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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
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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
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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
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7 Ways to Die in Trauma Hypovolemia Hypoxia Acidosis Obstructed airway
Flail chest Cardiac tamponade Tension pneumothorax
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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
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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
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Normal Blood Volumes Neonate 85 ml/kg Infant 80 ml/kg
Adult men 75 ml/kg Adult women 65 ml/kg
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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!
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Hypoxia Hypoxemia decreased oxygen content of the arterial blood
decreased oxygen content to the body’s cells and at the tissue level
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Causes of Hypoxia Reduction of oxygen in the system
Inadequate oxygen transport Inability of tissues to use the oxygen delivered
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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)
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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
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Chest wall abnormalities
flail chest scoliosis full thickness burns with contractions Increased thickness of the respiratory membrane pulmonary edema interstitial fibrosis
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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Magill Forceps
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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
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Thyroid cartilage Cricothyroid membrane Cricoid cartilage Thyroid gland Thyroid cartilage (Adam’s apple) Cricothyroid membrane Cricoid cartilage
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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
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Needle Cric Step #1 - needle advanced, confirmation by air being aspirated with the syringe Step #2 - catheter advanced while the stylet is removed
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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
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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
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Melker Cric Kit Department personnel recommended to review the CD from Cook Medical to review using the Melker Emergency Cricothyrotomy Catheter Set
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Case Scenario #3 This patient has been impaled by a foreign object
Do they need spinal immobilization for this injury? No
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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
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Flail Chest On Right Side
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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
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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
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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
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Cardiac Tamponade
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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)
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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
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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
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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
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Tension pneumothorax on the right side with shifting to the left
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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
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Field Interventions For Tension Pneumothorax
A true emergency requiring immediate identification and intervention Goal: reduce the pressure in the pleural space emergency needle decompression
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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)
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Landmarks For Needle Decompression
Rib #1 Rib #2 2nd intercostal space mid-clavicular line Rib #3
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Placement of Needle Flutter valve attached 2nd rib 3rd rib
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Placement of Needle
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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Difficult Intubations
Neck and chest tissue fall over the airway making intubation difficult Better patient positioning allows for improved chance of success in intubation
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Orotracheal Intubation
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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
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Lateral View of ETT Placement
Curved blade in vallecula
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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
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Opening Airway with Cervical Trauma - Jaw Thrust
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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
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In-Line Intubation Patient being stabilized Equipment prepared Cricoid
pressure being held
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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)
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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
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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
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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
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Cricoid Pressure
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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
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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
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Case Scenario #5 What airway significance could there be in this case and what needs to be monitored?
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Case Scenario #5 - End Results
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Region X SOP’s Field Triage Criteria For Assessing Trauma Patients
In-Field Spinal Clearance Routine Trauma Care Revised Trauma Score
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Field Triage Criteria Transport to highest level Trauma Center within 25 minutes if: systolic blood pressure < 90 x (peds < 80 x 2)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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
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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
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In-Field Spinal Clearance SOP
Patient reliability Signs of intoxication Abnormal mental status Communication difficulty Abnormal stress reaction
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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
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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
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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
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Region X Standard Operating Procedures. March 1, 2007.
Sanders, M. Mosby’s Paramedic Textbook. Elsevier
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Name That Rhythm SVT
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Name That Rhythm Second Degree Type II - Classical
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Name That Rhythm Atrial Fibrillation
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Identify ST Elevation ST elevation V1 - V4
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