg=liters of bloodFormula: 0.07 x weight in kg=liters of blood Ex: (adult) 0.07 x 80kg = 5.6 L Ex: (adult) 0.07 x 80kg = 5.6 L Ex: (newborn) 0.07 x 3kg = 0.2 L (200ml)Ex: (newborn) 0.07 x 3kg = 0.2 L (200ml)

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Pleural SpacePleural Space

A small area between 2 layers of pleuraA small area between 2 layers of pleura Normally filled with minimal fluidNormally filled with minimal fluid

Can potentially expand if filled with air or Can potentially expand if filled with air or bloodblood

Expansion is at the sacrifice of other organs in Expansion is at the sacrifice of other organs in the areathe area

Visceral pleuraVisceral pleura Directly lines lungsDirectly lines lungs

Parietal pleuraParietal pleura Inner lining of the chest wallInner lining of the chest wall

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MediastinumMediastinum

Midline area of the thoracic cavityMidline area of the thoracic cavity ContainsContains

HeartHeartAorta and pulmonary arteryAorta and pulmonary arterySuperior and inferior vena cavasSuperior and inferior vena cavasTracheaTracheaMajor bronchiMajor bronchiEsophagusEsophagus

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Mechanisms of InjuryMechanisms of Injury

Thoracic cage injuries can result from a Thoracic cage injuries can result from a variety of sourcesvariety of sources MVCMVC Motorcycle incidentsMotorcycle incidents FallsFalls CrushCrush Blunt Blunt Penetrating – firearms, knivesPenetrating – firearms, knives

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MOIMOI

Blunt trauma Blunt trauma Injuries more predictableInjuries more predictable

Penetrating injuriesPenetrating injuries Unpredictable organ injuryUnpredictable organ injury

Path of destruction can vary widelyPath of destruction can vary widely

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Major Signs/Symptoms of Chest Major Signs/Symptoms of Chest InjuriesInjuries

Shortness of breathShortness of breath Chest painChest pain ContusionsContusions Open woundsOpen wounds Sub Q emphysemaSub Q emphysema HemoptysisHemoptysis Distended neck veinsDistended neck veins Tracheal deviationTracheal deviation

CyanosisCyanosis ShockShock TendernessTenderness InstabilityInstability CrepitationCrepitation Altered breath soundsAltered breath sounds Asymmetrical chest Asymmetrical chest

movement including movement including paradoxical motionparadoxical motion

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Patient AssessmentPatient Assessment

Start with scene size-upStart with scene size-up Perform primary assessmentPerform primary assessment

Remember: Repeat ABC assessment if there Remember: Repeat ABC assessment if there is a change in patient conditionis a change in patient condition

Move into history taking with secondary Move into history taking with secondary assessmentassessment

EMS patients rarely have just one isolated EMS patients rarely have just one isolated injury with traumatic MOIinjury with traumatic MOI Signs and symptoms blur when injuries are Signs and symptoms blur when injuries are

mixed togethermixed together

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Airway ObstructionAirway Obstruction

Results in hypoxiaResults in hypoxia Tissue insult occurs quicklyTissue insult occurs quickly Once cells die, they are goneOnce cells die, they are gone Primary assessment starts with the Primary assessment starts with the

question:question: Is the airway open and do I need to Is the airway open and do I need to

apply manual c-spine control???apply manual c-spine control??? If the airway is not open, what do I need If the airway is not open, what do I need

to do???to do???

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Opening a Blocked AirwayOpening a Blocked Airway

In traumaIn traumaModified jaw thrustModified jaw thrust

In absence of traumaIn absence of traumaHead tilt/chin liftHead tilt/chin lift

Are secretions present?Are secretions present?Limit suctioning generally to Limit suctioning generally to <<10 seconds10 seconds

Are adjuncts required?Are adjuncts required?Is there a gag reflex?Is there a gag reflex?

If necessary, stroke eyelashes to check for blink If necessary, stroke eyelashes to check for blink reflexreflex

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Airway ManeuversAirway Maneuvers

Modified jaw thrustModified jaw thrust Used in presence Used in presence

of suspected or of suspected or known traumaknown trauma

Head tilt/chin liftHead tilt/chin lift

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Interventions for Obstructed Interventions for Obstructed AirwaysAirways

Cricothyroid membrane - Need to know Cricothyroid membrane - Need to know landmarks – patient can’t waitlandmarks – patient can’t wait

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QuickTrachQuickTrach

Device sized for Device sized for adult (4.0 mm) or adult (4.0 mm) or peds (2.0 mm)peds (2.0 mm)

Kit contains items Kit contains items noted to the rightnoted to the right

Need to add skin Need to add skin prep material and prep material and BVMBVM

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Adjuncts for Obstructed AirwayAdjuncts for Obstructed Airway

QuickTrach – emergency cricothyrotomyQuickTrach – emergency cricothyrotomy 1 medic assembles equipment1 medic assembles equipment 1 medic locates and palpates cricothyroid 1 medic locates and palpates cricothyroid

membranemembrane Run finger up from sternal notchRun finger up from sternal notch Cricoid cartilage first rigid ringCricoid cartilage first rigid ring Membrane is above the cricoid cartilageMembrane is above the cricoid cartilage

Prep skinPrep skin Insert needle at 90 degree angleInsert needle at 90 degree angle Aspirate air to confirm needle entry into tracheaAspirate air to confirm needle entry into trachea

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Quicktrach cont’dQuicktrach cont’d

Change angle of insertion to 60Change angle of insertion to 6000 sliding sliding catheter sheath forward until red stopper is catheter sheath forward until red stopper is flush with skinflush with skin

Remove red stopperRemove red stopper Hold needle & syringe firmly and slide plastic Hold needle & syringe firmly and slide plastic

cannula forward til hub of catheter snug to skincannula forward til hub of catheter snug to skin Remove needle and syringeRemove needle and syringe Begin to ventilate via BVM – hold equipment Begin to ventilate via BVM – hold equipment

securelysecurely Assess for placement – BS, chest rise & fallAssess for placement – BS, chest rise & fall Secure catheter with ties providedSecure catheter with ties provided

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Needle CricothyrotomyNeedle Cricothyrotomy Provides emergency access to an Provides emergency access to an

otherwise blocked airwayotherwise blocked airway

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Needle CricothyrotomyNeedle Cricothyrotomy

Locate cricothyroid membraneLocate cricothyroid membrane Prep sitePrep site Insert large gauge catheter with syringe Insert large gauge catheter with syringe

attached into trachea – midline 45attached into trachea – midline 4500 angle angle Aspirate with syringe to confirm placementAspirate with syringe to confirm placement Advance catheter while withdrawing styletAdvance catheter while withdrawing stylet Attach 3.0 mm ETT hubAttach 3.0 mm ETT hub Ventilate with BVM via the 3.0 mm ETT hubVentilate with BVM via the 3.0 mm ETT hub Assess for BS and chest riseAssess for BS and chest rise Secure catheterSecure catheter Note: Will need to allow extra time for exhalationNote: Will need to allow extra time for exhalation

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Flail ChestFlail Chest

Fracture of 3 or more (2 or more in some Fracture of 3 or more (2 or more in some sources) adjacent ribs in 2 or more places eachsources) adjacent ribs in 2 or more places each Section becomes free floatingSection becomes free floating

Be suspicious for the presence of pulmonary Be suspicious for the presence of pulmonary contusionscontusions It takes tremendous force to break that many ribsIt takes tremendous force to break that many ribs Organs under the rib cage most likely traumatizedOrgans under the rib cage most likely traumatized Compromise to normal diffusion of OCompromise to normal diffusion of O22 and CO and CO2 2 is is

usually presentusually present

Flail chest does NOT automatically equal the Flail chest does NOT automatically equal the presence of a tension pneumothoraxpresence of a tension pneumothorax

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Can be suspicious of condition during the Can be suspicious of condition during the primary assessmentprimary assessment Patient states “I can’t breathe”Patient states “I can’t breathe” The rib fractures cause significant pain as the The rib fractures cause significant pain as the

patient tries to take any breathspatient tries to take any breaths Patient is anxiousPatient is anxious May see paradoxical motion on visual May see paradoxical motion on visual

inspectioninspectionThis is often a later sign due to initial This is often a later sign due to initial

splintingsplinting

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Flail Chest and Primary Flail Chest and Primary AssessmentAssessment

DO NOT stop your primary assessmentDO NOT stop your primary assessment Just make note to go back to address why Just make note to go back to address why

there is respiratory distressthere is respiratory distress

Remember: the only 2 times to interrupt Remember: the only 2 times to interrupt YOUR primary assessment is to correct YOUR primary assessment is to correct an obstructed/closed airway or to control an obstructed/closed airway or to control major hemorrhagemajor hemorrhage

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Tremendous force Tremendous force to fracture this to fracture this many ribsmany ribs

Notice how lateral Notice how lateral the clavicular the clavicular midline really is!!!midline really is!!!

Landmark essential Landmark essential IFIF patient develops patient develops a tension a tension pneumothoraxpneumothorax

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Flail Chest Key Signs /SymptomsFlail Chest Key Signs /Symptoms

Paradoxical motion on visual inspectionParadoxical motion on visual inspection Potential bruising or other marks on chest Potential bruising or other marks on chest

wallwall Crepitation and tenderness on palpationCrepitation and tenderness on palpation Decreased breath sound depending on Decreased breath sound depending on

degree of injury, splinting and presence of degree of injury, splinting and presence of pneumothoraxpneumothorax

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Flail Chest TreatmentFlail Chest Treatment

Supplemental oxygen therapySupplemental oxygen therapy Non-rebreather ONon-rebreather O22 if intubation not needed if intubation not needed

Cardiac monitoringCardiac monitoring Potential high for cardiac contusionPotential high for cardiac contusion

Stabilizing the chest wall is controversialStabilizing the chest wall is controversial Do not tape the chest wallDo not tape the chest wall Providing positive pressure ventilation (i.e.: Providing positive pressure ventilation (i.e.:

intubation on a ventilator) is the preferred intubation on a ventilator) is the preferred method of support which can be done in the method of support which can be done in the ED if not necessary in the field)ED if not necessary in the field)

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Open/Sucking Chest WoundOpen/Sucking Chest Wound

Air allowed to enter the thoracic space due Air allowed to enter the thoracic space due to an opening in the chest wallto an opening in the chest wall

Results from penetrating trauma Results from penetrating trauma Air drawn into pleural spaceAir drawn into pleural space Air will enter via the largest openingAir will enter via the largest opening

The hole created in the chest wall versus the The hole created in the chest wall versus the glottic openingglottic opening

Air entering the pleural space does not reach Air entering the pleural space does not reach the alveolithe alveoli

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Visual inspection reveals the woundVisual inspection reveals the wound May hear a sucking or bubbling soundMay hear a sucking or bubbling sound May feel subcutaneous emphysema May feel subcutaneous emphysema

around the areaaround the area Lightly palpate the area and feel a crackling Lightly palpate the area and feel a crackling

sensation under your finger tipssensation under your finger tips Noticed skin “puffed up”Noticed skin “puffed up”

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Immediate treatment as soon as the Immediate treatment as soon as the wound is found is to cover the wound with wound is found is to cover the wound with a gloved handa gloved hand

Then place an occlusive dressing over the Then place an occlusive dressing over the sitesite

Secure occlusive dressing on 3 sides Secure occlusive dressing on 3 sides Leaves a means of escape of air on the 4Leaves a means of escape of air on the 4 thth

side to avoid the potential of converting the side to avoid the potential of converting the injury to a tension pneumothoraxinjury to a tension pneumothorax

If wound is large, try defib pad over woundIf wound is large, try defib pad over wound

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QuestionQuestion If the patient develops a tension If the patient develops a tension

pneumothorax after the sucking chest wound pneumothorax after the sucking chest wound is sealed with an occlusive dressing, do you is sealed with an occlusive dressing, do you need to perform a needle decompression?need to perform a needle decompression?

NO!!! – not usuallyNO!!! – not usually There is already a BIG hole in the chest wall that There is already a BIG hole in the chest wall that

air can escape fromair can escape from Just lift a corner of the dressing during exhalation Just lift a corner of the dressing during exhalation

for air to escapefor air to escape If there is no improvement, you might have to If there is no improvement, you might have to

decompress with a needledecompress with a needle

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You Evaluate…You Evaluate…

What’s right?What’s right? Wound immediately Wound immediately

covered with handcovered with hand

What’s wrong?What’s wrong? The care provider has no The care provider has no

gloves ongloves on

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Tension PneumothoraxTension Pneumothorax

A pneumothorax that generates and A pneumothorax that generates and maintains pressures greater than maintains pressures greater than atmospheric pressure in the thoraxatmospheric pressure in the thorax A one way valve is created and air flows into A one way valve is created and air flows into

the pleural space and cannot escapethe pleural space and cannot escape Most often associated with a traumatic Most often associated with a traumatic

event but can be spontaneousevent but can be spontaneous Can be a complication of treatment of an Can be a complication of treatment of an

open/sucking chest woundopen/sucking chest wound

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Tension Pneumothorax – Tension Pneumothorax – A Cascade of EventsA Cascade of Events

Air enters pleural spaceAir enters pleural space intrapleural pressure collapses lung, intercostal intrapleural pressure collapses lung, intercostal

bulging occurs, pressure exerted against bulging occurs, pressure exerted against mediastinummediastinum

Uninjured lung becomes compressedUninjured lung becomes compressed Vena cava compression Vena cava compression venous return venous return Cardiac output (CO) Cardiac output (CO) causing causing pulse; pulse; B/P B/P JVD present, narrowed pulse pressureJVD present, narrowed pulse pressure Tracheal shift is a Tracheal shift is a latelate but but rarerare sign (hard to view) sign (hard to view)

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X-ray - Tension PneumothoraxX-ray - Tension Pneumothorax

What’s wrong with this What’s wrong with this x-ray?x-ray? It should never have It should never have

been taken!been taken! Diagnosis is clinicalDiagnosis is clinical Arrow points to Arrow points to

completely collapsed completely collapsed lunglung

Dark filled images Dark filled images indicate air filled indicate air filled spacesspaces

Note tracheal shift to Note tracheal shift to the rightthe right

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Tension PneumothoraxTension Pneumothorax Typical signs and symptomsTypical signs and symptoms

Severe dyspneaSevere dyspnea Hyperinflation of affected sideHyperinflation of affected side Diminished, then absent breath soundDiminished, then absent breath sound Hyperresonance of affected sideHyperresonance of affected side DiaphoresisDiaphoresis CyanosisCyanosis JVDJVD TachycardiaTachycardia Altered mental statusAltered mental status Eventual hypotensionEventual hypotension

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Simple Simple PneumothoraxPneumothorax

There is a differenceThere is a difference These patient DO NOT require needle These patient DO NOT require needle

decompressiondecompression May not even auscultate decreased breath May not even auscultate decreased breath

sounds if collapse is smallsounds if collapse is small There is a clinical difference in There is a clinical difference in

presentation (i.e.: vital signs) from a presentation (i.e.: vital signs) from a simple to a tension pneumothoraxsimple to a tension pneumothorax

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Jugular Vein Distention - JVDJugular Vein Distention - JVD

JVD present when venous pressures are high JVD present when venous pressures are high and blood cannot easily drain into the right and blood cannot easily drain into the right atriumatrium Typically seen with tension pneumothorax,, cardiac Typically seen with tension pneumothorax,, cardiac

tamponade, right sided heart failure and volume tamponade, right sided heart failure and volume overloadoverload

Most appropriately measured with patient sitting Most appropriately measured with patient sitting at 45at 4500 angle and evaluating right side of neck angle and evaluating right side of neck May not be possible with traumatic injuryMay not be possible with traumatic injury

Note: Lack of JVD in supine position with Note: Lack of JVD in supine position with physical findings may indicate hypovolemic physical findings may indicate hypovolemic shockshock

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JVDJVD Jugular vein is prominent if distended at a Jugular vein is prominent if distended at a

point slightly higher than 1 inch above right point slightly higher than 1 inch above right clavicleclavicle

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Tension Pneumothorax TreatmentTension Pneumothorax Treatment

Rapid recognition is key!!!Rapid recognition is key!!! Severe dyspneaSevere dyspnea Distinct signs and symptomsDistinct signs and symptoms

Needle decompression to relieve Needle decompression to relieve intrapleural pressuresintrapleural pressures Administer supplemental OAdminister supplemental O22 via NRB via NRB

EquipmentEquipment Longest and largest needle you have – 3 Longest and largest needle you have – 3 inch inch

long and 12-14 gaugelong and 12-14 gauge Skin prep materialSkin prep material

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Needle Decompression LandmarksNeedle Decompression Landmarks

Finding Finding the Angle the Angle of Louis is of Louis is an easier an easier landmark landmark than than counting counting down rib down rib spacesspaces

Angle of Louis

2nd ICS

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Tension Pneumothorax TreatmentTension Pneumothorax Treatment

Needle decompressionNeedle decompression Identify 2Identify 2ndnd intercostal space (ICS) intercostal space (ICS)

Find Angle of LouisFind Angle of Louis Hang a Louis and slide into the 2Hang a Louis and slide into the 2ndnd ICS ICS From Angle of Louis, slide finger tips From Angle of Louis, slide finger tips

toward armpit crease toward armpit crease ORORPalpate down from MIDDLE of clavicle to Palpate down from MIDDLE of clavicle to

22ndnd ICS ICS Middle of clavicle more lateral than most Middle of clavicle more lateral than most

people identify; is male nipple linepeople identify; is male nipple line Insert needle over top of ribInsert needle over top of rib

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Landmarks for Needle DecompressionLandmarks for Needle Decompression

If needle placed too low and too close to sternum, tip may

end up placed in the heart

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Needle DecompressionNeedle Decompression

Goal of needle decompression:Goal of needle decompression: Provide a relief valve for air under tensionProvide a relief valve for air under tension

Do NOT need to make a flutter valveDo NOT need to make a flutter valve Air will enter the path of least resistance Air will enter the path of least resistance

(i.e.: the larger pathway)(i.e.: the larger pathway) Diameter of trachea larger than a 14 G needle Diameter of trachea larger than a 14 G needle

so air will enter via trachea into the lungs and so air will enter via trachea into the lungs and not through a 14G needle into the pleural not through a 14G needle into the pleural spacespace

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You Evaluate…You Evaluate…

What’s wrong?What’s wrong? Too low, tip may be Too low, tip may be

in the heartin the heart

Needle should have Needle should have been herebeen here

What’s right?What’s right? Catheter securedCatheter secured

X

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Pericardial/Cardiac TamponadePericardial/Cardiac Tamponade

Blood or fluid fills the pericardial sac Blood or fluid fills the pericardial sac surrounding the heartsurrounding the heart Sac does not expand but compresses into the Sac does not expand but compresses into the

heart limiting flow into the heartheart limiting flow into the heart

Penetrating trauma most frequent MOIPenetrating trauma most frequent MOI High mortality rate due to potential for High mortality rate due to potential for

rapid hemorrhagerapid hemorrhage

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Pericardial/Cardiac TamponadePericardial/Cardiac Tamponade AgitationAgitation TachycardiaTachycardia DiaphoreticDiaphoretic pulse strength & ratepulse strength & rate Muffled heart tonesMuffled heart tones Beck’s triad (next slide)Beck’s triad (next slide) Pulsus paradoxusPulsus paradoxus

Systolic B/P drops by 10 mmHg on inspirationSystolic B/P drops by 10 mmHg on inspiration Pulsus alternansPulsus alternans

Alteration between strong and weak pulsesAlteration between strong and weak pulses PEAPEA

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Beck’s TriadBeck’s Triad

Indicative of pericardial tamponade Indicative of pericardial tamponade (IF present)(IF present) This may be a LATE sign!This may be a LATE sign!

A grouping of 3 clinical signs A grouping of 3 clinical signs JVDJVDMuffled/distant heart tonesMuffled/distant heart tonesHypotensionHypotension

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Pericardial/Cardiac TamponadePericardial/Cardiac Tamponade

It takes as little as 150-300 ml to exert pressure It takes as little as 150-300 ml to exert pressure to impede contractile function on the heartto impede contractile function on the heart Removing as little as 20 ml may improve the Removing as little as 20 ml may improve the

contractile force to improve the patient’s conditioncontractile force to improve the patient’s condition

EMS goal: EMS goal: RAPIDRAPID IDENTIFICATIONIDENTIFICATION Then rapid transportThen rapid transport

There won’t be much intervention in the field There won’t be much intervention in the field that will save the patient’s life; they need that will save the patient’s life; they need transporttransport

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Aortic TearAortic Tear

Most commonly from blunt traumaMost commonly from blunt trauma MOI usually high speed MVC - especially MOI usually high speed MVC - especially

lateral impact - and falls from great heightslateral impact - and falls from great heights

High mortality rate – 85 - 95%High mortality rate – 85 - 95% GOAL:GOAL:

Rapid recognition of those patients that Rapid recognition of those patients that survive the initial impactsurvive the initial impact

Provide rapid and gentle transportation to a Provide rapid and gentle transportation to a Level I trauma center (Level I trauma center ( if within 25 minutes of if within 25 minutes of transport)transport)

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Aorta fixed at 3 points in the thoracic Aorta fixed at 3 points in the thoracic cavitycavity

Shearing forces can separate the arterial Shearing forces can separate the arterial layers of this large, high-pressured vessellayers of this large, high-pressured vessel Due to high pressures, aortic lining becomes Due to high pressures, aortic lining becomes

a false spacea false space Rupture can occur without surgical repairRupture can occur without surgical repair

Death from rupture is usually quick; Death from rupture is usually quick; dissection progresses more slowlydissection progresses more slowly

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Most commonly tear Most commonly tear just past the arch of just past the arch of the aortathe aorta

Less often at aortic Less often at aortic root (annulus) where root (annulus) where the aorta joins the the aorta joins the heart and the area heart and the area where aorta exits the where aorta exits the chest at the chest at the diaphragmdiaphragm

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Typically patient complains of a severe Typically patient complains of a severe tearing chest paintearing chest pain

Pain may radiate to the backPain may radiate to the back Reduced pulse strength in lower extremitiesReduced pulse strength in lower extremities

Mark pulse spots if palpatedMark pulse spots if palpated

Pulse deficit between left & right upper Pulse deficit between left & right upper extremitiesextremities If suspected, palpate to compare both radial If suspected, palpate to compare both radial

pulsespulses

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NEW!!! Permissive Hypotension in NEW!!! Permissive Hypotension in TraumaTrauma

Restrictive fluid therapyRestrictive fluid therapy At least until hemorrhage is controlledAt least until hemorrhage is controlled Highly suggested for aortic problemsHighly suggested for aortic problems Not recommended in the patient without a pulseNot recommended in the patient without a pulse

Aggressive fluid replacement tends to increase Aggressive fluid replacement tends to increase total volume of blood losstotal volume of blood loss

Call Medical Control for guidelines if you feel Call Medical Control for guidelines if you feel your patient may benefit from restricted fluid your patient may benefit from restricted fluid resuscitationresuscitation May order trendelenberg positioningMay order trendelenberg positioning

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Region X SOP’s - Fluid ChallengeRegion X SOP’s - Fluid Challenge

Fluid given in 200 ml INCREMENTSFluid given in 200 ml INCREMENTS You assess as you goYou assess as you go For medical calls patient more likely will tolerate and For medical calls patient more likely will tolerate and

need the 20 ml/kg replacement formulaneed the 20 ml/kg replacement formula Every body holds a different amount of blood Every body holds a different amount of blood

volumevolume Adult average 5.2 – 6 liters (5.5 – 6.5 quarts or 10-12 Adult average 5.2 – 6 liters (5.5 – 6.5 quarts or 10-12

pints)pints) Average blood donation is 450 ml or less than 1 Average blood donation is 450 ml or less than 1

pintpint Child average 2 litersChild average 2 liters Infant average is 85 ml/kg or <300 mlInfant average is 85 ml/kg or <300 ml

6666

Blood Volume by AgeBlood Volume by Age

Do not judge the volume you see lying in Do not judge the volume you see lying in the street until you know whose blood it isthe street until you know whose blood it is

6767

How Low Can You Go?How Low Can You Go?

Classes of shockClasses of shock Class I - <15% (<750 in the adult)Class I - <15% (<750 in the adult) Class II – 15-30% (750 – 1500ml in the adult)Class II – 15-30% (750 – 1500ml in the adult) Class III – 30-40% (1500-2000ml in the adult)Class III – 30-40% (1500-2000ml in the adult) Class IV - >40% (>2000ml in the adult)Class IV - >40% (>2000ml in the adult)

Compensated shock in Class I & IICompensated shock in Class I & II Decompensated shock by Class IIIDecompensated shock by Class III

Blood pressure falling is the keyBlood pressure falling is the key Blood pressure falling is also a Blood pressure falling is also a LATELATE sign sign

6868

Complications Related to Traumatic Complications Related to Traumatic InjuriesInjuries

EMS goal – Do no further harmEMS goal – Do no further harm Sometimes, doing our best just isn’t Sometimes, doing our best just isn’t

enoughenough Secondary injuries may develop based on Secondary injuries may develop based on

what we do or don’t do at first patient what we do or don’t do at first patient contactcontact

It’s simple – do the right thing at the right It’s simple – do the right thing at the right time and document accuratelytime and document accurately

6969

Complications: Crush InjuriesComplications: Crush Injuries

Traumatic insults of severe compressive Traumatic insults of severe compressive forcesforces Crush injury – an injury compressing a body partCrush injury – an injury compressing a body part

If short duration, local injury confined to injured partIf short duration, local injury confined to injured part

Crush syndrome – systemic effects of Crush syndrome – systemic effects of entrapment for longer than 4 hoursentrapment for longer than 4 hours A potentially life-threatening eventA potentially life-threatening event Limitation of effective & healthy circulationLimitation of effective & healthy circulation

Think cave-in’s, equipment entrapmentThink cave-in’s, equipment entrapment

7070

Crush SyndromeCrush Syndrome

Pressure remains imposed for long period Pressure remains imposed for long period of time (usually >4 hours)of time (usually >4 hours)

Traumatic rhabdomyolysis developsTraumatic rhabdomyolysis develops Crushed skeletal muscle disintegratesCrushed skeletal muscle disintegrates Release of metabolic by-products restricted to Release of metabolic by-products restricted to

the compressed area for as long as area the compressed area for as long as area remains compressedremains compressed Myoglobin – a muscle proteinMyoglobin – a muscle protein Phosphate & potassium (KPhosphate & potassium (K++) – from cell death) – from cell death Lactic acid – from anaerobic metabolismLactic acid – from anaerobic metabolism

7171

Crush SyndromeCrush Syndrome

When pressure released, metabolic When pressure released, metabolic by-products enter the central circulationby-products enter the central circulation

Cause severe metabolic acidosisCause severe metabolic acidosis Toxic to heart and kidneysToxic to heart and kidneys Myoglobin plugs kidney’s filtering systemMyoglobin plugs kidney’s filtering system Sodium, chloride and water flood into Sodium, chloride and water flood into

damaged tissue creating hypovolemiadamaged tissue creating hypovolemia Hyperkalemia reduces cardiac muscle Hyperkalemia reduces cardiac muscle

response to electrical stimuli response to electrical stimuli dysrhythmias dysrhythmias Aerobic process resumed producing more uric Aerobic process resumed producing more uric

acid increasing cellular acidity and injuryacid increasing cellular acidity and injury

7272

EMS Care of Crush InjuriesEMS Care of Crush Injuries Identify the potential patient prior to Identify the potential patient prior to

extricationextrication Scene safety is your fist priorityScene safety is your fist priority Goal of EMS:Goal of EMS:

Rapid transportRapid transport Adequate fluid resuscitationAdequate fluid resuscitation Diuresis – keep kidneys flushed and workingDiuresis – keep kidneys flushed and working Possibly systemic alkalinization Possibly systemic alkalinization

Corrects acidosis, hyperkalemia, prevents renal failureCorrects acidosis, hyperkalemia, prevents renal failure Hospital may need to send a team with meds like Hospital may need to send a team with meds like

sodium bicarbonate sodium bicarbonate

7373

EMS Care cont’dEMS Care cont’d

Cardiac monitoringCardiac monitoring Influence of potassium and lactate traveling to Influence of potassium and lactate traveling to

heart may cause dysrhythmiasheart may cause dysrhythmias Tenting or peaking of T waveTenting or peaking of T wave Prolonged PR intervalProlonged PR interval ST segment depressionST segment depression Widening QRS (high levels of KWidening QRS (high levels of K++))

NoteNote:: Apply the cardiac monitor prior to Apply the cardiac monitor prior to releasing the crushed area from entrapmentreleasing the crushed area from entrapment

Be prepared for rapid onset of shock after Be prepared for rapid onset of shock after release from entrapmentrelease from entrapment

7474

Tall, Peaked T waveTall, Peaked T wave Indicates excess potassium circulating in Indicates excess potassium circulating in

the bloodstreamthe bloodstream Normal potassium levels 3.5 – 5 meq/LNormal potassium levels 3.5 – 5 meq/L

Hyperkalemia (>5.5 meq/L) is a cardiac irritantHyperkalemia (>5.5 meq/L) is a cardiac irritant

7575

Compartment SyndromeCompartment Syndrome

Complication most commonly associated with Complication most commonly associated with closed injuries to the extremitiesclosed injuries to the extremitiesThink of the patient who has fallen and is in Think of the patient who has fallen and is in

one position for a period of time before a well-one position for a period of time before a well-being check finds thembeing check finds them

Major muscle groups contained in compartmentsMajor muscle groups contained in compartments Swelling of muscles will impede blood flow to Swelling of muscles will impede blood flow to

nerves, blood vessels and other structuresnerves, blood vessels and other structures Most common site are lower extremitiesMost common site are lower extremities

7676


Six P’sSix P’s Pain out of proportion – key finding!!!Pain out of proportion – key finding!!! PallorPallor ParalysisParalysis Paresthesia – pins & needles tinglingParesthesia – pins & needles tingling Pressure – feeling tension in extremityPressure – feeling tension in extremity Pulses – diminished or absentPulses – diminished or absent

Signs & symptoms not dependableSigns & symptoms not dependable

7777


Difficult to assessDifficult to assess Motor and sensory usually intactMotor and sensory usually intact Distal pulses often presentDistal pulses often present Capillary refill with little to no changeCapillary refill with little to no change

More likely to develop beyond 6-8 hours More likely to develop beyond 6-8 hours post-injury or even laterpost-injury or even later

Key: patient complaining of pain out of Key: patient complaining of pain out of proportionproportion Don’t assume they are a wimpDon’t assume they are a wimp

7878

EMS Care of Compartment EMS Care of Compartment SyndromeSyndrome

Maintain high index of suspicionMaintain high index of suspicion Elevation single most important tool for EMSElevation single most important tool for EMS

Reduces edemaReduces edema Increases venous returnIncreases venous return Lowers compartment pressureLowers compartment pressure Helps prevent ischemia Helps prevent ischemia

Cold pack applied to severe contusionsCold pack applied to severe contusions Hospital care includes measuring pressuresHospital care includes measuring pressures

Normal pressure near zeroNormal pressure near zero Pressure >30mmHg restricts capillary flowPressure >30mmHg restricts capillary flow

Irreversible ischemic changes after 10 hoursIrreversible ischemic changes after 10 hours

7979

Hospital Intervention Compartment Hospital Intervention Compartment SyndromeSyndrome

Fasciotomy is surgical intervention to open Fasciotomy is surgical intervention to open fascia to allow for swelling without restrictive fascia to allow for swelling without restrictive pressurespressures

When pressures go down, patient taken back When pressures go down, patient taken back to surgery to close the wound left opento surgery to close the wound left open

8080

Transport CriteriaTransport Criteria Highest level Trauma Center within 25 minutesHighest level Trauma Center within 25 minutes

Unstable per vital signsUnstable per vital signs Anatomy of injury – life threatening injuryAnatomy of injury – life threatening injury

Closest Trauma CenterClosest Trauma Center Based on mechanism of injury with higher potential for Based on mechanism of injury with higher potential for

traumatic injury or traumatic arresttraumatic injury or traumatic arrest Patient is stablePatient is stable Patient may have co-morbidity increasing their risk level Patient may have co-morbidity increasing their risk level

with the insultwith the insult

Closest appropriate comprehensive EDClosest appropriate comprehensive ED Do not meet any of the above criteria or Ems unable to Do not meet any of the above criteria or Ems unable to

establish an airway establish an airway

8181

Case ScenariosCase Scenarios

Discuss the following casesDiscuss the following cases What is your general impression?What is your general impression? Discuss the primary assessmentDiscuss the primary assessment

Have you identified a life threatening Have you identified a life threatening condition?condition?

What is your intervention and when do you What is your intervention and when do you perform it?perform it?

Where does this patient get transported to?Where does this patient get transported to?

8282

Case Scenario #1Case Scenario #1

Respond to a call for Respond to a call for MVC – 2 vehiclesMVC – 2 vehicles

Your patient is a 16 y/o Your patient is a 16 y/o female restrained female restrained driver hit head-on driver hit head-on approximately 45 mph approximately 45 mph by a Suburbanby a Suburban

This is what you see This is what you see as you approach the as you approach the scenescene

8383


+ seatbelt+ seatbelt Airbag deployedAirbag deployed Small staring at base of windshieldSmall staring at base of windshield Driver’s side window shattered; unable to Driver’s side window shattered; unable to

open dooropen door A & O x3; hystericalA & O x3; hysterical Active bleeding from noseActive bleeding from nose Multiple lacerations to face and extremitiesMultiple lacerations to face and extremities

8484


Primary assessmentPrimary assessment Mental – Patient awake, A & O x3, hystericalMental – Patient awake, A & O x3, hysterical Airway – openAirway – open C-spine – manual control takenC-spine – manual control taken Breathing – rapid, without effortBreathing – rapid, without effort Circulation – bleeding from nose; pulse rapid and Circulation – bleeding from nose; pulse rapid and

regularregular

Life threats identified?Life threats identified? NoneNone So keep moving on the survey and keep looking for So keep moving on the survey and keep looking for

injuriesinjuries

8585


If this patient had chest injuries, what clues If this patient had chest injuries, what clues would indicate:would indicate: Flail chestFlail chest

Multiple rib fractures found on palpationMultiple rib fractures found on palpation Pain with breathingPain with breathing

PneumothoraxPneumothorax Pain with breathingPain with breathing Decreased or absent breath soundsDecreased or absent breath sounds

Tension pneumothoraxTension pneumothorax Agitation, tachycardia, hypotension, absent BSAgitation, tachycardia, hypotension, absent BS

8686

Case Scenario #1 – EMS Care – Case Scenario #1 – EMS Care – What Would You Do?What Would You Do?

Flail chestFlail chest Supplemental OSupplemental O22

BVM for positive pressure ventilation if severeBVM for positive pressure ventilation if severe PneumothoraxPneumothorax

Supplemental OSupplemental O22

Watch for development tension pneumothoraxWatch for development tension pneumothorax Tension pneumothoraxTension pneumothorax

Needle decompression 2Needle decompression 2ndnd ICS ICS Place needle above the ribPlace needle above the rib

Avoid nerves and blood vesselsAvoid nerves and blood vessels

8787

Scenario #2Scenario #2

EMS has been called to the scene of a EMS has been called to the scene of a MVCMVC No witnessesNo witnesses Passer-by noticed MVC and called it inPasser-by noticed MVC and called it in

Patient has an altered level of Patient has an altered level of consciousnessconsciousness

What’s your primary assessment?What’s your primary assessment? Mental statusMental status ABC’s with c-spineABC’s with c-spine Identification of life threatsIdentification of life threats

8888


The scene is safeThe scene is safe Your patient is in Your patient is in

the red carthe red car They are looking They are looking

around upon your around upon your arrivalarrival

They do not follow They do not follow commandcommand

They are confusedThey are confused You take charge of the c-spineYou take charge of the c-spine

8989


Patient is wearing a seat beltPatient is wearing a seat belt Witnesses state the patient did not slow down Witnesses state the patient did not slow down

but just ran into the car in front of thembut just ran into the car in front of them

Airway – openAirway – open Breathing – rapid, regularBreathing – rapid, regular Circulation – clammy, pale, pulse regular Circulation – clammy, pale, pulse regular

and fastand fast No obvious bleedingNo obvious bleeding

9090


No life threats are foundNo life threats are found Why would the patient be confused???Why would the patient be confused???

Head injuryHead injury Alcohol, drugsAlcohol, drugs HypoglycemiaHypoglycemia

Blood sugar checked – 35Blood sugar checked – 35

Treatment indicated?Treatment indicated? Gain IV accessGain IV access Administer D50Administer D50

9191


IV infiltrates while pushing D50IV infiltrates while pushing D50 Now what???Now what???

Stop infusionStop infusion D/C lineD/C line Document eventDocument event Verbally give report to EDVerbally give report to ED

9292

Extravasation of IVP DextroseExtravasation of IVP Dextrose

Carefully monitor the site as you push any Carefully monitor the site as you push any medicationmedication

9393


Female driver in small car had tree fall on Female driver in small car had tree fall on her car during a rain stormher car during a rain storm

Patient impaled with branch of treePatient impaled with branch of tree Are these chest or abdominal wounds?Are these chest or abdominal wounds?

Could be both Could be both depending on depending on inhalation or inhalation or exhalation at time of exhalation at time of injury and path of FBinjury and path of FB

9494


How do you care for the open wound in How do you care for the open wound in the field?the field? Moist sterile saline dressing over the open Moist sterile saline dressing over the open

tissuetissue Covered with dry Covered with dry

dressingsdressings Avoid poking anything Avoid poking anything

into the woundinto the wound Observe for Observe for

eviscerationevisceration

9595

Case Scenario #3 – Pain Case Scenario #3 – Pain ManagementManagement

Fentanyl 0.5 mcg/kg IVP/IN/IOFentanyl 0.5 mcg/kg IVP/IN/IO May repeat in 5 minutes with same doseMay repeat in 5 minutes with same dose Max total 200 mcgMax total 200 mcg

Same formula for adult and pedsSame formula for adult and peds Less cardiovascular changes than Less cardiovascular changes than

morphinemorphine Less nausea from the medicationLess nausea from the medication As a synthetic narcotic, watch for As a synthetic narcotic, watch for

respiratory depressionrespiratory depression

9696


Tree branch removed from patientTree branch removed from patient

9797

Case Scenario Case Scenario #4#4

Patient fell onto Patient fell onto bicyclebicycle

Patient agitated, Patient agitated, complains of inability to breathcomplains of inability to breath

Patient is dyspneic, tachycardiac, Patient is dyspneic, tachycardiac, becoming cyanotic, with JVD increasingbecoming cyanotic, with JVD increasing

Blood pressure falling (radial pulse harder Blood pressure falling (radial pulse harder to palpate)to palpate)

What’s your impression?What’s your impression? Tension pneumothorax Tension pneumothorax

9898


What intervention is necessary?What intervention is necessary? Immediate needle decompressionImmediate needle decompression

What are the landmarks?What are the landmarks? 22ndnd ICS ICS Midclavicular lineMidclavicular line

Stay more lateral than you thinkStay more lateral than you think

9999


22ndnd ICS, midclavicular ICS, midclavicular line – “X” marks the line – “X” marks the spotspot

When needle When needle inserted, listen for inserted, listen for hiss of released airhiss of released air

Should have Should have immediate immediate improvement in improvement in patientpatient

X

100100

Steps for Needle Steps for Needle DecompressionDecompression

Find the Angle of LouisFind the Angle of Louis Slide your fingers toward the Slide your fingers toward the

armpit creasearmpit crease Stop at the midpoint of the Stop at the midpoint of the

clavicleclavicle This is in-line (vertical) with the male nippleThis is in-line (vertical) with the male nipple The male nipple horizontally lies in the 4The male nipple horizontally lies in the 4 thth ICS ICS

Insert needle above the rib, advance and Insert needle above the rib, advance and begin to separate needle from catheterbegin to separate needle from catheter

Secure in placeSecure in place

101101


Needle inserted above the rib Needle inserted above the rib Avoids puncturing the vessels or nervesAvoids puncturing the vessels or nerves

102102

BibliographyBibliography

Region X Advanced Life Support Standard Operating Region X Advanced Life Support Standard Operating Procedures February 1, 2012Procedures February 1, 2012

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Fourth Edition. Brady. 2013.Principles & Practices Fourth Edition. Brady. 2013.

Campbell, J. International Trauma Life Support for Campbell, J. International Trauma Life Support for Emergency Care Providers. 7Emergency Care Providers. 7thth edition. Pearson. 2012. edition. Pearson. 2012.

Caroline, N., Emergency Care in the Streets. 7Caroline, N., Emergency Care in the Streets. 7thth Edition. Edition. AAOS. 2013.AAOS. 2013.

Limmer, D., O’Keefe, M. Emergency Care 12Limmer, D., O’Keefe, M. Emergency Care 12thth Edition. Edition. Brady. 2012.Brady. 2012.

http://en.wikipedia.org/wiki/Beck's_triad_(cardiology)http://en.wikipedia.org/wiki/Beck's_triad_(cardiology) http://docpods.com/compartment-syndrome-in-the-lower-http://docpods.com/compartment-syndrome-in-the-lower-

legleg

Documents

1 Trauma Morbidity and Mortality September 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P