Refresher Program


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Refresher Program

  1. 1. Prehospital Trauma Life Support PHTLS Refresher Program
  2. 2. Course Purpose <ul><li>Reaffirm knowledge of prehospital trauma care </li></ul><ul><li>Introduce recent changes in trauma care as it affects the prehospital patient </li></ul><ul><li>Demonstrate proficiency at performing skills necessary in the care of critically injured patients </li></ul>
  3. 3. Prehospital Trauma Life Support Managing the Multisystem Trauma Patient Part I
  4. 4. Objectives <ul><li>Discuss the laws of energy and motion </li></ul><ul><li>Discuss trauma associated with blunt impact and penetrating injury </li></ul><ul><li>Overview of the effects of energy distribution in MVCs </li></ul><ul><li>Review the kinematics of blast and violent injuries </li></ul><ul><li>Use kinematics to predict injury patterns </li></ul>
  5. 5. Predicting Injury In a 50 mph (80 km/h) MVC, what types of injuries would occur if the patient were to strike the windshield?
  6. 6. What type of injury patterns might you see in a frontal impact? Frontal Impact
  7. 7. What types of injuries would you expect? Rear Impact
  8. 8. What types of injuries would you expect? Lateral Impact
  9. 9. What types of injuries would you expect? Rotational Impact
  10. 10. What injury patterns might you see following this crash? Rollover
  11. 11. <ul><li>Warfare/terrorism </li></ul><ul><li>Industrial/residential </li></ul><ul><li>What types of explosions may occur in your area? </li></ul>Blast Injuries
  12. 12. <ul><li>Three injury patterns </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><li>Secondary </li></ul></ul><ul><ul><li>Tertiary </li></ul></ul>Blast-Related Injuries
  13. 13. <ul><li>Cause: pressure/heat wave </li></ul><ul><li>from blast </li></ul><ul><li>Affected area: </li></ul><ul><ul><li>Gas-containing organs </li></ul></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><li>What types of injuries would you expect? </li></ul></ul>Primary Blast Injuries
  14. 14. <ul><li>Cause: flying debris </li></ul><ul><li>Affected areas </li></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><li>Internal organs </li></ul></ul><ul><ul><li>Skeleton </li></ul></ul><ul><li>What types of injuries would you expect? </li></ul>Secondary Blast Injuries
  15. 15. <ul><li>Cause: victim thrown </li></ul><ul><li>against an object </li></ul><ul><li>Affected area </li></ul><ul><ul><li>Area of impact or </li></ul></ul><ul><ul><li>referred energy </li></ul></ul><ul><li>What types of injuries would you expect? </li></ul>Tertiary Blast Injuries
  16. 16. <ul><li>Low velocity </li></ul><ul><li>Multiple wounds from a single weapon </li></ul><ul><li>Cone of injury </li></ul><ul><li>A knife, ice pick, and scissors are common weapons. Injuries are usually limited to depth and area of penetration </li></ul>Stab Wounds Would a longer knife have a larger cone of injury?
  17. 17. Stab Wounds: Key Issues <ul><li>Type of weapon </li></ul><ul><li>Number of wounds </li></ul><ul><li>Depth of penetration </li></ul><ul><li>Anatomic structures along potential path </li></ul>
  18. 18. Gunshot Wounds How do the injuries differ when created by medium- or high-velocity weapons?
  19. 19. Projectiles: Key Issues <ul><li>Profile </li></ul><ul><li>Fragmentation </li></ul><ul><li>Tumble/pathway </li></ul><ul><li>Velocity </li></ul>
  20. 20. To what is cavitation related? Gunshot Wounds: Cavitation
  21. 21. Entrance and exit wounds Gunshot Wounds
  22. 22. The ultimate in fragmentation is created by shotgun wounds Shotgun Wounds
  23. 23. <ul><li>Scene safety is the top priority! </li></ul><ul><li>Weapon type </li></ul><ul><li>Anatomic structures along potential path </li></ul><ul><li>Crime scene preservation </li></ul><ul><ul><li>Patient care takes precedence </li></ul></ul>Considerations for Penetrating Trauma
  24. 24. Objectives <ul><li>Discuss the importance of scene assessment </li></ul><ul><li>Identify components of the primary survey </li></ul><ul><li>Differentiate between critical and noncritical patients </li></ul><ul><li>Defend the need for early transport of critical patients </li></ul><ul><li>Describe when to perform a secondary survey </li></ul>
  25. 25. It’s mid-January and you have been dispatched to a multivehicle crash on the interstate. Initial reports indicate there are multiple patients and a fuel tanker is involved. When does your scene assessment begin? Scenario
  26. 26. What are the components of scene assessment?
  27. 27. Scene Safety <ul><li>Ensure safety of rescuers and patients </li></ul><ul><li>Threatening situations may include: </li></ul><ul><ul><li>Fire </li></ul></ul><ul><ul><li>Electrical lines </li></ul></ul><ul><ul><li>Hazardous materials </li></ul></ul><ul><ul><li>Blood and body fluids </li></ul></ul><ul><li>Can you think of any other hazards? </li></ul><ul><li>Traffic </li></ul><ul><li>Weapons </li></ul><ul><li>Environmental conditions </li></ul>
  28. 28. Scene Situation <ul><li>What really happened? </li></ul><ul><li>What are the kinematics? </li></ul><ul><li>How many patients involved? Ages? </li></ul><ul><li>Additional resources needed? </li></ul><ul><li>How will patients be transported? </li></ul>
  29. 29. <ul><li>Your patient is the 32-year-old female unrestrained driver who is found slumped over in the vehicle. She has no obvious external hemorrhage, is breathing rapidly, and is mumbling inappropriate words. </li></ul><ul><ul><li>What do these findings suggest? </li></ul></ul><ul><ul><li>How should you assess this patient? </li></ul></ul>Scenario
  30. 30. Patient Assessment <ul><li>Primary survey </li></ul><ul><ul><li>“ Treat as you go” </li></ul></ul><ul><li>Resuscitation </li></ul><ul><li>Secondary survey </li></ul><ul><li>Definitive care in the field </li></ul>
  31. 31. Glasgow Coma Scale <ul><li>Eyes </li></ul><ul><ul><li>“ Open your eyes” </li></ul></ul><ul><ul><li>Nailbed pressure or axillary tissue squeeze </li></ul></ul><ul><li>Verbal </li></ul><ul><ul><li>“ What happened to you?” </li></ul></ul><ul><ul><li>Add “T” to score if intubated </li></ul></ul><ul><li>Motor </li></ul><ul><ul><li>“ Hold up two fingers” </li></ul></ul><ul><ul><li>Nailbed pressure or axillary tissue squeeze </li></ul></ul>
  32. 32. Glasgow Coma Scale Eye Opening Spontaneous 4 To Voice 3 To Pain 2 None 1 Verbal Response Oriented 5 Confused 4 Inappropriate Words 3 Incomprehensible Words 2 None 1 Motor Response Obeys Command 6 Localizes Pain 5 Withdraws (pain) 4 Flexion (pain) 3 Extension (pain) 2 None 1
  33. 33. Expose/Environment <ul><li>Expose patient as environment allows to assess for other life-threatening conditions; then preserve/maintain body heat </li></ul><ul><ul><li>Life-threatening conditions missed because of failure to adequately expose the patient </li></ul></ul><ul><ul><li>Failing to preserve body heat and to consider environmental conditions </li></ul></ul>
  34. 34. Simultaneous Assessment Breathing Airway Kinematics Circulation Disability Expose/ Environment
  35. 35. Decision Making Trauma-related incident Scene assessment Primary survey Life -threatening or multisystem injuries No Yes Initiate rapid transport Reassess Secondary survey Secondary survey Reassess Manage injuries as appropriate Initiate transport
  36. 36. A 16-year-old loses control of his bicycle on gravel. Your patient is found on the side of the road holding his right wrist. Multiple abrasions are noted on his face and upper extremities. The scene is safe. Scenario
  37. 37. Primary Survey A: Patent B: Normal; BS clear C: Minor bleeding from chin laceration; radial pulse normal; skin warm, pink, and dry D: GCS score 15 E: Deformity noted to right wrist How do you proceed?
  38. 38. Secondary Survey <ul><li>Vital signs </li></ul><ul><li>AMPLE history </li></ul><ul><li>Head-to-toe exam </li></ul><ul><ul><li>Performing a secondary survey on a critical patient prior to initiating resuscitation </li></ul></ul><ul><ul><li>Failing to complete a secondary survey on a noncritical patient </li></ul></ul>
  39. 39. Head-to-Toe Exam <ul><li>Systematic and Complete </li></ul><ul><li>Observation </li></ul><ul><ul><li>What do we look for? </li></ul></ul><ul><li>Auscultation </li></ul><ul><ul><li>What do we listen for? </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>What do we feel for? </li></ul></ul>
  40. 40. Definitive Care in the Field <ul><li>Packaging </li></ul><ul><ul><li>Spinal immobilization if indicated </li></ul></ul><ul><ul><li>Splint musculoskeletal injuries </li></ul></ul><ul><ul><li>Dress wounds </li></ul></ul>
  41. 41. Transportation <ul><li>Closest appropriate facility </li></ul><ul><ul><li>In general, bypass closest facility to reach trauma center </li></ul></ul><ul><ul><li>Receiving facilities should be determined by local protocol </li></ul></ul><ul><li>Mode </li></ul><ul><ul><li>Ground </li></ul></ul><ul><ul><li>Aeromedical </li></ul></ul>
  42. 42. Trauma Center Candidates <ul><li>Triage to trauma centers determined by: </li></ul><ul><ul><li>Physiologic criteria </li></ul></ul><ul><ul><li>Anatomic criteria </li></ul></ul><ul><ul><li>Mechanism of injury </li></ul></ul><ul><ul><li>Preexisting conditions </li></ul></ul><ul><li>Follow local protocol </li></ul>
  43. 43. Pain Management <ul><li>Consider analgesia for: </li></ul><ul><ul><li>Isolated extremity injury </li></ul></ul><ul><ul><li>Spinal fracture </li></ul></ul><ul><li>Narcotics </li></ul><ul><ul><li>Titrate in small increments IV </li></ul></ul><ul><ul><li>Beware of ventilatory depression and vasodilation (hypotension) </li></ul></ul>
  44. 44. You are dispatched to a motorcycle and vehicle collision. Bystanders report that the motorcycle was traveling at about 40 mph (65 km/h) when a car pulled in front of the motorcycle. You find the patient lying on the pavement 30 ft (9 m) away from the crash. His helmet is heavily damaged and has been removed by a bystander. Scenario
  45. 45. Findings <ul><li>Gurgling ventilations </li></ul><ul><li>Blood is seen in the upper airway </li></ul><ul><li>Ventilations are rapid and labored </li></ul><ul><li>Patient is cyanotic </li></ul><ul><li>Is this airway compromised? </li></ul>
  46. 46. You arrive on the scene of a single vehicle MVC. Your patient is a 25-year-old female who is trapped upright in the driver’s seat. Her VR is 36 and she is cyanotic. Gurgling sounds do not improve with suctioning or manual maneuvers. The fire department estimates that it will be 10 minutes before she is extricated. How would you manage her airway at this point? Scenario
  47. 47. Face-to-Face Intubation <ul><li>Oral endotracheal intubation can be accomplished by using nontraditional methods </li></ul>
  48. 48. Your patient is a 35-year-old construction worker who fell 25 ft (7.6 m) and landed on his head. His GCS score is 3. He is apneic and is being ventilated with a BVM. Three attempts at orotracheal intubation are unsuccessful. What are the airway management options at this point? Scenario
  49. 49. Alternative Airway Procedures <ul><li>Laryngeal mask airway (LMA) </li></ul><ul><li>Digital intubation </li></ul><ul><li>Retrograde intubation </li></ul><ul><li>Percutaneous transtracheal ventilation (PTV) </li></ul><ul><li>Surgical cricothyrotomy </li></ul>
  50. 50. At a college baseball game a 22-year-old third baseman is struck in the head by a line drive. Upon your arrival his GCS score is 7 (E-1, V-1, M-5). His teeth are clenched and he is vomiting. How would you manage his airway? Scenario
  51. 51. Objectives <ul><li>Describe the pathophysiology of shock </li></ul><ul><li>Identify the types of shock </li></ul><ul><li>Differentiate between signs of compensated and decompensated shock </li></ul><ul><li>Discuss the role of hemorrhage control, hypothermia, PASG, and volume resuscitation in shock management </li></ul>
  52. 52. Shock “ The patient is in shock! ” What does this term mean?
  53. 53. Staged Death Hypoperfusion Cellular hypoxia Anaerobic metabolism Cell death Organ failure Patient death
  54. 54. What conditions can interfere with each component of the Fick principle? Alveolus Capillaries Red blood cells Capillaries Kidney O 2 O 2
  55. 55. Your patient is a 30-year-old woman who lost control of her vehicle, which then struck a light pole. The patient was unrestrained. There is significant damage to the vehicle. You find the patient slumped over in the driver’s seat. You see that the steering wheel is bent. The scene is safe. Scenario
  56. 56. Primary Survey A: Patent B: Fast; BS clear C: No external hemorrhage; weak and rapid radial pulse; cool and diaphoretic skin D: GCS score 14 (E-4, V-4, M-6); anxious E: Bruising across abdomen and right thigh deformity Vitals: VR, 24; pulse, 118; BP, 112/82 Is this patient in shock? Why?
  57. 57. What is the most likely cause of the patient’s shock? Why is the patient’s BP normal? Primary Survey
  58. 58. Estimated Blood Loss Approximate internal Bone blood loss (mL) Rib 125 Radius or ulna 250–500 Humerus 500–750 Tibia or fibula 500–1000 Femur 1000–2000 Pelvis 1000–massive
  59. 59. Hemorrhagic Shock
  60. 60. Your patient is a 27-year-old male who was working in a grain silo. His left leg became entrapped in an auger. After a 45-minute extrication process, the fire department manages to release his mangled leg. Scenario
  61. 61. Primary Survey A: Patent B: Marked tachypnea C: Moderate hemorrhage from extensive soft tissue injury to lower left leg; no radial pulse; very fast, weak carotid pulse; pale, cool, diaphoretic skin D: GCS score 12 (E-3, V-3, M-6) Vitals: VR, 38; pulse, 140; BP, 74/50 What stage of shock is the patient in?
  62. 62. A 27-year-old male dock worker was pinned between a fork lift and a loading dock. Upon your arrival, the patient is lying supine on the ground complaining of severe lower abdominal pain. The ambient temperature is 35° F (1° C). You are 25 minutes from the trauma center. Scenario
  63. 63. Primary Survey A: Patent B: VR fast C: No external hemorrhage; rapid and weak radial pulse; pale, cool, moist skin D: GCS score 15 E: Significant pain on palpation of lower abdomen and pelvis What are the principles of shock management?
  64. 64. PASG <ul><li>Indications </li></ul><ul><ul><li>Suspected pelvic fractures with </li></ul></ul><ul><ul><li>SBP less than 90 mm Hg </li></ul></ul><ul><ul><li>Suspected intraperitoneal hemorrhage with </li></ul></ul><ul><ul><li>SBP less than 90 mm Hg </li></ul></ul><ul><ul><li>Suspected retroperitoneal hemorrhage with </li></ul></ul><ul><ul><li>SBP less than 90 mm Hg </li></ul></ul><ul><ul><li>SBP less than 60 mm Hg </li></ul></ul>What are contraindications for PASG?
  65. 65. Volume Resuscitation <ul><li>Preferably two large-bore peripheral IVs </li></ul><ul><li>Lactated Ringer’s </li></ul><ul><li>Warmed fluid if possible (102° F/39 ° C) </li></ul><ul><li>Initial bolus </li></ul><ul><ul><li>Adults: 1 to 2 L </li></ul></ul><ul><ul><li>Pediatric: 20 mL/kg </li></ul></ul><ul><ul><li>Delaying transport of critical patients to initiate IVs on scene </li></ul></ul>
  66. 66. Prehospital Trauma Life Support Managing the Multisystem Trauma Patient Part II
  67. 67. Objectives <ul><li>Review the anatomy of the chest </li></ul><ul><li>Discuss the mechanics of breathing </li></ul><ul><li>Detail the assessment process </li></ul><ul><li>Cover the management of: </li></ul><ul><ul><li>Rib fracture </li></ul></ul><ul><ul><li>Flail chest injury </li></ul></ul><ul><ul><li>Pulmonary contusion </li></ul></ul><ul><ul><li>Pneumothorax (open and tension) </li></ul></ul><ul><ul><li>Hemothorax </li></ul></ul><ul><ul><li>Blunt cardiac injury </li></ul></ul>
  68. 68. Responding to a call at a police station, you encounter a 19-year-old male complaining of chest pain and dyspnea. You learn that your patient was kicked in the chest during a fight. What injuries could occur with this mechanism? Scenario
  69. 69. Primary Survey A: Patent B: Left chest pain during inspiration; BS equal, VR fast C: No external bleeding, normal pulse rate D: GCS score 15 What injuries can you rule out? How should this patient be managed?
  70. 70. Your patient sustained a close-range shotgun blast to the abdomen. A segment of bowel is eviscerated. How are eviscerations managed? Scenario
  71. 71. A 24-year-old female fell down a flight of stairs. She is 36 weeks pregnant. She is complaining of severe back pain. What physiologic changes occur during pregnancy? What are the common causes of injury in the pregnant patient? Scenario
  72. 72. Primary Survey A: Patent B: Normal C: Pulse rapid; skin warm and dry D: Anxious E: No obvious injury noted Vitals: pulse, 114; VR, 20; BP, 92/56 Are these findings due to trauma or pregnancy?
  73. 73. After immobilization to a long backboard, reassessment shows her radial pulse to be 140 and weak. Her BP is 80/60. What could explain these findings? How would you manage this patient? Scenario
  74. 74. Long Backboard
  75. 75. Objectives <ul><li>Define primary and secondary brain injury </li></ul><ul><li>Discuss how assessment findings suggest traumatic brain injury </li></ul><ul><li>Discuss management for suspected traumatic brain injury </li></ul>
  76. 76. Traumatic Brain Injury (TBI) <ul><li>Commonly occurs in young adults </li></ul><ul><li>Major contributing cause of trauma deaths </li></ul><ul><li>Many survivors have permanent disability </li></ul>
  77. 77. Anatomy Skull Periosteum Dura mater } One functional layer Arachnoid membrane Pia mater (directly attached to brain surface and not removable Vessels in subarachnoid space Epidural space Subdural space Subarachnoid space
  78. 78. The Brain
  79. 79. Pathophysiology <ul><li>Primary brain injury </li></ul><ul><li>Secondary brain injury </li></ul><ul><ul><li>Systemic causes </li></ul></ul><ul><ul><li>Intracranial causes </li></ul></ul><ul><li>Can you name some examples of systemic and intracranial causes? </li></ul>
  80. 80. <ul><li>Your patient is a 12-year-old Little League baseball player who was struck in the head by a line drive. How could TBI affect: </li></ul><ul><ul><li>Airway? </li></ul></ul><ul><ul><li>Breathing? </li></ul></ul><ul><ul><li>Circulation? </li></ul></ul><ul><ul><li>Disability? </li></ul></ul>Scenario
  81. 81. Primary Survey Bystanders report a 5-minute loss of consciousness. The child is now awake and complaining of a headache and has vomited once. A: Intact B: Normal C: Normal D: GCS score 14 (E-4, V-4, M-6), PERL What is a concussion?
  82. 82. You are called to a local bar where a 22-year-old male has been in a fight. Bystanders state that your patient was beaten with a pool cue. The scene is safe. Scenario
  83. 83. Primary Survey A: Snoring noises B: VR slow and shallow; BS equal C: No external hemorrhage, radial pulse fast D: GCS score 6 (E-1, V-1, M-4); pupils R>L, sluggish E: Multiple hematomas on scalp and face Vitals: VR, 8; pulse, 110; BP, 150/90 What injuries do these findings suggest?
  84. 84. You are called to the scene of a rollover MVC where a 16-year-old female was ejected from the vehicle. You see the patient lying supine on the ground. Her breathing is noisy and rapid. She has a large scalp laceration. You identify no hazards. Scenario
  85. 85. Primary Survey A: Snoring, gurgling noises B: VR rapid and shallow; BS decreased bilaterally C: Moderate bleeding from scalp; rapid, bounding carotid pulse D: GCS score 5 (E-1, V-1, M-3) Vitals: VR, 38; pulse, 124; BP, 80/P
  86. 86. What life-threatening conditions do you identify? What could be causing her shock? Primary Survey
  87. 87. Management Goals for the TBI patient include preventing and reversing causes of secondary brain injury
  88. 88. Objectives <ul><li>Identify life-threatening conditions associated with spinal trauma </li></ul><ul><li>Recognize the indications for spinal immobilization </li></ul><ul><li>Discuss the principles of spinal immobilization </li></ul><ul><li>Describe use of rapid extrication </li></ul>
  89. 89. Spinal Trauma <ul><li>As many as 15,000 to 20,000 spinal injuries occur annually </li></ul><ul><li>The most common age is 16 to 35 years old </li></ul><ul><li>Causes </li></ul><ul><ul><li>MVCs </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Penetrating injuries </li></ul></ul><ul><ul><li>Sports injuries </li></ul></ul>
  90. 90. You are called to a public pool for a 16-year-old male who sustained an injury while diving. Upon your arrival he has been removed from the pool. Scenario
  91. 91. Primary Survey A: Patent B: Rapid and shallow C: Slow heart rate; weak radial pulse; warm extremities D: GCS score 15, loss of motor and sensory function in extremities E: No other obvious injuries What is the life-threatening problem?
  92. 92. Sensory Assessment <ul><li>Nipple line = T4 </li></ul><ul><li>Umbilical line = T10 </li></ul>
  93. 93. How would you manage this patient? Scenario
  94. 94. A 28-year-old male has been shot in the neck by his girlfriend. Scenario
  95. 95. Primary Survey A: Patent B: Fast; BS equal C: Copious external hemorrhage from neck wound, radial pulse fast and weak D: GCS score 15; no neurological deficits in extremities E: Expanding hematoma to left side of neck When is spinal immobilization indicated for penetrating trauma?
  96. 96. <ul><li>Unstable spinal fractures from penetrating trauma are extremely rare </li></ul><ul><li>Life-threatening conditions take priority </li></ul>Penetrating Trauma Neurological deficit/complaint? No Yes IMMOBILIZE IMMOBILIZATION NOT INDICATED Rapid transport Rapid transport
  97. 97. You are called to a nightclub where a 35-year-old female has fallen down a flight of stairs. Your patient denies neck and back pain but complains of severe left ankle pain. You smell alcohol on her breath. Scenario
  98. 98. Primary Survey A: Patent B: Normal; BS clear C: Minor bleeding from small scalp laceration; normal radial pulse D: Slurred speech; GCS score 15 E: Grossly deformed left ankle When is spinal immobilization indicated for blunt trauma?
  99. 99. Blunt Trauma Altered level of consciousness (GCS less than 15) No Yes IMMOBILIZE Rapid transport Spinal pain or tenderness? or Neurological deficit or complaint? or Anatomic deformity of spine? No Yes IMMOBILIZE Rapid transport Concerning mechanism of injury?
  100. 100. Concerning Mechanism of Injury <ul><li>Violent impact to the head, neck, torso, or pelvis </li></ul><ul><li>Sudden acceleration, deceleration, or lateral bending forces to neck or torso </li></ul><ul><li>Any fall </li></ul><ul><li>Ejection or fall from any motorized or human-powered transport device </li></ul><ul><li>Shallow-water diving incident </li></ul>
  101. 101. Distracting Injuries <ul><li>Any injury that may have the potential to impair the patient’s ability to appreciate other injuries </li></ul><ul><ul><li>Long bone fracture </li></ul></ul><ul><ul><li>Suspected visceral injury </li></ul></ul><ul><ul><li>Large laceration, degloving, or crush injury </li></ul></ul><ul><ul><li>Large burns </li></ul></ul><ul><ul><li>Any other injury that produces acute functional impairment </li></ul></ul>
  102. 102. Inability to Communicate <ul><li>Speech or hearing impaired </li></ul><ul><li>Speaks foreign language </li></ul><ul><li>Small children </li></ul>
  103. 103. Presence of: Evidence of alcohol/drugs or Distracting injury or Inability to communicate When in doubt, immobilize! Concerning Mechanism of Injury No Yes IMMOBILIZE IMMOBILIZATION NOT INDICATED Rapid transport Transport No Yes IMMOBILIZATION NOT INDICATED Transport
  104. 104. You are called to the scene of a multivehicle crash on a highway. After your patient’s vehicle was rear-ended, it was propelled into the vehicle in front of it. The vehicle has moderate damage. The driver was unrestrained and the windshield is spider-webbed. On the basis of kinematics, why should spinal injury be suspected? Scenario
  105. 105. Primary Survey A: Patent B: Normal; BS clear C: Normal radial pulse D: GCS score 15 E: Abrasion on forehead What are the indications for rapid extrication?
  106. 106. The patient is complaining of neck pain. What role does a cervical collar play in spinal immobilization? How is spinal immobilization performed? Primary Survey
  107. 107. Prehospital Trauma Life Support Managing the Multisystem Trauma Patient Part III
  108. 108. Objectives <ul><li>Discuss the pathophysiology of musculoskeletal trauma </li></ul><ul><li>Discuss the management of musculoskeletal trauma in isolated trauma and multisystem trauma </li></ul>
  109. 109. You are called to the scene where an intoxicated male has stumbled and put his hand through a window. On your arrival you see a large amount of blood and broken glass by the front door. The police direct you to a 40-year-old male sitting in a chair, bleeding heavily from the upper arm. On examination you see a laceration to the antecubital fossa with copious, bright-red bleeding. Scenario
  110. 110. What, if any, life-threatening injuries are present? What are some examples of life-threatening musculoskeletal injuries? What ways exist to control the bleeding? Does this injury require rapid packaging and transport? Scenario
  111. 111. A 28-year-old female fell while skiing. Ski patrol has brought her to the lodge. She complains of severe right thigh pain. Scenario
  112. 112. Primary Survey A: Patent B: Normal C: No external hemorrhage; normal pulse rate; skin warm and dry D: GCS score 15 What are your conclusions based on these findings?
  113. 113. Secondary Survey You find a swollen angulated right thigh. How much blood could a patient lose from this type of injury? Is this enough to cause shock? How would you manage this injury?
  114. 114. Your patient is a 45-year-old male pedestrian who was struck by an SUV. He smells of alcohol. Scenario
  115. 115. Primary Survey A: Patent B: VR rapid and shallow; clear BS C: Blood oozing from multiple soft tissue injuries; weak and rapid radial pulse D: GCS score 13 (E-3, V-4, M-5) When you gently stress his pelvis, crepitus is noted and the patient screams in pain.
  116. 116. What are your conclusions based on the primary survey? What are your management priorities for this patient? Primary Survey
  117. 117. <ul><li>A 22-year-old male crashed while riding a mountain bike. Because of the remote location, you reach the patient about 1½ hours after the injury occurred. </li></ul><ul><ul><li>A: Patent </li></ul></ul><ul><ul><li>B: VR slightly increased </li></ul></ul><ul><ul><li>C: No external hemorrhage; rapid and weak radial pulse </li></ul></ul><ul><ul><li>D: GCS score 15 </li></ul></ul><ul><ul><li>E: Deformities noted to left upper arm and to both lower legs </li></ul></ul>Scenario & Primary Survey
  118. 118. Secondary Survey VR, 24; pulse, 122; BP, 104/72 There is no abdominal or pelvic tenderness. How do you explain these findings?
  119. 119. Table of Estimated Blood Loss Approximate internal Bone blood loss (mL) Rib 125 Radius or ulna 250–500 Humerus 500–750 Tibia or fibula 500–1000 Femur 1000–2000 Pelvis 1000–massive
  120. 120. A 70-year-old woman slipped on some ice and fallen down a staircase. On your arrival she is complaining of pain in her left wrist and left ankle. On examination, deformities are found in both extremities. Scenario
  121. 121. Primary Survey A: Patent B: VR slightly fast C: Moderate hemorrhage from oozing and open ankle; irregular pulse D: GCS score 15 VR, 22; pulse, 105; BP, 110/70 Complains of pain at fracture sites
  122. 122. Are life-threatening injuries present? How are you going to manage this patient? Primary Survey
  123. 123. Objectives <ul><li>Identify, manage, and differentiate critical and noncritical burns </li></ul><ul><li>Identify how chemical and electrical burns differ from thermal burns </li></ul><ul><li>Discuss assessment and care of CO inhalation </li></ul><ul><li>Address the priorities for assessing and managing heat-related injuries </li></ul><ul><li>Discuss the priorities for assessing and managing cold-related injuries </li></ul>
  124. 124. You are called to care for a patient who has been burned while fueling his lawn mower. As you approach, you see a 65-year-old male with burns to his right arm and anterior chest. The fire is now extinguished. Scenario
  125. 125. Primary Survey A: Patent B: Normal; clear BS C: No external bleeding; normal pulse rate DL GCS score 15 E: Bright-red skin with blisters on chest and entire right arm What are the key issues in assessing thermal burns?
  126. 126. Rule of Nines What percent of BSA is burned? 9% 18% 9% 9% 18% 18% 18% 1% 18% 18% 9% 9% 18% 1% 13.5% 13.5%
  127. 127. What are other factors in assessing patients with thermal burns? How are you going to treat this patient? When is pain management indicated? Primary Survey
  128. 128. Resuscitation <ul><li>Parkland formula </li></ul><ul><ul><li>4 mL × BSA × weight (kg) </li></ul></ul><ul><li>Calculate the Parkland formula for this patient (wt=70 kg) </li></ul><ul><li>How is this administered? </li></ul>
  129. 129. Wound Management <ul><li>Superficial (first degree) </li></ul><ul><ul><li>Generally no field treatment needed </li></ul></ul><ul><li>Partial thickness/full thickness (second degree/third degree) </li></ul><ul><ul><li>Dry, clean dressings preferred </li></ul></ul><ul><ul><li>Do not apply ointments or salves </li></ul></ul><ul><ul><li>Do not attempt to break blisters </li></ul></ul><ul><ul><li>Do not remove clothing that is melted to skin </li></ul></ul>
  130. 130. Pain Management <ul><li>Administer analgesics if indicated </li></ul><ul><ul><li>Intermittent IV doses of narcotics </li></ul></ul><ul><ul><li>Nitrous oxide </li></ul></ul><ul><li>Moist dressings </li></ul><ul><ul><li>ONLY if less than 10% BSA burned </li></ul></ul><ul><ul><li>If more than 10%, wet dressings can cause hypothermia </li></ul></ul>
  131. 131. You respond to a structure fire/explosion. On your arrival you see a 40-year-old male who has just been removed from the building and appears unresponsive. What are your first priorities? Scenario
  132. 132. Primary Survey A: Stridor noted; oral mucosa appears red B: Rapid; BS equal; rhonchi in all fields C: No external bleeding; weak and rapid pulse D: GCS score 3 (E-1, V-1, M-1) E: Partial-thickness burns of upper chest (9% BSA) What are your immediate concerns? Why is he showing signs and symptoms of shock?
  133. 133. Possible Injuries <ul><li>Airway and pulmonary burns secondary to inhalation of superheated gases </li></ul><ul><li>Associated injuries </li></ul><ul><li>CO poisoning </li></ul><ul><li>Burns </li></ul><ul><li>How are you going to treat this patient? </li></ul>
  134. 134. Special Burn Situations <ul><li>Chemical burns </li></ul><ul><ul><li>What is different about these burns? </li></ul></ul><ul><ul><li>How would you treat chemical burns? </li></ul></ul>
  135. 135. Electrical Burns <ul><li>Current burns </li></ul><ul><li>Arc (flash) injuries </li></ul><ul><li>Contact burns </li></ul>How do you manage these injuries?
  136. 136. Patients Requiring Burn Centers <ul><li>Inhalation injuries </li></ul><ul><li>Partial-thickness burns more than 10% </li></ul><ul><li>Full-thickness burns </li></ul><ul><li>Burns to face, hands, feet, genitalia, perineum, or major joints </li></ul><ul><li>Electrical burns </li></ul><ul><li>Chemical burns </li></ul><ul><li>Burn injury in compromised patient </li></ul><ul><li>Other special situations </li></ul>
  137. 137. Burns: Summary <ul><li>DO NOT become a victim yourself </li></ul><ul><li>Airway management and oxygenation are critical </li></ul><ul><li>Early shock after burns points to other injuries </li></ul><ul><li>Avoid hypothermia </li></ul><ul><li>Transport patient to an appropriate facility </li></ul><ul><li>Pain management </li></ul><ul><li>Fluid therapy as indicated </li></ul>
  138. 138. Environmental Injuries
  139. 139. You are doing race coverage for a 10-km (6-mile) race. The temperature is 90° F (32° C) with 90% humidity. On finishing the race, a 55-year-old male collapsed. On your arrival you find the patient confused. What places this patient at high risk for a heat emergency? How would you treat him? Scenario
  140. 140. Other Heat-Related Injuries <ul><li>How do the presentations and management differ for each of the following? </li></ul><ul><ul><li>Heat cramps </li></ul></ul><ul><ul><li>Heat exhaustion </li></ul></ul><ul><ul><li>Heat stroke </li></ul></ul>
  141. 141. Hypothermia <ul><li>Hypothermia begins when body temperature reaches 95° F (35° C) </li></ul><ul><ul><li>Shivering begins </li></ul></ul><ul><ul><li>Heart rate, ventilations, and BP begin to decrease </li></ul></ul><ul><ul><li>CNS impairment </li></ul></ul><ul><li>Below 90° F (32° C), shivering ceases </li></ul><ul><li>Below 82° F (28° C), ventricular fibrillation possible </li></ul>
  142. 142. You respond to the scene where a 34-year-old male has slipped in mud and fallen into a sewer. You are on the scene when, after 10 minutes, the rescue team brings up a limp body. Scenario
  143. 143. Primary Survey A: Water in oropharynx B: Apneic C: No active hemorrhage; very slow and weak carotid pulse D: Unresponsive; GCS score 3 (E-1, V-1, M-1) E: Clothing is wet How are you going to manage this patient?
  144. 144. Objectives <ul><li>Identify injury patterns common to geriatric and pediatric trauma patients </li></ul><ul><li>Identify anatomic and physiologic differences in pediatric and geriatric patients </li></ul><ul><li>Discuss the importance of obtaining history for pediatric and geriatric trauma patients </li></ul><ul><li>Discuss the management of pediatric and geriatric trauma patients </li></ul>
  145. 145. Pediatric Trauma <ul><li>Injury is the most frequent cause of death </li></ul><ul><ul><li>Approximately 20% to 40% of deaths may be preventable </li></ul></ul><ul><li>What are the common mechanisms of injury in children? </li></ul>
  146. 146. <ul><li>You respond to a call for an injured child. You arrive to find a 5-year-old boy on the ground next to his bicycle. </li></ul>How will your assessment differ for children? Scenario
  147. 147. Pediatric Vital Signs Age 0-2 months 3 months 6 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years Mean Weight (kg) 3.0 6.0 8.0 10.0 12.5 14.5 17.0 18.5 21.0 23.0 25.0 28.0 Pulse Range 100-170 100-170 100-170 90-170 90-170 70-130 70-130 70-130 60-110 60-110 60-110 60-110 Hypotensive Systolic Blood Pressure 60 60 60 70 70 70 70 80 80 80 80 80 Ventilatory Range 30-60 30-60 30-60 30-60 30-60 20-40 20-40 20-40 15-30 15-30 15-30 15-30
  148. 148. Primary Survey A: Snoring noises B: Rapid and shallow ventilations C: No obvious bleeding; weak and rapid pulse D: GCS score 10 (E-2, V-3, M-5); contusion to forehead E: Air is 50° F (10° C) and damp How would you manage this patient?
  149. 149. Fluid Management <ul><li>Access </li></ul><ul><ul><li>Peripheral IV preferred </li></ul></ul><ul><ul><li>Intraosseous (second-line) </li></ul></ul><ul><li>Administration </li></ul><ul><ul><li>Bolus 20 mL/kg and repeat up to 3 times </li></ul></ul>
  150. 150. You are on the scene with an 85-year-old woman who slipped and fell in her home. How does the assessment of the elderly patient differ from the younger adult? Scenario
  151. 151. Primary Survey A: Open B: VR rapid with slight wheeze C: No obvious bleeding; normal and regular pulse D: Unable to move legs due to pain; GCS score 12 (E-3, V-4, M-5) E: No obvious external trauma How are you going to manage this patient?
  152. 152. Special Considerations in the Elderly <ul><li>Preexisting disease may increase with age </li></ul><ul><li>Age and general physical condition greatly influence response to injury </li></ul><ul><li>Medical history </li></ul><ul><ul><li>Prescription medications </li></ul></ul><ul><li> Trauma may be the result of a medical emergency </li></ul>
  153. 153. You are dispatched to the scene of a pedestrian struck by a vehicle. Law enforcement and the fire department are en route. It is an overcast spring day with a temperature of 50° F (10° C). Scenario
  154. 154. What are your initial concerns as you arrive on the scene?
  155. 155. Ensure the safety of the prehospital care providers and the patient. What are the safety concerns with this scene? Overview
  156. 156. Assess the scene situation to determine the need for additional resources. What additional resources may be needed? Overview
  157. 157. Recognize the kinematics that produced the injuries. What are the factors relating to kinematics implied here? Overview
  158. 158. Use the primary survey approach to identify life-threatening conditions. What are the key concepts of the primary survey? Overview Breathing Airway Kinematics Circulation Disability Expose/ Environment
  159. 159. Provide appropriate management while maintaining cervical spine stabilization. The patient has noisy ventilations and blood is draining from the oropharynx. What should be considered when managing this airway? Overview
  160. 160. The patient’s ventilatory rate is 6 and is shallow. Cyanosis is visible on the patient’s face and fingers. There is bruising across the chest and decreased breath sounds are heard on the left. GCS score is 7 (E-2, V-1, M-4). Support ventilation and deliver oxygen to maintain SpO 2 at 95% or more. How can this be accomplished? Overview
  161. 161. Control any significant external hemorrhage. Overview
  162. 162. Direct pressure controls the external hemorrhage from the right arm. The radial pulse is weak and rapid at about 140 beats/min. The patient is pale, cold, and clammy. There is crepitus and tenderness on palpation of the pelvis and a left thigh deformity consistent with a left midshaft femur fracture. How would you manage these findings? Overview
  163. 163. Provide basic shock therapy, including restoring and maintaining normal body temperature and appropriately splinting musculoskeletal injuries. Consider the use of the PASG for patients with decompensated shock (SBP less than 90 mm Hg) and suspected pelvic, intraperitoneal, or retroperitoneal hemorrhage; and in patients with profound hypotension (SBP less than 60 mm Hg). Overview
  164. 164. Maintain manual spinal stabilization until the patient is immobilized onto a long backboard . When is spinal immobilization indicated? Overview
  165. 165. For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival on scene. Platinum 10 minutes Golden Period Overview 10
  166. 166. Initiate warmed intravenous fluid replacement en route to the receiving facility. What are the considerations with prehospital fluid therapy? Overview
  167. 167. Ascertain the patient’s medical history and perform a secondary survey when life-threatening problems have been satisfactorily managed or have been ruled out. Overview
  168. 168. Above all, do no further harm.
  169. 169. Fundamental Principles <ul><li>Rapid assessment </li></ul><ul><li>Key field interventions </li></ul><ul><li>Rapid transport to the closest appropriate facility </li></ul>
  170. 170. PHTLS Works!
  171. 171. QUESTIONS?