1. Trauma CNS Injury - Concussion

4. Cranial Injury Trauma must be extreme to fracture Basal Skull Linear
Depressed
Open
Impaled Object
Basal Skull
Unprotected
Spaces weaken structure
Relatively easier to fracture

5. Cranial Injury Basal Skull Fracture Signs Battle’s Signs Raccoon Eyes
Retroauricular Ecchymosis
Associated with fracture of auditory canal and lower areas of skull
Raccoon Eyes
Bilateral Periorbital Ecchymosis
Associated with orbital fractures

6. Cranial Injury Basilar Skull Fracture May tear dura
Permit CSF to drain through an external passageway
May mediate rise of ICP
Evaluate for “Target” or “Halo” sign

7. Brain Injury As defined by the National Head Injury Foundation
“a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.”
Classification
Direct
Primary injury caused by forces of trauma
Indirect
Secondary injury caused by factors resulting from the primary injury

8. Direct Brain Injury Types
Coup
Injury at site of impact
Contrecoup
Injury on opposite side from impact

9. Direct Brain Injury Categories
Focal
Occur at a specific location in brain
Differentials
Cerebral Contusion
Intracranial Hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral Hemorrhage
Diffuse
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury

10. Focal Brain Injury Cerebral Contusion
Blunt trauma to local brain tissue
Capillary bleeding into brain tissue
Common with blunt head trauma
Confusion
Neurologic deficit
Personality changes
Vision changes
Speech changes
Results from
Coup-contrecoup injury

11. Focal Brain Injury Intracranial Hemorrhage
Epidural Hematoma
Bleeding between dura mater and skull
Involves arteries
Middle meningeal artery most common
Rapid bleeding & reduction of oxygen to tissues
Herniates brain toward foramen magnum

12. Focal Brain Injury Intracranial Hemorrhage
Subdural Hematoma
Bleeding within meninges
Beneath dura mater & within subarachnoid space
Above pia mater
Slow bleeding
Superior sagital sinus
Signs progress over several days
Slow deterioration of mentation

13. Focal Brain Injury Intracranial Hemorrhage
Intracerebral Hemorrhage
Rupture blood vessel within the brain
Presentation similar to stroke symptoms
Signs and symptoms worsen over time

14. Diffuse Brain Injury Due to stretching forces placed on axons
Pathology distributed throughout brain
Types
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury

15. Diffuse Brain Injury Concussion
Mild to moderate form of Diffuse Axonal Injury (DAI)
Nerve dysfunction without anatomic damage
Transient episode of
Confusion, Disorientation, Event amnesia
Suspect if patient has a momentary loss of consciousness
Management
Frequent reassessment of mentation
ABC’s

16. Diffuse Brain Injury Moderate Diffuse Axonal Injury
“Classic Concussion”
Same mechanism as concussion
Additional: Minute bruising of brain tissue
Unconsciousness
If cerebral cortex and RAS involved
May exist with a basilar skull fracture
Signs & Symptoms
Unconsciousness or Persistent confusion
Loss of concentration, disorientation
Retrograde & Antegrade amnesia
Visual and sensory disturbances
Mood or Personality changes

17. Diffuse Brain Injury Severe Diffuse Axonal Injury
Brainstem Injury
Significant mechanical disruption of axons
Cerebral hemispheres and brainstem
High mortality rate
Signs & Symptoms
Prolonged unconsciousness
Cushing’s reflex
Decorticate or Decerebrate posturing

18. Intracranial Perfusion
Review
Cranial volume fixed
80% = Cerebrum, cerebellum & brainstem
12% = Blood vessels & blood
8% = CSF
Increase in size of one component diminishes size of another
Inability to adjust = increased ICP

20. ETCO2 Monitoring

21. Physiology of the Respiratory System

22. Respiration and Ventilation
Respiration is the exchange of gases between a living organism and its environment.
Ventilation is the mechanical process that moves air into and out of the lungs.

23. The Respiratory Cycle
Pulmonary ventilation depends upon changes in pressure within the thoracic cavity.
Coordinated interaction among the respiratory system, the central nervous system, and the musculoskeletal system.

24. The Respiratory Cycle Inspiration
Thoracic cavity is closed except for the tracheal opening
Respiratory centers stimulate nerves which stimulate muscle
Changes in pressure occur with diaphragmatic contraction and intercostals contract and air is drawn inward
Active process

25. The Respiratory Cycle Expiration
Receptors signal the respiratory center by way of the vagus nerve to inhibit inspiration.
Expiration occurs
Normally passive
Use of accessory muscles

26. Pulmonary Circulation
Respiration also requires an intact circulatory system.
Venous system carries deoxygenated blood to the right side of the heart, and the right ventricle pumps it into the pulmonary circulation.

27. Pulmonary Circulation
Diffusion occurs in the pulmonary capillaries.
Blood returns to the left side of the heart for systemic circulation.

28. Diffusion
Movement of a gas from an area of higher concentration to an area of lower concentration
Transfers gases between the lungs and the blood and between the blood and peripheral tissues

29. Measuring Oxygen and Carbon Dioxide Levels
The partial pressure of a gas is its percentage of the mixture’s total pressure.
Four major respiratory gases:
Nitrogen (N2)
Oxygen (O2)
Carbon dioxide (CO2)
Water (H2O)

30. Normal Arterial Partial Pressures
Oxygen (PaO2) =
100 torr (average = 80 – 100)
Carbon dioxide (PaCO2) =
40 torr (average = 35 – 45)

31. Factors Affecting Oxygen Concentration in the Blood
Decreased hemoglobin concentration
Inadequate alveolar ventilation
Decreased diffusion across the pulmonary membrane
Ventilation/perfusion mismatch occurs when a portion of the alveoli collapses

32. Factors Affecting Carbon Dioxide Concentrations in the Blood
Hyperventilation
Lowers CO2 levels due to increased respiratory rates or deeper respiration
Increased CO2 production include:
Fever, muscle exertion, shivering, and metabolic processes
Decreased CO2 elimination results from decreased alveolar ventilation

33. Respiratory Rate Involuntary; however, can be voluntarily controlled
Chemical and physical mechanisms provide involuntary impulses to correct any breathing irregularities

34. Nervous Impulses from the Respiratory Center
Main respiratory center is the medulla
Apneustic center assumes respiratory control if the medulla fails to initiate impulses
Pneumotaxic center controls expiration
Stretch receptors prevent overexpansion of the lungs
Hering-Breuer reflex

35. Chemoreceptors
Located in carotid bodies, arch of the aorta, and medulla
Stimulated by decreased PaO2, increased PaCO2, and decreased pH
Cerebrospinal fluid (CSF) pH is primary control of respiratory center stimulation

36. Hypoxic Drive
Hypoxemia is a profound stimulus of respiration in a normal individual.
Hypoxic drive increases respiratory stimulation in people with chronic respiratory disease.

37. Measures of Respiratory Function
Respiratory rate
Factors influencing rate include:
Fever, emotion, pain, hypoxia, acidosis, stimulant drugs, depressant drugs, sleep
Age
Rate per Minute
Adult
12–20
Children
18–24
Infants
40–60

38. Measures of Respiratory Function
Respiratory capacities and measurements
Total lung capacity
Total volume of air at maximum inhalation
Average adult male TLC- 6 liters
Tidal Volume
Average volume of gas inhaled or exhaled in one respiratory cycle
Approximately 500 cc

39. Measures of Respiratory Function
Respiratory capacities and measurements
Dead-space
Amount of gases in tidal volume that remains in the airway
Alveolar volume
The alveolar volume is the amount of gas in the tidal volume that reaches the alveoli for gas exchange
Minute volume
The amount of gas moved in and out of the respiratory tract in 1 minute

40. Measures of Respiratory Function
Respiratory capacities and measurements
Alveolar minute volume
Amount of gas that reaches the alveoli for gas exchange in one minute
Inspiratory reserve volume
The amount of air that can be maximally inhaled after a normal inspiration
Expiratory reserve volume
The amount of air that can be maximally exhaled after a normal expiration

41. Measures of Respiratory Function
Respiratory capacities and measurements
Residual volume
The amount of air remaining in the lungs at the end of maximal expiration
Functional residual volume
The volume of gas that remains in the lungs at the end of normal expiration
Forced expiratory volume
The amount of air that can be maximally expired after maximum inspiration

42. Non-Invasive Respiratory Monitoring
Devices will assist your measurement of the effectiveness of oxygenation and ventilation.
Pulse oximetry, capnography, esophageal detection, and peak flow measurements

43. Non-Invasive Respiratory Monitoring
Pulse Oximeter
Measures hemoglobin oxygen saturation in peripheral tissues
The “fifth vital sign”
Normal SpO2 varies between 95 and 99 percent
85 percent or lower indicates severe hypoxia
© Scott Metcalfe

44. SPO2 and waveform Plethysmograph
Optically measures bloodflow to an organ

45. Non-Invasive Respiratory Monitoring
Capnography
Recordings or displays of exhaled CO2 measurements are called capnography.
When perfusion decreases, as occurs in shock or cardiac arrest, ETCO2 levels reflect pulmonary blood flow and cardiac output, not ventilation.

46. Non-Invasive Respiratory Monitoring
Capnography (cont.)
A normal partial pressure of end-tidal CO2 (PETCO2) is approximately mmHg.
Increased ETCO2 levels are found with hypoventilation, respiratory depression, and hyperthermia.
Decreased ETCO2 levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction.

47. Non-Invasive Respiratory Monitoring
Capnography
Colorimetric Device
Contains pH-sensitive paper
Causes a color change in the paper
Electronic Devices
Use an infrared technique to detect CO2
May be either qualitative or quantitative
Reprinted by permission of Nellcor Puritan Bennett LLC, Pleasanton, California
© Scott Metcalfe

48. Non-Invasive Respiratory Monitoring
Capnography (cont.)
Clinical application
Allows continuous monitoring of airway placement and ventilation for intubated patients
Monitoring non-intubated patients
Useful in CPR
Rise with the onset of effective CPR
© Scott Metcalfe

49. Non-Invasive Respiratory Monitoring
Esophageal Detector Device
May be either a rigid syringe or a bulb syringe
© Wolfe Tory Medical

50. IV Therapy

51. Catheters
Sizes 24-14ga
Varies in model types

52. Components
Iv lock
Saline
Heparin
Iv tubing
Medication bag

53. Fluid Administration Administer up to 250ml of saline.
Medical control option for 250ml or more
Indicators
Excessive bleeding
Blood pressure below 100mm HG
Suspected dehydration
Suspected internal bleeding

54. Field Triage & Patient Assessment

55. Priority Determination
Once the initial assessment is completed, determine the patient’s priority.
If serious injury or illness is indicated by the initial assessment, conduct rapid head-to-toe assessment for other potential life-threats and initiate transport.

56. Top Priority Patients Poor general impression Complicated childbirth
Unresponsive
Conscious but cannot follow commands
Difficulty breathing
Hypoperfusion
Complicated childbirth
Chest pain and BP below 100 systolic
Uncontrolled bleeding
Severe pain
Multiple injuries

57. Expedite transport for a high-priority patient and continue assessment and care en route.
© Glen Jackson

58. The Focused History and Physical Exam

59. Types of Patients Trauma patient with significant mechanism of injury
Trauma patient with isolated injury
Responsive medical patient
Unresponsive medical patient

60. The Major Trauma Patient
Sustained significant injury
Exhibits altered mental status from the incident

61. Evaluate the trauma scene to determine the mechanism of injury.
© Robert J. Bennett

62. Predictors of Serious Internal Injury
Ejection from vehicle
Death in same passenger compartment
Fall from higher than 20 feet
Rollover of vehicle
High-speed motor vehicle collision
Vehicle-passenger collision
Motorcycle crash
Penetration of the head, chest, or abdomen

63. MOI Considerations for Infants and Children
Fall from higher than ten feet
Bicycle collision
Medium-speed vehicle collision with resulting severe vehicle deformity

64. A bent steering wheel indicates potentially serious injuries.
Courtesy of Edward T. Dickinson, MD

65. Rapid Trauma Assessment
Not a detailed physical exam
Fast, systematic assessment for other life-threatening injuries
Findings may influence transport decision

66. DCAP-BTLS Deformity Contusion Burns Abrasion Tenderness Penetration
Lacerations
Swelling

67. Deformity

68. Contusion

69. Abrasions

70. Penetrations

71. Burns
Superficial:
Partial thickness:
Full thickness:

72. Tenderness

73. Laceration

74. Swelling

75. Hemorrhage & Tourniquets

76. Hemorrhage Assessment
Scene Size-up
Standard precautions are essential
Evaluate the mechanism of injury
Time elapsed since injury
Determine the amount and rate of blood loss
© Jeff Forster

77. Hemorrhage Assessment
Primary Assessment
General Impression
Obvious Bleeding
Mental Status
ABC
Interventions
Manage as you go O2
Bleeding control
Shock
BLS before ALS!

78. Hemorrhage Assessment
Secondary Assessment
Rapid Trauma Assessment
Full head to toe
Consider air medical if stage 2+ blood loss
Focused Physical Exam
Guided by c/c
Vitals, SAMPLE, and OPQRST
Additional Assessment
Search for signs of internal bleeding
Bleeding from body orifice, melena, hematochezia
Orthostatic hypotension

79. Hemorrhage Assessment
Ongoing Assessment
Reassess vitals and mental status:
Q 5 min: UNSTABLE patients
Q 15 min: STABLE patients
Reassess interventions:
Oxygen ET IV
Medication actions
Trending: improvement vs. deterioration
Pulse oximetry
End-tidal CO2 levels

80. Hemorrhage Management
Assure that the airway is patent and breathing is adequate.
Maintain the airway and provide the necessary ventilatory support.
Administer high-flow oxygen.
Carotid pulse.
CaAssure that the patient has a palpable re for serious (arterial and heavy venous) hemorrhage, immediately after you correct airway and breathing problems.

81. Hemorrhage Management
Direct Pressure
Controls all but the most persistent hemorrhage
If bleeding saturates the dressing, cover it with another dressing
If ineffective, may be necessary to visualize wound to apply pressure directly to site

82. Hemorrhage Management
Tourniquet
Consider using a tourniquet only as a last resort when hemorrhage is prolonged and persistent.
Apply a blood pressure cuff just proximal to the hemorrhage site.
Inflate to apply pressure 20-30mmHg greater than the systolic blood pressure