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Trauma CNS Injury - Concussion. Cranial Injury  Trauma must be extreme to fracture  Linear  Depressed  Open  Impaled Object  Basal Skull  Unprotected.

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Presentation on theme: "Trauma CNS Injury - Concussion. Cranial Injury  Trauma must be extreme to fracture  Linear  Depressed  Open  Impaled Object  Basal Skull  Unprotected."— Presentation transcript:

1 Trauma CNS Injury - Concussion

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4 Cranial Injury  Trauma must be extreme to fracture  Linear  Depressed  Open  Impaled Object  Basal Skull  Unprotected  Spaces weaken structure  Relatively easier to fracture  Trauma must be extreme to fracture  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  Retroauricular Ecchymosis  Associated with fracture of auditory canal and lower areas of skull  Raccoon Eyes  Bilateral Periorbital Ecchymosis  Associated with orbital fractures  Basal Skull Fracture Signs  Battle’s Signs  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  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  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  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  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  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  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  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 Focal Brain Injury Intracranial Hemorrhage

12  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  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 Focal Brain Injury Intracranial Hemorrhage

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

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  Due to stretching forces placed on axons  Pathology distributed throughout brain  Types  Concussion  Moderate Diffuse Axonal Injury  Severe Diffuse Axonal Injury

15  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  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 Diffuse Brain Injury Concussion

16  “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  “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 Diffuse Brain Injury Moderate Diffuse Axonal Injury

17  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  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 Diffuse Brain Injury Severe Diffuse Axonal Injury

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  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

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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.  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.  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  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  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.  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.  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  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 (N 2 )  Oxygen (O 2 )  Carbon dioxide (CO 2 )  Water (H 2 O)  The partial pressure of a gas is its percentage of the mixture’s total pressure.  Four major respiratory gases:  Nitrogen (N 2 )  Oxygen (O 2 )  Carbon dioxide (CO 2 )  Water (H 2 O)

30 Oxygen (PaO 2 ) = 100 torr (average = 80 – 100) Oxygen (PaO 2 ) = 100 torr (average = 80 – 100)  Carbon dioxide (PaCO 2 ) =  40 torr (average = 35 – 45) Normal Arterial Partial Pressures

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  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 CO 2 levels due to increased respiratory rates or deeper respiration  Increased CO 2 production include:  Fever, muscle exertion, shivering, and metabolic processes  Decreased CO 2 elimination results from decreased alveolar ventilation  Hyperventilation  Lowers CO 2 levels due to increased respiratory rates or deeper respiration  Increased CO 2 production include:  Fever, muscle exertion, shivering, and metabolic processes  Decreased CO 2 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  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  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 PaO 2, increased PaCO 2, and decreased pH  Cerebrospinal fluid (CSF) pH is primary control of respiratory center stimulation  Located in carotid bodies, arch of the aorta, and medulla  Stimulated by decreased PaO 2, increased PaCO 2, 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.  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  Respiratory rate  Factors influencing rate include:  Fever, emotion, pain, hypoxia, acidosis, stimulant drugs, depressant drugs, sleep AgeRate per Minute Adult12–20 Children18–24 Infants40–60

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  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  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  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  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  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 SpO 2 varies between 95 and 99 percent  85 percent or lower indicates severe hypoxia  Pulse Oximeter  Measures hemoglobin oxygen saturation in peripheral tissues  The “fifth vital sign”  Normal SpO 2 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  Plethysmograph  Optically measures bloodflow to an organ

45 Non-Invasive Respiratory Monitoring  Capnography  Recordings or displays of exhaled CO 2 measurements are called capnography.  When perfusion decreases, as occurs in shock or cardiac arrest, ETCO 2 levels reflect pulmonary blood flow and cardiac output, not ventilation.  Capnography  Recordings or displays of exhaled CO 2 measurements are called capnography.  When perfusion decreases, as occurs in shock or cardiac arrest, ETCO 2 levels reflect pulmonary blood flow and cardiac output, not ventilation.

46 Non-Invasive Respiratory Monitoring  Capnography (cont.)  A normal partial pressure of end-tidal CO 2 (PETCO 2 ) is approximately 35-45 mmHg.  Increased ETCO 2 levels are found with hypoventilation, respiratory depression, and hyperthermia.  Decreased ETCO 2 levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction.  Capnography (cont.)  A normal partial pressure of end-tidal CO 2 (PETCO 2 ) is approximately 35-45 mmHg.  Increased ETCO 2 levels are found with hypoventilation, respiratory depression, and hyperthermia.  Decreased ETCO 2 levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction.

47  Capnography  Colorimetric Device  Contains pH- sensitive paper  Causes a color change in the paper  Electronic Devices  Use an infrared technique to detect CO 2  May be either qualitative or quantitative  Capnography  Colorimetric Device  Contains pH- sensitive paper  Causes a color change in the paper  Electronic Devices  Use an infrared technique to detect CO 2  May be either qualitative or quantitative Non-Invasive Respiratory Monitoring  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  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  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  Sizes 24-14ga  Varies in model types

52 Components  Iv lock  Saline  Heparin  Iv tubing  Medication bag  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  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.  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  Unresponsive  Conscious but cannot follow commands  Difficulty breathing  Hypoperfusion  Poor general impression  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  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  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  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  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  Not a detailed physical exam  Fast, systematic assessment for other life-threatening injuries  Findings may influence transport decision

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

67 Deformity

68 Contusion

69 Abrasions

70 Penetrations

71 Burns  Superficial:  Partial thickness:  Full thickness:  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  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 O 2 Bleeding control Shock BLS before ALS!  Primary Assessment  General Impression  Obvious Bleeding  Mental Status  ABC  Interventions  Manage as you go O 2 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  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 CO 2 levels  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 CO 2 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.  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  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  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


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