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Things That Make You Go Hmm Part 1ppt


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Abnormal Medical and Trauma
Shore EMS Conference 2010

Published in: Education, Health & Medicine
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Things That Make You Go Hmm Part 1ppt

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