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Lesson 10
- 1. Lesson 10 Summation Putting It All Together
- 2. Key Points (1 of 4) • Safety of providers and patients – Number one priority • Prearrival preparedness and scene assessment – Assessment begins before arriving at the scene • Sufficient resources? – How many patients are involved? – Are there special scene needs?
- 3. Key Points (2 of 4) • Access to patient • General impression – History and mechanism of injury (kinematics) • Identify immediate life threats and manage them – Primary assessment • Transport and destination decisions
- 4. Key Points (3 of 4) • Physically immobilize the patient as needed – Manually, then mechanically • Patient extrication • Assess and treat identified injuries and resulting conditions – Principles versus preferences • Transportation and destination • Communication and documentation
- 5. Key Points (4 of 4) • Principle is what needs to be done for a patient based upon the assessment. • Preference is how the principle is accomplished. – This will change depending on the: • Situation at the scene • Severity of the patient • Knowledge and skills of the prehospital care provider • Resources available
- 6. Identify and Manage Immediate Life Threats (1 of 5) • Airway and breathing – Manually stabilize cervical spine as indicated – Suction as needed – Provide supplemental oxygen early – Support ventilations as necessary
- 7. Identify and Manage Immediate Life Threats (2 of 5) • Airway and breathing (cont’d) – Use simple interventions before complex • Example: Bag-mask device before intubation – Ventilate before and between intubation attempts – Maintain a proper rate of ventilation
- 8. Identify and Manage Immediate Life Threats (3 of 5) • Circulation – Control obvious bleeding • Conserve red blood cells • Immobilize major fractures – Maintain body temperature
- 9. Identify and Manage Immediate Life Threats (4 of 5) • Circulation (cont’d) – IVs can be started while en route – Provide no more fluid than necessary • Avoid over-resuscitation that can lead to increased blood loss
- 10. Identify and Manage Immediate Life Threats (5 of 5) • Disability – Maintain manual cervical stabilization until immobilization is complete – Calculate GCS score – Reassess for changes in the patient’s condition over time
- 11. Transportation and Destination (1 of 2) • Patient handling – Identify patients requiring rapid extrication – Maintain manual stabilization while performing extrication – Recognize the limitations of immobilization devices – Maintain a team approach
- 12. • Transportation – Transport to appropriate destination without delay – Utilize appropriate transport method and mode Transportation and Destination (2 of 2)
- 13. Communication and Documentation • Communication – Provide clear, concise, accurate, timely, and complete communication with the receiving facility • Documentation – Complete documentation is important for continued care, research, and accountability
- 14. Potential Pitfalls (1 of 2) • Ignoring or failing to recognize scene hazards • Focusing on distracting, non-life-threatening injuries • Performing secondary assessment before life-threatening conditions have been assessed and managed • Not performing a secondary assessment when indicated
- 15. Potential Pitfalls (2 of 2) • Missing life-threatening conditions by not exposing and assessing the patient • Not maintaining body temperature • Prolonged scene times • Inappropriate selection of destination
- 16. Golden Principles (1 of 7) • Ensure the safety of the prehospital care providers and the patient • Assess the scene situation to determine the need for additional resources
- 17. Golden Principles (2 of 7) • Recognize the kinematics that produced the injuries • Use the primary assessment to identify life-threatening conditions Courtesy of Mark Woolcock
- 18. Golden Principles (3 of 7) • Provide appropriate airway management while maintaining cervical spine stabilization as indicated • Support ventilation and deliver oxygen to maintain an SpO2 greater than 95%
- 19. Golden Principles (4 of 7) • Control any significant external hemorrhage • Provide basic shock therapy, including appropriately splinting musculoskeletal injuries and restoring and maintaining normal body temperature
- 20. Golden Principles (5 of 7) • Maintain manual spinal stabilization until the patient is immobilized • For critically injured trauma patients, initiate transport to the closest appropriate facility as soon as possible after EMS arrival on scene Courtesy of Rick Brady
- 21. Golden Principles (6 of 7) • Initiate warmed intravenous fluid replacement en route to the receiving facility • Ascertain the patient’s medical history and perform a secondary assessment when life-threatening problems have been satisfactorily managed or have been ruled out • Provide adequate pain relief
- 22. Golden Principles (7 of 7) • Provide thorough and accurate communication regarding the patient and the circumstances of the injury to the receiving facility • Above all, do no further harm
- 23. “Our patients did not choose us. We chose them.” “We have accepted this responsibility . . . we must give to our patients the very best care that we can.” “We must be ready to treat our patients by learning from our experiences and the science provided by prehospital research.” Norman E. McSwain, MD Medical Director, PHTLSCourtesy Norman McSwain, MD, FACS, NREMT-P
- 24. Questions?
Editor's Notes
- Instructor Notes Lesson 10 will provide participants with a summary of the principles of PHTLS.
- Instructor Notes Expand on the following points: Once the first priority — safety for yourself, your team, and the patients — has been established, you may approach the patient. However, before you ever get to the scene, the patient assessment process has already begun. During this phase, take into consideration: Dispatch information Weather conditions What the scene will probably look like How many patients are involved Whether the resources deployed will be sufficient for the needs at the scene
- Instructor Notes Expand on the following points: Upon accessing the patient, you can begin to form a general impression. Using the information gathered about the event, you develop a sense of what immediate life threats are possible. Your assessment must be focused on identifying those threats and the appropriate management of those threats. Once life threats have been identified and managed during the primary assessment, the first decision on whether transport should be immediate or delayed is called for. If immediate transport is appropriate, the patient must be stabilized manually and then mechanically to prevent further injury.
- Instructor Notes Expand on the following points: Physically immobilize the patient as needed. The patient must be stabilized manually and then mechanically to prevent further injury. Once the patient is immobilized, extract the patient if necessary. Assess and treat the identified injuries and resulting conditions. Remember the importance of the “principles” over the “preferences.” The receiving facility should be chosen based on the needs of the patient and local protocol. Assessment should be continuous during transport, including the secondary assessment if time and personnel allow. All assessment findings, treatments, and the patient condition subsequent to treatment must be included in documentation and communication to the receiving facility.
- Instructor Notes Expand on the following points: The principle is what needs to be done for a patient based upon the assessment. The preference is how the principle is accomplished. The principle remains the same regardless of the level of prehospital care provider. The preference of how the principle is accomplished is affected by: The situation at the scene The severity of the patient The knowledge and skills of the prehospital care provider The resources available
- Instructor Notes Expand on the following points: When evaluating and managing the airway, it must be done while protecting the cervical spine if you have determined the potential for injury. Any evidence of fluids in the airway should be suctioned, oxygen should be administered early, and ventilations should be supported.
- Instructor Notes Expand on the following points: Keep in mind that simple interventions should be applied before complex. Insufficient breathing, whether too slow, too fast, or ineffective, should be replaced with bag-mask ventilations once the airway is secured. Ventilate the patient before and between intubation attempts. Recent research has underscored the importance of maintaining the proper rate of ventilations with even moderate hypo- or hyperventilation causing hypoxia and shock.
- Instructor Notes Expand on the following points: The goal is to protect every red blood cell: Stop bleeding when possible. Stabilize injured extremities to limit bleeding. Maintaining body temperature is also important as failure to do so can accelerate the onset of shock.
- Instructor Notes Expand on the following points: Consideration should also be given to starting the IVs while transporting to avoid additional delays in getting the patient to definitive repair and controlling external and internal bleeding. Manage fluid infusion to prevent flushing out the red cells or popping clots.
- Instructor Notes Expand on the following points: When assessing the patient, it is important to maintain manual cervical stabilization of the spine until immobilization is complete. Using the Glasgow Coma Scale allows us to establish a baseline that will be used in the continuing assessment of the patient throughout care in the field and in the hospital. Regularly reassess the patient for changes in condition.
- Instructor Notes Expand on the following points: Decisions on patient handling have to be made with the patient’s condition in mind, along with the physical situation you find the patient in. If you suspect spinal injury in a critical patient, the decision to use manual stabilization and rapid extrication is appropriate. Recognize the limitations of immobilization devices and maintain a team approach to safeguard the patient’s welfare. If the patient is not critical and has a potential spinal injury, then time can be taken to mechanically stabilize the patient as much as possible before moving the patient.
- Instructor Notes Expand on the following points: Critical patients should be transported to an appropriate destination without delay. Utilize the appropriate transport method and mode according to the patient’s needs. We should do what the patient needs for us to do — no more, no less.
- Instructor Notes Expand on the following points: Communication is of the utmost importance in ensuring the patient gets the best possible care. Team members need to be able to understand each other and work together smoothly and quickly. Receiving facilities need to be clear on the patient’s needs in order to prepare for his or her arrival. Everything that happened to the patient before and after care must be documented to ensure subsequent health care providers have a full history of the event, the assessments, and the care received by this patient. Complete documentation is important for continued care, research, and accountability.
- Instructor Notes Expand on the following points: Becoming a casualty or causing further harm to your patient clearly is not helpful. This can occur through: Ignoring or failing to recognize scene hazards Focusing on distracting, non-life-threatening injuries Performing the secondary assessment before life-threatening conditions have been assessed and managed Not performing a secondary assessment when indicated
- Instructor Notes Expand on the following points: Missing life-threatening conditions by not being thorough, not understanding the mechanism of injury, focusing on non-life-threatening injuries, or not exposing the patient appropriately is also a danger. Not maintaining the patient’s body temperature can exacerbate shock. Do not prolong time on the scene. Disorganization, performing unnecessary care, or providing care that can be done en route will only further delay definitive care. Not choosing the facility best suited to your patient can also have a negative effect on your patient’s outcome.
- Instructor Notes Expand on the following points: Throughout this course, we have stressed the importance of “principles” over “preferences.” There may be multiple ways to address a patient’s needs, and as long as the method satisfies the principle, it is appropriate. Remember the 15 golden principles of prehospital trauma care: Ensure the safety of the prehospital care providers and the patient. Assess the scene situation to determine the need for additional resources.
- Instructor Notes Expand on the following points: Remember the 15 golden principles of prehospital trauma care (continued): Recognize the kinematics that produced the injuries. Use the primary assessment approach to identify life-threatening conditions.
- Instructor Notes Expand on the following points: Remember the 15 golden principles of prehospital trauma care (continued): Provide appropriate airway management while maintaining cervical spine stabilization as indicated. Support ventilation and deliver oxygen to maintain an SpO2 greater than 95%.
- Instructor Notes Expand on the following points: Remember the 15 golden principles of prehospital trauma care (continued): Control any significant external hemorrhage. Provide basic shock therapy, including appropriately splinting musculoskeletal injuries and restoring and maintaining normal body temperature.
- Instructor Notes Expand on the following points: Remember the 15 golden principles of prehospital trauma care (continued): Maintain manual spinal stabilization until the patient is immobilized. For critically injured trauma patients, initiate transport to the closest appropriate facility as soon as possible after EMS arrival on scene.
- Instructor Notes Expand on the following points: Remember the 15 golden principles of prehospital trauma care (continued): Initiate warmed intravenous fluid replacement en route to the receiving facility. Ascertain the patient’s medical history and perform a secondary assessment when life-threatening problems have been satisfactorily managed or have been ruled out. Provide adequate pain relief.
- Instructor Notes Expand on the following points: Remember the 15 golden principles of prehospital trauma care (continued): Provide thorough and accurate communication regarding the patient and the circumstances of the injury to the receiving facility. And above all, do no further harm.
- Instructor Notes Expand on the following points: Remember, often it is the first decision that determines outcomes. If we understand the event, we will aggressively assess for life threats. If we address the patient’s needs, no more and no less, continuously assess throughout our care, get the patient to the right place in a timely manner, and communicate and document the patient’s history, we give our patient the best chance at the best possible outcome.
- Instructor Notes Allow time for a question and answer session to answer any questions about the topics presented in the lesson.