2. Objectives
Provide opportunity for questions
Demonstrate, practice with new
equipment
◦ Zoll X Series
◦ Nexiva and Clear Link
Case-based review of:
◦ Cardiac Emergencies
◦ Bleeding and Shock
6. BD Q-Syte Split Septum
Smooth surface is
easily cleaned prior to
access
No crevices or
gaps around the
surface to harbor
bacteria
Clear housing
allows visual
assessment of
fluid path
Simple fluid path
design reduces
places for microbes to
grow
Simple Luer Lock System – eliminates multiple pieces
9. ClearLink Solution Set
Luer ports – residual 0.03cc of air
Flush line – age considerations
Disinfect site prior to access
No need to “pinch line” due to back
check valve
Flush with 1ml of saline after
medication administration
10. Preparing Solution Set
6 month – Adult: remove air from
back check valve and Y luer ports by
inverting and tapping to flush out
bubbles
0 – 6 month: remove air from back
check valve by inverting and tapping
to flush out bubbles. Disinfect each (3)
Y luer port and withdraw air using a 10
cc syringe until saline enters syringe.
15. Case 1
04:30 call for a 58 year
old female,
unresponsive, but
breathing
Patient’s husband called
911, wife had
complained of chest
discomfort/nausea then
collapsed on way to
bathroom
On arrival: you find the
patient lying on the floor,
16. Assessment Approach
What would you like to know?
What are your assessment priorities?
What are some differential diagnoses?
17. Initial Findings Vital Signs
AVPU: patient
responds to loud
voice/painful
stimulation
A: airway is patent
B: mildly
tachypnea
C: Weak, slow
radial pulses
No evidence of
trauma
Palpated pulse: 38
Spo2: not reading
RR: 26
BP: 106/68
Temp: 36.8
18. Further History
HPI:
◦ Woke to chest
pain/nausea
◦ Collapsed on way to
bathroom
◦ Assisted onto floor by
husband
◦ Regained
consciousness once
supine, but now
confused
PMHx:
◦ HTN
◦ Thyroid
◦ Arthritis
◦ Positive family cardiac
history
◦ Hyperlipidemia: diet
controlled
Meds:
◦ Metoprolol
◦ Levothroid
◦ Arthrotec
20. Detailed Exam
CNS: Alert to pain/strong voice,
improves when supine, confused to
events
CVS: C/O non-specific chest
discomfort, ECG Third Degree block,
weak peripheral pulses, skin pale,
cool, diaphoretic
RESP: A/E clear=bilat, difficulty
obtaining sats
GI/GU: C/O nausea prior to collapse
21. Treatment
ABC’s
Oxygen
Establish IV
Nitrates?
◦ Nitro patch? When do you administer?
12 Lead?
STEMI?
Transport
22. Slightly Different Situation
What if this patient’s BP was 88/60?
How would this change your treatment?
Nitrates?
12 lead/ look for STEMI?
Atropine 0.5 - 1.0 mg IV
◦ Responsive? Repeat q 3 to max of 0.04
mg/kg
Not responsive to Atropine? Establish
TCP
◦ Fentanyl?
◦ Midazolam?
Transport
◦ Destination?
23. 12 Lead Contest
Ten 12-Lead ECG’s for your
consideration
Equal number of positive for STEMI
and negative for STEMI
All are actual 12 Leads transmitted by
WFPS
Are you up for it?
45. Case 2
21:30 call for a 22
year old male,
thrown? or jumped?
from a third floor
window at the
McLaren Hotel to
sidewalk
Police arrive on
scene, report
conscious male,
requesting “rush”
On arrival,
bystanders report
approximately 5
minute period of
unconsciousness
46. Prehospital Trauma Life
Support
Recall our PHTLS approach to trauma?
“Find it, manage it, move on”
Search for life threatening injuries and
take immediate action: treat as you go
◦ If unable to manage, transport immediately
Limited interventions on scene, do this
enroute
◦ Recognizing that time taken with
interventions increases time to blood,
surgery, CT, etc.
Consider if interventions on scene
actually harm the critical patient by
increasing time to definitive care
49. Other Key PHTLS Concepts
Limited scene intervention:
◦ Control bleeds, correct life-threatening
airway/breathing/circulation concerns
◦ Assist ventilations as required
Other interventions (eg. IV and fluid
resuscitation) to occur enroute
Limited scene time/ expedited
transportation to appropriate facility
Ideally; Trauma center
50. Other Key PHTLS Concepts
For a critical patient:
◦ Vitals on scene?
◦ Detailed history on scene?
◦ Detailed physical exam on scene?
51. Back to the Patient
21:30 call for a 22
year old male,
thrown? or jumped?
from a third floor
window at the
McLaren Hotel to
sidewalk
Police arrive on
scene, report
conscious male,
requesting “rush”
On arrival,
bystanders report
approximately 5
minute period of
unconsciousness
52. Assessment Approach
What would you like to know?
What are your assessment priorities?
What are some expected injuries
given the kinematics of the fall?
53. Scene Assessment
WPS has arrived and secured scene
Scene is safe us and everyone else
Patient is in back lane and traffic has
been blocked from entering
Appears to be only one patient
EMS unit and Fire unit arrive together
◦ No need for further resources
◦ Everyone has taken standard precautions
62. Internal Hemorrhage
If suspected, quickly expose the
abdomen and pelvis
Palpate abdomen and pelvis
63. There it is!
When you palpate the pelvis the patient
groans loudly and it does not feel stable
When you expose you note that the
patient’s scrotum/inner thigh area is turning
purple
Later at hospital, staff sees this:
64. Time to go?
Set of vitals first?
Start one IV on scene?
How do we package the patient?
2 new products:
Nexiva:
Dual ports
BD Q syte luer access split septum
All in one closed system
Built in stabilization device
BD instaflash needle technology
Clearlink:
Luer access, not interlink
Needless system
Cover septum with transparent dressing and tape over – not a port. White sponge to clean off needle as it’s withdrawn from the catheter.
No interlink or needle, just luer lock
Smooth surface for cleaning with alcohol swab – 20 – 30 seconds with good rub/good scrub ie friction
We will be using 5ml posiflushes
Break seal on posiflush prior to removing white cap by pushng forward on syringe (prevents saline from shooting out)
Functions of PosiFlush: Flush Nexiva for IV lock, flush after medication administration with 1ml of saline, use to pre-prime Nexiva for use with 0-6month age group, used with trouble shooting techniques
Not to be used to mix medication – not vetted for this use, syringe volume markings are less precise
Straight on approach
Push and twist
No needles or blunt plastic cannulas required, only syringe
All our syringes have luer connects (1, 3, 10cc)
2C8537 – 3 port, DEHP Solution set
Meets the needs of the ER’s as well as the Stemi program
Hospitals plan to be converted by end of April – then they will discontinue interlink
WFPS plans to convert end of April to mid May - once ARML training complete
Best practice 20 – 30 sec good rub, good scrub with alcohol swap to disinfect port.
Refer to SWP, explain concern with air in ports re: neonatal population vs 6 month- adult population
Fire/PCP’s will need to be proficient with setting up the CLearLink
Invert and tap back check valve to remove air bubbles
Invert and tap “y” luer ports to remove air bubbles
Discuss that kinking the IV tubing to administer meds is no longer required due to the back check valves
- can use the dyed IV solution to demonstrate
0.03 cc residual air between the valves
Luer connection
Push and twist
Straight on approach
Use 10 cc syringe to remove air from ports when using with infants 0 -6 months (<8Kg) – disinfect prior to access and withdraw on syringe until fluid aspirated.
Solicit responses to assessment approach and priorities, differentials
Have FF/PCP set up ClearLink, flush tubing. Focus on aseptic technique (identified by MS’s as an issue)
Have discussion around use of nitrates. Patient meets requirements, but is the chest pain rate related? Will this patient tolerate nitrates with BP 106/68 and pulse rate of 38?
Have discussion around nitro patch admin with second nitro spray. Why not with initial spray?
Have discussion around doing 12 lead vs treating for bradycardia right away. Is this patient “stable” enough: not hypotensive, but has chest pain/ decreased LOC/ signs of poor perfusion.
Would be a good candidate for 12 lead, but need to be concerned about criticality of patient.
Nitrates? Obviously no.
12 lead/ look for STEMI? This should not take priority over treating symptomatic bradycardia in this critical patient. Could it be performed after administering Atropine while briefly waiting to see if Atropine is effective?
Fentanyl/Midazolam? Contraindicated due to BP less than 90 systolic and difficulty obtaining sats. Have discussion around why contraindicated (besides being in protocol)
- ask ACP’s about dosages if it was indicated: Fentanyl 25 mcg q 5 for first three doses then q 10
Midazolam 1 – 2.5 mg q 5 for first three doses then q 10
- ask ACP’s how they would determine Midaz dose
Have ACP’s set up X Series and use pacer (connected to rhythm generator)
Positive STEMI
Positive STEMI according to ZOLL
Negative STEMI
Discuss need for elevation in 2 or more contiguous leads
Negative STEMI
Positive STEMI
Positive STEMI
Negative STEMI
Discuss pericarditis on 12 lead
Negative STEMI per ZOLL, possible limb lead reversal
Positive STEMI
Negative STEMI
Introduce PHTLS approach to FF/PCPs and EMS providers not trained in PHTLS and explain its principles
Reinforce with EMS the importance of this approach, the need to change old methods (eg. start one IV on scene, another enroute). What is going to save the patient: taking time to get an IV on scene or getting them to blood, surgery, CT, etc.?
With certain patients does taking the time to immobilize to a backboard help or hurt them? Eg. a GSW to the lateral chest. (Delays time to surgery)
Work through approach to the patient with the algorithm. Please draw attention to the footnotes and that our system doesn’t employ all of the interventions on the list. (eg PASG)
Please emphasize that this is meant to increase awareness of PHTLS for the FF/PCPs and non-trained EMS providers is a very brief review of some concepts/vs taking the course, and to be a review for trained EMS providers.
Also draw attention (especially to Fire/PCPs) to how different it is from a BLS/ACLS approach to a medical patient
ARRIVAL ON SCENE:
- safety for all
- recognizing multiple patients and need for additional resources.
GENERAL IMPRESSION:
- global overview of the patient’s appearance, respiratory, circulatory, neurologic status as you are walking up.
- color, WOB, AVPU?
AIRWAY AND C-SPINE STABILIZATION:
- airway management and manual c-spine stabilization should be considered one step. Can rule out/rule in need for immobilization with further assessment
- lead provider to delegate c-spine control and focus on airway if enough resources on scene
- airway patent? If not- manage it: jaw-thrust, suction
- If not managed: OPA, ETT, needle cricothyroidotomy if needed.
- Don’t progress past “A” if you can’t manage it- transport!
BREATHING (VENTILATION):
- breathing? If apneic, too slow (eg less than 10) or ventilatory depth at any rate is inadequate- begin immediate BVM assist
- if breathing fast (over 20) or abnormally fast (over 30), assess ventilatory depth and consider BVM assist
- ensure patient’s airway is adequate enough with BVM assist, if further managing is needed (not done at “A”) do it now
- auscultate breath sounds
- ACP: consider chest decompression (refer to footnotes)
- Don’t progress past “B” if you can’t manage it- transport!
CIRCULATION (HEMORRHAGE AND PERFUSION):
- Hemorrhage: searching for bleeds and controlling (note using direct pressure, and PHTLS teaching that if that fails moving to tourniquet)
- if internal bleed suspected: expose thorax and abdomen and palpate for injuries. Palpate pelvis if required. Bind pelvis if required.
- Perfusion: Quick check of pulse (presence, quality, regularity), skin (color, temperature, moisture), cap refill to assess for presence of shock.
- Don’t progress past “C” if you can’t manage it or patient is in shock- transport!
DISABILITY:
- Steps A, B, and C will have evaluated (and controlled to the extent possible) factors involved in delivering O2 to lungs and perfusing vital organs. If we were unable to manage we would have transported.
- “D” will assess cerebral function and therefore, cerebral oxygenation.
- Determine GCS: Eyes opening: (spontaneous, on command, to pain, none), Best verbal response: (answers appropriately, confused, inappropriate, unintelligible, none),
Best motor response: (follows commands, localizes to pain, withdraws from pain, responds with abnormal flexion, responds with abnormal extension, no response)
- If patient unresponsive, not oriented- check pupils.
DISABILITY:
- Steps A, B, and C will have evaluated (and controlled to the extent possible) factors involved in delivering O2 to lungs and perfusing vital organs. If we were unable to manage we would have transported.
- “D” will assess cerebral function and therefore, cerebral oxygenation.
- Determine GCS: Eyes opening: (spontaneous, on command, to pain, none), Best verbal response: (answers appropriately, confused, inappropriate, unintelligible, none),
Best motor response: (follows commands, localizes to pain, withdraws from pain, responds with abnormal flexion, responds with abnormal extension, no response)
- If patient unresponsive, not oriented- check pupils.
EXPOSE/ENVIRONMENT:
- remove all clothing necessary to ensure finding all wounds. Clothing can trap/hide blood and injuries.
- secondary concern: consider how we are removing clothing of victims of crime (forensic evidence preservation)
- hypothermia in the trauma patient is a serious concern- always cover patient with a blanket.
SPINAL IMMOBILIZATION: some differences from WFPS protocol (eg foregoing immobilization in presence of penetrating trauma with no neural deficits). **However, decisions like this are to be made by PHTLS trained and certified providers only** Otherwise, follow WFPS protocol.
NO vitals, detailed history or physical exam on scene with a critical patient. Time to be spent managing life threats and packaging for rapid transport.
Solicit responses to assessment approach and priorities, differentials
Police confirm fall from third story
Solicit what they will look for in general appearance.
GENERAL APPEARANCE: As pictured, moderate amount of blood under/adjacent to head
- Right leg contorted
- Looks pale and unresponsive
AVPU: Moans to strong painful stimulation
Airway assessment (concurrent with manual c-spine immobilization)
OPA not tolerated
Provider that is immobilizing can consider jaw thrust
BREATHING:
- provider should expose, palpate, and auscultate
- respirations estimated at 28, increased WOB noted, equal chest rise, no fractures or flail noted, lungs clear
- SPO2? No- don’t spend time getting vitals during primary
HEMORRHAGE CONTROL:
Moderate bleed to head controlled with direct pressure/abd pad
No other bleeds noted
PERFUSION:
- Barely palpable radial pulse estimated at 120 +
- Skin cool, pale, moist
Question the group if the respiratory rate and pulse rate/strength/skin condition fit the picture with a moderate external bleed?
Is the patient in shock?
What else could be going on?
What else should we assess?
Should we do vitals now? NO!
Where could a massive bleed go unnoticed?
Patient’s GCS: E-2, V-2, M-4
Need to expose patient, blood can collect and be hidden in clothing.
We have had incidents at WFPS where grievous injuries were not discovered until in the ER
Don’t forget to cover the patient! Treat the shock state by keeping patient warm as possible.
If there is unexplained tachycardia/hypotension (shock state)
Try to find the cause of the shock state after exposing the patient
A pelvis fracture is capable of producing the largest internal bleed of any fracture in the body (intra-abdominal bleed). It is possible to have a internal loss of minimum 1000 ml- up to massive loss of several liters
Frequently overlooked
Picture is meant to depict bruising to buttocks/pelvis area from internal bleeding. (Not many good pictures of this!)
Take vitals now? NO- do this enroute
Start one IV on scene- NO do this enroute
Need to package for immediate transport
Package patient by binding pelvis with sheet
Absolutely need to immobilize this patient, but do it quickly and expedite transport!
Log roll the patient after binding the pelvis
Will need to straighten this patients leg- no practical way to transport otherwise, but don’t spend time using traction splints, etc in the critical patient
Key point: keep patient warm/treat for shock shock
Destination? Trauma Center
Solicit: what do we do enroute?
Reassess A, B, C
Consider need for advanced airway
Consider need for BVM assist
VITALS, finally!
Establish two large bore IV’s.
Ask the ACP’s how much fluid?
Titrate to maintain 80-90 SBP
Detailed physical exam/ SAMPLE if time permits
Solicit what patient code for the patch?
Get someone to do a verbal report for hospital.
