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Abnormal Medical and Trauma

Abnormal Medical and Trauma
Shore EMS Conference 2010

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    Things That Make You Go Hmm    Part 1ppt Things That Make You Go Hmm Part 1ppt Presentation Transcript

    • Things That Make You Go Hmm… Unusual EMS Sean M. Elwell, EMT, RN Injury Prevention Coordinator Trauma Program Alfred I.duPont Hospital for Children Wilmington, DE
    • About Me…
      • Injury Prevention Coordinator
      • Registered Nurse-NJ, DE
      • EMT-B, NJ and NR
      • EMT Instructor
      • Fire Instructor
      • EMS/Rescue Captain-7 Years
      • BLS/PALS Instructor
    •  
    • Alfred I. duPont Hospital for Children
      • 182 Bed pediatric hospital
      • 23 Bed Emergency Room
      • 24 Bed PICU
      • 12 Bed NICU
      • Specialize in:
      • Orthopedics
      • Child abuse
      • Cardiac
      • Pediatric cancer
      • Neurosurgery
      • Organ transplants
    • Delaware Trauma Level Designation LEVEL I  A regional resource trauma center able to care for all trauma patients LEVEL II  Regional trauma center able to provide care to all patients. May need to transfer out depending on resources available LEVEL III  Provides for initial care of all trauma patients arranging for transfer for those requiring resources of a Level I or II Trauma Center LEVEL IV  A participating hospital that is an acute care facility which transfers trauma patients with moderate or severe injuries to Trauma Center after initial resuscitation. Not Designated  
    • Trauma Alert Criteria: Stable
      • Injuries
        • Diminished mental status
        • (GCS 9-13)
        • Open or depressed skull fracture
        • Significant, blunt maxillofacial trauma
        • Pelvic fracture (stable)
        • Partial or full thickness burns <20% BSA or inhalation injury
        • Deep penetrating injuries to proximal extremities
        • Two or more long bone fractures without neurovascular compromise
      • Mechanisms
        • Falls over 12 feet
        • Death or severe injury of same-car occupant
        • Pedestrian hit by vehicle and thrown, dragged or run over
        • Pedestrian struck at 20 mph or greater
        • Ejection from motorize vehicle
        • Submersion injuries
      • Other
        • Emergency Physician’s Discretion
        • Stable trauma transfers < 24 hours post injury that initially met code/alert criteria
        • Request of Trauma Alert by pre-hospital providers according to EMS protocols
      • Consider Trauma Alert
        • Motor Vehicle Crash
          • Unrestrained passenger with rollover
          • High speed auto crash
        • If patient condition deteriorates: Upgrade to Trauma Code
    • Trauma Code Criteria: Unstable
      • Airway
        • Intubation/assisted ventilations *
        • Significant maxillofacial injury with potential airway obstruction
      • Breathing
        • Respiratory arrest *
        • Respiratory distress (ineffective respiratory effort, stridor or grunting)*
      • Circulation: PALS Criteria for Shock
        • 0-28 days
          • Systolic BP < 60
        • 1 month-10 years of age
          • Systolic BP <:
          • BP 70 + 2X age years
        • 10 years and older
          • Systolic BP < 90
        • Clinical Signs of Shock*
          • Pale; cold; clammy; tachycardia with weak pulses; capillary refill > 3 sec assuming a warm environment
        • Transfer from another hospital receiving blood, fluids or medications to maintain vital signs*
      • Neurological
        • GCS < 8*
        • Suspected spinal cord injury associated with neurological deficits
        • Suspected head injury (GCS <12) with major torso or extremity injury
      • Specific Traumatic Injury
        • Penetrating injury to head, neck, torso, groin (GSW, impaling injuries)*
        • Open chest wound
        • High voltage electrical and lightening injuries
        • Burns > 20% TBSA (2 nd /3 rd degree)
        • Amputation proximal to ankle/wrist
        • Flail chest
      • Other
        • Initiation of Trauma Code by pre-hospital providers according to EMS protocols
        • Emergency Physician’s Discretion*
      • *Mandatory Criteria as defined by American College of Surgeons
    • New Jersey EMS… Captain Chief President All EMS and Rescue Operations All Fire Suppression Operations All Executive Operations EMS Chain of Command: Captain, Lieutenant, Chief, Deputy Chief
    • A Review
    • Back to Basics-Primary Survey
      • Rapid assessment to find and treat all immediate life-threatening conditions
      • “ Find and fix”
      • “ Treat as you go”
      • Decide if the patient needs immediate transport or additional on-scene assessment and treatment
    • Primary Survey Steps
      • The primary survey has several parts:
        • General impression
        • A irway/level of responsiveness/cervical spine protection
        • B reathing (ventilation)
        • C irculation with bleeding control (perfusion)
        • D isability (mini-neurological exam)
        • E xpose (for examination)
        • Identification of priority patients
    • Back to Basics-Secondary Survey
      • Purpose
        • Discover medical conditions and/or injuries that were not identified in the primary survey
      • Physical exam
      • Obtain vital signs
      • Reassess changes in the patient’s condition
      • Determine
        • Chief complaint
        • History of present illness
        • Significant past medical history
    • Secondary Survey
      • Should be performed in the following situations:
      • Trauma patients with a significant mechanism of injury
      • Trauma patients with an unknown or unclear mechanism of injury
      • Trauma patients with an injury to more than one area of the body
      • All unresponsive patients
      • All patients with an altered mental status
      • Some responsive medical patients, as indicated by history and focused physical examination findings
    • Case Studies
    • By The Way…
      • ALS is NOT Available for These Alarms
    • Case 1…
    • Dispatch
      • Hagersville Road
      • MVC
      • Initial Dispatch
        • Rescue
        • Squad
        • Engine
      • Officer on Radio
        • Report tree fell on vehicle
        • No other information available
        • Requested 2 nd rescue dispatched
    • What are your initial reactions?
      • Scene Size Up Starts at Dispatch
    • Scene Size-Up
      • En route to the scene consider:
        • What additional help might be needed on the scene?
          • Law enforcement personnel?
          • Fire department?
          • Utility company?
          • Advanced Life Support personnel?
        • How will you gain access to the patient?
        • What questions will you ask the patient or family?
    • Upon Arrival
    • Now What?
      • Wires Down
      • Is there a patient?
      • How can we gain access?
    • Plan of Action
      • Downed wires are cable lines
      • We are able to get to the car
      • Only access is through back window
      • Window punch used to gain access
      • First communication with patient there is no response
    • Extrication Dilemmas
      • Tree Branches-Supporting Tree
      • Tree Covers Entire Car
      • Vehicle Still Running
      • Patient is Unresponsive
      • Fire Potential
    • C-Spine
      • Sent EMT into Vehicle to Assess and Hold C-Spine
    • Proper Collar Sizing
      • Measure the width of the patient’s neck by placing your fingers between the patient’s lower jaw and shoulder
    • Things to Remember
      • Too tight
        • Can reduce blood flow in the neck
      • Too loose
        • Can cause an airway obstruction
        • Will not adequately stabilize head/neck
      • Too short or too tall
        • Will not provide adequate stabilization
    • Primary Assessment
      • Airway
        • Patient Speaking
      • Breathing
        • RR 16, Unassisted.
        • O2 Provided
        • 15 lpm via NB
      • Circulation
        • Carotid Pulse 60
        • Unable to Obtain BP
        • Unable to Check PMS
    • Extrication Complete
    • Secondary Assessment
      • Focused adjuncts:
        • Full set of vital signs
        • Family
      • Give Comfort:
        • Positioning, padding
        • Meds?
      • History:
      • Inspection:
        • Time to log roll!
    • Transport Decisions
      • Drive or Fly
      • Weather Considerations-High Winds
      • Patient is Stable
      • Transported to Trauma Center for Evaluation
    • Patient Outcome
    • Compression Injury
      • Can result from a fall from a significant height onto the head or legs
        • Force of injury can drive weight of head into neck or pelvis into torso
    • Paraplegia
      • Loss of movement and sensation in the body from the waist down
      • Results from spinal cord injury at the level of the thoracic or lumbar vertebrae
    • Case 2…
    • Dispatch
      • Silverlake Road
      • Injured Person
      • Ambulance Makes Response
        • Reported bicycle injury
    • What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
    • Upon Arrival
      • Upon BLS arrival find an 11 year old male
      • Was going over a jump
      • Flipped off his bike
      • Upon landing handlebars impaled patients leg
      • Femur area
      • What are your concerns?
    • Femoral Artery
    • Bike Accident X
    • Bike Accident
    • Primary Assessment
      • AVPU-Neg LOC
      • Airway
        • Patent
      • Breathing
        • RR 16
      • Circulation
        • HR 70
        • BP 116/78
      • Denies PAIN!!
    • Secondary Assessment
      • Focused adjuncts:
        • Full set of vital signs
        • Family
      • Give Comfort:
        • Positioning, padding
        • Meds?
      • History:
      • Inspection:
        • Time to log roll!
    • BLS Actions
      • Requested Rescue
      • Requested ALS
      • Drive or Fly?
    • Rescue Arrival
      • Cut handlebars off. Patient packaged with handlebars still attached.
      • Boarded and collared per mechanism
      • Couldn’t lay flat
    •  
    • Next…
      • ALS Arrived
      • LZ Established
      • Patient Transported to Trauma Center
    • Patient Outcome
      • Arrived as a Trauma Alert
      • Surgery to Remove Handlebar
      • Stayed in Hospital Overnight
      • Returned Home Next Day
      • No other deficits
      • LUCKY!
    • What if?
      • Femoral artery was severed?
      • Bleeding was uncontrolled?
      • Patient was unresponsive?
      • Other potential injuries?
    • Femoral artery was severed?
      • Severe Bleeding
      • Death in Maximum Three Minutes
    • Bleeding was uncontrolled?
    • Patient was unresponsive?
      • Manage
        • Airway
        • Breathing
        • Circulation
      • Think Mechanism!
    • Other potential injuries?
      • Head Injury
      • Abdominal Injury
      • Any Extremity Injury
    • Case 3…
    • Dispatch
      • Main Street
      • Injured Person
      • Initial Report: Patient was Playing Basketball and Suffered Facial Trauma
    • What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
    • Upon Arrival
      • 12 Year Old Playing Basketball
      • Lower the Basket so he could Dunk
      • On descent got teeth caught in the net
      • Immediate bleeding
    • Primary Assessment
      • Uncontrolled bleeding
      • Airway-Patient crying
      • Breathing-No SOB, does not appear to be any teeth missing, no coughing choking, or gagging
      • Circulation-Heart Rate 80
    • Does this patient meet alert or code criteria?
    • Secondary Assessment
      • Vitals
        • HR 80, RR 16, BP 128/84
      • Rapid Trauma Assessment Completed
      • No other injuries noted
    • Interventions
      • Airway Compromise?
      • Control Bleeding?
      • Suctioning?
      • Splinting Injury?
    • Oxygen Delivery
      • NB or NC?
      • NPA or OPA?
      • Contraindications
    • Oral Airway
      • Curved device made of rigid plastic
      • Inserted into patient’s mouth
      • Keeps tongue away from back of throat
      • May only be used in unresponsive patients without a gag reflex
    • Nasal Airway
      • Soft, rubbery tube placed in the nose
      • Can be used in unresponsive patients
      • Can be used in semi-responsive patients who have a gag reflex due to
        • Intoxication
        • Drug overdose
    • Transport Decisions
      • ALS?
      • Fly or Drive?
      • Cervical Spine Immobilization?
      • Treat for Shock?
    • What is Shock?
      • Shock is failure of the cardiovascular system to keep adequate blood circulating to the vital organs of the body, namely the heart, lungs and brain
    • Shock
      • Caused by failure of the body’s:
        • Pump (heart)
        • Fluid (blood)
        • Container (blood vessels)
      • Life-threatening condition
      • Types of Shock
        • Cardiogenic Shock
        • Hemorrhagic Shock
        • Hypovolemic Shock
      • Stages of Shock
        • Early (compensated)
        • Late (decompensated)
        • Irreversible (terminal)
    • Signs of Shock
      • Confused behavior
      • Very fast or very slow pulse rate
      • Very fast or very slow breathing
      • Trembling and weakness in the arms or legs
      • Cool and moist skin
      • Pale or bluish skin, lips and fingernails
      • Enlarged pupils
    • Treatment for Shock
      • Putting a victim in a lying-down position improves circulation
      • If the victim is not suspected of having head or neck injuries, or leg fractures, elevate the legs
      • If you suspect head or neck injuries, keep the victim lying flat. If the victim vomits, turn on their side
      • If victim is experiencing trouble breathing, place them in a semi-reclining position
      • Maintain the victim's body temperature, but do not overheat
      • Give oxygen
      • Prevent heat loss
      • Watch closely to make sure airway remains clear
      • Control all obvious external bleeding
      • Perform physical examination
      • Take vital signs, gather medical history
      • Rapid transport
      • Splint any bone or joint injuries en route
      • Comfort, calm, and reassure patient
      • Ongoing assessment every 5 minutes
    •  
    • Patient Outcome
      • Bleeding Controlled
      • Transported to Trauma Center
      • Diagnosed with Open Maxillary Fracture
      • Admitted for Surgery
    • Open Maxillary Fracture
      • Maxilla
        • Upper Jaw
        • Fractures are rare
        • Associated with other injuries
        • Nose or central face fractures
      • Vertical fracture through palatine process
        • Between tooth 6 and 7 on the right
        • Between tooth 10 and 11 on the left
    • Treatment
      • Realign and set the fragmented bone
      • More complex fractures to the maxilla and surrounding bone may need to be treated with a procedure called &quot;open reduction.“
      • This means surgically exposing the bone and re-positioning the fractured pieces with the use of small screws and plates that are attached directly to the bone.
      • These screws are left to hold the bone together while it heals over the following several weeks.
    • In The End…
      • Admitted for Observation
      • On soft food/liquid diet
      • Will return to pre-trauma state
    • Case 4…
    • Dispatch
      • Pedestrian struck by ice cream truck
      • Initial Dispatch:
        • Squad
        • Rescue
        • ALS Unit
    • What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
    • Arrival
    • Findings
      • 10 Year Old
      • Behind Ice Cream Truck
      • Laying on Ground
      • Initial Reactions?
    • Level of Consciousness?
      • AVPU
        • Alert
        • Verbal
        • Painful
        • Unresponsive
        • Responsive to Painful Stimuli
    • Primary Assessment
      • Airway
        • Patent, No bleeding noted
      • Breathing
        • RR 16
      • Circulation
        • HR 60
        • BP 90/60
    • Secondary Assessment Secondary Assessment
      • Focused adjuncts:
        • Full set of vital signs
        • Family
      • Give Comfort:
        • Positioning, padding
        • Meds?
      • History:
      • Inspection:
        • Time to log roll!
    • Injuries
      • Deep Skin Laceration Over the Lateral Malleolus
      • Open Lateral Malleolar Fracture
      • Road Rash
    • Interventions
      • Open Fracture Management
        • Bleeding Control (Don’t Remove Dressings)
        • Irrigation if Necessary (Not if Bleeding)
        • Splinting
          • Check PMS Before and After
          • Secure Above and Below Fracture
        • Air Splint or Vacuum Splint?-Not Suggested
        • Best is Sam Splint
        • Position of Comfort
        • Secure Fracture
        • Continual Reassessment
    • Open Fracture
    • Put Bone Back In?
      • Tissue Damage
      • Vessel Damage
      • Bone Damage
      • Introduce Bacteria
      • Introduce Foreign Bodies
    • Pain Management
      • Ohio Study
      • 1,073 Patients Diagnosed with an Extremity Fracture
      • 182 (17%) Received Ice
      • 268 (25%) Had a Splint Placed
      • 18 (1.67%) Received Pharmacological Treatment
      • What does this show?
    • RICE
      • Rest
      • ICE
      • Compression
      • Elevation
      • Therapeutic Touch?
      • Causes blood vessels to constrict (Will Initially Throb)
      • Decreases Swelling
      • Decreases Pressure
    • Transport Decisions
      • Level of consciousness
      • Pain Management
      • Mechanism
        • Board and Collar?
      • Destination
    • Arrival to ED
      • Report Given to ED
      • Patients Pain Has Decreased
      • Vital Signs Remain Stable
    • Injuries
    • Management
      • Taken to the OR
      • No evidence of tendon injury
      • Laceration of the saphenous vein
      • Possible injury to the sural nerve
      • The periosteum could not be closed over the distal fibula
      • Therefore, local coverage of the subcutaneous tissues and local muscle were mobilized and secured over the bone
      • The wound was left open for drainage, covered with a sterile compressive dressing, and a short-leg splint was applied to the foot
      • Returned to OR three days later for closure
    • Outcome
      • Patient Admitted for 7 Days
      • Left Non-Weight Bearing (Crutches)
      • Follow Up 6 Weeks Later
      • Expected to have full mobility
    • Case 5…
    • Dispatch
      • Froggy Bottom Lane
      • Injured Person
      • Initial Report: Child with a Nose Bleed
    • What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
    • Upon Arrival
      • Child Does Have a Nosebleed
      • Probably Because He Was Running, Fell, and a Pencil Was Shoved Up His Right Nare
      • Treatment Priorities?
    • Concerns
      • How far did the pencil go?
      • Damage that occurred?
      • Remove the pencil or keep it in?
    • Primary Assessment
      • Airway
        • Patent
        • Visible Obstruction in Right Nare
      • Breathing
        • Increased WOB
        • RR 12
      • Circulation
        • Regular rate and rhythm
    • Secondary Assessment Secondary Assessment Secondary Assessment
      • Focused adjuncts:
        • Full set of vital signs
        • Family
      • Give Comfort:
        • Positioning, padding
        • Meds?
      • History:
      • Inspection:
        • Time to log roll!
    • Neurological Assessment
      • Consists of:
      • Normal Neuro Exam
      • Normal Sensation
      • Age appropriate mental status
    • Pencil Stabilization
      • How would you stabilize any object?
      • How about a pencil?
    • Transport Decisions
      • Trauma Center?
      • High Priority?
    • Arrival at Emergency Department
      • Report Given to ED Staff
      • They Get Initial Films to Determine Placement and Damage
    • Pencil Through Nose
    • Now the Real Pictures
    • Findings
      • CT Reveals Pencil is Penetrating Ethmoid Sinus into the Cranial Vault with Evidence of Pneumocephaly
    • Ethmoid Sinus
      • Matchbox-sized areas
      • Filled with 7 to 10 interconnected bubbles
      • Made of very thin-walled bone.
      • These bubbles are lined with mucous membrane
      • Each bubble has its own opening to drain into the nasal cavity
    • Pneumocephaly
      • Pneumocephalus
        • the presence of intra cranial air
        • implies there is a communication between the extra- and intra-cranial compartments.
    • Management
      • Taken to the OR by Neurosurgery
      • Pencil Was Removed
      • Dura was Inspected
        • Had Not Been Penetrated
        • Had Been Stained
      • No CSF Leaks Found
      • Admitted to PICU for Observation of ICP
    • Outcome
      • Patient Remained Stable in PICU
      • Patient DC’d Two Days Later
      • Follow Up Visit One Week Later
        • Normal Cognitively
      • No Need for Additional Follow-Up
    • Case 6…
    • Dispatch
      • State Park, for an Injured Person
      • Winter-Snowing
      • Initial Dispatch: Utility and Squad
    • Where Are We Going?
      • New Partner
      • Never Heard of Location
      • Caller Didn’t Know Exactly Where He Was
    • What are your initial reactions? Scene Size Up Starts at Dispatch
    • Upon Arrival
      • Met by Park Ranger
      • States your apparatus wont be able to make it to the patient
      • Only one person can fit on park ATV
      • You jump on the park ATV and are taken to the patient
      • After traveling for about 2 miles you reach the patient
    • Patient Contact
      • You find a 6 year old who was sledding
      • Using a car hood as a sled, and being pulled by an ATV.
      • The “sled” went into a tree causing the injury
      • Initial thoughts?
    • Primary Assessment
      • Level of Consciousness
        • Positive LOC
      • Airway
        • Jaw Thrust?
      • Breathing
        • Increased WOB
      • Circulation
        • Environmental Concerns?
      • Focused adjuncts:
        • Full set of vital signs
        • Family
      • Give Comfort:
        • Positioning, padding
        • Meds?
      • History:
      • Inspection:
        • Time to log roll!
      Secondary Assessment
    • Injuries Noted
      • 5 CM Laceration on Scalp
      • No Other Injuries Noted
      • Vomited X2
      • No Headache
      • No Visual Disturbances or Changes
    • Management
      • Cervical Spine Precautions Taken
      • Bleeding Controlled by Bandaging Laceration
      • Vital Signs Obtained
      • GCS=15
    • Transport Decisions
      • How do we get the patient to the ambulance?
      • Weather considerations
      • Treat for Shock?
      • Keep Patient Warm
    • What About the Driver
      • As your taking care of your patient, you notice the driver of the ATV has fallen and begins to have a seizure
      • No signs of trauma
      • Manage the seizure which lasts for 1 minute
      • Patient is pale and diaphoretic
      • Vitals are: BP 110/72, HR 112, RR 26
      • The patient regains consciousness and state he has blacked out twice this week
    • What do you think?
    • Huffing
      • Toxic Chemicals are Inhaled from Spray Cans
      • Aerosols-Sprays that Contain Propellants and/or Solvents
      • Common Among Pre-Teens and Adolescents
        • Low Cost
        • Easy Access
        • Absence of Paraphernalia
      • Signs and Symptoms:
        • Apathy, Fatigue, Irritation or Aggression, Forgetfulness, Dizziness, Unsteady Gait, Nystagmus, Anxiety, Slowed Reflexes, Slurred Speech, Red Watery Eyes
    • Huffing Management
      • Only Pre-Hospital Treatment
        • Supportive Care
        • Manage Signs and Symptoms
        • Maintain ABCs
        • Provide Supplemental Oxygen to help Decontaminate the Lungs
    • Critical Thinking
      • Which Patient is Priority?
      • Who Do We Transport First?
      • How Do We Transport?
    • Back to our 6 Year Old
      • Boarded and Collared
      • Taken By Park Ranger Back to Ambulance
      • Secondary Assessment Completed
      • Patient Transported to Local Hospital
    • Arrival at ED
      • Patient in and out of Consciousness En Route
      • Report Given/Initial Assessment Completed
      • CT Scan Completed
    • CT Scan
    • Outcome
      • Parietal Skull Fracture
      • Subdural Bleed
      • Admitted to be Monitored
      • Diagnosed with Concussion
      • Tylenol to Assist with Headache
      • Follow up with Concussion Clinic in 1 Week
    • When Can I Return to Play?
      • All symptoms must disappear
      • Once they disappear, light aerobic exercise can be started
      • If still no symptoms, can begin sport specific exercises
      • If still symptom free, can start NON CONTACT drills
      • If first 4 steps go well contact physician for approval to go back to full activity
    • Summary