1. 1 ECRN: Assessment Based Management; Thoracic & Abdominal Trauma; Neurological Considerations Condell Medical Center EMS System 2006 Site Code: #10-7214-E-1206 Revised by Sharon Hopkins, RN, BSN

2. 2 Objectives Upon successful completion of this module, the ECRN should be able to: 1. Understand the factors that affect patient assessment and decision making capabilities. 2. Describe the steps of patient assessment based on ITLS guidelines. 3. Identify mechanisms of injury that can lead to thoracic and abdominal traumatic injuries. 4. Understand EMS interventions appropriate for thoracic and abdominal injuries.

3. 3 Objectives cont’d 5. Describe a variety of degenerative neurological diseases. 6. Review case scenarios. 7. Successfully complete the quiz with a score of 80% or better.

4. 4 ASSESSMENT BASED MANAGEMENT Involves the use of: critical thinking skills problem solving abilities clinical decision making Includes avoiding: tunnel vision (can create distractions) patient labeling or jumping to conclusions based on preconceived ideas “the drunk”; “the frequent flyer”; “the whiner”

5. 5 Goals of Our Profession Provide competent, compassionate care for each and every patient interaction You need a strong knowledge base and excellent assessment skills to care for patients

6. 6 Factors Affecting Assessment and Decision-Making Attitude needs to be non-judgmental May “short circuit" information gathering leading to insufficient information gathering May leap to conclusions before gathering a thorough assessment Garbage in = garbage out Patients depend on us for medical assessment/ management and not determination of social standing or "likability"

7. 7 Factors Affecting Assessment and Decision-Making Uncooperative Patients Perception of intoxication - drugs or alcohol In all uncooperative, restless, belligerent patients consider other possible causes hypoxia hypovolemia hypoglycemia head injury

8. 8 Factors Affecting Assessment and Decision-Making Patient compliance influenced by: Patient confidence in the medical team Prior experiences of the patient and their family Cultural and ethnic barriers

9. 9 Factors Affecting Assessment and Decision-Making Distracting injuries can divert attention from more serious problems Need to resist the temptation of forming an initial diagnosis too early Gut instincts may lead to snap judgements Systematic approach to patient care helps prioritize & avoid being swayed by the wrong impression

10. 10 Factors Affecting Assessment and Decision-Making Distractors in the environment Scene chaos Violent & dangerous situations Crowds of bystanders High noise levels Crowds of responders enough help is crucial but they must be used wisely

11. 11 General Approach to Patient Assessment in The Field & The ED Size-up the situation Identify need for body substance isolation (BSI) gloves, gown, mask, eye protection as needed Evaluate scene safety hazards to yourself, the team, the patient Identify mechanism of injury or nature of illness can help determine severity of situation

12. 12 Patient Assessment Initial assessment To identify life-threatening conditions Mental status (AVPU) A - awake, not necessarily oriented V - responding to verbal stimulation P - responding only after touch or lite pain applied U - unresponsive (absolutely no response) Airway assessment Breathing assessment Circulation status pulses present? obvious bleeding to be controlled?

13. 13 Initial assessment cont’d Forming a general impression What do you think is going on? These answers drive the care you want to start providing. Which protocol will you follow?

14. 14 Patient Assessment Focused history and physical exam performed based on chief complaint and information gathered so far trauma patient with significant mechanism of injury or altered mental status needs rapid head-to-toe trauma patient with isolated injury (ie: ankle sprain) focus on body systems related to complaint medical patient (responsive) - focus exam on c/o medical patient (unresponsive) needs rapid assessment with head-to-toe exam when patient input not available

15. 15 Patient Assessment Vital signs CMC ED policy: take and record vital signs minimally every 2 hours or more often as needed SAMPLE history - reminds you to obtain: symptoms allergies medications pertinent past medical history last oral intake food or liquids including water events leading up to the incident Check for medic alert bracelet, necklace

16. 16 Blood Pressure A measurement of the force of blood against the walls of the blood vessels Reassessment over time gives most accurate reflection of patient state Changes in B/P can be very significant Is last vital sign to change in decompensation Cuff should cover 2 / 3 rds of the upper arm Cuff should not be placed over clothing Arm should be maintained at heart level Obese arm? Wrap cuff around forearm; place stethoscope over radial pulse area

17. 17 Tips, Tricks & Pearls on Blood Pressure & Pulses B/P by palpation can only determine a systolic reading As cuff is deflated, palpate over the radially area until the pulse returns Record as “90/systolic” Guidelines suggest that palpated pulses equate with systolic blood pressures carotid pulse felt means B/P at least 60/systolic radial pulse felt means B/P at least 80/systolic No peripheral pulse? Think circulatory collapse B/P should always be attempted & documented

18. 18 Patient Assessment Detailed physical exam a more detailed & slower head-to-toe exam than the initial one performed clinical experience and patient condition often dictate how & if a detailed exam is done in the field & if there is time before ED arrival Ongoing Assessment - always done used to detect trends, determine changes in patient condition, and assess effectiveness of interventions mental status, ABC’s, vital signs (pulse, respirations, B/P, SaO 2, pain level), EKG

19. 19 Assessment Techniques Inspection observation; looking beyond the obvious Palpation use your sense of touch to gather information pads of fingers more sensitive than tips for touch back of hand is better for sense of temperature Percussion - not often done in the field Auscultation listening for sounds (lungs, heart, intestines) for lung sounds, note abnormal sounds, location, timing during inspiration or expiration

20. 20 Accurate Decision Making Relies on: Patient history obtained Physical, hands-on exam performed Recognizing a pattern comparing information gathered with what you already know (existing knowledge base) Impression or field diagnosis made the first diagnosis is based on the most probable cause of the patient’s complaint based on the information gathered during the assessment used to formulate a plan of action based on the patient’s condition and the environment

21. 21 Use of Protocols & SOP’s Protocol - policies and procedures of all components of the EMS system Standard operating procedures (SOP’s) - preauthorized treatment procedures Exercise judgement when following protocol and SOP’s know which protocol/SOP to choose know when and how to follow protocol/SOP’s recognize when you must deviate from the stated protocol/SOP - allergies, abnormal vital signs (ie: hypotension)

22. 22 SOP’s/Protocols & The ECRN An ECRN, by the restriction of their license, cannot give a medical order; the ECRN is only authorized to give an order if it is printed in the SOP/protocol The ECRN must consult with the ED MD to give an order to EMS that is not listed in the SOP (ie: lidocaine drip after bolus given for stable ventricular tachycardia)

23. 23 Difficulty Establishing An Airway In The Field If EMS cannot establish an airway on any patient in the field, EMS is to transport the patient to the closest Comprehensive Emergency Department even if they are on by-pass A Comprehensive Emergency Department is one that is open 24 hours, 7 days a week and has a physician on duty as well as other support services

24. 24 Communication Hospital reports are best when they: Are given in less than one minute Are clear and concise Avoid use of unfamiliar or unclear medical or technical terms including “10” codes Follow a basic format Include both pertinent findings and pertinent negatives (findings that would be expected but are not present) Conclude with specific actions, requests, or questions related to the plan

25. 25 Transmission of Patient Information Provider identified by name and vehicle number Age, sex, and approximate weight of patient Level of consciousness Chief complaint and degree of distress Vital signs, EKG, pulse oximetry, blood glucose if obtained If indicated, lung sounds, pupils, skin condition and color, GCS, pain assessment Treatment rendered and patient response Patient history ETA and destination

26. 26 Calling Report on Trauma Patients Important for EMS to include information the hospital can use to categorize the trauma level for this patient as well as determine which members of the trauma team that need to be activated mechanism of injury destruction to vehicle/surroundings injuries noted or suspected vital signs, GCS Restlessness: first think hypoxia & shock

27. 27 THORACIC TRAUMA

28. 28 Anatomy & Physiology of the Thorax Thoracic cage responsible for moving air in and out Place where carbon dioxide and oxygen exchange takes place to support metabolism Includes thoracic skeleton, diaphragm, and supporting musculature Location of major organs and vessels heart, aorta, trachea, lungs, mediastinum

29. 29 Thoracic Trauma Classifying thoracic injuries Blunt trauma - closed injury from kinetic energy transmitted through tissue blasts deceleration compression/crush Penetrating trauma - open wound; direct or indirect trauma transmitted via kinetic energy dart

30. 30 Blunt Trauma From Blast Injuries Blast injury - explosion caused by dust, fumes, natural gas, explosive compounds Confined space blast/shock wave pressure wave & debris cannot dissipate as far & so maintains higher energy level longer danger of structural collapse & flying debris extremely deadly overpressures created

31. 31 Thoracic Injuries Thoracic cage - ribs & sternal fx, flail segment Cardiovascular - contusion, tamponade Pleural and pulmonary- contusions, pneumo’s Mediastinal - pneumomediastinum Diaphragm - tear, laceration, rupture Esophageal - laceration Penetrating cardiac trauma - laceration aorta, vena cava, pulmonary arteries/veins Spinal cord injuries

32. 32 Flail Chest Definition 3 or more adjacent ribs broken in 2 or more places Most common mechanism of injury - blunt trauma falls, MVC, industrial injuries, assaults Risks to the patient reduces tidal volume (air moving in and out) increases respiratory effort usually accompanied by pulmonary and possibly cardiac contusions

33. 33 Flail Chest Signs and symptoms paradoxical motion of the chest wall asymmetrical chest wall movement; flail segment moves in opposite direction from the rest of the chest increased respiratory effort and rate decreased pulse oximetry readings increased amount of pain to the chest wall Treatment support respiratory effort - supplemental O 2 via nonrebreather mask; BVM as needed support fractured section manually - no taping of the chest or sandbags/IV’s placed on chest EKG monitoring

34. 34 Sucking Chest Wound Definition open wound of the chest with air passage into the pleural space Risks to the patient collapse of the lung on the affected side uninjured lung unable to fully expand change in intrathoracic pressures negatively affect venous return to the heart if the chest wall opening is at least 2 / 3 the diameter of the trachea (normally the size of the patient’s little finger), air will move in & out thru the chest wall defect & not thru the trachea

35. 35 Sucking Chest Wound Signs and symptoms open wound to the thorax & frothy blood noted around the chest wall defect gurgling sound heard near the chest wound severe dyspnea possible hypovolemia - associated injury & hemorrhage increased pulse rate & respiratory rate; decreased blood pressure evidence of air hunger if, with each breath, more air enters thru the chest wall defect than thru the trachea

36. 36 Sucking Chest Wound Treatment Immediately seal the chest wound (gloved hand to start with if necessary); eventually with occlusive dressing taped on 3 sides Open pneumothorax now converted to closed pneumothorax - watch for increased respiratory distress leading to tension pneumothorax if needed, burp dressing by lifting one corner during exhalation O 2 via nonrebreather mask Monitor vital signs, pulse ox, EKG

37. 37 Tension Pneumothorax Definition An open or simple pneumothorax that generates and maintains a greater pressure than atmospheric pressure within the thorax via a created one-way valve Risks to the patient Air is trapped in the pleural space and puts pressure on the affected lung, the structures in the mediastinum, the opposite lung

38. 38 Tension Pneumothorax (rare & late sign not often appreciated) decreased B/P Low pulse ox, narrowed pulse pressure (JVD) Dyspnea, SOB PEA tachycardia

39. 39 Needle Decompression Treatment Provide supplemental oxygenation (nonrebreather mask) or BVM Initially perform needle decompression identify site: 2 nd intercostal space in midclavicular line; above the rib prep the site prepare a flutter valve on a 3  large gauged needle insert 3  needle largest gauge available (12-14g) straight into the chest wall over the top of a rib can take the plug off the catheter end and attach a syringe upon feeling a “pop” or noting air return in syringe, advance catheter & remove needle; secure catheter

40. 40 Needle Decompression

41. 41 Hemothorax Definition an accumulation of blood in the pleural space due to internal hemorrhage more of a blood loss problem than an airway issue each side of the thorax may hold up to 3000 ml of blood Risks to the patient hypovolemic shock reduction of tidal volume & efficiency of ventilations

42. 42 Hemothorax Signs & Symptoms decreased blood pressure History blunt or penetrating trauma

43. 43 Hemothorax Treatment support the patient with supplemental oxygenation (nonrebreather mask) and potentially BVM IV access for fluid resuscitation 20 ml/kg normal saline (Routine Trauma Care Protocol) carefully administer fluids to avoid worsening the edema and congestion of pulmonary contusions Note: Hemothorax is primarily a blood loss problem more than a respiratory one

44. 44 Cardiac Tamponade Definition A restriction to cardiac filling caused by blood or fluid in the pericardial sac Most common mechanism of injury penetrating trauma (could be medical problem) Risks to the patient accumulating blood exerts pressure on the heart pressure limits cardiac filling restricting venous return to the heart cardiac output is diminished

45. 45 Cardiac Tamponade Muffled heart tones agitation (JVD) Diaphoretic, ashen or cyanotic PEA

46. 46 Cardiac Tamponade Treatment keep high index of suspicion field care limited to supportive oxygenation (nonrebreather mask or BVM),IV fluids, and rapid transport definitive care must be provided in-hospital removal of some of the accumulated fluid from the pericardial sac in the ED and then patient needs to go to the OR

47. 47 ABDOMINAL TRAUMA A high degree of suspicion must be exercised based on mechanism of injury and kinematics.

48. 48 Abdominal Anatomy and Physiology Boundaries superiorly the diaphragm inferiorly the pelvis posteriorly the vertebral column, posterior & inferior ribs, back muscles laterally the flank muscles anteriorly the abdominal muscles

49. 49 Abdominal Anatomy and Physiology The 3 abdominal spaces ¬ peritoneal space organs or portions of organs covered by abdominal (peritoneal) lining ­ retroperitoneal space organs posterior to the peritoneal lining ® pelvic space organs contained within the pelvis

50. 50 Abdominal Quadrants RUQ gallbladder, right kidney, most of the liver, some small bowel, portion of ascending & transverse colon, small portion of pancreas LUQ stomach, spleen, left kidney, most of pancreas, portion of liver, small bowel, transverse & descending colon RLQ appendix, portions urinary bladder, small bowel, ascending colon, rectum, female genitalia LLQ - sigmoid colon, portion urinary bladder, small bowel, descending colon, rectum, female genitalia

51. 51 Blunt Abdominal Trauma Produces least visible signs of injury Responsible for 40% of splenic injuries Responsible for 20% or liver injuries Bowel and kidneys next most frequently injured organs Injuries must be anticipated by evaluating mechanism of injury with force & direction of impact Maintain high index of suspicion based on mechanism of injury

52. 52 Blunt Mechanisms Compression forces Shear forces Deceleration forces Motor vehicle crashes Motorcycle collisions Pedestrian injuries Falls Assault Blast injuries

53. 53 Penetrating Abdominal Trauma Low velocity - injury limited to the direct area Knife, ice pik Medium velocity Handgun & shotgun wounds High velocity High power hunting rifles Military weapons Ballistics - study of projectiles in motion Trajectory - path a projectile follows Distance traveled a consideration

54. 54 Evisceration of the bowel caused by a knife wound Cover eviscerated area with sterile, moistened dressing Minimize patient movement, coughing

55. 55 Hollow Organ Injury Hollow organs Stomach, small bowel, large bowel, rectum, urinary bladder, gallbladder, pregnant uterus Anticipated injuries May rupture due to forces especially if the organ is full and distended Can cause hemorrhage and spillage of the contents into the peritoneal, retroperitoneal or pelvic spaces Contents spilled may have high bacterial counts, contain irritating chemicals, have high acid counts, or contain digestive enzymes

56. 56 Solid Organ Injury Solid organs spleen, liver, pancreas, kidneys Anticipated injuries Prone to contuse resulting in organ damage; bleeding often minimal if organ intact and contained within the organ but could be severe If organ torn or lacerated may cause life- threatening hemorrhage

57. 57 Patient Assessment Maintain high index of suspicion Serious trauma to the abdomen is often a surgical problem and requires prompt and rapid transport with frequent reassessment Identify additional causative forces of injury seatbelt worn above the iliac crest no seatbelt restraint used, steering wheel deformity type of weapon used in penetrating trauma

58. 58 Patient Assessment For Abdominal Trauma Early signs of serious or continuing internal hemorrhage diminishing level of consciousness increasing anxiety or restlessness thirst increasing pulse rate decreasing pulse pressure - systolic and diastolic numbers moving closer together increasing capillary refill time (>2 seconds) increasing abdominal distention, bruising

59. 59 Abdominal Assessment Inspection Redness, ecchymosis, contusions, open wounds, distention May hold up to 1.5 L of blood before distended Palpation Gently palpate each quadrant individually with tips of fingers Quadrants with pain or injury are palpated last Distention, tenderness, crepitus, instability, guarding, pulsations Auscultation - Not often done in field in trauma - too much time and need for quieter environment

60. 60 Initial Abdominal Trauma Treatment Timely, thorough assessment repeated often Critical findings: rigid or distended abdomen or guarding; presence of shock; shock out of proportion to findings (maybe haven’t found all the sources of bleeding yet) Supportive oxygenation (nonrebreather mask) IV access EKG monitoring

61. 61 Neurological Emergencies The human body’s ability to maintain a state of homeostasis results primarily from the nervous system’s regulatory and coordinating activities A disruption in the nervous system affects the functioning of the body and can be in a variety of forms from simple to severe

62. 62 Headache Common ailment Described as a symptom rather than a disorder Can accompany many disorders Can be brought on by emotional events Recurring headaches may be an early sign of a more serious disease Most are caused by vasodilatation in tissues surrounding the brain

63. 63 Headache Immediate attention is needed if: Severe and sudden in onset Other neurological impairments such as visual disturbances, confusion, motor dysfunction or sensory loss also occur Accompanied by fever or stiff neck Patient states “the worse headache in my life”

64. 64 Types of Headache Migraine Usually one sided and accompanied by nausea Personal or environmental triggers Dietary substances or medication triggers Cluster Unilateral intense pain over and behind the eye Lasts about an hour and occur in clusters (bunches) Tension Prolonged overwork or stress Usually occipital region

65. 65 Headache Treatment in general Medications based on individual history, symptoms and needs Analgesics may or may not be effective Mild diuretics may be effective at times Dark environment Rest Determine trigger and use avoidance Accurate diagnosis necessary in case of more severe problem!

66. 66 Neoplasms - Tumor Any abnormal growth of cells May be benign or malignant Cell multiplication is fast and uncontrolled Classified by origin Treatment - depends on type, location & age of tumor Observation Chemotherapy Radiation therapy Surgical removal

67. 67 Malignant Neoplasms Cancerous tumor Embryonic or poorly differentiated cells Grow in a disorganized manner Necrosis and ulceration is common sign Invasion of surrounding tissue for nutritional needs Metastatic in nature (i.e.: Initiates growth of like tumors in other areas)

68. 68 Benign Neoplasms Usually not dangerous to life unless they occur in a vital organ Slow growth Do not invade tissue for nutrition Usually encapsulated Do not form secondary tumors in other organs

69. 69 Assessment of Neoplasms Some are painful yet some have no pain at all External presentation Irregular borders Rough texture Brown/black in color Capsule formation under the skin Ulceration of overlying skin Dependant on the organ or organ system affected

70. 70 Neoplasm When to be concerned: Change in bowel or bladder habits A sore throat that does not heal Unusual bleeding or discharge Thickening on breast or other soft tissue Indigestion or difficulty swallowing Obvious change in a wart or mole Nagging cough or hoarseness

71. 71 Neoplasm Treatment Chemotherapy Intravenous pharmacological therapy to slow growth or kill tumors Cytotoxic to all cells of the body even though target is cancerous cells Can cause lethargy, hair loss, unsteady gait, weakness and nausea

72. 72 Neoplasm Treatment Radiation therapy Ionizing radiation Dose of particulate or electromagnetic radiation to a specific area of the organ or body Can come from outside the body or inside the body (implanted radiotherapy) More effective and less harmful than when first introduced

73. 73 Neoplasm Treatment Surgical intervention Dependant on type and amount of tissue involvement with the tumor Can be radical or precise Can be used in conjunction with other therapy methods Can cause self esteem issues

74. 74 Neoplasms Prevention strategies to include in patient teaching: Self breast exams Mammograms PAP smears Yearly physical exams Self testicular exams Prostate screening PSA Digital inspection Seek medical evaluation early after abnormal finding

75. 75 Bell’s Palsy Seventh cranial nerve inflammation or trauma Temporary weakness or paralysis in facial muscles Can reoccur Good to complete recovery with nerve regeneration Conditions that compromise the immune system increase odds of disease Lyme disease, herpes viruses, mumps and HIV infections

76. 76 Degenerative Neurological Disorders Muscular fatigue usually attributed to interruption in the ability of the axon to communicate with the muscular endplate for various reasons Symptoms can be mild to severe depending on manifestation and advancement of the disease process; can come and go; can be localized or systemic Chronic conditions can be debilitating and affect quality of life

77. 77 Degenerative Neurological Disorders Pathophysiology is variable and dependant on the specific disease Some are caused by an autoimmune type response to a toxic invader Example: Multiple sclerosis Some are the muscle’s inability to use the proteins provided by the body as fuel Example: Muscular dystrophy Some are actual nerve tissue breakdown Example: Parkinson’s disease

78. 78 Degenerative Neurological Disorders Partial facial paralysis Example: Bell’s Palsy Degeneration of the cell bodies in the gray matter of the anterior spinal cord, brain stem and pyramidal tract Example: Amyotrophic Lateral Sclerosis (ALS) Contraction of muscles or muscle groups that can contribute to convulsive disorders Example: Myoclonus

79. 79 Degenerative Neurological Disorders An abnormal closing of the protective bony casement for the spinal cord. Nervous meninges may or may not be exposed Example: Spina bifida Non-inflammatory lesions that affect the peripheral nervous system Example: Peripheral neuropathy

80. 80 Degenerative Neurological Disorders General disease manifestations Weakness General body aches Partial paralysis that comes and goes Parasthesia - pins & needles sensation Peripheral sensory impairment Respiratory insufficiency (chronic stages) Immunosuppression - more vulnerable to contract communicable diseases Multiple medication interactions

81. 81 Degenerative Neurological Disorders Pharmacological interventions range from anti-inflammatory drugs to experimental protein altering medications Medication usage depends on the organ system involved and the severity of symptom Environmental changes (living in a cool area) can help some diseases Decreased exercise or production of muscular heat can decrease symptoms

82. 82 Degenerative Neurological Disorders Caring for the patient in crisis must include maintaining ABC’s Endotracheal intubation or bagging the patient through an in-place tracheostomy may be necessary Supportive care for hypotension Patients may need total lift assistance to move

83. 83 Muscular Dystrophy Inherited through DNA degeneration of muscle fibers Early recognition in children who are slow to sit and walk Calf muscles become bulky as wasted muscle turns to fat Pulmonary infections and heart failure are frequent causes of death

84. 84 Multiple Sclerosis Myelin in the brain and spinal cord are destroyed. Autoimmune system sees myelin as foreign material. Experience numbness to paralysis Damage to white matter causes fatigue, vertigo, unsteady gait, slurred speech, pain Some disable at onset; others degenerative over many years

85. 85 Structure of the Neuron and Multiple Sclerosis The myelin sheath is a membranous extension of specialized cells called oligodendrocytes. These form an insulating substance. Non-myelinated axons (not insulated) conduct impulses very slowly

86. 86 Parkinson’s Disease Degeneration of nerve cell in basal ganglia in the brain Lack of dopamine inhibits basal ganglia from modifying nerve pathways that control muscle contraction Tremors, joint rigidity Leading cause of neuro disability in those over 60 years old

87. 87 Lou Gehrig’s Disease - ALS Progressive motor neuron disease Types Spinal muscular atrophy Bulbar palsy Primary lateral sclerosis Pseudobulbar palsy

88. 88 Amyotrophic Lateral Sclerosis (ALS) Upper motor neurons affected in the central nervous system; lower motor neurons affected in the peripheral muscles

89. 89 Amyotrophic Lateral Sclerosis (ALS) More common men over 50 Weakness, quivering (fasciculations) Unable to speak, swallow, move, breath on own Intellect and awareness maintained Become ventilator dependent Aspiration pneumonia constant threat Starvation, failure to thrive

90. 90 Trigeminal Neuralgia Trigeminal nerve – 5 th cranial nerve with opthalmic, maxillary and mandibular functions Affects skin of upper eye, side of nose, half of scalp Affects mucous membranes of nose, forehead, upper lip Affects lower teeth and tongue

91. 91 Peripheral Neuropathy Axon or myelin sheath in peripheral nervous system damaged/irritated causing blockage of electrical signals Can affect: muscle activity sensation reflexes internal organ function Can be caused locally - trauma, compression (tight casts, tourniquet use), carpal tunnel, infections Can be demyelination or degeneration of peripheral nerves - diabetes, Guillain-Barre syndrome

92. 92 Myoclonus Temporary, involuntary rapid, uncontrolled muscular contractions (jerking) or twitching of a group of muscles Generally considered a symptom more than a diagnosis Can occur at rest or during movement Can distort normal movement and interfere with the ability to eat, walk, and talk

93. 93 Spina Bifida Defect of neural tube closure Portion of vertebra fails to develop leaving a portion of the spinal cord unprotected Lower back most affected Nerve damage is permanent Long term effects physical & mobility limitations loss of bowel & bladder control most have some form of a learning disability

94. 94 Spina Bifida

95. 95 Degenerative Neurological Diseases Make treating the chief complaint a priority Do not overlook the underlying history but do not allow it to cloud judgement for a more serious issue Management Plan History Acute or chronic complaint for today? General health? Previous medical conditions? Medications?

96. 96 Degenerative Neurological Diseases Management Oxygen Position of comfort Venous access Pharmacological interventions Check for hypoglycemia in setting of altered level of consciousness Antihistamine - benadryl for dystonic reactions (impairment of muscle tone (peculiar posturing & difficulty speaking) after exposure usually to certain meds) Psychological support

97. 97 Degenerative Neurological Diseases Treatment concerns: mobility often limited communication often difficult - hearing, speech unclear respiratory compromise - especially exacerbations of underlying problems anxiety - coping with debilitating disease difficult on patient and family & stress and anxiety levels can run high

98. 98 Case Study #1 32 year old male unrestrained in head-on MVC at 55 mph Awake & oriented, increased respiratory rate, weak & rapid radial pulse Major complaint is pain to the left side of the chest with evident redness, crepitation felt on palpation Vital signs: B/P 102/50; P - 108; R - 24 pulse ox 94%; EKG - sinus tachycardia Breath sounds - decreased left side

99. 99 Case Study #1 General impression (what are possibilities)? Cardiac contusions Lung contusions Pneumothorax The patient is becoming more restless with increased anxiety; pulse ox dropping to 84%; respiratory rate climbing to 38 and now shallow with increasing dyspnea What’s going on now?

100. 100 Case Study #1 Reassess ABC’s Airway still open Breathing getting more difficult Breath sounds absent on the left Pulse more rapid and thready and barely palpable radially Impression: Tension pneumothorax Treatment: Initially needle decompression

101. 101 Case Study #1 Landmarks for needle decompression? 2 nd intercostal space in the midclavicular line Be above the rib (avoid vessels & nerves that run under the rib) Equipment used in the field Largest gauge & longest needle available 12-14 G and 3 inches long Flutter valve prepared Skin prepped Needle must be secured in place

102. 102 Case Study #2 55 year old extremely obese female unrestrained rear seat passenger of taxi cab involved in 60 mph MVC Patient is agitated, complaining of pain all over (was thrown around back of cab) Patient is pale, slightly diaphoretic (apologizes because she says she is always somewhat sweaty), unable to feel radial pulse “because of fat wrists”

103. 103 Case Study #2 If unable to take a blood pressure in the upper arm, what are alternatives? Place the cuff around the forearm and place the stethoscope over the radial pulse area. Not acceptable to not attempt any kind of blood pressure. Why is this patient so restless? Don’t be fooled by the obvious and don’t dismiss her concerns to her “weight”

104. 104 Case Study #2 What can cause restlessness? Hypoxia Hypovolemia Internal injury Hypoglycemia Pain Anxiety; being scared Being uncomfortable (pain, positioning, full bladder)

105. 105 Acknowledgement NIMSCA contribution for packet by: Kathy Wexelberg RN, Advocate Christ Marlene Blacklaw, RN, Advocate Christ Lonnie Polhemus, EMT-P, Silver Cross Additions made by: Sharon Hopkins, RN, BSN, Condell Medical Center Region X SOP’s, Effective March 2005