1. Trauma Patient Assessment Intubation Review Needle Decompression
Condell Medical Center EMS System
October, 2007 CE
Site Code # E1207
Prepared by: Sharon Hopkins RN, BSN, EMT-P

2. Objectives
Upon successful completion of this module, the EMS provider should be able to:
identify life threatening trauma to the adult population
describe the Region X interventions that apply to traumatically injured patients
actively participate in return demonstration of the use of the BVM

3. actively participate in return demonstration in use of emergency equipment to secure an airway via intubation including in-line technique
actively participate in return demonstration of needle decompression
review a variety of EKG rhythms
successfully complete the quiz with a score of 80% or better

4. 7 Ways to Die in Trauma Hypovolemia Hypoxia Acidosis Obstructed airway
Flail chest
Cardiac tamponade
Tension pneumothorax

5. Perfusion
Circulation is the movement of blood through the heart and blood vessels
Adequate circulation dependent on:
functioning pump
intact blood vessels
adequate volume of blood
Adequate perfusion
enough blood with an adequate supply of oxygen & nutrients delivered to organs & tissues and the removal of waste products

6. Hypoperfusion Inadequate perfusion also known as shock
Shock - a life threatening condition of inadequate blood flow to body cells that could result in death of cells

7. Normal Blood Volumes Neonate 85 ml/kg Infant 80 ml/kg
Adult men 75 ml/kg
Adult women 65 ml/kg

8. Typical Total Blood Volumes
Neonate (7#) - 3 kg x 85 ml = 255 ml
1 y/o infant (24#) - 11 kg x 80 ml = 880 ml
Adult man (180#) - 82 kg x 75 ml = 6150 ml
(200#) - 91 kg x 75 ml = 6825 ml
Adult woman (150#) - 68 kg x 65ml=4420ml

9. Stages of Blood Loss Stage 1 - compensated
blood loss up to 15% of circulating blood vol
154# person (70 kg) is ml loss
at a typical blood drive you donate 500 ml and over a period of minutes
early compensation
nervousness
slight paleness
slightly cool skin
slight elevation of pulse rate

10. Stage 2 blood loss - compensated
blood loss at % of circulating volume
ml of blood volume is lost
Additional compensatory measures in place ( in catecholamine release)
tachycardia definitely noted with normal blood pressure
pulse strength lessened
pulse pressure narrowed (diastolic & systolic values closer together)
peripheral vasoconstriction noted as cool, clammy skin
patient is anxious & thirsty

11. Stage 3 blood loss - decompensated
% loss of circulating blood volume
ml of blood is lost
compensatory mechanisms failing
classic signs of shock evident
rapid tachycardia with falling blood pressure
narrowed pulse pressure with barely palpable pulse
tachypnea, air hunger
anxious, restless, severe thirst
decreased level of consciousness
pale, cool, diaphoretic

12. Stage 4 blood loss High mortality rate
Blood loss greater than 35% total circulating blood volume
patient very lethargic, confused, or unconscious
barely palpable central pulses
rapid, shallow, ineffective breathing
skin very cool, clammy, extremely pale
High mortality rate
even with aggressive identification and intervention

13. Categories of Shock or Shock Syndromes
Low-volume shock - absolute hypovolemia
Number one cause of preventable deaths
Absolute loss of circulating blood volume
trauma
dehydration
diarrhea
vomiting
poor intake
fever

14. Distributive shock
vascular space too large for the amount of blood circulating
problem distributing the blood volume to all the body’s cells
sepsis
drug overdoses - including alcohol and anything that dilates blood vessels (ie: nitroglycerin, calcium channel blockers)
neurogenic shock (spinal shock) - injury to the spinal cord
anaphylactic shock

15. Mechanical (obstructive) shock
anything that slows or prevents the venous return of blood or obstructs the flow of blood to or through the heart can lower cardiac output and cause shock
tension pneumothorax
cardiac tamponade
myocardial contusion

16. Case Scenario #1 Your adult patient has fallen 30 feet off a ladder
They are confused
The abdomen is tender and rigid
The left femur is deformed and the thigh is increasing in diameter
The patient is pale, cool, and clammy. The pulse is tachycardic and the patient is tachypnic. B/P remains 88/60.
What is your impression?

17. Case Scenario #1 The patient is in hypovolemic shock
The patient meets criteria for a Category I trauma patient
The patient requires transportation to the highest level Trauma Center within 25 minutes
Does this patient require a blood glucose level in addition to all the trauma care they are receiving?
Yes - they are confused!

18. Hypoxia Hypoxemia decreased oxygen content of the arterial blood
decreased oxygen content to the body’s cells and at the tissue level

19. Causes of Hypoxia Reduction of oxygen in the system
Inadequate oxygen transport
Inability of tissues to use the oxygen delivered

20. Conditions That Can Affect Blood Oxygenation
Depressed respiratory drive
head injury
central nervous system depressants
narcotics, sedatives
Paralysis of respiratory muscles
spinal injury
inhalation injury
neuromuscular diseases
(ie: ALS, muscular dystrophy, polio)

21. Increased resistance in the airways
asthma
chronic bronchitis, emphysema
congestion
Decreased compliance of lungs and thoracic wall
interstitial lung disease from inhaling toxic material
infection
lung cancer
connective tissue diseases
chronic pulmonary hypertension

22. Chest wall abnormalities
flail chest
scoliosis
full thickness burns with contractions
Increased thickness of the respiratory membrane
pulmonary edema
interstitial fibrosis

23. Decreased surface area for gas exchange
emphysema
tuberculosis
pneumonia
pulmonary edema
atelectasis
Reduced capacity of blood to transport oxygen
anemias
hemoglobin abnormalities
carbon monoxide poisoning
methahemoglobinemia

24. Ventilation and perfusion mismatching (ventilated alveoli are not perfused or perfused alveoli are not ventilated)
asthma
pneumonia
pulmonary embolus
pulmonary edema
myocardial infarction
respiratory distress syndrome
shock

25. Respiratory Acidosis
Primarily a problem with inadequate elimination of carbon dioxide (CO2) from the lungs (or increased CO2 retention)
respiratory depression or arrest
neuromuscular impairment (ie: ALS, muscular dystrophy, polio)
sedative, hypnotic medications
chest wall injury
flail chest, pneumothorax
pulmonary disorders
airway obstruction, COPD, pulmonary edema

26. Acidosis
When a patient is not ventilating/breathing effectively, they will develop respiratory acidosis. This is often followed by the development of metabolic acidosis
Many medications administered in critical situations are not effective when given in an acidotic environment

27. Hypoxia and Acidosis
If the patient needs or you suspect that they need O2, you must supply the patient with supplemental oxygen
Do not withhold oxygen therapy to the patient with COPD
Adequately ventilating and oxygenating the patient will prevent/treat/reverse hypoxia and/or acidosis

28. Oxygenation & Ventilation
Oxygen therapy for patients in the field
nasal cannula at l/min
delivers 24% - 44% O2
non-rebreather oxygen mask at enough flow to keep the reservoir inflated during inhalation (typically l/min)
delivers 90% plus O2
Ventilation rates
patient with a heart rate buts needs ventilation support - ventilate 1 breath every seconds
once intubated, ventilate 1 breath every seconds

29. Case Scenario #2
Your 56 year-old patient has been involved in a head-on crash into a tree. Upon your arrival, you note a dusky, cyanotic appearing patient with a rapid respiratory rate who is struggling to breathe. The patient is so anxious they are uncooperative.
Breath sounds indicate bilateral wheezing with very diminished breath sounds.
What is your first impression?

30. Case Scenario #2
This patient was on their way to the ED for treatment of an asthma attack
While trying to reach for their inhaler, they lost control of the vehicle and struck the tree
EMS approach is to treat them as a trauma patient with a medical emergency
this patient requires trauma care while an albuterol nebulizer treatment is simultaneously started

31. Obstructed Airway Foreign bodies
food, foreign material, blood
swollen tissues
Patient is unable to speak, cough, or cough is weak & highpitched
Patient is becoming dusky or cyanotic
Totally obstructed airways will cut off oxygen supply
You have 4-6 minutes to reopen an airway to minimize negative consequences

32. Adult Airway Obstruction
Conscious patient who is unable to speak
continuous abdominal thrusts
chest compressions for pregnant or obese patients
Unconscious patient
open airway & attempt to ventilate
reposition head and repeat attempt once
perform direct visualization of the airway and attempt removal with the magill forceps
if obstruction unrelieved, begin CPR steps
during ventilation steps, attempt ventilations twice, reposition between the 2 attempts
consider cricothyrotomy

33. Magill Forceps

34. Needle Cricothyrotomy
While patient supine, locate the cricothyroid membrane
soft membrane between thyroid cartilage (Adam’s apple) and cricoid cartilage
Stabilize larynx with thumb & middle finger of one hand
Prep the area of the cricothyroid membrane
Insert 14 G or larger angiocath, with syringe attached, into trachea at 450 angle
Aspirate air with the syringe

35. Thyroid cartilage
Cricothyroid
membrane
Cricoid cartilage
Thyroid gland
Thyroid cartilage (Adam’s apple)
Cricothyroid membrane
Cricoid cartilage

36. Air should return easily if in the trachea
Advance the catheter while withdrawing the stylet (like starting an IV)
Attach a 3.0 mm ETT adapter (the colored proximal tip of the ETT the BVM attaches to) to the needle hub
Ventilate assessing for breath sounds
Secure the angiocath
Continue to ventilate
May need to allow for longer exhalation time than inhalation time

37. Needle Cric
Step #1 - needle advanced, confirmation by air being aspirated with the syringe
Step #2 - catheter advanced while the stylet is removed

38. Step #3 - the 3. 0 mm adapter removed from the proximal end of a 3
Step #3 - the 3.0 mm adapter removed from the proximal end of a 3.0 mm ETT
Step #4 - the 3.0 mm ETT adapter will be attached to the needle hub of the IV catheter when the stylet is removed
Step #5 - patient can be ventilated; assess for breath sounds, allowing adequate time for exhalation

39. Cricothyrotomy Indications
contraindication for placement of an endotracheal tube
endotracheal tube placement not possible
attempt to place an endotracheal tube fails
to relieve upper airway obstruction
emergency access with severe facial trauma

40. Melker Cric Kit
Department personnel recommended to review the CD from Cook Medical to review using the Melker Emergency Cricothyrotomy Catheter Set

41. Case Scenario #3 This patient has been impaled by a foreign object
Do they need spinal immobilization for this injury? No

42. Flail Chest Fracture of 3 or more adjacent ribs in 2 or more locations
Chest wall segment becomes unstable
Mortality rate is % due to associated injuries
Secondary lung contusion is often associated with flail chest
Development of hypoxia is common

43. Flail Chest On Right Side

44. Signs & Symptoms Flail Chest
History of chest wall injury
Tenderness & bony crepitus on palpation
Tachypnea ( respiratory rate)
Tachycardia
Decreased pulse oximetry
Late sign is paradoxical motion
muscle spasms may hide the paradoxical motion for the first few hours

45. Field Interventions For Flail Chest
Supportive oxygenation
non-rebreather oxygen mask
possibly BVM if ventilations need to be supported (1 breath every 5-6 seconds)
intubation (probably in-line technique) if necessary
Fluid replacement for co-existing injuries
Do not “tape” chest wall for support

46. Cardiac Tamponade
Tears in the heart chamber walls with blood entering the pericardial space
Occurs in <2% of patients with chest trauma
A result of penetrating trauma, blunt trauma, and occasionally, spontaneous
Increase in pericardial pressure
Heart is prevented from expanding and refilling with blood
Stroke volume and cardiac output decreases

47. Cardiac Tamponade

48. Signs & Symptoms of Cardiac Tamponade
Peripheral vasoconstriction (cool & clammy)
Tachycardia
Narrowed pulse pressure (diastolic blood pressure rises more than systolic blood pressure)
Beck’s Triad
JVD (early sign)
muffled heart tones
hypotension (late sign)

49. Is It Tamponade or Hypovolemic Shock?
JVD is present in cardiac tamponade
compression of the heart chambers causing a decrease in filling which creates a backup of fluid noted as JVD
JVD is not present in hemorrhagic shock
there is a total decrease in blood volume throughout the entire circulatory system so there is nothing to be backing up

50. Field Interventions For Cardiac Tamponade
Cardiac monitoring
Oxygen support
IV fluid replacement if shock present
20 ml/kg
reevaluate every 200 ml
Rapid transport with high index of suspicion
Removal of blood from the pericardial sac will be performed at the hospital

51. Tension Pneumothorax Trapping of air in the pleural space
Increase in pleural pressure producing a shift in the mediastinum
Compression of:
the lung on the unaffected side
vena cava reducing blood flow return to the heart with a decrease in cardiac output

52. Tension pneumothorax on the right side with shifting to the left

53. Signs & Symptoms of Tension Pneumothorax
Anxiety
Cyanosis
Increasing dyspnea
Tachycardia
Hypotension or unexplained signs of shock
Diminished or absent breath sounds on affected side with profound hypoventilation
Distended neck veins (JVD)
Subcutaneous emphysema

54. Field Interventions For Tension Pneumothorax
A true emergency requiring immediate identification and intervention
Goal: reduce the pressure in the pleural space
emergency needle decompression

55. Needle Decompression Prepare equipment Identify landmarks Clean site
2-3” long catheter G
skin surface prep material(ie: alcohol prep pad)
flutter valve attached to IV catheter
Identify landmarks
2nd intercostal space, mid-clavicular line
Clean site
Insert needle, bevel up, over the top of the 3rd rib (into the 2nd intercostal space)

56. Landmarks For Needle Decompression
Rib #1
Rib #2
2nd intercostal space
mid-clavicular line
Rib #3

57. Placement of Needle
Flutter valve attached
2nd rib
3rd rib

58. Placement of Needle

59. As air is released, clinically the patient should show improvement
less distress; less anxiety
greater ease in breathing/ventilating
rise in pulse ox saturation level
Secure angiocath and flutter valve
place opened, loosened 4x4’s around base of the angiocath
Monitor patient status watching for deterioration

60. Case Scenario #4
Your patient was a pedestrian struck by a vehicle at a high rate of speed. Upon your arrival you initially felt a faint pulse but now there is none. The patient is not breathing and bagging is difficult due to the resistance felt.
What is this rhythm and how is it treated?
6 second strip - there is no pulse

61. Case Scenario #4 The rhythm is PEA (with a rapid rate)
The patient is treated as an arrested trauma with suspicions of chest injuries (difficulty bagging)
Any airway maneuvers need to provide immobilization of the airway
opening airway using jaw thrust maneuver
intubation would be the in-line technique

62. Case Scenario #4 Patient interventions Transport destination
Full spinal immobilization
CPR - IV - O2 support - monitor
Consider the 6 H’s and 5 T’s as causes
Perform bilateral chest decompressions
Fluid challenges reevaluating every 200 ml
Drugs - Epinephrine 1 mg every 3-5 minutes
Rate is >60 so Atropine not indicated
Transport destination
Traumatic arrest - to closest Trauma Center

63. Intubation
Preferred advanced airway for controlling the airway in patients who are unable to maintain an open airway
Indications
unable to ventilate an unconscious patient
patient cannot protect their own airway
prolonged ventilation is required

64. Intubation Advantages airway is isolated preventing aspiration
ventilation (breathing) and oxygenation is easier to accomplish
suctioning of the trachea is easier
gastric insufflation of air during inhalation is prevented

65. Intubation Disadvantages
inadvertent placement in the esophagus with lack of recognition of improper placement
ineffective ventilation volumes
use enough volume to gently make the chest rise
inappropriate ventilation rate
patient with a pulse, breath once every 5-6 seconds
during CPR with intubated patient, ventilate once every 6-8 seconds while chest compressions continue uninterrupted

66. Intubation Equipment BVM connected to oxygen source Handle and blade
bulb bright and tight
straight blade lifts epiglottis up
preferred for infant intubations
curved blade fits into the vallecular space
ETT (generally size 7-8 for men and size 7 for women; no cuff under age 8)

67. Tape or commercial tube holder to secure tube Cervical collar
Stylet
does not protrude beyond distal end of ETT
reform tube into curved position after straight stylet passed into position
Syringe
do not leave attached to cuff once ETT is in place; air will be pulled out of the cuff
Tape or commercial tube holder to secure tube
Cervical collar
tube positions are better maintained when head movement is minimized

68. Patient Preparation
Pre-oxygenate the patient with 100% O2 for seconds before the intubation attempt
Consider medications for conscious sedation
Lidocaine 1.5 mg /kg, if head insult is present, to eliminate the cough reflex
Versed 5 mg initially; 2 mg every minute until sedated; 1 mg every 5 minutes to maintain sedation post intubation
Morphine 2 mg every 3 minutes to relieve pain, reduce anxiety, potentiate the effects of Versed
Benzocaine 2 second spray to eliminate the gag reflex, if present

69. Patient Positioning - Non-Trauma
Non-trauma patient - sniffing position
neck is flexed allowing the best alignment of anatomical landmarks
place a few towels under the patient’s head

70. Influence of Positioning
Landmarks not in alignment;
intubation more difficult for the
practitioner and with increased
risk of injury to patient
Anatomical landmarks lined
up; intubation is easier on the
medical personnel and the
patient

71. Difficult Intubations
Neck and chest tissue fall
over the airway making
intubation difficult
Better patient
positioning allows
for improved chance
of success in intubation

72. Orotracheal Intubation

73. Cricoid Pressure - Sellick’s Maneuver
Helps prevent gastric distention when bagging the patient using the mouth-to-mask technique
Helps prevent passive regurgitation with aspiration while bagging the patient or attempting intubation
With pressure applied over the cricoid cartilage, the esophagus becomes occluded
Can improve the view of the vocal cords for the intubator
Can help stabilize the trachea

74. Lateral View of ETT Placement
Curved blade in
vallecula

75. In-line Intubation Techniques
Indication
when spinal precautions need to be observed
Equipment
identical to normal intubation procedures
Manual cervical spine control
stabilization must be constantly maintained in a neutral position during the procedure
head is securely controlled post-procedure

76. Opening Airway with Cervical Trauma - Jaw Thrust

77. In-Line Intubation Intubator positioning
Intubator may sit at the patient’s head and their legs straddle the patient’s shoulders and arms; patient’s head is gripped with the intubator’s thighs
Intubator may lie on their stomach facing the patient’s head
A second rescuer stabilizes the patient’s head by gripping the head from the side and grasping along the jaw and lower face, spreading their fingers near the temple (ear) area

78. In-Line Intubation Patient being stabilized Equipment prepared Cricoid
pressure
being held

79. Orotracheal Intubation
Face-to-face procedure to intubate a patient when the provider cannot take a position above the patient’s head (ie: patient in the sitting position)
Manual stabilization must be maintained by a second rescuer at all times (often from behind if there is room for the provider behind the patient)

80. Orotracheal Intubation Procedure
Primary rescuer takes a position facing the patient
Open the mouth with the left hand
Hold the laryngoscope in the right hand
Insert the blade into the patient’s mouth
Follow the normal curvature of the tongue
Visualize the vocal cords from above the patient’s mouth

81. With the left hand, pass the ETT between the cords
Remove the stylet, if used
Begin to ventilate the patient with the BVM
Inflate the cuff and remove the syringe
Confirm proper ETT placement

82. Confirming Placement and Securing ETT
Direct visualization
cricoid pressure can be helpful
stabilizes the trachea
may “drop” the trachea into view
with enough pressure, can stop vomitus coming back up
once cricoid pressure is applied for blocking vomitus, pressure is maintained until the cuff is inflated

83. Cricoid Pressure

84. Bilateral & equal rise and fall of the chest 5 point auscultation
listen over the epigastrium (expect to hear nothing)
listen 4 points over the lungs
listen anteriorly just under the clavicles on either side of the sternum
listen in the axillary line approximately 5th intercostal space
ETCO2 detector
after 6 breaths should see & maintain the yellow color to indicate exhaled CO being detected

85. EDD bulb back-up tool to the ETCO2 detector
need to interrupt ventilation to use
when bulb is depressed and placed on the end of the ETT tube, will reinflate rapidly if ETT is placed in the trachea

86. Case Scenario #5
What airway significance could there be in this case and what needs to be monitored?

87. Case Scenario #5 - End Results

88. Region X SOP’s Field Triage Criteria For Assessing Trauma Patients
In-Field Spinal Clearance
Routine Trauma Care
Revised Trauma Score

89. Field Triage Criteria
Transport to highest level Trauma Center within 25 minutes if:
systolic blood pressure < 90 x (peds < 80 x 2)

90. Field Triage Criteria
Transport to highest level Trauma Center within 25 minutes if patient is a Category I
Vital signs unstable
Glasgow Coma Scale <10 or deteriorating mental status
respiratory rate <10 or >29
Revised Trauma Score <11

91. Field Triage Criteria
Transport to highest level Trauma Center within 25 minutes if patient is a Category I
Based on anatomy of injury
Penetrating injuries to head, neck, torso, groin
Combination trauma with burns >20%
Two or more proximal long bone fractures
Unstable pelvis
Flail chest
Limb paralysis and/or sensory deficits above the wrist or ankle
Open and depressed skull fractures
Amputation proximal to wrist or ankle

92. Field Triage Criteria
Transport to closest Trauma Center if the patient is a Category II trauma patient
Mechanism of injury
Ejection from automobile
Death in same passenger compartment
Motorcycle crash >20 mph or with separation of rider from bike
Rollover (unrestrained)
Falls >20 feet (peds falls >3x body length)
Pedestrian thrown or runover

93. Mechanism of injury (continued)
Auto vs pedestrian/bicyclist with >5mph impact
Extrication > 20 minutes
High speed MVC
Speed > 40 mph
Intrusion > 12 inches
Major deformity > 20 inches
Co-morbid factors
Age < 5 without car/booster seat
Bleeding disorders or on anticoagulants
Pregnancy > 24 weeks

94. Field Triage Criteria
If patient is not a Category I trauma patient (based on unstable vital signs or anatomy of the injury)
and
patient is not a Category II trauma patient (based on mechanism of injury or co-morbid factors)
then
provide routine trauma care and transport to the closest Trauma Center

95. Field Triage Criteria Transport to the closest Trauma Center if:
traumatic arrest
isolated burns > 20% BSA
Transport to closest Emergency Department if:
no airway can be established

96. Region X SOP’s Routine Trauma Care
Scene size-up
Initial assessment
Airway / spinal precaution
Breathing
Circulation
Disability - AVPU and GCS
(alert; responds to verbal; responds to pain; unresponsive)
General impression

97. Routine Trauma Care Identify priority of transport Treatment
Begin rapid transport (treatment enroute)
Based on mechanism of injury or patient complaint
Begin treatment and initiate transport
Treatment
Airway control - oxygen support
IV (200 ml if fluid challenge required)
Detailed exam as time permits
Ongoing assessment - on all patients
Every 5 minutes if patient is a rapid transport

98. Case Scenario #6
Your patient is a 63 year-old male involved in a head-on MVC on a road with posted speed of 55 mph
Scene size-up
head-on car vs truck
restrained driver
heavy front-end damage
airbag deployed
back of seat broken

99. Case Scenario #6 - Assessment
By-standers state patient was initially unresponsive
Upon your arrival the patient is awake, alert, and cooperative
GCS 15
136/88; P - 68; R - 20; SaO2 98%; NSR; breath sounds clear bilaterally
Complaints: soreness over multiple abrasions of chest, abdomen, and extremities; blood in the nostrils; tenderness with mild rigidity over the left abdominal wall where abrasions are noted

100. Case Scenario #6 What initial care is to be established?
What Category Trauma does this patient meet for transport decisions?
What are the potential injuries you need to consider this patient receiving?

101. Case Scenario #6 Patient meets criteria for a Category II Trauma
Stable vital signs
No anatomical injuries meeting criteria
High speed MVC with major deformity
Vitals & condition on arrival to ED
104/82; P - 64; R - 18; SaO %; NSR
Patient now cool, pale, diaphoretic, clear breath sounds; capillary refill < 2 seconds; abdomen flat, non-tender; pain over lower right chest

102. Case Scenario #6 Follow-up
Patient became hypotensive in the ED (B/P - 65/34; P-50; R - 18)
The patient went to OR and was found to have 2 liver lacerations and multiple liters of free blood in the abdominal cavity
The patient went to ICCU after OR
Why would this patient’s pulse rate not be higher if he lost so much blood?
The patient was taking beta blockers for hypertension control

103. In-Field Spinal Clearance SOP
A reliable patient without signs or symptoms of neck or spine injury and a negative mechanism of injury does not require full spinal immobilization
When in doubt, fully immobilize patient

104. In-Field Spinal Clearance SOP
Mechanism of injury
High velocity MVC > 40 mph
Unrestrained occupant in MVC
Passenger compartment intrusion > 12 inches
Ejection from vehicle
Rollover MVC
Motorcycle collision > 20 mph
Death in same vehicle
Pedestrian struck by vehicle
Falls > 2 time patient height
Diving injury

105. In-Field Spinal Clearance SOP
Signs and symptoms
Pain in neck or spine
Tenderness/deformity of neck or spine upon palpation
Paralysis or abnormal motor exam
Paresthesia in extremities
Abnormal response to painful stimuli

106. In-Field Spinal Clearance SOP
Patient reliability
Signs of intoxication
Abnormal mental status
Communication difficulty
Abnormal stress reaction

107. In-Field Spinal Clearance SOP
If the patient meets the criteria of need for spinal immobilization based on mechanism of injury, and/or signs & symptoms, and/or reliability, then patient intervention includes:
routine trauma care
full spinal immobilization
transport

108. Revised Trauma Score - RTS
Points scored are based on:
Respiratory rate
Systolic blood pressure
Glasgow Coma Scale (scale 3-15 and points converted for RTS)
eye opening
verbal response
motor response
Revised Trauma Score scale is
Provide the ECRN with the components and they can score pt

109. Bibliography Bledsoe, B., Porter, R., Cherry, R.
Essential of Paramedic Care. 2nd
Edition. Brady
Campbell, J. Basic Trauma Life support
5th Edition. Brady
Caroline, N. Emergency Care In The Streets. 6th Edition. AAOS
Limmer, D., O’Keefe, M. Emergency
Care 10th Edition. Brady

110. Region X Standard Operating Procedures. March 1, 2007.
Sanders, M. Mosby’s Paramedic
Textbook. Elsevier

111. Name That Rhythm
SVT

112. Name That Rhythm
Second Degree Type II - Classical

113. Name That Rhythm
Atrial Fibrillation

114. Identify ST Elevation
ST elevation V1 - V4