Module 3 - Patient Assessment


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  • .Perception of intoxication .In all uncooperative, restless, belligerent patients consider the following as possible causes Hypoxia Hypovolemia Hypoglycemia Head injury/ concussion
  • Mechanism of injury Classification Blunt thoracic trauma - injury resulting from kinetic energy forces transmitted through the tissues. Deceleration - injuries which occur when the body is in motion and strikes a fixed object Compression - crush injury Penetrating thoracic injuries- Object enters chest and causes direct or secondary trauma from transmitted kinetic energy forces related to cavitational wave of high velocity projectiles. a. Low energy - knives, arrows b. High energy - rifles, handguns,
  • Blast injury - Explosions caused by dust, fumes, natural gas, explosive compounds, etc Confined space blast/- shock wave - pressure wave and debris cannot dissipate as far and maintains its energy longer. Danger of structural collapse and debris from confining structure can increase the blast’s projectile content. Creates extremely deadly .overpressures Most lethal blasts cause structural collapse followed by those involving confined spaces.
  • Thoracic cage injuries - rib fracture, flail segment, sternal fracture Cardiovascular - myocardial contusion, pericardial tamponade, myocardial rupture, penetrating cardiac injuries Pleural and pulmonary - simple pneumothorax, open pneumothorax, tension pneumothorax, hemothorax, hemopneumothorax, pulmonary contusion, tracheobronchial tree lacerations Mediastinal - pneumomediastinum Diaphragmatic - penetration, laceration, rupture, intra-abdominal penetration with associated organ injury Esophageal - lacerations Penetrating cardiac - lacerations of aorta, vena cava, pulmonary arteries/veins Spinal cord injuries
  • Blunt trauma to abdomen creates several types of injuries. Solid organs contuse, lacerate, or fracture. Hollow organs may rupture and abdominal vasculature may tear. May have hemorrhage, organ dysfunction, irritation, destruction of abdominal lining. Motor vehicle collisions Head-on or frontal impact Down and under path Up and over path Rear impact Lateral or side impact Rotational impact Rollover Restrained (type of restraint) or unrestrained Seat belt injuries Steering wheel injuries
  • Increased incidence of morbidity and mortality due to delay in surgical intervention. Death occurs as a result of increased hemorrhage due to delay
  • Module 3 - Patient Assessment

    1. 1. ECRN: Assessment Based Management; Thoracic & Abdominal Trauma; Neurological Considerations Condell Medical Center EMS System 2006 Site Code: #10-7214-E-1206 Revised by Sharon Hopkins, RN, BSN
    2. 2. Objectives <ul><li>Upon successful completion of this module, the ECRN should be able to: </li></ul><ul><li>1. Understand the factors that affect patient assessment and decision making capabilities. </li></ul><ul><li>2. Describe the steps of patient assessment based on ITLS guidelines. </li></ul><ul><li>3. Identify mechanisms of injury that can lead to thoracic and abdominal traumatic injuries. </li></ul><ul><li>4. Understand EMS interventions appropriate for thoracic and abdominal injuries. </li></ul>
    3. 3. Objectives cont’d <ul><li>5. Describe a variety of degenerative neurological diseases. </li></ul><ul><li>6. Review case scenarios. </li></ul><ul><li>7. Successfully complete the quiz with a score of 80% or better. </li></ul>
    4. 4. ASSESSMENT BASED MANAGEMENT <ul><li>Involves the use of: </li></ul><ul><ul><li>critical thinking skills </li></ul></ul><ul><ul><li>problem solving abilities </li></ul></ul><ul><ul><li>clinical decision making </li></ul></ul><ul><li>Includes avoiding: </li></ul><ul><ul><li>tunnel vision (can create distractions) </li></ul></ul><ul><ul><li>patient labeling or jumping to conclusions based on preconceived ideas </li></ul></ul><ul><ul><ul><li>“ the drunk”; “the frequent flyer”; “the whiner” </li></ul></ul></ul>
    5. 5. Goals of Our Profession <ul><li>Provide competent, </li></ul><ul><li>compassionate care </li></ul><ul><li>for each and every </li></ul><ul><li>patient interaction </li></ul><ul><li>You need a strong knowledge base and excellent assessment skills to care for patients </li></ul>
    6. 6. Factors Affecting Assessment and Decision-Making <ul><li>Attitude needs to be non-judgmental </li></ul><ul><ul><li>May “short circuit&quot; information gathering leading to insufficient information gathering </li></ul></ul><ul><ul><li>May leap to conclusions before gathering a thorough assessment </li></ul></ul><ul><ul><li>Garbage in = garbage out </li></ul></ul><ul><ul><li>Patients depend on us for medical assessment/ management and not determination of social standing or &quot;likability&quot; </li></ul></ul>
    7. 7. Factors Affecting Assessment and Decision-Making <ul><li>Uncooperative Patients </li></ul><ul><ul><li>Perception of intoxication - drugs or alcohol </li></ul></ul><ul><ul><li>In all uncooperative, restless, belligerent patients consider other possible causes </li></ul></ul><ul><ul><ul><li>hypoxia </li></ul></ul></ul><ul><ul><ul><li>hypovolemia </li></ul></ul></ul><ul><ul><ul><li>hypoglycemia </li></ul></ul></ul><ul><ul><ul><li>head injury </li></ul></ul></ul>
    8. 8. Factors Affecting Assessment and Decision-Making <ul><li>Patient compliance influenced by: </li></ul><ul><ul><li>Patient confidence in the medical team </li></ul></ul><ul><ul><li>Prior experiences of the patient and their family </li></ul></ul><ul><ul><li>Cultural and ethnic barriers </li></ul></ul>
    9. 9. Factors Affecting Assessment and Decision-Making <ul><li>Distracting injuries </li></ul><ul><ul><ul><li>can divert attention from more serious problems </li></ul></ul></ul><ul><li>Need to resist the temptation of forming an initial diagnosis too early </li></ul><ul><li>Gut instincts may lead to snap judgements </li></ul><ul><li>Systematic approach to patient care </li></ul><ul><ul><ul><li>helps prioritize & avoid being swayed by the wrong impression </li></ul></ul></ul>
    10. 10. Factors Affecting Assessment and Decision-Making <ul><li>Distractors in the environment </li></ul><ul><ul><li>Scene chaos </li></ul></ul><ul><ul><li>Violent & dangerous situations </li></ul></ul><ul><ul><li>Crowds of bystanders </li></ul></ul><ul><ul><li>High noise levels </li></ul></ul><ul><ul><li>Crowds of responders </li></ul></ul><ul><ul><ul><li>enough help is crucial but they must be used wisely </li></ul></ul></ul>
    11. 11. General Approach to Patient Assessment in The Field & The ED <ul><li>Size-up the situation </li></ul><ul><ul><li>Identify need for body substance isolation (BSI) </li></ul></ul><ul><ul><ul><li>gloves, gown, mask, eye protection as needed </li></ul></ul></ul><ul><ul><li>Evaluate scene safety </li></ul></ul><ul><ul><ul><li>hazards to yourself, the team, the patient </li></ul></ul></ul><ul><ul><li>Identify mechanism of injury or nature of illness </li></ul></ul><ul><ul><ul><li>can help determine severity of situation </li></ul></ul></ul>
    12. 12. Patient Assessment <ul><li>Initial assessment </li></ul><ul><ul><li>To identify life-threatening conditions </li></ul></ul><ul><ul><li>Mental status (AVPU) </li></ul></ul><ul><ul><ul><li>A - a wake, not necessarily oriented </li></ul></ul></ul><ul><ul><ul><li>V - responding to v erbal stimulation </li></ul></ul></ul><ul><ul><ul><li>P - responding only after touch or lite p ain applied </li></ul></ul></ul><ul><ul><ul><li>U - u nresponsive (absolutely no response) </li></ul></ul></ul><ul><ul><li>Airway assessment </li></ul></ul><ul><ul><li>Breathing assessment </li></ul></ul><ul><ul><li>Circulation status </li></ul></ul><ul><ul><ul><li>pulses present? </li></ul></ul></ul><ul><ul><ul><li>obvious bleeding to be controlled? </li></ul></ul></ul>
    13. 13. Initial assessment cont’d <ul><ul><li>Forming a general impression </li></ul></ul><ul><ul><ul><li>What do you think is going on? </li></ul></ul></ul><ul><ul><ul><li>These answers drive the care you want to start providing. </li></ul></ul></ul><ul><ul><ul><li>Which protocol will you follow? </li></ul></ul></ul>
    14. 14. Patient Assessment <ul><li>Focused history and physical exam performed based on chief complaint and information gathered so far </li></ul><ul><ul><li>trauma patient with significant mechanism of injury or altered mental status </li></ul></ul><ul><ul><ul><li>needs rapid head-to-toe </li></ul></ul></ul><ul><ul><li>trauma patient with isolated injury (ie: ankle sprain) </li></ul></ul><ul><ul><ul><li>focus on body systems related to complaint </li></ul></ul></ul><ul><ul><li>medical patient (responsive) - focus exam on c/o </li></ul></ul><ul><ul><li>medical patient (unresponsive) </li></ul></ul><ul><ul><ul><li>needs rapid assessment with head-to-toe exam when patient input not available </li></ul></ul></ul>
    15. 15. Patient Assessment <ul><li>Vital signs </li></ul><ul><ul><li>CMC ED policy: take and record vital signs minimally every 2 hours or more often as needed </li></ul></ul><ul><li>SAMPLE history - reminds you to obtain: </li></ul><ul><ul><li>s ymptoms </li></ul></ul><ul><ul><li>a llergies </li></ul></ul><ul><ul><li>m edications </li></ul></ul><ul><ul><li>p ertinent past medical history </li></ul></ul><ul><ul><li>l ast oral intake food or liquids including water </li></ul></ul><ul><ul><li>e vents leading up to the incident </li></ul></ul><ul><li>Check for medic alert bracelet, necklace </li></ul>
    16. 16. Blood Pressure <ul><li>A measurement of the force of blood against the walls of the blood vessels </li></ul><ul><li>Reassessment over time gives most accurate reflection of patient state </li></ul><ul><li>Changes in B/P can be very significant </li></ul><ul><li>Is last vital sign to change in decompensation </li></ul><ul><li>Cuff should cover 2 / 3 rds of the upper arm </li></ul><ul><li>Cuff should not be placed over clothing </li></ul><ul><li>Arm should be maintained at heart level </li></ul><ul><li>Obese arm? Wrap cuff around forearm; place stethoscope over radial pulse area </li></ul>
    17. 17. Tips, Tricks & Pearls on Blood Pressure & Pulses <ul><li>B/P by palpation can only determine a systolic reading </li></ul><ul><ul><li>As cuff is deflated, palpate over the radially area until the pulse returns </li></ul></ul><ul><ul><li>Record as “90/systolic” </li></ul></ul><ul><li>Guidelines suggest that palpated pulses equate with systolic blood pressures </li></ul><ul><ul><li>carotid pulse felt means B/P at least 60/systolic </li></ul></ul><ul><ul><li>radial pulse felt means B/P at least 80/systolic </li></ul></ul><ul><li>No peripheral pulse? Think circulatory collapse </li></ul><ul><li>B/P should always be attempted & documented </li></ul>
    18. 18. Patient Assessment <ul><li>Detailed physical exam </li></ul><ul><ul><li>a more detailed & slower head-to-toe exam than the initial one performed </li></ul></ul><ul><ul><li>clinical experience and patient condition often dictate how & if a detailed exam is done in the field & if there is time before ED arrival </li></ul></ul><ul><li>Ongoing Assessment - always done </li></ul><ul><ul><li>used to detect trends, determine changes in patient condition, and assess effectiveness of interventions </li></ul></ul><ul><ul><li>mental status, ABC’s, vital signs (pulse, respirations, B/P, SaO 2 , pain level), EKG </li></ul></ul>
    19. 19. Assessment Techniques <ul><li>Inspection </li></ul><ul><ul><li>observation; looking beyond the obvious </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>use your sense of touch to gather information </li></ul></ul><ul><ul><li>pads of fingers more sensitive than tips for touch </li></ul></ul><ul><ul><li>back of hand is better for sense of temperature </li></ul></ul><ul><li>Percussion - not often done in the field </li></ul><ul><li>Auscultation </li></ul><ul><ul><li>listening for sounds (lungs, heart, intestines) </li></ul></ul><ul><ul><li>for lung sounds, note abnormal sounds, location, timing during inspiration or expiration </li></ul></ul>
    20. 20. Accurate Decision Making <ul><li>Relies on: </li></ul><ul><ul><li>Patient history obtained </li></ul></ul><ul><ul><li>Physical, hands-on exam performed </li></ul></ul><ul><ul><li>Recognizing a pattern </li></ul></ul><ul><ul><ul><li>comparing information gathered with what you already know (existing knowledge base) </li></ul></ul></ul><ul><ul><li>Impression or field diagnosis made </li></ul></ul><ul><ul><ul><li>the first diagnosis is based on the most probable cause of the patient’s complaint based on the information gathered during the assessment </li></ul></ul></ul><ul><ul><ul><li>used to formulate a plan of action based on the patient’s condition and the environment </li></ul></ul></ul>
    21. 21. Use of Protocols & SOP’s <ul><li>Protocol - policies and procedures of all components of the EMS system </li></ul><ul><li>S tandard o perating p rocedures (SOP’s) - preauthorized treatment procedures </li></ul><ul><li>Exercise judgement when following protocol and SOP’s </li></ul><ul><ul><li>know which protocol/SOP to choose </li></ul></ul><ul><ul><li>know when and how to follow protocol/SOP’s </li></ul></ul><ul><ul><li>recognize when you must deviate from the stated protocol/SOP - allergies, abnormal vital signs (ie: hypotension) </li></ul></ul>
    22. 22. SOP’s/Protocols & The ECRN <ul><li>An ECRN, by the restriction of their license, cannot give a medical order; the ECRN is only authorized to give an order if it is printed in the SOP/protocol </li></ul><ul><li>The ECRN must consult with the ED MD to give an order to EMS that is not listed in the SOP (ie: lidocaine drip after bolus given for stable ventricular tachycardia) </li></ul>
    23. 23. Difficulty Establishing An Airway In The Field <ul><li>If EMS cannot establish an airway on any patient in the field, EMS is to transport the patient to the closest Comprehensive Emergency Department even if they are on by-pass </li></ul><ul><li>A Comprehensive Emergency Department is one that is open 24 hours, 7 days a week and has a physician on duty as well as other support services </li></ul>
    24. 24. Communication <ul><li>Hospital reports are best when they: </li></ul><ul><ul><li>Are given in less than one minute </li></ul></ul><ul><ul><li>Are clear and concise </li></ul></ul><ul><ul><li>Avoid use of unfamiliar or unclear medical or technical terms including “10” codes </li></ul></ul><ul><ul><li>Follow a basic format </li></ul></ul><ul><ul><li>Include both pertinent findings and pertinent negatives (findings that would be expected but are not present) </li></ul></ul><ul><ul><li>Conclude with specific actions, requests, or questions related to the plan </li></ul></ul>
    25. 25. Transmission of Patient Information <ul><li>Provider identified by name and vehicle number </li></ul><ul><li>Age, sex, and approximate weight of patient </li></ul><ul><li>Level of consciousness </li></ul><ul><li>Chief complaint and degree of distress </li></ul><ul><li>Vital signs, EKG, pulse oximetry, blood glucose if obtained </li></ul><ul><li>If indicated, lung sounds, pupils, skin condition and color, GCS, pain assessment </li></ul><ul><li>Treatment rendered and patient response </li></ul><ul><li>Patient history </li></ul><ul><li>ETA and destination </li></ul>
    26. 26. Calling Report on Trauma Patients <ul><li>Important for EMS to include information the hospital can use to categorize the trauma level for this patient as well as determine which members of the trauma team that need to be activated </li></ul><ul><ul><li>mechanism of injury </li></ul></ul><ul><ul><li>destruction to vehicle/surroundings </li></ul></ul><ul><ul><li>injuries noted or suspected </li></ul></ul><ul><ul><li>vital signs, GCS </li></ul></ul><ul><li>Restlessness: first think hypoxia & shock </li></ul>
    28. 28. Anatomy & Physiology of the Thorax <ul><li>Thoracic cage responsible for moving air in and out </li></ul><ul><li>Place where carbon dioxide and oxygen exchange takes place to support metabolism </li></ul><ul><li>Includes thoracic skeleton, diaphragm, and supporting musculature </li></ul><ul><li>Location of major organs and vessels </li></ul><ul><ul><li>heart, aorta, trachea, lungs, mediastinum </li></ul></ul>
    29. 29. Thoracic Trauma <ul><li>Classifying thoracic injuries </li></ul><ul><ul><ul><li>Blunt trauma - closed injury from kinetic energy transmitted through tissue </li></ul></ul></ul><ul><ul><ul><ul><li>blasts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>deceleration </li></ul></ul></ul></ul><ul><ul><ul><ul><li>compression/crush </li></ul></ul></ul></ul><ul><ul><ul><li>Penetrating trauma - open wound; direct or indirect trauma transmitted via kinetic energy </li></ul></ul></ul>dart
    30. 30. Blunt Trauma From Blast Injuries <ul><li>Blast injury - explosion caused by dust, fumes, natural gas, explosive compounds </li></ul><ul><li>Confined space blast/shock wave </li></ul><ul><ul><li>pressure wave & debris cannot dissipate as far & so maintains higher energy level longer </li></ul></ul><ul><ul><li>danger of structural collapse & flying debris </li></ul></ul><ul><ul><li>extremely deadly overpressures created </li></ul></ul>
    31. 31. Thoracic Injuries <ul><li>Thoracic cage - ribs & sternal fx, flail segment </li></ul><ul><li>Cardiovascular - contusion, tamponade </li></ul><ul><li>Pleural and pulmonary- contusions, pneumo’s </li></ul><ul><li>Mediastinal - pneumomediastinum </li></ul><ul><li>Diaphragm - tear, laceration, rupture </li></ul><ul><li>Esophageal - laceration </li></ul><ul><li>Penetrating cardiac trauma - laceration aorta, vena cava, pulmonary arteries/veins </li></ul><ul><li>Spinal cord injuries </li></ul>
    32. 32. Flail Chest <ul><li>Definition </li></ul><ul><ul><li>3 or more adjacent ribs broken in 2 or more places </li></ul></ul><ul><li>Most common mechanism of injury - blunt trauma </li></ul><ul><ul><li>falls, MVC, industrial injuries, assaults </li></ul></ul><ul><li>Risks to the patient </li></ul><ul><ul><li>reduces tidal volume (air moving in and out) </li></ul></ul><ul><ul><li>increases respiratory effort </li></ul></ul><ul><ul><li>usually accompanied by pulmonary and possibly cardiac contusions </li></ul></ul>
    33. 33. Flail Chest <ul><li>Signs and symptoms </li></ul><ul><ul><li>paradoxical motion of the chest wall </li></ul></ul><ul><ul><ul><li>asymmetrical chest wall movement; flail segment moves in opposite direction from the rest of the chest </li></ul></ul></ul><ul><ul><li>increased respiratory effort and rate </li></ul></ul><ul><ul><li>decreased pulse oximetry readings </li></ul></ul><ul><ul><li>increased amount of pain to the chest wall </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>support respiratory effort - supplemental O 2 via nonrebreather mask; BVM as needed </li></ul></ul><ul><ul><li>support fractured section manually - no taping of the chest or sandbags/IV’s placed on chest </li></ul></ul><ul><ul><li>EKG monitoring </li></ul></ul>
    34. 34. Sucking Chest Wound <ul><li>Definition </li></ul><ul><ul><li>open wound of the chest with air passage into the pleural space </li></ul></ul><ul><li>Risks to the patient </li></ul><ul><ul><li>collapse of the lung on the affected side </li></ul></ul><ul><ul><li>uninjured lung unable to fully expand </li></ul></ul><ul><ul><li>change in intrathoracic pressures negatively affect venous return to the heart </li></ul></ul><ul><ul><li>if the chest wall opening is at least 2 / 3 the diameter of the trachea (normally the size of the patient’s little finger), air will move in & out thru the chest wall defect & not thru the trachea </li></ul></ul>
    35. 35. Sucking Chest Wound <ul><li>Signs and symptoms </li></ul><ul><ul><li>open wound to the thorax & frothy blood noted around the chest wall defect </li></ul></ul><ul><ul><li>gurgling sound heard near the chest wound </li></ul></ul><ul><ul><li>severe dyspnea </li></ul></ul><ul><ul><li>possible hypovolemia - associated injury & hemorrhage </li></ul></ul><ul><ul><li>increased pulse rate & respiratory rate; decreased blood pressure </li></ul></ul><ul><ul><li>evidence of air hunger if, with each breath, more air enters thru the chest wall defect than thru the trachea </li></ul></ul>
    36. 36. Sucking Chest Wound <ul><li>Treatment </li></ul><ul><ul><li>Immediately seal the chest wound (gloved hand to start with if necessary); eventually with occlusive dressing taped on 3 sides </li></ul></ul><ul><ul><li>Open pneumothorax now converted to closed pneumothorax - watch for increased respiratory distress leading to tension pneumothorax </li></ul></ul><ul><ul><ul><li>if needed, burp dressing by lifting one corner during exhalation </li></ul></ul></ul><ul><ul><li>O 2 via nonrebreather mask </li></ul></ul><ul><ul><li>Monitor vital signs, pulse ox, EKG </li></ul></ul>
    37. 37. Tension Pneumothorax <ul><li>Definition </li></ul><ul><ul><li>An open or simple pneumothorax that generates and maintains a greater pressure than atmospheric pressure within the thorax via a created one-way valve </li></ul></ul><ul><li>Risks to the patient </li></ul><ul><ul><li>Air is trapped in the pleural space and puts pressure on the affected lung, the structures in the mediastinum, the opposite lung </li></ul></ul>
    38. 38. Tension Pneumothorax (rare & late sign not often appreciated) decreased B/P Low pulse ox, narrowed pulse pressure (JVD) Dyspnea, SOB PEA tachycardia
    39. 39. Needle Decompression <ul><li>Treatment </li></ul><ul><ul><li>Provide supplemental oxygenation (nonrebreather mask) or BVM </li></ul></ul><ul><ul><li>Initially perform needle decompression </li></ul></ul><ul><ul><ul><li>identify site: 2 nd intercostal space in midclavicular line; above the rib </li></ul></ul></ul><ul><ul><ul><li>prep the site </li></ul></ul></ul><ul><ul><ul><li>prepare a flutter valve on a 3  large gauged needle </li></ul></ul></ul><ul><ul><ul><li>insert 3  needle largest gauge available (12-14g) straight into the chest wall over the top of a rib </li></ul></ul></ul><ul><ul><ul><li>can take the plug off the catheter end and attach a syringe </li></ul></ul></ul><ul><ul><ul><li>upon feeling a “pop” or noting air return in syringe, advance catheter & remove needle; secure catheter </li></ul></ul></ul>
    40. 40. Needle Decompression
    41. 41. Hemothorax <ul><li>Definition </li></ul><ul><ul><li>an accumulation of blood in the pleural space due to internal hemorrhage </li></ul></ul><ul><ul><li>more of a blood loss problem than an airway issue </li></ul></ul><ul><ul><li>each side of the thorax may hold up to 3000 ml of blood </li></ul></ul><ul><li>Risks to the patient </li></ul><ul><ul><li>hypovolemic shock </li></ul></ul><ul><ul><li>reduction of tidal volume & efficiency of ventilations </li></ul></ul>
    42. 42. Hemothorax Signs & Symptoms decreased blood pressure History blunt or penetrating trauma
    43. 43. Hemothorax <ul><li>Treatment </li></ul><ul><ul><li>support the patient with supplemental oxygenation (nonrebreather mask) and potentially BVM </li></ul></ul><ul><ul><li>IV access for fluid resuscitation </li></ul></ul><ul><ul><ul><li>20 ml/kg normal saline (Routine Trauma Care Protocol) </li></ul></ul></ul><ul><ul><ul><li>carefully administer fluids to avoid worsening the edema and congestion of pulmonary contusions </li></ul></ul></ul><ul><li>Note: </li></ul><ul><ul><li>Hemothorax is primarily a blood loss problem more than a respiratory one </li></ul></ul>
    44. 44. Cardiac Tamponade <ul><li>Definition </li></ul><ul><ul><li>A restriction to cardiac filling caused by blood or fluid in the pericardial sac </li></ul></ul><ul><li>Most common mechanism of injury </li></ul><ul><ul><li>penetrating trauma (could be medical problem) </li></ul></ul><ul><li>Risks to the patient </li></ul><ul><ul><li>accumulating blood exerts pressure on the heart </li></ul></ul><ul><ul><li>pressure limits cardiac filling restricting venous return to the heart </li></ul></ul><ul><ul><li>cardiac output is diminished </li></ul></ul>
    45. 45. Cardiac Tamponade Muffled heart tones agitation (JVD) Diaphoretic, ashen or cyanotic PEA
    46. 46. Cardiac Tamponade <ul><li>Treatment </li></ul><ul><ul><li>keep high index of suspicion </li></ul></ul><ul><ul><li>field care limited to supportive oxygenation (nonrebreather mask or BVM),IV fluids, and rapid transport </li></ul></ul><ul><ul><li>definitive care must be provided in-hospital </li></ul></ul><ul><ul><ul><li>removal of some of the accumulated fluid from the pericardial sac in the ED and then patient needs to go to the OR </li></ul></ul></ul>
    47. 47. ABDOMINAL TRAUMA A high degree of suspicion must be exercised based on mechanism of injury and kinematics.
    48. 48. Abdominal Anatomy and Physiology <ul><li>Boundaries </li></ul><ul><ul><li>superiorly the diaphragm </li></ul></ul><ul><ul><li>inferiorly the pelvis </li></ul></ul><ul><ul><li>posteriorly the vertebral column, posterior & inferior ribs, back muscles </li></ul></ul><ul><ul><li>laterally the flank muscles </li></ul></ul><ul><ul><li>anteriorly the abdominal muscles </li></ul></ul>
    49. 49. Abdominal Anatomy and Physiology <ul><li>The 3 abdominal spaces </li></ul><ul><ul><li>peritoneal space </li></ul></ul><ul><ul><ul><li>organs or portions of organs covered by abdominal (peritoneal) lining </li></ul></ul></ul><ul><ul><li>retroperitoneal space </li></ul></ul><ul><ul><ul><li>organs posterior to the peritoneal lining </li></ul></ul></ul><ul><ul><li>pelvic space </li></ul></ul><ul><ul><ul><li>organs contained within the pelvis </li></ul></ul></ul>
    50. 50. Abdominal Quadrants <ul><li>RUQ </li></ul><ul><ul><li>gallbladder, right kidney, most of the liver, some small bowel, portion of ascending & transverse colon, small portion of pancreas </li></ul></ul><ul><li>LUQ </li></ul><ul><ul><li>stomach, spleen, left kidney, most of pancreas, portion of liver, small bowel, transverse & descending colon </li></ul></ul><ul><li>RLQ </li></ul><ul><ul><li>appendix, portions urinary bladder, small bowel, ascending colon, rectum, female genitalia </li></ul></ul><ul><li>LLQ - sigmoid colon, portion urinary bladder, small bowel, descending colon, rectum, female genitalia </li></ul>
    51. 51. Blunt Abdominal Trauma <ul><li>Produces least visible signs of injury </li></ul><ul><li>Responsible for 40% of splenic injuries </li></ul><ul><li>Responsible for 20% or liver injuries </li></ul><ul><li>Bowel and kidneys next most frequently injured organs </li></ul><ul><li>Injuries must be anticipated by evaluating mechanism of injury with force & direction of impact </li></ul><ul><li>Maintain high index of suspicion based on mechanism of injury </li></ul>
    52. 52. Blunt Mechanisms <ul><li>Compression forces </li></ul><ul><li>Shear forces </li></ul><ul><li>Deceleration forces </li></ul><ul><li>Motor vehicle crashes </li></ul><ul><li>Motorcycle collisions </li></ul><ul><li>Pedestrian injuries </li></ul><ul><li>Falls </li></ul><ul><li>Assault </li></ul><ul><li>Blast injuries </li></ul>
    53. 53. Penetrating Abdominal Trauma <ul><li>Low velocity - injury limited to the direct area </li></ul><ul><ul><li>Knife, ice pik </li></ul></ul><ul><li>Medium velocity </li></ul><ul><ul><li>Handgun & shotgun wounds </li></ul></ul><ul><li>High velocity </li></ul><ul><ul><li>High power hunting rifles </li></ul></ul><ul><ul><li>Military weapons </li></ul></ul><ul><li>Ballistics - study of projectiles in motion </li></ul><ul><li>Trajectory - path a projectile follows </li></ul><ul><li>Distance traveled a consideration </li></ul>
    54. 54. Evisceration of the bowel caused by a knife wound Cover eviscerated area with sterile, moistened dressing Minimize patient movement, coughing
    55. 55. Hollow Organ Injury <ul><li>Hollow organs </li></ul><ul><ul><li>Stomach, small bowel, large bowel, rectum, urinary bladder, gallbladder, pregnant uterus </li></ul></ul><ul><li>Anticipated injuries </li></ul><ul><ul><li>May rupture due to forces especially if the organ is full and distended </li></ul></ul><ul><ul><li>Can cause hemorrhage and spillage of the contents into the peritoneal, retroperitoneal or pelvic spaces </li></ul></ul><ul><ul><li>Contents spilled may have high bacterial counts, contain irritating chemicals, have high acid counts, or contain digestive enzymes </li></ul></ul>
    56. 56. Solid Organ Injury <ul><li>Solid organs </li></ul><ul><ul><li>spleen, liver, pancreas, kidneys </li></ul></ul><ul><li>Anticipated injuries </li></ul><ul><ul><li>Prone to contuse resulting in organ damage; bleeding often minimal if organ intact and contained within the organ but could be severe </li></ul></ul><ul><ul><li>If organ torn or lacerated may cause life-threatening hemorrhage </li></ul></ul>
    57. 57. Patient Assessment <ul><li>Maintain high index of suspicion </li></ul><ul><li>Serious trauma to the abdomen is often a surgical problem and requires prompt and rapid transport with frequent reassessment </li></ul><ul><li>Identify additional causative forces of injury </li></ul><ul><ul><li>seatbelt worn above the iliac crest </li></ul></ul><ul><ul><li>no seatbelt restraint used, steering wheel deformity </li></ul></ul><ul><ul><li>type of weapon used in penetrating trauma </li></ul></ul>
    58. 58. Patient Assessment For Abdominal Trauma <ul><li>Early signs of serious or continuing internal hemorrhage </li></ul><ul><ul><li>diminishing level of consciousness </li></ul></ul><ul><ul><li>increasing anxiety or restlessness </li></ul></ul><ul><ul><li>thirst </li></ul></ul><ul><ul><li>increasing pulse rate </li></ul></ul><ul><ul><li>decreasing pulse pressure - systolic and diastolic numbers moving closer together </li></ul></ul><ul><ul><li>increasing capillary refill time (>2 seconds) </li></ul></ul><ul><ul><li>increasing abdominal distention, bruising </li></ul></ul>
    59. 59. Abdominal Assessment <ul><li>Inspection </li></ul><ul><ul><li>Redness, ecchymosis, contusions, open wounds, distention </li></ul></ul><ul><ul><li>May hold up to 1.5 L of blood before distended </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Gently palpate each quadrant individually with tips of fingers </li></ul></ul><ul><ul><li>Quadrants with pain or injury are palpated last </li></ul></ul><ul><ul><li>Distention, tenderness, crepitus, instability, guarding, pulsations </li></ul></ul><ul><li>Auscultation - Not often done in field in trauma - too much time and need for quieter environment </li></ul>
    60. 60. Initial Abdominal Trauma Treatment <ul><li>Timely, thorough assessment repeated often </li></ul><ul><ul><li>Critical findings: rigid or distended abdomen or guarding; presence of shock; shock out of proportion to findings (maybe haven’t found all the sources of bleeding yet) </li></ul></ul><ul><li>Supportive oxygenation (nonrebreather mask) </li></ul><ul><li>IV access </li></ul><ul><li>EKG monitoring </li></ul>
    61. 61. Neurological Emergencies <ul><ul><li>The human body’s ability to maintain a state of homeostasis results primarily from the nervous system’s regulatory and coordinating activities </li></ul></ul><ul><li>A disruption in the nervous system affects the functioning of the body and can be in a variety of forms from simple to severe </li></ul>
    62. 62. Headache <ul><li>Common ailment </li></ul><ul><li>Described as a symptom rather than a disorder </li></ul><ul><li>Can accompany many disorders </li></ul><ul><li>Can be brought on by emotional events </li></ul><ul><li>Recurring headaches may be an early sign of a more serious disease </li></ul><ul><li>Most are caused by vasodilatation in tissues surrounding the brain </li></ul>
    63. 63. Headache <ul><li>Immediate attention is needed if: </li></ul><ul><ul><li>Severe and sudden in onset </li></ul></ul><ul><ul><li>Other neurological impairments such as visual disturbances, confusion, motor dysfunction or sensory loss also occur </li></ul></ul><ul><ul><li>Accompanied by fever or stiff neck </li></ul></ul><ul><ul><li>Patient states “the worse headache in my life” </li></ul></ul>
    64. 64. Types of Headache <ul><li>Migraine </li></ul><ul><ul><li>Usually one sided and accompanied by nausea </li></ul></ul><ul><ul><li>Personal or environmental triggers </li></ul></ul><ul><ul><li>Dietary substances or medication triggers </li></ul></ul><ul><li>Cluster </li></ul><ul><ul><li>Unilateral intense pain over and behind the eye </li></ul></ul><ul><ul><li>Lasts about an hour and occur in clusters (bunches) </li></ul></ul><ul><li>Tension </li></ul><ul><ul><li>Prolonged overwork or stress </li></ul></ul><ul><ul><li>Usually occipital region </li></ul></ul>
    65. 65. Headache <ul><li>Treatment in general </li></ul><ul><ul><li>Medications based on individual history, symptoms and needs </li></ul></ul><ul><ul><li>Analgesics may or may not be effective </li></ul></ul><ul><ul><li>Mild diuretics may be effective at times </li></ul></ul><ul><ul><li>Dark environment </li></ul></ul><ul><ul><li>Rest </li></ul></ul><ul><ul><li>Determine trigger and use avoidance </li></ul></ul><ul><li>Accurate diagnosis necessary in case of more severe problem! </li></ul>
    66. 66. Neoplasms - Tumor <ul><li>Any abnormal growth of cells </li></ul><ul><li>May be benign or malignant </li></ul><ul><li>Cell multiplication is fast and uncontrolled </li></ul><ul><li>Classified by origin </li></ul><ul><li>Treatment - depends on type, location & age of tumor </li></ul><ul><ul><li>Observation </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>Radiation therapy </li></ul></ul><ul><ul><li>Surgical removal </li></ul></ul>
    67. 67. Malignant Neoplasms <ul><ul><li>Cancerous tumor </li></ul></ul><ul><ul><li>Embryonic or poorly differentiated cells </li></ul></ul><ul><ul><li>Grow in a disorganized manner </li></ul></ul><ul><ul><li>Necrosis and ulceration is common sign </li></ul></ul><ul><ul><li>Invasion of surrounding tissue for nutritional needs </li></ul></ul><ul><ul><li>Metastatic in nature (i.e.: Initiates growth of like tumors in other areas) </li></ul></ul>
    68. 68. Benign Neoplasms <ul><li>Usually not dangerous to life unless they occur in a vital organ </li></ul><ul><li>Slow growth </li></ul><ul><li>Do not invade tissue for nutrition </li></ul><ul><li>Usually encapsulated </li></ul><ul><li>Do not form secondary tumors in other organs </li></ul>
    69. 69. Assessment of Neoplasms <ul><li>Some are painful yet some have no pain at all </li></ul><ul><li>External presentation </li></ul><ul><ul><li>Irregular borders </li></ul></ul><ul><ul><li>Rough texture </li></ul></ul><ul><ul><li>Brown/black in color </li></ul></ul><ul><li>Capsule formation under the skin </li></ul><ul><li>Ulceration of overlying skin </li></ul><ul><li>Dependant on the organ or organ system affected </li></ul>
    70. 70. Neoplasm <ul><li>When to be concerned : </li></ul><ul><ul><li>Change in bowel or bladder habits </li></ul></ul><ul><ul><li>A sore throat that does not heal </li></ul></ul><ul><ul><li>Unusual bleeding or discharge </li></ul></ul><ul><ul><li>Thickening on breast or other soft tissue </li></ul></ul><ul><ul><li>Indigestion or difficulty swallowing </li></ul></ul><ul><ul><li>Obvious change in a wart or mole </li></ul></ul><ul><ul><li>Nagging cough or hoarseness </li></ul></ul>
    71. 71. Neoplasm Treatment <ul><li>Chemotherapy </li></ul><ul><ul><li>Intravenous pharmacological therapy to slow growth or kill tumors </li></ul></ul><ul><ul><li>Cytotoxic to all cells of the body even though target is cancerous cells </li></ul></ul><ul><ul><li>Can cause lethargy, hair loss, unsteady gait, weakness and nausea </li></ul></ul>
    72. 72. Neoplasm Treatment <ul><li>Radiation therapy </li></ul><ul><ul><li>Ionizing radiation </li></ul></ul><ul><ul><li>Dose of particulate or electromagnetic radiation to a specific area of the organ or body </li></ul></ul><ul><ul><li>Can come from outside the body or inside the body (implanted radiotherapy) </li></ul></ul><ul><ul><li>More effective and less harmful than when first introduced </li></ul></ul>
    73. 73. Neoplasm Treatment <ul><li>Surgical intervention </li></ul><ul><ul><li>Dependant on type and amount of tissue involvement with the tumor </li></ul></ul><ul><ul><li>Can be radical or precise </li></ul></ul><ul><ul><li>Can be used in conjunction with other therapy methods </li></ul></ul><ul><ul><li>Can cause self esteem issues </li></ul></ul>
    74. 74. Neoplasms <ul><li>Prevention strategies to include in patient teaching: </li></ul><ul><ul><li>Self breast exams </li></ul></ul><ul><ul><li>Mammograms </li></ul></ul><ul><ul><li>PAP smears </li></ul></ul><ul><ul><li>Yearly physical exams </li></ul></ul><ul><ul><li>Self testicular exams </li></ul></ul><ul><ul><li>Prostate screening </li></ul></ul><ul><ul><ul><li>PSA </li></ul></ul></ul><ul><ul><ul><li>Digital inspection </li></ul></ul></ul><ul><ul><li>Seek medical evaluation early after abnormal finding </li></ul></ul>
    75. 75. Bell’s Palsy <ul><li>Seventh cranial nerve inflammation or trauma </li></ul><ul><li>Temporary weakness or paralysis in facial muscles </li></ul><ul><li>Can reoccur </li></ul><ul><li>Good to complete recovery with nerve regeneration </li></ul><ul><li>Conditions that compromise the immune system increase odds of disease </li></ul><ul><ul><li>Lyme disease, herpes viruses, mumps and HIV infections </li></ul></ul>
    76. 76. Degenerative Neurological Disorders <ul><li>Muscular fatigue usually attributed to interruption in the ability of the axon to communicate with the muscular endplate for various reasons </li></ul><ul><li>Symptoms can be mild to severe depending on manifestation and advancement of the disease process; can come and go; can be localized or systemic </li></ul><ul><li>Chronic conditions can be debilitating and affect quality of life </li></ul>
    77. 77. Degenerative Neurological Disorders <ul><li>Pathophysiology is variable and dependant on the specific disease </li></ul><ul><li>Some are caused by an autoimmune type response to a toxic invader </li></ul><ul><ul><li>Example: Multiple sclerosis </li></ul></ul><ul><li>Some are the muscle’s inability to use the proteins provided by the body as fuel </li></ul><ul><ul><li>Example: Muscular dystrophy </li></ul></ul><ul><li>Some are actual nerve tissue breakdown </li></ul><ul><ul><li>Example: Parkinson’s disease </li></ul></ul>
    78. 78. Degenerative Neurological Disorders <ul><li>Partial facial paralysis </li></ul><ul><ul><li>Example: Bell’s Palsy </li></ul></ul><ul><li>Degeneration of the cell bodies in the gray matter of the anterior spinal cord, brain stem and pyramidal tract </li></ul><ul><ul><li>Example: Amyotrophic Lateral Sclerosis (ALS) </li></ul></ul><ul><li>Contraction of muscles or muscle groups that can contribute to convulsive disorders </li></ul><ul><ul><li>Example: Myoclonus </li></ul></ul>
    79. 79. Degenerative Neurological Disorders <ul><li>An abnormal closing of the protective bony casement for the spinal cord. Nervous meninges may or may not be exposed </li></ul><ul><ul><li>Example: Spina bifida </li></ul></ul><ul><li>Non-inflammatory lesions that affect the peripheral nervous system </li></ul><ul><ul><li>Example: Peripheral neuropathy </li></ul></ul>
    80. 80. Degenerative Neurological Disorders <ul><li>General disease manifestations </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>General body aches </li></ul></ul><ul><ul><li>Partial paralysis that comes and goes </li></ul></ul><ul><ul><li>Parasthesia - pins & needles sensation </li></ul></ul><ul><ul><li>Peripheral sensory impairment </li></ul></ul><ul><ul><li>Respiratory insufficiency (chronic stages) </li></ul></ul><ul><ul><li>Immunosuppression - more vulnerable to contract communicable diseases </li></ul></ul><ul><ul><li>Multiple medication interactions </li></ul></ul>
    81. 81. Degenerative Neurological Disorders <ul><li>Pharmacological interventions range from anti-inflammatory drugs to experimental protein altering medications </li></ul><ul><li>Medication usage depends on the organ system involved and the severity of symptom </li></ul><ul><li>Environmental changes (living in a cool area) can help some diseases </li></ul><ul><li>Decreased exercise or production of muscular heat can decrease symptoms </li></ul>
    82. 82. Degenerative Neurological Disorders <ul><li>Caring for the patient in crisis must include maintaining ABC’s </li></ul><ul><li>Endotracheal intubation or bagging the patient through an in-place tracheostomy may be necessary </li></ul><ul><li>Supportive care for hypotension </li></ul><ul><li>Patients may need total lift assistance to move </li></ul>
    83. 83. Muscular Dystrophy <ul><li>Inherited through DNA degeneration of muscle fibers </li></ul><ul><li>Early recognition in children who are slow to sit and walk </li></ul><ul><li>Calf muscles become bulky as wasted muscle turns to fat </li></ul><ul><li>Pulmonary infections and heart failure are frequent causes of death </li></ul>
    84. 84. Multiple Sclerosis <ul><li>Myelin in the brain and spinal cord are destroyed. Autoimmune system sees myelin as foreign material. </li></ul><ul><li>Experience numbness to paralysis </li></ul><ul><li>Damage to white matter causes fatigue, vertigo, unsteady gait, slurred speech, pain </li></ul><ul><li>Some disable at onset; others degenerative over many years </li></ul>
    85. 85. Structure of the Neuron and Multiple Sclerosis <ul><li>The myelin sheath is a membranous extension of specialized cells called oligodendrocytes. These form an insulating substance. Non-myelinated axons (not insulated) conduct impulses very slowly </li></ul>
    86. 86. Parkinson’s Disease <ul><li>Degeneration of nerve cell in basal ganglia in the brain </li></ul><ul><li>Lack of dopamine inhibits basal ganglia from modifying nerve pathways that control muscle contraction </li></ul><ul><li>Tremors, joint rigidity </li></ul><ul><li>Leading cause of neuro disability in those over 60 years old </li></ul>
    87. 87. Lou Gehrig’s Disease - ALS <ul><li>Progressive motor neuron disease </li></ul><ul><li>Types </li></ul><ul><ul><li>Spinal muscular atrophy </li></ul></ul><ul><ul><li>Bulbar palsy </li></ul></ul><ul><ul><li>Primary lateral sclerosis </li></ul></ul><ul><ul><li>Pseudobulbar palsy </li></ul></ul>
    88. 88. Amyotrophic Lateral Sclerosis (ALS) Upper motor neurons affected in the central nervous system; lower motor neurons affected in the peripheral muscles
    89. 89. Amyotrophic Lateral Sclerosis (ALS) <ul><ul><li>More common men over 50 </li></ul></ul><ul><ul><li>Weakness, quivering (fasciculations) </li></ul></ul><ul><ul><li>Unable to speak, swallow, move, breath on own </li></ul></ul><ul><ul><li>Intellect and awareness maintained </li></ul></ul><ul><ul><li>Become ventilator dependent </li></ul></ul><ul><ul><li>Aspiration pneumonia constant threat </li></ul></ul><ul><ul><li>Starvation, failure to thrive </li></ul></ul>
    90. 90. Trigeminal Neuralgia <ul><li>Trigeminal nerve – 5 th cranial nerve with opthalmic, maxillary and mandibular functions </li></ul><ul><li>Affects skin of upper eye, side of nose, half of scalp </li></ul><ul><li>Affects mucous membranes of nose, forehead, upper lip </li></ul><ul><li>Affects lower teeth and tongue </li></ul>
    91. 91. Peripheral Neuropathy <ul><li>Axon or myelin sheath in peripheral nervous system damaged/irritated causing blockage of electrical signals </li></ul><ul><li>Can affect: </li></ul><ul><ul><li>muscle activity </li></ul></ul><ul><ul><li>sensation </li></ul></ul><ul><ul><li>reflexes </li></ul></ul><ul><ul><li>internal organ function </li></ul></ul><ul><li>Can be caused locally - trauma, compression (tight casts, tourniquet use), carpal tunnel, infections </li></ul><ul><li>Can be demyelination or degeneration of peripheral nerves - diabetes, Guillain-Barre syndrome </li></ul>
    92. 92. Myoclonus <ul><li>Temporary, involuntary rapid, uncontrolled muscular contractions (jerking) or twitching of a group of muscles </li></ul><ul><li>Generally considered a symptom more than a diagnosis </li></ul><ul><li>Can occur at rest or during movement </li></ul><ul><li>Can distort normal movement and interfere with the ability to eat, walk, and talk </li></ul>
    93. 93. Spina Bifida <ul><li>Defect of neural tube closure </li></ul><ul><li>Portion of vertebra fails to develop leaving a portion of the spinal cord unprotected </li></ul><ul><li>Lower back most affected </li></ul><ul><li>Nerve damage is permanent </li></ul><ul><li>Long term effects </li></ul><ul><ul><li>physical & mobility limitations </li></ul></ul><ul><ul><li>loss of bowel & bladder control </li></ul></ul><ul><ul><li>most have some form of a learning disability </li></ul></ul>
    94. 94. Spina Bifida
    95. 95. Degenerative Neurological Diseases <ul><li>Make treating the chief complaint a priority </li></ul><ul><ul><li>Do not overlook the underlying history but do not allow it to cloud judgement for a more serious issue </li></ul></ul><ul><li>Management Plan </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><ul><li>Acute or chronic complaint for today? </li></ul></ul></ul><ul><ul><ul><li>General health? </li></ul></ul></ul><ul><ul><ul><li>Previous medical conditions? </li></ul></ul></ul><ul><ul><ul><li>Medications? </li></ul></ul></ul>
    96. 96. Degenerative Neurological Diseases <ul><li>Management </li></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Position of comfort </li></ul></ul><ul><ul><li>Venous access </li></ul></ul><ul><ul><li>Pharmacological interventions </li></ul></ul><ul><ul><ul><li>Check for hypoglycemia in setting of altered level of consciousness </li></ul></ul></ul><ul><ul><ul><li>Antihistamine - benadryl for dystonic reactions (impairment of muscle tone (peculiar posturing & difficulty speaking) after exposure usually to certain meds) </li></ul></ul></ul><ul><ul><ul><li>Psychological support </li></ul></ul></ul>
    97. 97. Degenerative Neurological Diseases <ul><li>Treatment concerns: </li></ul><ul><ul><li>mobility often limited </li></ul></ul><ul><ul><li>communication often difficult - hearing, speech unclear </li></ul></ul><ul><ul><li>respiratory compromise - especially exacerbations of underlying problems </li></ul></ul><ul><ul><li>anxiety - coping with debilitating disease difficult on patient and family & stress and anxiety levels can run high </li></ul></ul>
    98. 98. Case Study #1 <ul><li>32 year old male unrestrained in head-on MVC at 55 mph </li></ul><ul><li>Awake & oriented, increased respiratory rate, weak & rapid radial pulse </li></ul><ul><li>Major complaint is pain to the left side of the chest with evident redness, crepitation felt on palpation </li></ul><ul><li>Vital signs: B/P 102/50; P - 108; R - 24 pulse ox 94%; EKG - sinus tachycardia </li></ul><ul><li>Breath sounds - decreased left side </li></ul>
    99. 99. Case Study #1 <ul><li>General impression (what are possibilities)? </li></ul><ul><ul><li>Cardiac contusions </li></ul></ul><ul><ul><li>Lung contusions </li></ul></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><li>The patient is becoming more restless with increased anxiety; pulse ox dropping to 84%; respiratory rate climbing to 38 and now shallow with increasing dyspnea </li></ul><ul><li>What’s going on now? </li></ul>
    100. 100. Case Study #1 <ul><li>Reassess ABC’s </li></ul><ul><ul><li>Airway still open </li></ul></ul><ul><ul><li>Breathing getting more difficult </li></ul></ul><ul><ul><li>Breath sounds absent on the left </li></ul></ul><ul><ul><li>Pulse more rapid and thready and barely palpable radially </li></ul></ul><ul><li>Impression: </li></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Initially needle decompression </li></ul></ul>
    101. 101. Case Study #1 <ul><li>Landmarks for needle decompression? </li></ul><ul><ul><li>2 nd intercostal space in the midclavicular line </li></ul></ul><ul><ul><li>Be above the rib (avoid vessels & nerves that run under the rib) </li></ul></ul><ul><li>Equipment used in the field </li></ul><ul><ul><li>Largest gauge & longest needle available </li></ul></ul><ul><ul><ul><li>12-14 G and 3 inches long </li></ul></ul></ul><ul><ul><li>Flutter valve prepared </li></ul></ul><ul><ul><li>Skin prepped </li></ul></ul><ul><ul><li>Needle must be secured in place </li></ul></ul>
    102. 102. Case Study #2 <ul><li>55 year old extremely obese female unrestrained rear seat passenger of taxi cab involved in 60 mph MVC </li></ul><ul><li>Patient is agitated, complaining of pain all over (was thrown around back of cab) </li></ul><ul><li>Patient is pale, slightly diaphoretic (apologizes because she says she is always somewhat sweaty), unable to feel radial pulse “because of fat wrists” </li></ul>
    103. 103. Case Study #2 <ul><li>If unable to take a blood pressure in the upper arm, what are alternatives? </li></ul><ul><li>Place the cuff around the forearm and place the stethoscope over the radial pulse area. </li></ul><ul><li>Not acceptable to not attempt any kind of blood pressure. </li></ul><ul><li>Why is this patient so restless? </li></ul><ul><li>Don’t be fooled by the obvious and don’t dismiss her concerns to her “weight” </li></ul>
    104. 104. Case Study #2 <ul><li>What can cause restlessness? </li></ul><ul><li>Hypoxia </li></ul><ul><li>Hypovolemia </li></ul><ul><li>Internal injury </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Pain </li></ul><ul><li>Anxiety; being scared </li></ul><ul><li>Being uncomfortable (pain, positioning, full bladder) </li></ul>
    105. 105. Acknowledgement <ul><li>NIMSCA contribution for packet by: </li></ul><ul><ul><li>Kathy Wexelberg RN, Advocate Christ </li></ul></ul><ul><ul><li>Marlene Blacklaw, RN, Advocate Christ </li></ul></ul><ul><ul><li>Lonnie Polhemus, EMT-P, Silver Cross </li></ul></ul><ul><li>Additions made by: </li></ul><ul><ul><li>Sharon Hopkins, RN, BSN, </li></ul></ul><ul><ul><li>Condell Medical Center </li></ul></ul><ul><ul><li>Region X SOP’s, Effective March 2005 </li></ul></ul>