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TOPIC
NeonatologyNeonatology
56
Objectives
• Identify incidence and morbidity/mortality in neonatal complications.
• Review leading causes of death in the <1 year bracket.
• Discuss the assessment format and interventions for a newborn child.
• Review a mnemonic to assist the paramedic in remembering steps and interventions on a neonate.
Introduction
• In utero, the fetus is totally dependent on the mother for survival.
• Once born, the neonate now needs to rely on his own body processes for survival.
• Many times, there are congenital or acquired anomalies that disturb the body's processes.
Epidemiology
• 2 percent to 5 percent of all live births have some type of congenital anomalies.
• 20 percent to 30 percent of perinatal deaths are the result of congenital anomalies.
Epidemiology
• 10 percent of births will need some medical help at birth to begin life.
• 1 percent will need aggressive resuscitation to survive the neonatal period.
Terminology
• Review of terminology related to newborns– Fetal or in utero– Gestational period– Premature– Term– Late term– Perinatal– Infancy
Transitioning
• Review the anatomic and physiologic changes from in utero to the extrauterine environment.
• The lungs must open and allow gas to be exchanged for the first time.
• Discuss how meconium aspiration, structural defects, and infection can affect the neonate.
ABCs ABCs “In That Order, Every “In That Order, Every Time”Time”
• Airway– Anatomical differences make positive
pressure ventilation challenging.– Do not place pressure on the trachea.– The insertion of an oropharyngeal
airway or a nasopharyngeal airway may help control the airway.
– The use of a bag-valve-mask does not require much force or strength.
To provide positive pressure ventilation, use a bag-valve mask. Maintain a good mask seal. Ventilate with just enough force to raise the infant’s chest.
Ventilate at a rate of 40–60 per minute for 30 seconds, then reassess
Pathophysiology
• Breathing– Rate of 40–60 per minute.• 30–40 for older neonate.
Pathophysiology
• Breathing– Tidal volumes• 15–25 mL for a newborn.• 25–50 for a neonate up to 1 month of age.• “Just enough to move the chest.”
– Use a manometer to keep airway pressure <30 cmH2O.
Pathophysiology
• Breathing– If adequate:• Rapid improvement in color and perfusion
will occur.• Heart rate will normalize.• Spontaneous respirations may return.• Use a blended mix of oxygen to achieve a
desired pulse oximetry level.
Pathophysiology
• Careful and efficient basic airway management is preferred over advanced techniques.
• Meconium aspiration should only be performed to distressed babies.
• Review the 2010 AHA Guidelines for achieving the desired SpO2 levels.
Pathophysiology
• Circulation– If persistently bradycardic (<60 bpm),
signs of poor perfusion after 1 minute of BVM with oxygen, start compressions.
– “Thumb technique” is recommended.– Compression: Breath ratio 3:1
To provide chest compressions, circle the torso with the fingers and place both thumbs on the lower third of the infant’s sternum. If the
infant is very small, you may need to overlap the thumbs. If the infant is very large, compress the sternum with the ring and middle
fingers placed one finger’s depth below the nipple line. In the newborn, compress the chest one-third the depth of the chest at the
rate of 120 per minute and a ratio of 3:1 compressions to ventilations.
Pathophysiology
• Circulation• Obtain intravenous access– Can be challenging.– Use intraosseous if needed.
• Consider 1:10,000 epinephrine if heart rate does not increase.
• Determination of poor perfusion
What is after ABC? DEFGWhat is after ABC? DEFG“Don't Ever Forget Glucose”“Don't Ever Forget Glucose”• Fuel stores in infants are quickly
exhausted.– Coordinating feeding and breathing is
exercise enough for a sick infant.– Ascertain feeding and sleeping patterns.– Always access a blood glucose level.– Glucose (D10W) administration in the
neonate. – 5-10ml/kg iv over 20 min.
H is for Hypothermia
• Hypothermia– Environmental temperature is important– The best resuscitation efforts will fail on
a cold neonate.– If the temperature in the back of the
ambulance is comfortable for you, then it is too cold for the neonate.
I is for Infection
• Infection–Major killer of neonates– ANY of the following requires physician
evaluation:• ANY history of fever, cyanosis, apnea, rapid
or shallow breathing.• ANY history of poor feeding, decreased urine
output, or vomiting.• ANY blood in stool, urine, or emesis.• ANY rash beyond “baby acne.”
Safe Transport of the Infant
• Transport in parent's arms is not acceptable.
• Transporting the neonate in an isolette is ideal.
• Use a commercially available age-appropriate car seat, or an integrated car seat.
Case Study
• You are called to care for a 3-week-old baby who has “stopped breathing.” Upon your arrival, you are met at the door by a frantic young mother holding a limp baby. The mother is crying and, through her sobs, you can barely understand her saying something about “sleeping,” “blue,” and “not breathing.”
Case Study (cont'd)
• What kinds of problems could this neonate have?
• What are your priorities?
Case Study (cont'd)
• Scene Size-Up– Standard Precautions taken.– Scene is safe, no entry or egress
problems.– 3-week-old male, about 6 or 7 pounds.– Patient found in mother's arms, limp.
Case Study (cont'd)
• Scene Size-Up–Mechanism of illness/nature of injury is
unresponsiveness. – First child, no prenatal care, minimal
hospital stay at birth.
Case Study (cont'd)
• Primary Assessment Findings– Patient unresponsive.– Airway looks clear with manual
technique.– Breathing slow and irregular. – Carotid pulse 98/min, peripheral pulse
absent.– Peripheral skin cool and blue.– Poor muscle tone, neonate is very limp.
Case Study (cont'd)
• Is this patient a high or low priority? Why?
• What are the patient's life threats, if any?
• What care should be administered immediately?
• Should endotracheal intubation be initiated immediately?
Case Study (cont'd)
• Medical History– Born 1 week early, recent diagnosis of
upper respiratory infection.
• Medications– Nebulized med for upper respiratory
infection.
• Allergies–Mother does not think infant has any.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils sluggish to respond to light.– Airway patent, patient being ventilated
at 30/min.– Central pulse present now only
60/minute.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Skin is still cool, cyanosis has resolved
some.– Pulse oximetry only 90 percent with PPV
and supplemental oxygen.– Patient still limp, no response to
interventions.
Case Study (cont'd)
• Is the infant improving or deteriorating?
• Is there any additional treatment or change in treatment required?
• What is the likely underlying cause for the emergency?
Case Study (cont'd)
• Care provided:– Patient positioned supine, secured for
transport.– Ongoing PPV with oxygen.– Compressions administered when heart
rate dropped below 60/min with poor perfusion.
Case Study (cont'd)
• Care provided:– Temperature maintained with
ambulance heater and warm blankets.– Rapid transport with paramedic
intercept.
Case Study (cont'd)
• What signs and symptoms would indicate that the patient’s condition is still deteriorating?.
• What additional interventions will you provide?
Case Study (cont'd)
• Additional care provided:– Peripheral IV access or IO access.• Fluid administration with use of buretrol.
– Administration of epinephrine.– Reassess and monitor the patient.
Summary
• Neonatal emergencies are stressful for the parent as well as EMS providers.
• Remember the mnemonics for assessing and managing neonates:– ABCs “In that order every time”– DEFG “Don't ever forget glucose”– H is for hypothermia – I is for infection
Summary
• Also ensure proper and secure transport to hospital in ambulance.
• Paramedics must remember that good basic interventions are preferred when managing for this age group, but they must be competent in providing advanced interventions when needed.
TOPIC
Obstetrics (Antepartum Obstetrics (Antepartum Complications)Complications)
55
Objectives
• Review rates for complications seen during pregnancy.
• Discuss specific pathology related to obstetric emergencies.
• Review specific questions to ask when obtaining an obstetric history.
• Review assessment parameters and current treatment standards for a patient with antepartum complications.
Introduction
• Antepartum refers to the period of pregnancy prior to the onset of labor.
• Emergencies that occur during this time may be benign or even life threatening.
• The goal of the paramedic is to differentiate between these and provide safe, and occasionally lifesaving, treatment to these patients.
Epidemiology
• 4 percent of all pregnancies develop third trimester complications.– 22 percent are placenta previa cases.– 31 percent are abruptio placentae cases.
Pathophysiology
• Placenta Previa– Placenta implants over the internal
cervical os.– Types include complete, marginal, and
partial.– Cervical effacement can lead to
hemorrhage at the implantation site.
Placenta previa.
Pathophysiology
• Abruptio Placentae– Placental lining separates from the
uterus.– The expanding collection of blood
continues to force the placenta away, which increases bleeding.
– Complete and partial abruption occurs.
Abruptio placentae.
Pathophysiology
• Ectopic Pregnancy– Pregnancy in which the ovum implants
outside the uterine cavity.– Still the leading cause of pregnancy-
related deaths in the first trimester.– Almost 100 percent result in fetal death.
Ectopic pregnancy.
Pathophysiology• Preeclampsia and Eclampsia – Preeclampsia has hypertension, edema, protein
in the urine, visual disturbances, and headaches.
– Eclampsia is all the above, but in addition the patient has now developed generalized tonic-clonic seizures.
– Preeclampsia is the third leading cause of pregnancy-related death.
• New hypertension >140/90 mmHg• Previous history of hypertension > 30/15 mmHg
above norm
Pathophysiology
• Spontaneous Abortion– Loss of pregnancy before the age of
viability.– Spontaneous means abortion was
unintentional, involuntary, and due to some natural cause.
– Patient will commonly have abdominal cramping, discharge, and expulsion of tissues of conception.
Types of Abortion
Assessment
• Physical exam should follow the standard primary and secondary assessments.
• Assessment techniques should be the same as those for a non-pregnant patient.
Assessment
• Patient interview should include a focus on:–When was last menstrual period?– Have you been pregnant before?– Are you experiencing any pain or
discomfort?– Are you having any vaginal discharge?– Any prenatal care? –When is your due date?
Antepartum Complications and Associated Signs and Symptoms
Emergency Medical Care
• Consider spinal immobilization.• Assess and maintain the airway.• Determine breathing adequacy.– Provide oxygen if adequately breathing.– Provide high-flow oxygen via positive
pressure ventilation if inadequately breathing.
Emergency Medical Care
• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.– Suspect internal hemorrhage
Emergency Medical Care
• Position patient left lateral recumbent tilted to the left side.
• Provide aggressive care for seizures.–Magnesium sulfate– Benozdiazapines
• Initiate IV access and administer fluids based on presentation.
• Expedite transport to facility.• Reassess and reassure while en
route.
Case Study
• At about 0230 hours, your EMS unit is dispatched to a local battered women's shelter in the downtown area. Upon your arrival, you find a 19-year-old female, 8½ months pregnant. She has bruises and cuts on her face, and dried blood on her shirt. She states her boyfriend beat her up and kicked her in the stomach. She now has abdominal pain and bleeding.
Case Study (cont'd)
• What kinds of injuries could this patient have?
Case Study (cont'd)
• Scene Size-Up– Standard Precautions taken.– Scene is safe, no entry or egress
problems.– 19-year-old pregnant female, 160
pounds.
Case Study (cont'd)
• Scene Size-Up– Patient found in sitting position.–Mechanism of injury is physical
altercation.– The police have been summoned but not
on scene yet.– First pregnancy with no prenatal care.
Case Study (cont'd)
• Primary Assessment Findings– Patient responsive.– Airway appears open.– Breathing fast but adequate.– Carotid and radial pulses present.– Peripheral skin cool and slightly
diaphoretic.– Pants soaked with blood from vaginal
bleeding.
Case Study (cont'd)
• Is this patient a high or low priority? Why?
• What are the patient's life threats, if any?
Case Study (cont'd)
• Medical History– None other than pregnancy.
• Medications– She takes OTC multivitamin.
• Allergies– Patient denies any.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils reactive to light bilaterally.– Airway patent, patient’s breathing is
rapid.– Central and peripheral pulses present.– Pulse oximeter reading 99 percent on
oxygen.– Soft tissue injuries to face are minor.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– BP 100/60, heart rate 122, respirations
22.– Painful dark red blood escaping from the
vagina.– Abdomen is tense to the touch, tender
also.
Case Study (cont'd)
• What is the patient's para and gravida status?
• What do you think is the patient's primary problem?
• Why is the abdomen tense?• What complications could the patient
have as a result of this condition?• What care will you provide?
Summary
• Antepartum emergencies can be the reason for the EMS call, or a consequence of some other trauma or medical problem.
• In many instances, there are two lives at stake—the mother and the unborn child.
• The paramedic must properly assess, treat, and transport these patients.
TOPIC
Trauma in Special Trauma in Special Populations: GeriatricsPopulations: Geriatrics
51
Objectives
• Discuss statistical rates pertinent to the aging population.
• Discuss incidence rates for geriatric trauma and death.
• Identify pathophysiologic changes that accompany injuries in geriatrics.
Objectives
• Differentiate early from late assessment findings.
• Review current treatment strategies for the geriatric patient suffering from trauma.
Introduction
• In trauma, age is one of the most important determinants.
• Elderly patients do not survive trauma, and concurrent chronic diseases make survival even more unlikely.
• It is important to reconsider the assessment and management of the geriatric trauma patient
Epidemiology
• Over 40 million geriatric people in the United States
• Geriatric patients use a disproportionate amount of EMS and health care services.
• Geriatric patients account for 75 percent of fall-related deaths.
Epidemiology
• The elderly drive fewer miles, but have a three times higher death rate in motor vehicle crashes.
Pathophysiology
• Head and Brain Trauma– Brain atrophy increases injury.– Higher risks of blood occupying lesions.• Findings may be delayed.
– Patient or family may not remember injury.
– Pupillary findings may not be reliable.
Pathophysiology
• Neck Trauma– Perception of pain is diminished.– C1 and C2 fractures common with
minimal traumatic mechanisms.– Immobilization concerns
Pathophysiology
• Spinal Trauma– Degenerative bone disorders are more
common.– Presence of kyphosis or scoliosis
increases injury risks.– Anterior cord syndrome is almost
exclusively a geriatric emergency.
Neck injuries are common in patients with a history of either head or chest
wall trauma.
Pathophysiology
• Thoracic Trauma– Ribs become brittle.– Disease states of lung tissue decrease
function.– Compensatory mechanisms are unable
to recover when a thoracic injury occurs.
Pathophysiology
• Abdominal Trauma– Liver and spleen are more exposed to
injury.– Internal bleeding can be masked by
what is thought to be a “normal” systolic pressure.
Pathophysiology
• Musculoskeletal Trauma– Bones are more at risk of injury due to
decrease adipose tissue, weakening cartilaginous support, and underlying disease.
– Osteoporosis contributes to bone weakness and fractures.
– Isolated fractures can become life threatening.
Pathophysiology
• Burn Trauma– Fourth leading cause of death in
geriatrics.– Changes in the skin make burns more
severe.– Burn shock occurs more readily as does
airway occlusion due to burns.– Linear increase in mortality of a burn
injury based on age alone.
Common Manifestations of Trauma in Geriatric Patients
Common Manifestations of Trauma in Geriatric Patients
Common Manifestations of Trauma in Geriatric Patients
Emergency Medical Care
• Spinal immobilization considerations– Allow for cervical/spinal curvature.
• Assess and maintain the airway.• Assess and manage circulatory
components.
Emergency Medical Care
• Determine breathing adequacy.– Apply high-flow oxygen via
nonrebreather to maintain a normal oxygen saturation with adequate breathing.
– Provide positive pressure with high-flow oxygen if inadequately breathing.
Emergency Medical Care
• Provide full immobilization.• Initiate transport to an appropriate
trauma facility.• Consider establishing IV access to
keep systolic blood pressure >90 mmHg.
• Treat any minor injuries, time allowing.
• Frequently reassess for rapid deterioration.
Case Study
• You are called to a residential address where an elderly male was trying to retrieve Christmas ornaments from his attic, when he slipped and fell down the attic steps. Upon your arrival, the patient is at the bottom of the steps, moaning, with blood coming from a temporal laceration. His right ankle looks angulated.
Case Study (cont'd)
• Scene Size-Up– Standard Precautions taken.– Scene is safe, no entry or egress
problems.– 82-year-old male, 160 lbs.– Patient found in lateral fetal position.–Mechanism of injury is fall down 10–12
wooden steps.– No additional resources needed at this
time.
Case Study (cont'd)
• What kinds of injuries could this patient have?
• What will be your assessment approach to him?
• What is your first priority?
Case Study (cont'd)
• Primary Assessment Findings– Patient moaning, but responsive to
yes/no questions only.– Airway open, breathing adequate, rate
fast.– Carotid and radial pulses present,
tachycardic.
Case Study (cont'd)
• Primary Assessment Findings– Peripheral skin cool and slightly
diaphoretic.– Bleed to right temporal region.– No other major bleeding noted.
Case Study (cont'd)
• Is this patient a high or low priority? Why?
• What interventions should be provided at this time?
Case Study (cont'd)
• Medical History– Hypertension, myocardial infarction,
COPD, constipation, hemorrhoids
• Medications– Coumadin, Nitro PRN, Proventil, Colace,
Preparation H
• Allergies–Morphine
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils equal and reactive, membranes
hydrated.– Airway patent, minute volume
adequate, breath sounds diminished.– Central and peripheral pulses present.– Pulse oximeter reading 94 percent on
ambient air.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Patient is becoming more unresponsive.– BP 180/90, heart rate 108, respirations
28.– Right ankle angulated with swelling,
pain, and tenderness noted.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Physical assessment reveals no other
skeletal trauma.– No other findings are contributory to
this report.
Case Study (cont'd)
• Provide two different explanations for his change in mental status.
• What else about this patient's medical history could make managing him more difficult?
Case Study (cont'd)
• Will his age or his medical history make you alter your treatment any?
• If the patient starts to improve, what would be the expected findings for:–Mental status– Heart rate–Muscle tone
Case Study (cont'd)
• Care provided:– Patient cervical spine manually
immobilized.– High-flow oxygen via mask initially, PPV
with supplemental oxygen after patient is in respiratory failure.
– Patient carefully immobilized to supine.– Patient loaded and transported to
appropriate trauma center.
Case Study (cont'd)
• Care provided:– Intravenous access should be
established and fluids should be administered only to maintain SBP of 90 mmHg.
– Patient reassessed and reassured during transport without change in condition.
– Treat laceration and ankle en route if possible.
Summary
• Although they are adults, approaching a geriatric patient should be given the same consideration as approaching the pediatric patient.
• Many times the paramedic will need to anticipate deterioration, modify treatment to fit the patient, and not expect all care to have the same effect as it would on a younger patient.
TOPIC
Complete and Incomplete Complete and Incomplete Spine and Spinal Cord InjuriesSpine and Spinal Cord Injuries
49
Objectives
• Discuss the predisposition, incidence, and mechanism of spinal cord injuries.
• Review normal spinal cord anatomy.• Discuss the pathophysiology of spinal
cord injuries.• Review motor and sensory findings
for incomplete spinal cord injuries.
Objectives
• Review assessment tests that ascertain spinal cord involvement.
• Review current treatment standards for cord injuries.
Introduction
• Cord injuries in the traumatized patient may be subtle or obvious.
• The paramedic must keep a high index of suspicion for possible spinal cord damage.
• Failure to manage, or the mismanagement of, a cord injury can have permanent, if not fatal, outcomes.
Epidemiology
• 11,000 new cases of spinal cord injury per year in the United States
• About 80 percent occur to men, average age 38 years.
• Incidence of elderly spinal cord injury is on the rise.
Illustration of the spinal nerves (a) laterally and (b) posteriorly. The
ganglia are detailed as well.
Cross section of spinal cord showing corticospinal, spinothalamic, and
posterior columns.
Ligaments and intervertebral disks of the spine. Lateral view of the spinal column
(anterior to the right). The lower vertebrae have been cut sagittally to reveal the spinal
canal and some of the ligaments.
Pathophysiology
• Injury to the spinal cord– Flexion, rotation, compression,
hyperextension, lateral bending, distraction, penetration
– Primary cord injury (structural damage)– Secondary cord injury (ongoing damage
from swelling or ischemia/necrosis)
Pathophysiology
• Complete spinal cord injury– Total loss of motor and sensory
function.– Fairly easy to detect.– Can be mimicked by spinal shock.–Management still remains the same.
Pathophysiology
• Incomplete spinal cord injury– A portion of the spinal cord is injured– Partial neurologic function– Requires immobilization– Specific presentations of incomplete
spinal injury include:• Central cord syndrome• Brown-Séquard syndrome• Anterior cord syndrome
Cross sections of the spinal cord, showing the H-shaped gray matter surrounded by white matter. Illustrated here are the three most common types of incomplete spinal cord injury (the areas of the injury are highlighted in red): (a) Central cord
syndrome results from injury to the central cord. (b) Brown-Séquard syndrome results from injury to the right or left half of the cord. (c) Anterior cord syndrome results from injury to the anterior cord.
Incomplete Spinal Cord Injury Syndrome Assessment Findings
Pathophysiology
• Spinal shock– Loss of neurologic function and
autonomic tone distal to injury site.– Neurogenic hypotension, hypothermia,
bradycardia may result.
Differential Assessment Findings: Hypovolemic Shock Versus Neurogenic
Shock
Assessment Findings
• Dispatch information may provide a clue.
• Assess spinal tracts by testing for pain, light touch, and motor function.
• Goal is to assess the cord at multiple levels to ensure presence/absence of injury.
Spinal Cord Motor Assessment and Level of Loss of Function
Level of Spinal Cord Injury Correlated to Loss of Sensory
Function
Emergency Medical Care
• The following patients should always be immobilized– Significant mechanism of injury.– Patient has an altered mental status.– Patient has pain or tenderness to
vertebral column.– Patient is unreliable.– Any sensory or motor dysfunction is
found.
Emergency Medical Care
• Manual cervical spine considerations• Assess and maintain the airway.• Determine breathing adequacy.
– Administer oxygen to maintain SpO2 above 94 percent
– Provide positive pressure ventilation with high flow oxygen if inadequate
Emergency Medical Care
• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.
• Initiate transport to an appropriate facility and reassess patient’s ABC’s and neurologic function en route.
Emergency Medical Care
• Initiate intravenous access with a large-bore catheter.– Administer IV fluids to keep systolic
blood pressure >90 mmHg.– If hypoglycemic (blood glucose level
<60 mg/dL), administer 25 g of 50% dextrose in water.
– Consider vasoactive agents in severe cases of spinal shock.
Case Study
• You have a 31-year-old construction worker who fell from a scaffolding onto a pile of waste material from about 20 feet. Bystanders state he landed on his back and was unresponsive for about 15 seconds. Upon your arrival, the patient can speak to you, but is not sure what happened.
Case Study (cont'd)
• Scene Size-Up– Standard Precautions taken.– Scene is safe, workers have cleared
area of debris.– 31-year-old male patient, 180 lbs.– Mechanism of injury appears to be a fall– Additional resources are not requested
at this time
Case Study (cont'd)
• Scene Size-Up– Patient found supine, no gross
hemorrhages.– Patient entry made, egress not
problematic.– No additional resources needed at this
time.
Case Study (cont'd)
• Primary Assessment Findings– Patient responsive, but amnestic to fall.– Airway open, breathing adequate, no
dyspnea.– Carotid and radial pulses present,
normal rate.
Case Study (cont'd)
• Primary Assessment Findings– Peripheral skin warm and slightly
diaphoretic.– No major bleeds noted to body.– Patient keeps telling you that he cannot
move his arms.
Case Study (cont'd)
• Is this patient a high or low priority? Why?
• What interventions should be provided at this time?
Case Study (cont'd)
• Medical History– Asthma
• Medications– Proventil inhaler PRN
• Allergies– No drug allergies
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils equal and reactive, membranes
hydrated.– Airway patent, good minute ventilation.– Central and peripheral pulse and
perfusion good.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pulse oximeter reading 98 percent on
ambient air.– Patient has normal lower extremity
motor tone; however, he cannot move his arms.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– He can feel light touch in all extremities,
but not painful stimuli to arms.– Deformity and abrasion to base of neck
noted.– B/P 104/80, heart rate 70, respirations
12.– BGL is 120 mg/dL
Case Study (cont'd)
• Do you suspect a spinal cord injury? If so, what type?
• Explain the reason for the conflicting assessment findings.
• What spinal nerve tract is injured on this patient?
• What treatments would you provide to this patient?
Case Study (cont'd)
• Care provided:– Patient’s cervical spine manually
immobilized.– Administer oxygen to maintain SpO2
above 94 percent.– Patient carefully immobilized.– Transported to an appropriate facility.– Initiated intravenous access and provide
fluids to maintain SBP >90 mmHg.
Summary
• As mentioned, the traditional method for assessing motor, sensory, and perfusion is not sufficient for incomplete spinal injuries.
• Incomplete SCI need immobilization as well to prevent the incomplete from progressing to complete.
TOPIC
Traumatic Brain InjuryTraumatic Brain Injury
48
Objectives
• Discuss the predisposition, incidence, and death rates for brain injuries.
• Review the pathophysiology behind the types of brain injuries.
• Define assessment considerations and findings for patients with brain injuries.
• Review current treatment parameters for patients with herniating and non-herniating brain injuries.
Introduction
• Brain injuries may manifest themselves now, or weeks later.
• The physiology of the brain and surrounding structures leaves itself open to certain types of brain injuries.
• Understanding the pathophysiology of brain injuries will allow the paramedic to provide optimal treatment.
Epidemiology
• 1.5 million head injuries occur per year in the United States
• It is the leading cause of death in accident victims younger than 45.
• 50,000 people die each year from brain injury.
Pathophysiology
• Intracerebral hemorrhage– Extraaxial hemorrhage
• Epidural, subdural, subarachnoid
– Intraaxial hemorrhage• Occurs within brain tissue itself• Intracerebral hemorrhage
– Intraparenchymal hemorrhage– Intraventricular hemorrhage
Pathophysiology
• Diffuse axonal injury (DAI)– Most devastating of traumatic brain
injuries– Acceleration-deceleration mechanism– Frequent outcome is coma– Stretching and swelling of axons
Pathophysiology
• Diffuse axonal injury– Concussion
• Mild DAI• GCS 13-15
– Epidural hematoma• Serious complication of head injury• Bleeding between dura and skull
Pathophysiology
• The rise in ICP causes a cascade of signs and symptoms, including:• Decreased mental status • Severe headache • Fixed and dilated pupils • Vomiting• Altered or absent breathing • Posturing • Systolic hypertension with associated
bradycardia (Cushing reflex, a late finding)
Figure 48–1 Epidural hematoma.
Pt. will suffer a loss of consciousness and then a period of responsiveness. Shortly thereafter, his level of consciousness will deteriorate rapidly.Result from low velocity impact skull Fx is common occurring in 90% of pt.
Pathophysiology
• Diffuse axonal injury– Subdural hematoma
• Bleeding between arachnoid and dura• Low-pressure bleed• Phases include acute, subacute, and chronic
Pathophysiology
• Acute phase—Signs and symptoms begin immediately
• Subacute phase—begins three to seven days after the injury
• Chronic phase—begins two to three weeks later• Subdural hematoma is seen in child abuse cases
and incidents involving shaken baby syndrome.• typical mortality rate around 60 percent.
Pathophysiology
• Signs and symptoms of acute subdural hematoma include:
• Declining level of consciousness • Abnormal or absent respirations • Dilation of one pupil • Weakness or paralysis to one side of the body• Vomiting• Seizures • Increasing systolic blood pressure• Decreasing heart rate
Figure 48–2 Subdural hematoma.
Pathophysiology
• Diffuse axonal injury– Subarachnoid hemorrhage
• Brain tissue becomes ischemic• Severe headache common• May rapidly progress to seizures and cardiac
arrest
Assessment Findings
• Dispatch information – Seizures, headache, trauma, etc.
• Soft tissue injuries to skull• Closed or open skull injuries• Alteration in mental status• Possible loss of airway patency• Breathing may be irregular and slow• Changes to vitals (Cushing response)
Assessment Findings
• Response to painful stimuli– Purposeful vs. nonpurposeful– Decorticate vs. decerebrate
• Assess and reassess mental status.– Compute Glasgow Coma Score, look for
trends.
• Assess vital signs– Trends of vitals may also help identify
brain injury.
Nonpurposeful responses to painful stimuli include (a) flexion (decorticate) posturing and (b)extension
(decerebrate) posturing.
Glasgow Coma Scale
Implications of Changes in Vital Signs with Head Injuries
Emergency Medical Care
• Manual cervical spine considerations• Assess and maintain the airway.• Determine breathing adequacy.
– Administer oxygen to maintain SpO2 above 94 percent.
– Positive pressure ventilation with high flow oxygen if inadequate.
– Consider hyperventilation (at no more than 20/min) with brain herniation.
Emergency Medical Care
• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.
• Transport immediately to an appropriate medical facility.
Emergency Medical Care
• Initiate a large-bore intravenous catheter.– Administer fluids to keep systolic blood
pressure >90 mmHg.– Do not cause hypertension with IV
fluids.
Emergency Medical Care
• Be prepared to manage seizure activity.
• Constantly monitor airway, breathing, and circulation.
• Mental status changes are key to determining improvement or deterioration.
Case Study
• You are called to a motorcycle accident where a rider who was not wearing a helmet lost control of his cycle on a turn and hit a tree. When you arrive, the patient is lying supine, blood covering his face and shirt, and the patient is actively seizing. The police are already on scene and you can hear the wail of the fire department sirens approaching.
Case Study (cont'd)
• Scene Size-Up– Standard precautions taken.– Scene is safe, police stopped traffic – 43-year-old male patient, 200 lbs.– Patient supine, blood on face and shirt.– MOI- motorcycle accident– Entry made, egress not problematic.– PD on scene, FD pulling up.– Additional resources requested
Case Study (cont'd)
• Based on the information provided and the scene size-up, what differential diagnosis might you suspect?
• What types of additional resources may you consider requesting?
• What are your priorities at this time?• Would you consider this a high-
priority patient? Why?
Case Study (cont'd)
• Primary Assessment Findings– Patient unresponsive, active tonic-clonic
seizures.– Mouth clenched shut, blood on face,
sonorous breath sounds with gurgling.– Breathing is ineffective due to seizure
activity.
Case Study (cont'd)
• Primary Assessment Findings– Carotid and radial pulses present.– Peripheral skin warm and sweaty.– No major bleeds noted to body.
Case Study (cont'd)
• What interventions should be provided at this time?
• How would you manage the airway of this patient?
• What could be the cause of his seizure activity?
Case Study (cont'd)
• Medical History– Unknown
• Medications– Unknown
• Allergies– Unknown
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils unequal, sluggish to light.– Airway patent, spontaneous breathing
still ineffective.– Patient is still unresponsive and seizing.– Pulse oximeter reading 82 percent
initially with attempts at PPV. 93 percent on high-flow oxygen.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– B/P 198/90, heart rate 56, spontaneous
respirations 4 and irregular.– Crepitus noted to posterior vertebrae.– Depressed right frontal skull fracture
noted.– Sinus bradycardia on monitor– Blood glucose level 65 mg/dL
Case Study (cont'd)
• What type of brain injury would you suspect?
• Is this patient displaying any indications of herniation? Why?
• What interventions might you provide at this time?
Case Study (cont'd)
• Care provided:– Stabilize cervical spine– Considering hyperventilation based on
protocol– Maintain airway, oxygenation, and
ventilation
Case Study (cont'd)
• Care provided:– IV initiation and fluid therapy– Stop seizures (based on protocol)– Full spinal immobilization– Rapid transport to appropriate facility
Summary
• Brain injuries are a common cause of death and disability following traumatic events.
• Prehospital recognition and proper management can help reduce the long-term effects of brain injuries.
• As with any trauma, focus first on supporting lost function.
TOPIC
Soft Tissue Injuries: Crush Injury Soft Tissue Injuries: Crush Injury and Compartment Syndromeand Compartment Syndrome
45
Objectives
• Review the occurrences and mechanisms of soft tissue trauma.
• Discuss pathophysiological changes at the cellular level of crush and compartment syndrome injuries.
• Review assessment findings and current treatment interventions for these types of injuries.
Introduction
• Crush injury is a mechanism of blunt trauma, whereas compartment syndrome is an injury pattern.
• Crush injuries are caused by excessive compressive forces on the body.
• Can occur to small localized areas (thumb), or to large regions (thorax).
Epidemiology
• A broad definition of soft tissue injury accounts for the vast majority of traumatic injuries.
• Crush injuries are a small portion of this category.
• Crush injuries result from a wide range of mechanisms.
Mechanism
• Direct force– Tissue destruction from compressive
forces
• Entrapment/Weight-based compression– Compression caused by patient's
position
• Internal compression– Internal swelling causing compartment
syndrome
Direct force can cause crush injuries, some resulting in open wounds.
A stroke patient who has fallen and trapped her right leg beneath her body
weight.
Pathophysiology
• Direct compression destroys tissue cells.
• Pressure can also inhibit normal blood flow to tissues, worsening tissue damage.
• Compression > four hours may result in muscle breakdown with toxin release.– Can have devastating systemic effects.
Pathophysiology
• Compartment syndrome– Compression from the opposite
direction.– Swelling or bleeding in muscle occurs.– Fascia enveloping muscle is
nondistensible.– Pressure builds, causing changes to
blood flow.
Assessment Findings
• Common findings– Pain to traumatized area– Possible entrapment of extremity– Bruising, tenderness, ecchymosis– Deformity, loss of function– Diminished or absent distal circulation,
motor, or sensory findings– Internal hemorrhage, shock
Assessment Findings
• Specific compartment syndrome findings– Pain, discomfort, burning sensation– Pain that continues after immobilization– Tenderness, unusual firmness at injury
site– Altered CMS distal to the injury–Weakness or paralysis of muscle
Assess circulation in an extremity following a crush injury.
Emergency Medical Care
• Spinal immobilization considerations• Assess and maintain the airway.• Determine breathing adequacy.–Maintain adequate oxygenation.– Positive pressure ventilation with high
flow oxygen if inadequate.
• Assess circulatory components.– Check pulse, skin characteristics.– Control major bleeds.
Emergency Medical Care
• Relieve any compression pressure if possible.– Cellular waste products may be released
into the blood stream.–May result in massive internal bleeding.
• Initiate intravenous therapy.• Consider the administration of
medications.
Emergency Medical Care
• Prepare for cardiac arrest.• Treat any minor injuries, time
allowing.• Consider full spinal immobilization.• Transport to appropriate facility.
Emergency Medical Care
• Preventing and treating compartment syndrome.– Elevate extremities.– Beware of constricting immobilization.– Apply cold.–Monitor distal CMS.
Case Study
• You are called to a remote area of your response district where a man was injured while cutting down trees. The man was reportedly trapped by a fallen tree for hours prior to being found missing by his family. When you arrive, the patient's abdomen and legs are still entrapped, and the fire department is extricating him. The patient is able to respond to you.
Case Study (cont'd)
• Scene Size-Up– Standard Precautions taken.– Scene is safe, no further fear of pinning.– Adult male, 40 years old, 230 lbs.– Patient found supine, large tree stump
across his abdomen and legs.
Case Study (cont'd)
• Scene Size-Up– Patient entry made, egress problematic
due to woods and distance to carry.– Additional resources of FD on scene
already.
Case Study (cont'd)
• Primary Assessment Findings– Patient responsive, seems lethargic
though.– Airway open and maintained by self.– Breathing is rapid, alveolar sounds
present.
Case Study (cont'd)
• Primary Assessment Findings– Carotid and radial pulses present,
cannot assess lower extremities.– Peripheral skin cool, pale, sweaty.– You see some evidence of bleeding from
legs, but nothing current.
Case Study (cont'd)
• Is this patient a high or low priority? Why?
• What interventions should be provided at this time?
• What type of injuries do you expect from this mechanism?
• Describe how this mechanism could cause compartment syndrome.
Case Study (cont'd)
• Medical History– High cholesterol.
• Medications– Patient denies any, watches his diet.
• Allergies– “Some antibiotics,” he states.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils dilated but reactive, membranes
pale.– Airway patent, breathing tachypneic.– Peripheral perfusion diminishing to
arms.– Breath sounds present bilaterally.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Patient's mental status still continuing to
deteriorate.– Pulse oximeter reading 98 percent on
high flow.– BP 100/82, heart rate 114, respirations
20.– Unable to assess lower extremities or
abdomen.
Case Study (cont'd)
• The fire department reports that it will take them at least 10 minutes to lift the tree stump off of the patient.
• They ask you if you need anything else ready or set up. What would be your response?
• What additional emergency medical care might you consider while waiting for extrication?
Case Study (cont'd)
• After lifting the tree from the patient, he arrests about 30 seconds later. Explain why this may have happened.
• What emergency care will you provide?
Case Study (cont'd)
• Care provided:– Patient immobilized.– Open and maintain airway.– PPV with oxygen due to apnea.– Cardiopulmonary resuscitation initiated
upon arrest.
Case Study (cont'd)
• Care provided:– Advanced cardiovascular life support
provided accordingly.– All lower extremity fractures managed
by immobilization to backboard.– Rapid transport.
Summary
• Crush injuries are a rare, but potentially fatal mechanism for soft tissue trauma, since the injury pattern could be so widely dispersed.
• The paramedic should indentify and treat life threats before managing the soft tissue trauma and compartment syndrome issues.
TOPIC
Chest TraumaChest Trauma
43
Objectives
• Review annual injury and death rates for chest trauma victims.
• Understand pathophysiologic changes that occur with chest trauma.
• Discuss common clinical findings of chest trauma.
• Identify the importance of mechanism of injury in determining presence of chest trauma.
Introduction
• Chest injuries can be obvious and dramatic, or small and easy to miss.
• The assessment of the chest must be comprehensive in order to find all injuries.
• The paramedic must understand the physiology of the chest wall and its response to trauma.
Epidemiology
• 20 percent to 25 percent of trauma deaths each year are due to thoracic trauma.
• The most common mechanism is motor vehicle collision.
Epidemiology
• Immediate deaths are due to myocardial or aorta rupture.
• Early deaths are due to tension and open pneumothorax, tamponade, flail segments, and hemothorax.
Pathophysiology
• Chest trauma distorts the normal thoracic anatomy.
• Distortion injures body system and causes a change in physiology.
• V/Q ratio disturbances, hypoxemia, and hypercapnea ensue.
• Ultimately, cellular death occurs.
Pathophysiology
• Tension pneumothorax– Disruption of visceral pleura– Accumulation of intrathoracic air– Collapse of lung tissue– Shifting of mediastinum– Changes in hemodynamics– Assessment• Early findings• Late findings
In a tension pneumothorax, air continuously fills the pleural space, the lung collapses, pressure rises, and the trapped air compresses the heart and the other
lung.
Pathophysiology
• Open pneumothorax– Disruption of parietal pleura from hole in
chest– Accumulation of intrathoracic air– Collapse of lung tissue– Injury may turn into tension
pneumothorax– Assessment findings
In an open pneumothorax, air enters the chest cavity through an open chest wound or leaks from a
lacerated lung. The lung then cannot expand.
Pathophysiology
• Flail chest– Fractured ribs (2 or more in 2 places)– Creates “free floating” segment of chest– Paradoxical motion inhibits adequate
ventilation– Resulting pulmonary contusion– Assessment findings
Flail chest occurs when blunt trauma causes the fracture of two or more ribs, each in two or more
places.
With a flail chest, (a) the flail segment is drawn inward as the rest of the lung expands with
inhalation; (b) the flail segment is pushed outward as the rest of the lung contracts with exhalation.
Pathophysiology
• Hemothorax– Similar to pneumothorax– Pleural cavity fills with blood (chest
trauma)– Collapse of lung tissue creates
hypoventilation–May also cause hypovolemia– Assessment findings
In a hemothorax, blood leaks into the chest cavity from lacerated vessels or the lung itself,
and the lung compresses.
Pathophysiology
• Acute pericardial tamponade– Injury to heart causes blood to collect in
pericardial sac– Pericardial sac nondistendable– Collapsed ventricles, poor stroke volume– Assessment findings
In pericardial tamponade, accumulating blood compresses the heart inward.
Assessment Findings
• Inspection– Any open chest injuries– Any structural abnormalities
• Auscultation– Type, quality, location of breath sounds
• Palpation– Structural abnormalities– Subcutaneous emphysema
Differential Field Diagnosis of Chest Injury
Emergency Medical Care
• Spinal immobilization considerations• Assess and maintain the airway.• Determine breathing adequacy.– Provide positive pressure ventilation
with high-flow oxygen @ 10-12/min if inadequately breathing.
– Occlude any punctures to chest wall.– Decompress a tension pneumothorax.
Emergency Medical Care
• Assess circulatory components– Check pulse, skin characteristics– Control major bleeds
• Provide full immobilization• Initiate safe and expeditious
transport• Establish a large bore IV en route.– Avoid aggressive fluid administration
• Consider pain medication
Case Study
• Your EMS unit is summoned for a patient who was injured while hunting. Upon your arrival, you find a male patient holding his hand over his right thorax. Some blood is seeping past his fingers, and the breathing looks labored. Friends report he was accidently shot with an arrow.
Case Study (cont'd)
• Scene Size-Up– Standard Precautions taken.– Scene is safe, no sign of struggle.– Young male, 18 years old.– Patient found sitting along edge of road.– No patient entry nor egress problems.– No additional resources needed
presently.
Case Study (cont'd)
• Primary Assessment Findings– Patient responsive.– Airway open and maintained by self.– Breathing is rapid, patient is dyspneic.– Breath sounds diminished on the right.– Carotid and radial pulses present but
radial gets weaker with inhalation.– Peripheral skin cool, pale, sweaty.– No other major bleeds or concerns.
Case Study (cont'd)
• Is this patient a high or low priority? Why?
• What interventions should be provided at this time?
Case Study (cont'd)
• What are your differentials thus far that the patient could be suffering from?
• Do you think that this patient will have a problem with the ventilation or perfusion side of the V/Q ratio? Why?
Case Study (cont'd)
• Medical History– Patient states he has attention deficit
hyperactivity disorder and Tourette syndrome
• Medications– Patient states he takes Vyvance, Tenex,
and Albilify
• Allergies– Patient states he is allergic to penicillin
Case Study (cont'd)
• Pertinent Secondary Assessment Findings– Pupils dilated but reactive, membranes
pale.– Airway patent, breathing tachypneic.– Peripheral perfusion diminishing.– Absent breath sounds to right thorax.– Patient's mental status still continuing to
deteriorate.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings – No jugular venous distention noted– No tracheal deviation noted– Penetration injury fourth intercostal
space, right anterior chest.– Pulse oximeter reading 98 percent with
supplemental O2.
Case Study (cont'd)
• Pertinent Secondary Assessment Findings – Occlusive dressing “burped.”– B/P 82/palp, heart rate 114,
respirations 20.– Pulsus paradoxus noted
Case Study (cont'd)
• What would be key clinical indications the patient is deteriorating despite treatment?
• What advantage does “burping” the occlusive dressing have?
• Why would PPV possibly be detrimental to the patient?
Case Study (cont'd)
• Based on the assessment findings, what is your differential diagnosis?
• What additional treatments would you perform?
• How would the patient benefit from your interventions?
Case Study (cont'd)
• Care provided:– Patient immobilized.– High-flow oxygen via nonrebreather
mask, switched to PPV due to failing ventilations.
– Occlusive dressing to chest injury which is burped.
Case Study (cont'd)
• Care provided:– Needle decompression.– Transport to trauma hospital initiated.– Established intravenous access to
maintain systolic BP of 90 mmHg.
Summary
• Chest wall injuries can result in significant disturbances to the V/Q ratio.
• Although these injury typically require surgery, the paramedic can provide treatments that will support lost function.