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Introduction to advanced life support for trauma and medical emergency
1. Providing Advanced Life Support for Medical and
Traumatic Emergencies For EMT’s
By Melaku Sintayehu (Bsc,Msc.EMCCN)
09/01/2024
2. Respond to emergency call
• By the compeletion of the lesson the student will be able
to
✓ Define important terms
✓Diferentiate BLS from ALS
✓ describe mass casualty and other life threatening incidents)
✓ apply and practice Documentation and reporting
09/01/2024
3. Defnition of terminologies
• In the state of Massachusetts there are four levels of emergency care
providers:
• First Responder
• Emergency Medical Technician (EMT) – Basic
• EMT – Intermediate
• EMT - Paramedic
4. • CPR trained at the health care professional level
• Required minimum training for all police and firefighters in
Massachusetts
• Usually the first on the scene in an emergency
• Trained to treat life-threatening emergencies with a minimum
amount of equipment
First Responder
5. • All of the skills of the first responder plus:
• Trained in the use and operation of the ambulance
• Certified to administer oxygen, glucose, epinephrine and some other
medications at the on-line or off-line direction of the closest emergency
department’s lead physician
• Called the “medical control” physician
EMT - Basic
6. EMT - Intermediate
• All of the skills of the EMT-Basic plus:
• Capable of starting an intravenous line and infusing volume-
replacing normal saline
• Trained to place an endotracheal tube in a patient’s windpipe to
create a secure means of ventilating the lungs
7. • All of the skills of the EMT-Intermediate plus:
• Administration of intravenous medications for cardiac, diabetic and other
medical conditions under either off-line or on-line direction
• Many other optional and advanced skills such as chest decompression and
needle crichothyrotomy, etc.
EMT - Paramedic
8. Basic or Advanced?
• Basic life support called BLS describes the care given by First Responders
and EMT-Basics
• Advanced life support, called ALS, is the higher level of care performed
by EMT-Intermediates and Paramedics
• Permitted to perform invasive procedures
• Procedures that introduce foreign substances or equipment into the patient’s body
9. Training
• The EMS provider is legally prohibited from performing skills that are
beyond his or her level of training
• Each group of skills requires the proper certification
• The length of time required for learning the advanced skills is
considerable
10. First Responder Training
• Prerequisite: Health Care Professional level CPR
• 8 hours
• 24-hour class
• Three-year certification period
• Certification is maintained with a refresher course
• 12 hours
11. EMT Intermediate Training
• Prerequisite: Health Care Professional level CPR
• 8 hours
• 180-hour class plus
• 100 hours of clinical observations and skills
• 30 i.v. starts
• 10 intubations
• 100 hours of field observations and skills
• 10 i.v. starts
• 1 intubation
12. Introduction
• The Advanced Life Support (ALS) course aims to coach vital resuscitation
skills to medical personnel especially those working in acute and critical
care areas.
• This course extends beyond the basic ABCs of resuscitation and intends
to equip participants with the skills and knowledge to perform as a vital
member of the resuscitation team
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13. • This ALS course entails active participant immersion in a series of
simulations and scenarios with the objective of enhancing the
participant’s skills in treating patients with unstable arrhythmias or
patients with cardiac arrest.
• Strong Basic Life Support (BLS) skills are the foundation of ALS
therefore participants are expected to have passed the BLS Course
before enrolling for this course.
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14. • The ALS course focuses on developing skills as an individual and as
part of a resuscitation team.
• These simulations are designed to reinforce the important core
concepts of:
• Basic Life Support (BLS)
• Advanced Life Support (ALS)
• Effective resuscitation team dynamics
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15. • The BLS goal is to support or restore effective oxygenation, ventilation, and
circulation until ROSC or until ALS interventions can be initiated.
• Performance of the actions in the BLS Primary Survey substantially
improves a patient’s chance of survival and a good (or better) neurologic
outcome.
• Before conducting the BLS Primary Survey, you should assess Danger, check
patient Responsiveness, Shout for help (activate emergency medical system
and get an AED.
•
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16. • For example:
• Check for responsiveness before shouting for help and opening the
airway
• Check breathing before starting chest compressions
• Attach an AED, then analyse for a shockable rhythm before delivering
a shock
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17. • The BLS Primary Survey is an ABCD approach using a series of sequential
assessments.
• Each assessment is followed by appropriate action(s) if needed. As you
assess each step (the patient’s airway, breathing, circulation, and
determine if defibrillation is needed), you stop and perform an action, if
necessary, before proceeding to the next assessment step.
• Assessment is a key component in this approach.
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19. The ALS Secondary Survey
• The ALS Secondary Survey is conducted after the BLS Primary Survey when
more advanced management techniques are needed.
• Advanced airway interventions may include the laryngeal mask airway
(LMA), or endotracheal tube (ETT) insertion.
• Advanced circulatory interventions may include drugs to control heart
rhythm and support blood pressure.
• An important component of this survey is the differential diagnosis, where
identification and treatment of the underlying causes may be critical to
patient outcome
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20. • In the ALS Secondary Survey, you continue to assess and perform an
action as appropriate until transfer to the next level of care. Many
times, assessments and actions in ALS will be performed
simultaneously by team members
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24. Team Dynamics
• Roles
• Team Leader
• Organizes the group, monitors individual performance of team
members, be able to perform all necessary clinical skills, direct and
back up team members, model excellent team behaviour, trains and
coaches, facilitates understanding and focuses on comprehensive care
and able to provide critique of group performance after resuscitation
effort.
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25. Team Member
• Must be proficient to perform skills within their scope of practice.
• They are clear about their role assignment, prepared to fulfil the role
responsibilities, wellpracticed in resuscitation skills, knowledgeable
about ACLS algorithms and committed to the success of the team.
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26. Team Dynamics and Communication
❖Closed Loop Communication
• Clear communication between team leaders and team members is
essential. When communicating with team members, the leader should
use closed loop communication.
• The leader gives clear order or assignment and then confirm that the
message is heard.
• The team member verbally repeats the order to confirm that the order or
assignment is heard and informs the leader when the task is complete
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27. Clear Messages
• All messages and orders should be delivered in a calm and direct
manner without yelling or shouting. The team leader should speak
clearly while the team members should question an order if they are
unsure what is said.
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28. Clear Roles and Responsibilities
• Every member of the team should know his/her role and responsibilities.
To avoid inefficiencies, the team leader should clearly delegate tasks.
• A team member should not accept assignments above his/her level of
expertise.
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29. Knowing One’s Limitations
• Every member of the team should know his/her imitations and capabilities
and the team leader should be aware of them. A new skill should not be
attempted during the arrest, instead call for expert help at early stage.
• Knowledge Sharing
• A critical component of effective team performance is information sharing.
The team leader can ask for suggestions when the resuscitation efforts
seem to be ineffective.
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30. Constructive Intervention
• During a code, team leader or member may need to intervene if an action is
about to occur at an inappropriate time. For example, the person recording
the event may suggest that adrenaline be given as the next drug because it
has been 5 minutes since the last dose.
• In actual fact the adrenaline should be repeated every 3 to 5 minutes. All
suggestions for a different intervention or action should be done tactfully and
professionally by the team leader or member. Again, in all settings, we must
be professional and gracious when providing constructive feedback.
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31. Re-evaluation and Summarising
• An essential role of the team leader is monitoring and re-evaluation
of the status of the patient, interventions that have been done and
assessment findings.
• Mutual Respect
• The best teams are composed of members who share a mutual
respect for each other and work together in a collegial, supportive
manner. All team members should leave their egos at the door.
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32. Team debriefing
• A team debriefing could be done, led by the team leader after the
resuscitation has been completed and the patient has been admitted to a
critical care ward to discuss pertinent issues that occurred during the
resuscitation and reinforce teaching points among members
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34. Objectives:
•What is a Mass Casualty Incident ?
•Review Incident Management from EMS
perspective
•Review Triage
35. Mass Casualty Incident (MCI)
• Definition
• An incident which produces multiple
casualties such that emergency
services, medical personnel and
referral systems within the normal
catchment area cannot provide
adequate and timely response and
care without unacceptable mortality
and/or morbidity.
36. EMS Goal
• To save the largest number of
people of a multiple casualty
incident
37.
38. How do you start?
• Command
• Safety
• Triage
• Staging
• Communication
• Treatment
39. Communication
• Obstacles
• Terrain
• Different Frequencies
• Overloaded channels
• Hospital
• Medical Control
• Patient Routing
• Transportation Officer
• Staging Officer
40. Things to Remember…
• Maintain strict radio procedures
• Enroute communications must be
limited to urgent matters only
• Transport patients in adequate
vehicles
• Transport patients with adequate
escort staff
• Maintain a log of all Patients (PCR)
43. BUT - HOW IS EMS TRAINED?
• BLS, ALS
• CPR, ACLS, PALS
• PHTLS, BTLS
• EMT, EMT-I, EMT-CC, EMT-P
How many patients are you taught to treat at one time?
44. WHAT CHANGES WHEN YOU HAVE AN MCI ?
• What are my resources?
• Who is a Patient?
• Which Patient do I treat first?
• Who can be salvaged?
• Who gets transported first?
• Who needs a Trauma/Specialty Center?
• Who can help care for others?
45. THE GOLDEN HOUR
“The critical trauma patient has only 60
minutes from the time of injury to reach
definitive surgical care, or the odds of
a successful recovery diminish
dramatically”
TIME IS VERY IMPORTANT
47. Scene Management
• Command
Who is in Charge?
Who is in charge of what?
Who is going to do what?
Who else needs to be here?
• Safety
Is there a hazard or threat?
Should I be here?
Am I protected?
What should I worry about?
48. Scene Management
• Assessment
What is going on?
How big is this, how many
people?
What do I need?
How does what I do affect others?
What are they doing that can
affect me?
• Communications
Who needs to know?
What do they need to know?
Does Command & Ops know?
Do the other players know?
49. Scene Management
• Triage
Who is doing it?
Where are they doing it?
What are they finding?
• Treatment
What the typical EMS provider
comes “preloaded” with…
How to organize?
How much can we do?
50. Scene Management
Transport
• Who is doing it?
• From where are they doing it?
• Where are the patients going?
• How many patients going where?
51. Triage
• “Large scale triage is the hardest job anyone in pre-hospital care will
ever do.”
52. When do we triage
• When casualties exceed the number of skilled rescuers
53. How often should you triage?
• Primary
• On scene
• Secondary
• Time of transport
59. Victims
• Female, 30’s, walking
• Female, teens, walking, pale, complaining of severe abdominal pain
• Male, teens, walking, confused
• Male, teens, you open airway, does not breathe
• Male, 20’s, unconscious, breathing, RR 36, radial pulse absent
• Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to
instructions
60. Victims
• Female, 30’s, walking
• Female, teens, walking, pale, complaining of severe abdominal pain
• Male, teens, walking, confused
• Male, teens, you open airway, does not breathe
• Male, 20’s, unconscious, breathing, RR 36, radial pulse absent
• Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to
instructions
61. Burn MCI
• Bali Nightclub 2002
• Over 200 killed
• Additional 250 injured
• All burn beds filled in Australia
62. Burn Resources in the U.S.
• Just over 100 facilities listed in ABA directory
• Only 200 open beds at any time
• It only takes a few to make a burn disaster
63. Common in most burn MCI
• Up to 40% of casualties
• 50% discharged from ED
• Mortality 5%
64. EMS Considerations
• Scene safety first
• May require decontamination
• Scene may be a crime scene
• Designate field commander
• Where to go may be different?
66. EMS supplies
• LR
• O2
• Clean sheets/plastic wrap
• Narcotics
• (hospitals need the same stockpile, might add burn ointment)
67. Disposition from scene
• Severe: to burn center
• Moderate: local care facilities
• Minor: any care facility
68. Where to take them?
• International classification
• Type A: resuscitation only
• Type B: first 48 hours
• Type C: everything
• What this means in WI
• Two Type C
• Level 2 hospitals are Type B
69. What does this really mean?
• If burn > 20% and/or inhalation injury, this is severe.
• All others can be triaged again at hospital
71. Summary
• MCIs require
• Change in EMS providers approach
• Ability to apply limited resources effectively
• Organization, coordination, communication
• Appropriate distribution to definitive care
• After action evaluation
