International Trauma Life Support: International Edition, 6th Edition

Not ice on Ca.., l>rocn1 urr$ It is Ihe inlell' of the authors and publisher that this Ic)(tbook lli: used as PUI of an educalion "r"'Sram taughl by 4U<1lified instructors and SUP<'rv ised by a li(('n5/.'d physician, The procedur,'s deKTibcd in this tUlbook arc bas..-d upon consuit;at ion "'ilh paramedics., nurS.('s, and physicians, The authors and publisher ha'.... laken care to m~ke ccrtain Ihal these procedures renect currenlly acccpt.,.J clinical pr
Pu bl ishcr. Julie Levin Akxander Publishff's Assista nt: R..-,;ina Bruno uecuti,'c Edi tor: Marknl' Mcllugh Pran Stnior Acquisitions Editor: Stq ,hen Smith Stnior Managing Edit or (nr De\'dopll'en t: Lois Ikrlowit1, tH,'dopmf nt Edi tor: 1o Celli:datrick W"l sh Productio n Liai50n: Julie I.i Product ion Editor: Am)' Gehl Medi u Prod uct Ma nager: John Jordan New Med ia Projl"C1 Manage r: Tina Rudo_ki Man ufaclUring Manager: lkne S;.nford Manufacturing Bu rer: 1)~tlJrown Stnlor Daig" Coord ina tor: Christopher Weig'llld Interior Daisncr: L« Goldstein Cl,'e. [)nigner: Rob Akm:ln Cl"a I>ho lo: Mark Ide Composit ion: S4C:arlisle Publishin g Ser"ices Prillt ing ~ nd Bind ing: Couri.. r K.. ndJU"iU .. Cl"cr I'rinter: Coral GI"Jphics

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Notice on Gender Usage Thc English language hai historicaU), gi"en prcfcr;,'nce 10 the male gender, Among manr ,,-urds, the pronoulls.,iteand !tis arc: conlillonly used 10 d~ribe both genders, Society e\'olves faster than language, and Ihe male prnnoullS stillprcdominale our s","'ceh, The: authou ha,'e m~de grc;lt cffortlO treat the two genders cqu
Copyright 0 2008 br Pearson Edu{1I lion, In<.:" Upp~r Saddle Ri"~r, New lersc:r, 07458.I'earson Prentice I-lJU, All righ's rcsc:rvoo, Prim,od illlhe Unitlod Sta' cs of America, This J'lIbliC<Jtion i5 protected by Cupyright aud permissioll shou ld be obt~;ned (rom the publisher prior to an)' prohibited reproduction, storag,· in a mricvals)'stem, or trJnsmission in any form or by any means., electronic, mechanical, phOlocop)'i ng, recording, or likewise, For information rcgardillg pcrmission(s), write to: Rights and l'crmissions !x"arttnent. Pearso n Prrn tice Hail '" is a Ir:t.d.. mar k of P"3fS()n EduC:llion, fnc. Pea rso n' is a registered trJdcnlark of l'carson pic 1)~lllicc HaU ' is il registered tratkmark of l'carson EduC
-

Pearson EduGI,ion Norlh As;a I.ld 1'c~rson Edu~ion de Mexico, S.A, de C.V. i'earsOIl Education Mala)'sia, Pte, l.td I\'arson Education, Up",'r S:>ddle KiWI", New lersey

PEARSON

Prentice

Hall

f0987654321

I SBN-1.0: 0 - 13-1.35449-3 ISBN- ]' 3: 978-0-13-1.35449-4

Chapter 1

Scene Size-up

Chapter 21 The Trauma Cardiopulmonary Arrest 306

1

Chapter 2 Assessment and Initial Management of the Trauma Patient

Chapter 3

27

Patient Assessment Skills 45

Chapter 4 Initial Airway Management 58 Chapter 5

Airway Management Skills 78

Chapter 6

Thoracic Trauma

Chapter 7

Thoracic Trauma Skills 114

94

Chapter 8 Shock Evaluation and Management 118 Chapter 9

Head Trauma

Chapter 11

Spinal Trauma

Receiving Hospital

356

Appendix C

Documentation: The Patient

Care Record

362

Appendix D Trauma Care in the Cold 371

Appendix F

Trauma Scoring in the

380

Drowning, Barotrauma, and

384

Appendix H Injury Prevention and the Role ofthe EMS Provider 391

203

Extremity Trauma

Chapter 15

Extremity Trauma Skills

Appendix I

211

Triage

229

258

Chapter 18 Trauma in the Elderly

278

Chapter 19 Trauma in Pregnancy

288

Chapter 20 Patients Under the Influence of Alcohol or Drugs 299

Multicasualty Incidents and

400

Appendix J

Agricultural Rescue Course

408

Overview

237

Chapter 17 Trauma in Children

-~-

Communications with the

Decompression Injury

Chapter 14

IV

Appendix B

Appendix G

160

Chapter 13 Abdominal Trauma

Burns

Optional Skills

Prehospital Care Setting

141

Chapter 12 Spine Management Skills 183

Chapter 16

327

Appendix A

Appendix E Role of the Medical Helicopter 377

Fluid Resuscitation Skills 136

Chapter 10

Chapter 22 Standard Precautions in the Prehospital Setting 315

Appendix K ITLS Access Overview Appendix L Tactical EMS Glossary Index

429

433

414

412

ABOUT THE EDITOR

AUTHORS xiii WHAT'S NEW IN THIS EDITION ACKNOWLEDGMENTS ABOUT ITLS

Assessment and Initial Management of the Trauma Patient

X II

xv

Objectives • Case Study

xvii

Introduction 28 Patient Assessment 29 IlLS Primary Survey 29 lTLS Secondary Survey 38 Procedure: Performing a Secondary Sutvey 38 ITLS Ongoing Exam 41 Procedure: Performing an Ongoing Exam 41

xix

ITLS COURSE DESCRIPTIONS XX II ENROLLING IN AN ITLS COURSE xxiii

Chapt, ' 1

Scene Size-up

1

Objectives • Case Study

Introduction 2 Philosophy of Assessme nt and Managem e nt of the Trauma Patient 2 Sce ne Size-up 4 Standard Precautions 4 Scene Safety 4 Total Number of Patients 5 Essential Eq uipment and Addit ional Resources 6 Mechanism of Injury 6

Motor-Vehi cle Collisions

Pedestr ian Injuries

I

:;

Patient Assessment Skills 45

Objectives

Procedure: ITLS Primary Survey-Critical Information

46

Procedure: ITLS Secondary Survey-Critical Information Information

50 53

Management

54

12

15

18

19

Falls 19 Penetrating Injuries 20 Wound Ballistics 20

Blast Injuries

ChaDle

Procedure: Patient Assessment and

Head-on Collision 10 T-Bone or Lateral-Impact Co llision Rear-Impact Collision 13 Ro llove r Collision 14 Rotational Col lision 15

Small-Vehicle Crashes

Case Study (continued) • Case Study Wrap-up · Summary • Bibliography

Procedure: ITLS Ongoing Exam-Critical

a

Occupant Restraint Systems Tractor Accidents 17

27

22

Case Study (continued) • Case Study Wrap-up • Summary • Bibliography

Char

Initial Airway

Management

58

Objectives • Case Study

Introduction 59 Anato my and Physiology 60 Nasop ha rynx 60 Oropharynx 60 Hypopharynx 60 Larynx 61 Trachea and Bronchi 62 The Lungs 64

v

vi •

CONTENTS

The Patent Airway Observa tion 6S

Suction

64

Pathophysiology 96 Emergency Care of Chest Injuries

66

Airway Obstruction

A irway Adjuncts 67 Supplemental O xygen 70 Ventilation 71 Norma l Venti lation 71 Positive Pressure (Artificial) Ventilation Compliance 72 Ventilation Techniques 73 Airway Equ ipment 74

Pneumothorax Flail Chest 71

Skills

78

Tears

80

Naso tracheal Intubation 87 Procedure: Nasotracheallntubation 87 Immediate Confirmation of Tube Placement 88 Procedure: Immediate Confirmation of Tube

Placement 89 Procedure: Reconfirming ET Tube Position 90 Procedure: Confirming and Monitoring ET Tube Placement with Capnography 92 93

95

106

108

Rupture

83

Objectives • Case Study Introduction 9S Anatomy of the Chest

Tamponade

Tracheal or Bronchial Tree Injury 108 Myocardial Contusion 108 Diaphragmatic Tears 109 Procedure: Management of Diaphragmatic

Procedure: Using the Bag-Valve Mask 80 The Pulse Oximeter 80 Advanced Airway Management 81 Preparations 81 Laryngoscopic Orotrachea l lntubation 82 Procedure: Laryngoscopic Oro tracheal

Thoracic Trauma

101

Tension Pneumothorax 103 Procedure: Management of Tension Pneumothorax 104 Massive Hemothorax 104 Procedure: Management of Massive Hemothorax 10S Cardiac Tamponade 106 Procedure: Management of Cardiac Traumatic Aortic Rupture 107 Procedure: Management of Potential Aortic

Objectives Basic Airway Management 79 Procedure: Suctioning the Airway 79 Procedure: Inserting the Nasopharyngeal Airway (NPA) 79 Procedure: Inserting the Oropharyngeal Airway (OPA) 79 Procedure: Using a Pocket Mask with

Anchoring the Tube

99

99

Procedure: Management of Flail

Chest

Airway Management

Intubation

97

Open Pneumothorax 97 Procedure: Management of Open

Case Study (continued) • Case Study Wrap-up • Summary • Bibliography

Supplemental Oxygen

97

109

Pulmonary Contusion 109 Other Chest Injuries 110 Case Study (continued) • Case Study Wrap-up • Summary • Bibliography

Chd~t{'r

7

Thoracic Trauma Skills

Objectives Chest Decom pressio n 115 Indications 115 Complications 11 S Procedure: Performing a Chest

Decompression

11 5

Bibl iography

Shock Evaluation and Management

94

114

Objectives • Case Study Introduction 119 Basic Pathophysiology 119 Assessment and Shock 120 Compensated and Decompensated

Shock

121

118

CONTENTS • vii

Eva luation of Tachycard ia 122 Capnography 123 Th e Shock Syndromes 123 Management and Treatment 128 General M anagement of Post-Traumatic

Shock States

128

Treatment of Post-Traumat ic Hemorrhage 129 Procedure: Managing Shock When Bleeding

Has Been Controlled 129 Procedure: Managing Shock Due to Exsanguinating External Hemorrhage That You Cannot Control 130 Procedure: Managing Shock Due to Internal Hemorrhage 131 Specia l Situations in Hypovolemic

Shock

132

Treatment of Nonhemorrhagic Shock Syndromes 133 Case Study (continued) • Case Study Wrap-up • Summary . Bibliography

Evaluation of the Head-Trauma Patient 150 ITlS Primary Survey 150 ITlS Secondary Survey 155 ITlS O ngoing Exam 155 Management of the Head-Trauma Patient 155 Procedure: Managing the Head-Trauma

Patient

155

Case Study (continued) • Case Study Wrap-up • Summary · Bibliography

Spinal Trauma

160

Objectives • Case Study Introduction 161 The Normal Spinal Column and Cord Spinal Column 16 1 Spinal Cord 162

Spinal Injury

161

164

Mechanisms of Blunt Spinal-Column

Injury

164

Mechanisms of Blunt Spinal -Cord Chapter 9

Fluid Resuscitation Skills 136

Objectives Cannulation of the External Jugular Vein 137 Procedure: Performing External Jugular

Cannulation

137

Intraosseous Infu sion 137 Indications 137 Potential Complications 138 Procedure: Performing Intraosseous Infusion in a Child 138 length-Based Resuscitation Tapes 139 Procedure: Estimating a Child's Weight with a Length-Based Resuscitation Tape 140

Chapter 10

Head Trauma

141

Objectives · Case Study Introduction 142 Anatomy of the Head 143 Pathophysiology of Head Trau ma 144 Primary and Secondary Brain Injuries 144 Intracranial Pressure 145 Cerebral Herniation Syndrome 146 Head Injuries 147 Scalp Wounds 147 Skull Injuries 147 Brain Injuries 148

Injury

164

Neurogenic Shock 166 Assessment and Management of the Trauma Patient 166 Assessing for Possible Spi ne Inj ury 166 Managing the Trauma Patient 167 Airway Intervention 175 Special SMR Situations 175 Case Study (continued) • Case Study Wrap-up • Summary . Bibliography

Spine Management Skills

183

Objectives Essential Components of an SMR

System

184

Applying Spinal Motion Restrictions (SMR) 184 Patients Requiring SMR 184 SMR with a Short Backboard 184 Procedure: Applying a Short

Backboard

184

Emergency Rescue and Rapid Extrication 190 Procedure: Performing a Rapid

Extrication

191

SMR Using the Long Backboard

191

viii • CONTENTS Procedure: Log-Rolling the Supine Patient onto a Long Backboard 194 Procedure: Log-Rolling the Prone Patient with an Adequate Airway onto a Long Backboard 197 Securing the Patient to the

Backboard

198

Procedure: Applying and Securing a Long Backboard to a Standing Patient 198 Helme t Manag e me nt 199 Procedure: Removing a Motorcycle Helmet from a Trauma Patient 199 Procedure: Alternative Procedure for Removing a Helmet 201 Bibliography

Abdominal Trauma 203 Objectives . Case Study Intro duct ion 204 Anatomy of th e Abdom e n 204 Types of Injuries 205 Assessme nt a nd St a bilization 206 Scene Size-up 206 Patient Assessment 207 Stabi lization 207 Case Study (continued) • Case Study Wrap-up • Summary . Bibliography

Extremity Trauma

211

Objectives · Case Study Introducti o n 21 2 Injuries to Extre mities 21 2 Fractures 212 Dislocations 213 Amputations 2 14 Open Wounds 215 Neurovascula r Injuries 215

Impaled Objects 215 Compartment Synd rome 215 Assessme nt a nd Ma nag e me nt 216 Scene Size-up and History 216 Assessment 216 Ma nagement of Extremity Injuries 216 Procedure: Rules of Splinting 217 Management of Specific Inj uries 220 Case Study (conti nued) • Case Study Wrap-up • Summary · Bibliography

Extremity Trauma 229

Skills

Objectives Tra cti o n Splints 2 30 Procedure: Applying a Thomas Traction Splint (Half-Ring Splint) 230 Procedure: Applying a Hare Traction Splint 231 Procedure: Applying a Sager Traction Splint 234 Pe lvic Sta bilization Te chn iqu es 234 Procedure: Stabilizing the Pelvis with a Sheet or Blanket 236 Proce dure: Sta bilizing the Pe lvis with a Commercial De vice 236

Burns 237 Objectives • Case Study Introducti o n 238 Anat o my a nd Pathophysio lo g y

2 38 The Skin 238 Classifying Bu rns by Depth 239 Determin ing the Severity of Burns 240 Patie nt Assessment a nd Mana g e me nt 24 2 Patient Assessment 243 Patient Management 245 Special Problems in Burn Management 24 5 Proce dure : Removing the Source of Chemical

Burns 249 Case Study (continued) • Case Study Wrap-up · Summary • Bibliography

Ch"ph>r 17

Trauma in Children

Objectives • Case Study Introduction 25 9 Co mmunicat ing with th e Child a nd Fa mily 259 Pa re nta l Con sent 2 61 Assessme nt a nd Care 261 Pediat ric Equ ipment 26 1 Com mo n Mechanisms of Injury 261 Assessment of the Airway 264 Assessment of Breathing 266 Assessment of Circulation 268 Con trol of Bleedi ng 269 The Critica l Trau ma Situation 269 ITLS Secondary Survey 27 1

258

CONTENTS • ix Potentially Life.Threatening Injuries 271 Head Injury 27 1 Chest Injury 272 Abdom inallnjury 273 Spinal Injury 273 Child Restraint Seats 273 Case Study (continued) • Case Study Wrap·up • Summa ry • Bibliography

Ch lptvr 18 Trauma in the Elderly 278 Objectives • Case Study Introduction 279 Pathophysiology of Aging 280 The Aging Body 280 Medications 281 Assessment and Ma nagement 282 ITLS Primary Survey 283 Critical Transport Decisions 284 Packaging and Tra nsport 285 ITLS Secondary Survey and O ngoing Exams 285 Case Study (continued) • Case Study Wrap-up • Summary • Bibliography

Trauma in Pregnancy

288

Objectives • Case Study Introduction 289 Pregnancy 290 Feta l Development 290 Phys iologica l Cha nges During Pregnancy 290 Responses to Hypovolemia 29 1 Asse ssment and Management 292 Special Conside rations 292 Types of Trauma 294 Trauma Prevention in Pregnancy 296 Case Study (continued) • Case Study Wrap-up • Summary • Bibliography

Chapter 21

The Trauma Cardiopulmonary Arrest

Objectives • Case Study Introduction 307 The Unsa lvageable Patient 307 Hypoxemia 308 Circulatory Problems 310 Approach to Trauma Patients in Cardiac Arrest 311 General Plan of Action 311 Procedure: Initial Assessment and Critical Actions 312 Case Study (continued) • Case Study Wrap-up . Summary • Bibliography

Standard Precautions in the Prehospital Setting 315 Objectives · Case Study Introduction 317 Hepatitis B 317 Hepatitis C 318 Human Immunodeficiency Viru s Infection 318 Tuberculosis 319 Preca utions for Prevention of Transmission of Infectious Agents 321 Procedure: General Considerations 321 Procedure: Personal Protection During

Patient Exposures

323

Procedure: Handling and Cleaning of Items Exposed to Blood or OPIM 323 Procedure: Reporting Accidental Exposure to Blood or OPIM 323 Case Study (continued) • Case Study Wrap-up · Summary • Bibliography

Optional Skills Optional Skill 1: Digital Intubation

Patients Under the Influence of Alcohol or Drugs

Chapter 20

306

327 327

Optional Skill 2: Transillumination (lighted

299

Objectives • Case Study Introduction 300 Assessment and Manage ment 300 Th e Uncooperative Patient 302 Case Study (continued) • Case Study Wrap-up • Summary . Bibliography

Stylet) 330 Optional Skill 3: Translaryngeal Jet Ventilation 333 Optiona l Skill 4: Pharyngotrachea l Lumen Airway 336 Optional Skill 5: Esophageal Tracheal Combitube 339

x • CONTENTS Optional Skill 6: King LT-O Airway

Role of the Medical

341

Optional Skill 7: laryngeal Mask Airway 345 Optional Skill 8: Adult Intraosseous Infusion 348 Optional Skill 9: Rapid Sequence Intubation 351

Helicopter Objectives 377

Medical Helicopter Services 377 The Medical Helicopter and the Trauma Patient 378 ITlS and the Medical Helicopter 379 Bibliography

Communications with the 356 Receiving Hospital Objectives

356

Communication Basics 356 Four-Phase Communications Policy

Trauma Scoring in the Prehospital Care Setting 380 Trauma Scoring Systems Uses for Tra uma Scoring Bibliography

Documentation: The Patient Care Record

362

Objectives 362

Introduction 362 The Narrative Report 362 Improving Documentation Skills 368 Important Points About the Written

Objectives

371 371

Introduction 371 Cold Weather Trauma Care 371 Notes for Wilderness Rescuers 375 Bibliography

i ..

376

Drowning, Barotrauma. and Decompression Injury 384

Bibliography

Trauma Care in the

Cold

383

Drowning 385 Barotrauma 385 Decompression Sickness 387 Management of Diving Injuries

370

Apr'

380 380

Objectives 384

Report 368 Bibliography

379

Objectives 380

356

361

Bibliography

377

389

390

Injury Prevention and the Role of the EMS Provider 391 Objectives 391

The Injury Epidemic 391 The Injury Process 392 Injury Prevention and Control Bibliography

399

395

CONTENTS •

Multicasualty Incidents and Triage Objectives

400 400

IlLS Access Overview 412 Objectives 412

Disasters an d Multicasualty Incidents 400 Triage 403 ITLS Recommendations 407 Bibliography

XI

Bibliography

413

407

Tactical EMS

414

Objectives 414

Agricultural Rescue Course

Overview

408

Objectives 408

Introduction 414 What Is Tactical EMS? 415 Tactica l EMS Mod els 417 Specific TEMS Equipme nt and Tactics 419 Evide nce Preservation 426 Toxic Mat erial Hazards 426 Special Issues 426 Additional Resources for TEMS Training 427

Rescue on the Farm 408 Rural Rescue 409 Farm Trauma Is Unique 409 Teamwork Training 409 Tractor and Machinery Incidents 410 Farm Confined Spaces 410 Agricultural Rescue-An Opportunity 411

GLOSSARY 429

Bibliography

INDEX 433

411

Bibliography

428

The sixth edi tion of the ITLS textbook, Internatiollal Trallll/a Ufe SlIpport for PrellOspilal Care Providers, has been updated and refined to reflect the latest and most effective approaches to the ca re of the trauma patient. The text also has been made 10 conform 10 the newest AHA guidelines for artificial ventilation and CPR. Other general changes include the reposi tio ning of the "Pearls" feature so that it consistentl )' appears in the margins beside relevant text and ma ny of the illustrations have been redrawn for a more up-to-date look. Important chapter-by-chapter changes ;Ire listed below. • In Chapter I, the term standard precautiolls is used for the first time instead of body substance isolatio n (BS I). This change is reflected throughout the text. A new pho to of a tactical fla shlight has been added as well. • In Chapter 2, the description of the ITLS patient assessment plan has been revised so that it now consistently addresses it as a three-step plan composi.'d of the ITLS Primary Survey, the ITLS Seconda ry Survey, and the I"J"LS Ongoing Exam. The patien t assessment algorithm has been updated to reflect that change and new Primary and Secondary Survey fl owsheets have been added. Up-to-date scoop st retchers are now shown. Hemostatic agents and tourniquC"ts have been added to the equipment that may be needed by EMS personnel. • Cha pter 3 rdlects the new descript ion of the ITL.) patient ;:Issessment plan. A table identifying "Critical l hmma Si tuations" has bee n added. • In Chapter 4, the KI NG LT-D airway is included as another exa mple of a blind insertion ,Iirway device. A table on "Esti mating Difficulty of Intubation," which describes the Mallamp:lI i Score, has been addi.'d. A new illustration that describes the response to difficult bag-mask ven ti lation is also included. • In Chapter 5, the use of capnograp hr to con firm placement of the endotracheal tu be has been added. • In Chapter 6, flowsheets for the signs of tension pn eumothorax, open pneumothorax, flail chest, and cardiac tamponade arc included. • In Chapter 8, the lise of hemostatic agents for uncon trolled extremity ht.'lllorrhage has been added, as has the (opic of capnography. Also included arc new flowshee ts on absolute hypovolemi a, relative hypovolem ia, and mechan ical shock. • Chapter 10 has been updated to reflect the new second edit ion Brain Trauma Foundation gu idelines. • In Chapler I I, new photos of removing a helmet's face guard from a possible spin cinjured p;\ticnt have been added, and so has a discussion of the practic
xvi • WHAT'S NEW IN TH IS EDITION • In Chapter 15, photos o n the stabiliz..1tion of pelvic fractures have been added. • In Chapter 16, the topic o f radiation burns is includ ed. • In Chapter 17, the topic o f capnogra phy .md x- rays of broken bones ha ve been added. • In Chapter 18, the topic of capnography has been included. • In Chapter 2 1, guidelin es for the unsa [vageable patien t have been added. • New append ices arc Appendix I. Agricultural Rescue Course Overview; Appendi x K, ITLS Access Overview; and Appendix 1., Tactical EM S. • In Appendix A, the KI NG LT-D ai rway .md rapid sequence intubation have been added as o ptional skill s w ith illu strations. The top ic of capnography is included. And the top ics of the ant ishock garment ;lnd esop hageal gastric tube airway as o ptiona l skills have been deleted . • In Appendix I, illustra tio ns for the o n-scene incident command structu re, medical incident comma nd , and the IT LS triage decision tree have been added.

Spec;al thanks to these friellds of /TLS who prOllided i1l1-'alllable assistallce with ideas. revicws, alld correctiOllS of the text. "l'1,;s was sllch a b;gjob, lmd there were so lIIallY people 11'110 COIItribllted, t1wt I (1m slire Ilwl'e leJt someolle Ollt. My (lp%gies ill adl'{lIIce. Roy Alson, MD, FACE P Jere B3ldwin . MD. FACEI' 1- David Barrick. BS, NREMT-P David Butkl

Eduardo Romero Hicks. MD O \·Villiarn Pfeifer, rvto. FACS Mar)' M. Radanovich RN, BSN, EMT-P John T. Stevens, ErvIT-P Ron Stewart, M D, FACEI' Arlo Weltge, J\ol D, FACEP Brian J. Wi lson, NREMT-P

We lVis/l to thallk the EMS professio/w/s who rev;clVet/materia/ especi(lll), for this 6th Editioll of Interna ti onal Tr:lll ma Life Su pport fo r Prehospital Clf(' Providers. Their assist(lllee is appreciated. Chris Cousar, BS, NREMT- P, EM S Educator, University o f New Mexico EM S Academy Steve Creech, EMT- P, Training Officer, Washington Cou nty EM S, Plymouth , Nort h Ca rolina John S. Molnar, N REMT- P, Manage r, CPR/ere; Inst ructor. Cleveland Cli nic Heal th S)'s tem ; Adjunct IPRN, BTLS affiliate fa culty at School of EMS, Euclid, O hio

Tim Swa im , Para m ed ic Instructor, Rockingh'lm Com mu nit y Co llege, Wentworth, No rth Carolina Jason I~ Z ielewicz. MS, NREi\IIT- P. EMS Su pervisor and In structor, O ffi ce of EMS, Th e Pennsylvania State University

Allotller special tha nks goes to the following photographers wllo dOllated tlteir work to "elp jill/strate tile text. Roy Also n, MD, I:ACEP Brant Burden, H 'IT- I) Antho ny Cd litti , NREMT-P Leon Charpentier, EM T- P Buddy Den so n, EMT- P Pamela Drexel, Bra in Traum3 ]:oundation David Effron, ~'lD, FACEP Ferno Washington, Inc. KING Ai rway Systems Kyee H. Him, MD. FRCS, HAEM

Edu 'lrdo Romero Hicks, MD leff Hinshaw, MS, PA-C, NREMT- P 130n nie Mcneely, EMT- P Noni n Medical, Inc.

Ilob Page. NREM T-P William Pfeifer, tvl D, FACS Don Resch Sam Spl ints Surefi re '[1ctiC<11 Lights Z-Medica Corporation

xvii

xx • ABOUT ITl5

ITLS LEADERSHIP Editorial Board Donna Hastings, EMT-P Chair Calga ry, Alberta, Canada John E. Campbell, MO, FACEP Chair Emeritus Camp Hill , Alabama Roy L. A1so n, PhD, MO, FACEr Winston-Salem , Nort h Carolin a Kyee H . H.n, MBSS, FRCS, FFAEM Middl esbrough . England Ed ua rdo Romero Hicks. MD Guanajuato. Mexico

Arthur Proust, MD, FACEP SI. Charles, Illinoi s S. Robert Seitz, MEd, RN, NREMT-P Pittsbu rgh, Pennsylvan ia

J. T. Stevens, NREMT-P Douglasville, Geo rg ia

Executive Director Virgin ia Kennedy Pal ys, JD Oakbrook Terrace, llI inois

W illiam Pfeifer, MD, FACS Littleton, Colorado

WHAT MAKES ITLS BETTER? Since its beginn ings morc than 25 years ago as Basic Trauma Life Su pport, ITLS has beco me a global force for excellence ill traum a educatio n a nd response, w ith more tha n 75 chapters and train ing centers worldwide. What makes ITLS a better choice for trauma train ing? Here arc just a few of the reasons.

• Evidellce-based. ITLS is based on current science and research. • Praclical. ITLS training is a realistic, hands-on approach proven to work in the field "from scene to surgery,'" • Dynamic. ITLS conten t is current, relevant, and respo nsive to the latest thinking in trauma management. • Flexible. lTLS courses are taught through a strong network of chapters and training centers that customize content to reflect local needs and priorities. • Recognized. ITLS is an internationall y recogn ized certification that is the standard for prehospi tal tra uma ed uca tion. • Team centered. ITLS emphasizes a cohesive tea m app roach that wo rks in the reaJ wo rld and recognizes the impo rtance of the emergency care provider's role. • Grmmded in emergency medicine. Practicing emergency physicians-medicine's front -lin e responders-lead ITLS's efforts to deliver stimulating content that has its base in sol id emergency medicine. • Cllalletlgillg. ITLS course content raises the bar o n pe rformance in the field by integrati ng classroom knowledge with practical appl ication of skills through interactive stations. • COllfidence bllilding. The unique ITLS course format builds confide nce in new prov iders and knowledge in experienced providers.

ABOUT ITLS •

FOCUSED CONTENT THAT DELIVERS ITLS is accepted internationally as the standard trai ning course for prehospitaltrauma carc. II is taught not only as a continuing ed ucation course, but also used as essential curricu la in many paramedic, EMT. and first Responder tra in ing programs. ITLS courses combine classroom learning and hands-on skill stations. T hey also challenge the student with scenario assessment stations where learning is pu t to work in si mulated I rallm:l situations. ITLS courses arc designed, managed. and del ivered by cou rse directors. coo rdinators, and instructors experienced in EMS, p rchospital carc, and the ITLS approach. rll.s is syno nymous with t raining EMS personnel in p roviding o pt imal care for the injured in the prchospital setting. The program provides a va riety of trai ning options to sui t the requircmen ts of alllcvcls and backgrounds of prehospital emergency perso nnel around the world.

xxi

ITlS BASIC AND ADVANCED These comprehensive co urses arc designed for trauma care providers who ,Ife first to assess and initiate treatment for th e trauma patient. The courses provide complete training in the skills needl.'d for mpid assessment , H.'sliscitatio n, stabilization , and transpo rtat io n of trauma patients. The ITLS Basic cou rse provides the core of knowledge and skills appropriate for all levels of EMS personnel , including EMT- Bs. First Responders, and other technicians. The IlLS Advanced course builds 0 11 that knowledge, emphasizi ng assessment steps .md sequ encin g as well as treatment interventions and packaging pa tients for transport.llLS Advanced is approp riate fo r advanced EM Ts, paramedics, traunm nu rses, physician s, and oth er advan ced EM S person nel. Frequently, the Basic and Adva nced courses arc combi ned, with students participati ng in the skill statio ns appropriate for their level of training. Ha ndS-O il skill st'lt ions include: • Patient assessment and management • Basic and adva nced airway management • Needle chest deco mpression and fluid resusci tation • Spinal motion restriction, incl uding r.l pid ext ri cation, short backboa rd, helmet man agement, log-roll, and long backboard/scoop stretcher ut iliz.1t io n • Ext remity immobili7.a tion and trilct ion splint application

ITlS INSTRUCTOR COURSES Instructor courses prep.lre EM S profession:ll s to teach ITLS courses. 10 participa te, potential inst ructors must sllccessfully compl ete the provider cOllrse th e)' wan t to teach, demo nstrate inst ructo r potential, and meet local IT LS requiremen ts.

ITlS REFRESHER COURSES IT LS o ffe rs refresher courses for experienced ITLS providers .md instructors to keep thelll up to da te with the ITLS curriculum and skills.

ITlS PEDIATRIC Pediatric ITLS co ntinues the training of the Basic and Adva nced courses with an emphasis on understa ndi ng and responding to traum'l in children. The eight - ho ur course teaches the proper assessment, stabilization , and packaging o f pediatric tra uma patients. It also

xxii

ITLS COURS E DESCRIPTIONS •

highlights tC'chniques fo r com lllunica ting with young patients and their parents. H:mdso n statio ns include: • Patient assessment and ma nagement • Airway management and chest decom pression • Fluid resllscitat io n • Spine motion restriction, including pediatric immobilil.at io n devices

ITLS ACCESS ITI..s Access gives EMS crews and First Responders Ihe training tbey need to reach, stabilize, and extricate pa lients tr'lpped in molo r-vehicle coll isions. The upda ll'd course includes techn iques fo r hybrid vehicles, trucks, buses, and small aircraft in :Iddi tio n to its primary focu s o n traditional vehicles. The eight -hour course is built around the concept of usi ng hand tools cO lllmo nly ca rri ed o n an ambulance or first responde r unit .

ITLS MILITARY rn..s offers a custom edition of a stand -alone military edition tex t, edited by a military surgeon. The scenorios arc military bosed and cater to military pl' rso nnc l.

ENROLLING IN AN ITLS COURSE ITLS provides its courses through its chapters a nd training centers. Each ch:lptcr is based

a geographic regio n, with the except io n of the U.S. mi lita ry. Train ing centers are cstablisl1l'd for proprietary training organiL1tions to ed uca te their own personnel in ITLS. For info rmation about your local chapter, cont'act International Trauma Life Support at 888·495· ITLS (or 630-495-6442 for international " IUers). ITLS .staff will pUI )'OU in touch wil h a chnpter-or help you start a chapter in )'ou r area. YOli can also find a listing of all lTLS chapters and co ntact in form ation onl ine at http://www.itra unm.org 0 11

Intern:llio nal Trau ma Life Support J South 280 Summit Avenu e, Co urt B-2

Oakbrook Terrace, II, 6018 1 USA Phone: 888-495· ITLS (U.S. and Canada) 630-495·6442 (Internationa l)

Fax: 630-495-6404 \\'eb: hl tp:llwww.i trauma .org E-mai l: info@it rauma.o rg

xx iii

(0 CraigjacksQ uJln Ih" D~ rk Pho!ogr~phy)

Dan, Joyce, and Buddy of the Emergency Tra nsport Service (£IS) have been dispatched to a two-car

( I'holo C jeff Forster)

collision in wh ich one auto ran into the side of the other. They are informed that a

How do they go about sizing up the scene when they arrive? What should they do before they approach the patients? What equipment should they carry with them as they approach the patient(s)? What injuries should they expect in a collision of this type? resc ue truck is on-scene and attempting to extri cate one of the drivers.

Keep these que stio ns in mind as you read the chapter. Then, at the end of the chapter, find out how th e rescuers completed this ca ll.

INTRODUCTION Trauma, the medical term for injury, cont in ues to be the most expensive health problem in the United States and most other countries. In the United States, trauma is the fo urth leadi ng cause of death for all ages and the leading cause of death for children and adults under the age of 45 years. For every fatality,there arc 10 more patients admittt'd to h osp i ~ tals and hundreds more treated in emergency depa rtments. The cost of injury in the United States is estimated to be over $2 10 billio n annually. This represents a cos! twice that of ca rd iovascular disease and ca ncer combined. The price of trauma , in both physical and fi scal resources, mandates that all emergency Im'd ical personnel learn more about th is d is ~ case to treat its effects and dec reasc its incidence. (Sec Appendix H, " Injury Prevention and the Role of the EMS Provider.")

PHILOSOPHY OF ASSESSMENT AND MANAGEMENT OF THE TRAUMA PATIENT

2

For the severely injured patient , survival is ti me~ d epen d e nt. The direct relationship be~ tween the timing of definitive (surgical) treatment and the survival of trauma patients was first described by Dr. R. Adams Cowley of the f.unous S h ock ~Tra ulll a Center in Baltimore, Maryland. He discovered that when seriously inj ured pat ients were able to gain access to the operati ng room within an hour of the time of inju ry, the highest survival ra te was achieved (approximately 85 percent ). He referred to this ;IS the "Golden HOllr." The Golden Ho ur begins at the mo ment the patient is injured, no t at the time you ar~ rive at the scene. Rarely is there much of the hou r left when }'Oll begin your assessment, so you must be well organized in what you do. In the prehospital setting you do not have a Golden Hour, rather ;1"platinum 10 mi nutes" in which to identify live patien ts, make treat ~ ment decisio ns, and begin to move patients to the appropri,lte medical facility. This mea ns th at every actio n must have a lifesaving purpose. Any actio n that increases scene time but

CHA PTER 1 Scene Size-up _ 3

is not po tentially life saving must be omitted. Not only must )'O U reduce evaluation and reSllscitation to the most efficient and crit ical steps, you must also develop the habit of assessing and treating every trau ma patient in a pla nned logical and sequent ial manner so you do not forget critical actions. When perform in g patient assessment, it is best to proceed in a "he,ld -to-toe" man ner so that noth ing is m issed . If yo u jump around d uring your assessment, yo u will inevitably fo rget to evaluate ~ome th in g crucial. Working as a team with yo ur partner is also important, because many act io ns must be done at the sa me time. It has been said that medicine is a profession that was created for obsessive-compulsive people. Nowhere is th is more true than in the care of the trauma patient. Often the patient's life depends on how well YOll manage the detai ls; and, remember, not all of the details are at the scene o f the injury. You or a member of your team must • Know how to main tain your ambulance or rescuc vehicle so that it is serviced and ready to respo nd when needed. • Know the quickest way to the scene of an injury. • Know how to size li p a scene in order to recognize dangers and identify mechanisms of injury. • Know which scenes ,Ire s,lfe and , if no t safe, what to do abO Llt them . • Know when YOll can handle a situation and when to call fo r help. • Know when to approach the pat ient and when to leave with the patient. • Know )'our equ ip ment an d mai ntain it in working order. • Know the most app ropriate hospital and the fastest way to get there. (Organ ized trauma s),stems :lIl d tra nsfer/bypass guidelines can shorten the time it takes to get a trauma patient to definitive ca re.) As if all that were not enough, you also have to: • Know where to put your ha nds, which questions to ask, what interventio ns to perfo rm, when to perform them, and how to perform critical proced ures qu ickly and correctl y. If you thi nk the deta ils arc no t important, then leave the profession now. Ou r job is saving lives, ,I most honorable profession. If we have a bad day, so meo ne will pay fo r our mistakes with suffering or even death. Since the early beginni ngs of Emergency Medical Services (EMS), patients and even rescuers have lost thei r lives because allent ion was not paid to the details listed above. Many of us can recall patients that we m igh t have saved if wc had been a little smarter, a litt le fasler, or a li ttle better o rganized. Make no mistake, there is 110 "high" like saving il life, but yo u wi ll carry th e scars of YO Uf fa ilu res all o f your life. Your mindsct and attitu de are very impo rta nt. You must be concerned but no t emotional, alert but not excited , q uick b ut not hasty. Above all, you must con tin uo usl), strive for what is best for your patient. When your train ing has not prepared you for a situation, always fall back on the q uestion: W1ml is best for my pa/iclIf? When you no longe r care, burnout has set in and you r effectiveness is severely limited. When this happe ns, seek help (yes, all of us need help when the stress overcomes us) or seek a n alternative profession. Since 1982, the Interna tional Trauma Life Suppo rt ( ITLS, formerly BT LS) o rga nization has been identify ing the best methods to get the most out o f those few m in utes that prehospital EMS providers have to save the patient's life. Not all pat ients Gill be saved, but our goal is never to lose a life that cou ld have been saved. The knowledge in this book can help you make a difference. Learn it well

4 • CHAPTER 1 Scene Size-up

SCENE SIZE-UP Scene Size-up is the first step in the ITLS Primary Survey (Table \-\). It is a criti"ll part of trauma assessment and begins before you approach the patient-lfyoll fa il to perform the preliminary steps of Scene Size-up, yo u may jeopardize your life and the life of you r pa tient. Scene Size- up includes taki ng standard precau tions to prevent exposure to blood and other potential1y infective material, eval uating the sccne fo r dangers, determ ining the total num ber of patients, determining essential equipment needed for this particu lar scene, and identifying the mechanisms of inju ries (Table J-2). Scene Size- up actually begins at dispatch, when yO ll ant icipate wha t yO li will find at the scene. Althat time, you should think about wha t equipment you wiJl need and whether other resourccs (more units, special ext rication equipment, Illulticasualty incident IMCI] protocols) may be needed. Although in fo rmation from dispatch is useful to begin to thi nk about a plan , do not ovcrre1r on th is information. Such info rmatio n given to the dispatcher is often exaggerated o r even completely wrong. Be prepared 10 change your plan depending on your own survey of the scene.

Standard Precautions Trauma scenes are among the most likely to subject the rescuer 10 conta minatio n by blood or oIl,er potentially infectious IIInter;{I/ (OPIM). This subject wi ll be covered in more detail in Chapter 22. Not only arc trauma patients often bloody; they freq ul'ntly require airway managemen t under adverse condit ions. Persona l protective eq uipment (PPE) is always needed at tra uma scenes. Protect ive gloves arc alwa)'s needed, and many situations wi ll requ ire eye protection. It is wise for the rescuer in charge of airway management to have a face shield o r eye protect ion and mask. [n highly contaminated sit uations, im pervio us gowns with mask or face shield may also be needed. Remember to protect your p.lIien! from body flu ids by changing gloves between pa tients.

Scene Safety Begin sizing up the scene for hazards as yo u approach. Your tirst decision is to determine the nea rest safe place to park the ambu lance or rescue vehide. You wo uld like the vehide

-'

I \1;1 1 I

I

r""

ITLS Primary Survey

Perform a Scene Size-up. Perform Initial Assessme nt. Perform a Rapid Trauma Surveyor Focused Exam. Make Critical Interventions and Transpo rt Decision. Contact me dical d irection.

IllS Secondary Survey

Repeat Initial Assessment. Repeat vital signs and conside r monitors. Perform a neurological exam. Perform a Detailed (head-to-toe) Exam.

ITlS Ongoing Exam

Repeat Initial Assessment. Repeat vital signs and check monitors. Reassess the abdomen . Check injuries and interventions.

CHAPTER 1 Scene Size-up _ 5

0

11 ' , 1 1 " ' "

'"

1. Standard precautions (personal protective equipment) 2. Scene safety 3. Initial triage (total number of patients) 4. Need for more help or equipment 5. Mechanism of injury

as close as possible, and yet it must be far enough away from the scene for you to be safe whil e you are performing the scene size- up. Try to park facing away from the scene, so if dangers arise you can load the patient and leave q uickly. Next. determine if it is sa fe to approach the patient (s). Perform a "windsh ield survey" before leaving your response vehicle. Consider the following:

• Crash!rcsC//c scelll-'s. Is there danger from fire o r toxic substances? Is there danger of electrocution? Are unstable surfaces or structu res present such as ice, water, slope, or build ings in danger o f collapse? Areas with potential for low oxygen levels or toxic chemical levels (sewers, ship holds, silos, and so on ) should never be en tered until you have the proper protective equ ipment and breathing apparatus. You should never enter a dangerous area withou t a partner ;Illd a safety line attached.

• Crillle sceues. Danger may exisl even after a crime has been committed. Be alert for persons fleeing the scene, for persons attempt ing to conceal themsclves, and for persons who are armed or who are making threatening statements or gestures. Do not approach a known crime scene if law enforcement person nel are not present. Wait fo r law (.'nforcemen t, nol only for the safety of you and the victims, but also to help preserve evidence. Do not appro;lCh the scene if YOll see th at law enforcement person nel arc in defensive positions or have their weapo ns drawn.

• Bystanders. You and the victim(s) may be in danger from bystanders. Are bystanders ta lking in loud , angry voices? Arc people fighting? Are weapo ns present? Is there evidence of the use of alcobol o r illegal drugs? Is th is a domestic-violence scene? You ma)' not be recognized ilS a rescuer, but as a symbol of authori ty and thus attacked. Arc dangero us an imals present? Request law en forcem ent person nel at any sign of danger from violence. Consider whether the scene poses a contin ued threal to the patient. If there is danger of fire, water, structure collapse, toxic exposure, and so on, the patient may have to be mo\'ed immediately. Th is does not mean that you sho uld expose yourself or )'our partners 10 un necessary danger. You may need 10 call for special equipmen t and proper backup from the pol ice, fire services, or the power company. If the scene is unsafe, ),ou shou ld make it safe or try to remove the pa tien ts from the scene wit hou t putting yourself in danger. Sometimes there is no clearly good way to do this. Use good judgment. You arc there to S3\'e lives, not give up you r own.

Total Number of Patients Determine the total number of pat ients now. If th ere arc more pat ients than your te;11ll can effectively handle. call for backup. Remember that you usually need one ambulance for each serio usly injured patient. If there are many patients, establ ish medical command and initiate mu lt icasualty incident (Me l) protocols. Are aUpa tients acco unted for? If th e patient (s) is unconscio us, and there are no witnesses to the incident, look for clues (school books o r diaper bug, passenger list in a commercial vehicle) that other patients

6 •

CHAPTER 1 Scene Size-up

FIGURE 1·1 bample of a small but powerful tactical flashlight. (Ph% 1(lc/;((I/ Ugh's)

COllr/t-sy afSureFire· ..

l11ight be pres('nt. Carefu ll y evaluate the scene for o ther patients. This is especia lly important at nigh t or iftherl' is poor visibilit y. It is \\·ise to invest in a high· intensity tact ica l light (Figu re I-I ). They :tre small enough to ca rr y in ro ur shi rt pocket but arc nl;lIl)' times b righter than regular flashligh ts.

Essential Equipment and Additional Resources If possibk, carryall essenlial medical equipmen t to the scene. Th is prevrllts loss of lime returning to the v('hicit". l~ell1{" m be r to ch:lI1ge glol'('s between pa tients. The (olloll'ing equipment is always Ilerdcd for trauma pat ien ts. • Pcrson:11 protect ion equipment (Sec previo lls d iscussion.) • Long backboard with effective st rapping and head Illo tion-r('striction d evice • Appropriately sh.ed rigid cervical extrication collar • Oxygen and 'Iirway equipment (Suction equ ipment and a bag-valve mask IBVM j should be include-d. ) • Trauma box (bandag(' rnat('rial, blood pressur(' cuff, stethoscope) If special extrication equipment, more ambulances, or additional personnel are needed, call now! Yo u arc less likd )' to call fo r help when Itwolved in patient ca re. Be sun.' 10 tell additional responders exactly where to respond.

Mechanism of Injury Once you determine that it is sa fe to approach the patient, begin to assess fo r the lIIec/ulIIiSJII of injllry. This rnay be :l pparent frorn the scene itself but il ma)' requi re questioning the patient or bystanders. Energy transm issio n follows the laws of physics; therefore, injuries p resent in predictable patterns (Table 1-3 ). Kno\\'lcdge and Ilpprcdal ion of the mech:lIlism of inju ry is very helpful in your eval uat io n of the patient. "" lis5(><1 o r overlooked injuries m il)' be catastroph ic, especially when the)' occome knol\'n only after the compens;.lto ry mechan isms arc exhausted.

CHAPTER 1 Scene Size-up _ 7

~

I

Mechanisms of Injury

Potential Injury Patterns

Frontal impact Deformed steering wheel Dashboard knee imprints

• Cervical-spine fracture

Spider deformity of windscreen

T-bone

• Flail chest • Myocardial contusion • • • • •

Pneumothorax Aortic disruption Spleen or liver laceration Posterior hip dislocation Knee dislocation

• Contralateral neck sprain • Cervical-spine fracture • Lateral flail chest • Pneumothorax • • • •

Aortic disruption Diaphragmatic rupture Laceration of spleen, liver, kidney Pelvic fracture

Rear impact

• Cervical-spine injury

Ejection

• Exposure to all mechanisms and mortality increased

Pedestrian vs. car

• Head injury • Aortic disruption • Abdominal visceral injuries • Fracture lower extremities and pelvis

Remember th at patients who are invol ved in a high-energy event arc ,11 risk fo r severe inj ury. Despit e no rm al vil al signs and no apparen t anatomic injury o n the in il ial assessment , 5 to 15 percent of these pat ient s will later ex.hibit severe inju ries that arc discovered o n repea l exam inatio ns. Therefore, a high-energy e\'enl signifies a large release of unco ntrolled energy, and )'OU should consider the patienl injured unt il you have pro\'en o lherwise. It is im portan t to be awa re of whether the mechanism is ge/leralized (MVe, fa ll from a height, and so o n) o r [ocl/sed (stab wound of ,Ibdomen, hit in head by hammer). Generali7.ed mechanisms req uire a rapid trau ma su rvey, whereas focused mechanisms may o nly require a mo re limited exam of the affected areas o r syslems. Factors to be considered are direction and speed of impact. patient kinetics and physical si1.c. and the signs of energy rele,lsc (e.g., majo r vehiciedam'lge). A strongcorrdatio n ex ists between injury severity and automobile velocity changes, as measured by the amoun t of vehid e dam'lgc. It is impo rtant Ihat YO ll consider these two questio ns: Whllt happet/ed? How !Vas tile patient il/jl/red? Mechanism of injury is also ;\n important triage too l and is info rmatio n that YO ll shou ld repo rt to the emergency physician or trauma surgeon. Severity of vehicle damage has also been suggested as il non physiologic triage tool. l'. lotion (mechanical ) injuries arc by and large respon sible for the majo rit y of th e mortal ity fro m trauma in the United States. Thi s chapter rev iews the most co mmo n

8 •

CHAPTER 1 Scene Size-up

.,

I

.1'

Blunt Injuries

Penetrating Injuries

• Rapid forward deceleration (collisions) • Rapid vertical deceleration (falls) • Energy t ransfer from blunt instruments (baseball bat, blackjack)

• Projectiles • Knives • Falls upon fixed objects

mechanisms of mot ion injuries and stresses the injuries that may be associated with these mechanisms. It is essential to develop an awareness of mechan isms of injury a nd thus have a high index of suspicion for occult injuries. Always cons ider the potent ial injury to be present until it is ruled out in a hosp it al setting. There are I>vO basic mechan isms of mo tion injury, blu1I1 and pelle/rating (Table 1-4). Patients may have injuries from both at the same time.

MOTOR·VEHICLE COLLISIONS Various injury patterns will be discllssed in the follow ing examples, which include automobi les, motorcycles, ali-lelTai n vehicles (ATVs), personal watercraft , and tracto rs. The important co ncept to appreciate is that the kinetic energy of motion mllst be absorbed, and this absorption of energy is the basic component in producing injury. Motion injury may be blunt or penetrating. Genera lly, blunt trau ma is more common in the rura l selli ng, and penetra ting tmuma is more commo n in th e urban selling. Rapid forward deceleration is usually blunt but may be penetmting. The most com mo n exampl e of rapid forward deceleration is the motor-vehicle collision (MVC). You should consider all MVCs to occur as three separate events (Figu re 1-2) . • Machine collisio n • Bod)' collisio n • Organ coll ision Co nsider approaching a n MVC in which an automobile has hit a tret' head-on at 40 miles per hour. The tree brings the auto to an immediate stop by transferring the energy into damage to the tree and the auto mob ile. The person inside the auto is still travel ing at 40 miles per hou r until he st rikes something th.ll stops him (such as steering wheel, windshield, dashboard). AI that point , energy transfers into damage to the person and to the surfa ce struck. The organs imide the perso n are also traveling at 40 miles per hour unt il they arc stopped by striking a stationary object (such as inside of skull . sternum , steeri ng wheel, dashboard ) or by their ligalllentous attachmen ts (aort:l by lig:lmentum arterioslllll , and so on). In this 'llIt o-versus- trce example, app reciation of the rapid forward deceler:u ing mechanism (high-energy event) coupled with a hi gh index of suspicion should make you co ncerned t hat the victi m mar have possi ble head injury, cervical-spine injury, lllyOGlrd ial contusio n, allY of the "deadly dozen" chest injuries. intra-abdominal injuries, and musculoskeletal inju ries (espcciaU)' fract ure or dislocation of the hip). '10 explai n the forces involved, consider Sir Isaac Newton's first law of motion: "A body in motio n remains in motion in a straight li ne unless acted upon by an outside force." Motio n is created by force (energy exchange}, and therefore fo rce will stop motion. If this energy exchange occurs withi n the body, damage of the tissues is produced. This law is well exempli fied in the automobile crash. The kinetic energy of the vehicle's forward motion is absorbed as each part of the vehicle is broughlto a sudden halt by the impact. Remember that the body

CHAPTER 1 Scene Size-up _ 9

a. Vehicle collision

,

•

Imp"C:1 point.

Head YS. windshiel d

b. Body collisions

c. Organ collision

The energy Q( body c:oIIition ill transmitted

to !he irl!eric:x.

FIGURE '·2 The three collisions of a motor-vehicle crash.

10 •

CHAPTER 1 Scene Size-up

Secondary collisions

FIGURE 1-3 Secondary collisions in a de<:e1eration MVC.

o f the occupant is also traveli ngat 40 miles per hou r u ntil impacted by some structure within the car such as the windshield, steering wheel, o r dashboa rd. With awareness of this mechanism, o ne can see the multitude of injuries that may occur. Be aware of the following clues. • Deformity o f th e vehicle (indication o f fo rces involved--energy exchange) • Deformity of in te rior structures (indicatio n of where the patient impacted--energy exchange) • Defo rmity o r inj ury patte rns of the patient (ind icatio n of what parts of the body may have been im pacted ) Add itio nal collisions may occur other tha n the three already mentioned. Objects inside the automobile (books, bags, luggage, and other persons) will become m issiles traveli ng at the o rigin al speed o f the auto and may strike persons in front o f them (Figu re 1-3). These are called sccof/(/arycollisiolls. A good example of th is is when a parent is holding a child in her lap and crushes the ch ild between her and the dashboard in a deceleration collision. In many auto coll isio ns. additio nal impacts occur when the ,lutO strikes another auto and is then in turn st ruck by an auto fo llowing. Also, vehicles frequently deOcct from hi tting on(> o bject and then collide with a second o r even th ird vehide or stationa ry objec t. These are much like a rollover collision in that the persons inside the vehicle are subjected to energy tra nsfer frOIll mult iple directions. It is o ften more d ifficult to p redict inju ries in these cases and you m ust q uickly but c;l refully look fo r clues inside the veh icle. MVCs occur in se\'eral forms, and each fo rm is associated with certain patterns o f injury. The fi ve com mon fo rms o f MVCs are the following: • Head -on coll ision (fro ntal) • T-bone or lateral-imp,lCt conision (lateral) • Rear-impact collision (rea r) • Ro llover collisio n • Rota tional collision

Head-on Collision In it MVC involving a head-on collision, an unrest rained body is b ro ught to a sudden h:llt, and the energy transfer is capable of produci ng multiple injuries.

CHAPTER 1 Scene Size-up _ 11

Windshield injuries occur in the rapid forward -dt'celerating type of event, in which the unrestrained occupa nt imp.lets forcefull y wit h the windshield (i;igure 1-4). The possibi lit)' for injuries is grt'a t under these conditio ns. Of ut most concern is the pott'ntiaJ for seriolls airway and cervical-spine injury. Remembering the th ree separate colli sion events, note the following:

Mad/ine rollisiOIl-deformed front end Hotly colfisicm- spiderwcb pattern of windshield Orgall colfis;ol1---cou p/co ntracoup brain, so ft -t issue injury (scalp, face, neck ), hypcrextensionlflexion of cervical spine From the spiderweb appearance o f the windsh ield and an appreciation of the mech;mislll of injury, you should maintain a high index o f suspicion for possible occu lt injuries of the cervical spine. The head usuall y st ri kes the windshield, resulting in direct trau ma to tne face and head. External signs of trauma include cuI's, abrasions, and contusions. These may be quite dramatic in appearance; howevcr, the key concern is airway maintcnance with Illotion restriction of the cervical spinc and eval uation of level of consciousness. Steerin g wheel injuries most often occur to an unrest rained driver of a veh icle in a head-on co llisio n. The driver m;IY subsequent ly also impact with the windshiel d . The steering wheel is the vehicle's most lethal weapon for the unrest rained d river, and any degree of steering wheel deformity (check under collapsed airbags) must be t reated wit h a high index of suspi cion for facl." neck, tho racic, or abdominal injury. The Iwo compo nents of this weapon are the rin g and colu mn ( Figure 1-5). The ring is a semirigid, plastic-covered metal ring attached to ;1 fixed infl ex ible post- a battering ram. Utilizing the three-collision co ncept, check for the presence of the followin g:

FIGURE 1-4 In a head-on collision, most injuries arc inflicted b)' th(· windshield, steering wheel, and dashboard.

Steering Wheel

tnjuries

Machine collision-fro nt -end deformity /Joffy colfision- ring fr:lcture/de form it)" colu mn

Soft-tissue neck injuries

normaVdisp1:lCed

Larynx and tracheat injuries

Organ collisioll- t raumat ic tattooing of skin The he:ld-on col[ision is entirely dependent upon the area of the body that impacts with the steeri ng whl'e!. Signs may be readily visible, with direct trauma such as lacerations of mouth and chin , co ntusion! bru ises of the anterior neck, t raumatic tattoos of the chest wall, and bruising of the abdomen. These external signs m;IYbe subtle or drama tic in appearance, but more imlx>rla nt, lhey Illay represent the tip of the iceberg. Deeper structures and orga ns Illay harbor occult injuries due 10 shearillg forces, compressioll forces, and disp/aCt'IIICtll of killetic energy. Orga ns that arc susceptible to shearing injuries due to their ligamentous attachments arc the aortic arch, live r, spleen , kidneys,

Fractured sternum Myocardial contUSion

Hemothorax Flail chest

Intra-abdominal injuries (ruptured spleen or liver) Bowel injuries

FIGURE 1-5 Steeri ng " 'heel injuries.

12 • CHAPTER 1 Scene Size-up

",
DiSlocate<:! hlp or knee

Lap belt

No belt

FIGURE 1-6 Dashboard injuries.

and bowel. With the exception of small-bowel tea rs, these injuries are sources fo r occult bleeds and hemorrhagic shock. Compression injuries are common with the lung, heart, diaphragm, and urinary bladder. An important sign is respiratory distress, which may be due to pulmonary contusions, pneumothorax, diaphragmatic herniil (bowel sou nds in chest), or fla il chest. Consider il bruised chest wall as il myocardial contusion that requires monitoring of cardiac rhythm and, if ilvailable, a 12 -lead EKG. In short, the steering wheel is a lethal wC'lpon capable of producing dcv;\sl;lting injuries. many of wh ich are occult. Steering wheel deformity isa cause for alarm and must heighten your index of suspicion. You must also relay this information to the receiving physician. Dashboard injuries occur most often to an unrest rained passenger. The dashboard hus the cap:lbility of producing a variety of injuries, depend ing upon the area of the body that strikes the dashboard. Most frequently, injuries involve the face and knecs; howcver, many types of in juries have becn described ( Figure 1-6 ). Applying the three-event co ncept of collis ion, you will note:

Mac/line collisioll-d eformity of the car Bod)1collision--fracture/deformity of the dash

Organ collisioll- facial trauma, coup/contracoup brain, hyperex\cnsion/flexion of the cervical spine, pelvis, hip, and knee trauma Facial . brain, and cervical-spine injuries havc alre:ldy been discussed. Like chest contusion, knee trauma may represen t only the tip of the iceberg. Knees commonly impact with the dashboard. This may range from the simple contusion noted about the patella to the scvere compound fracture of t he patella. Fr
T-Bone or Lateral-Impact Collision The mechanism of the T-bone collision is similar to thil t of the head-on collision, with the addition of lateral e/lergy displacement (Figure 1-7). Applying the three-coll ision concept , look fo r the presence of the fo llowing:

Machine follisiott-primary deformity of the car---check the impact side (driverfpassengcr)

CHAPTER 1 Scene Size·up _ 13

Body colfisioll- degree o f door deformi ty (e.g., armrest bent , outward o r inward bowing of door)

Orgat! collision-cannot be pred icted by external exa m alone; consider organs u nderneat h areas of external injury Look for the following commo n injuries.

• Head. Coup/contracoup is d ut' to lateral d isplacement.

• Neck. Lateral displacement injuries range from cervical· musde stra in to frac ture o r subl UJ(a tion with neurological defi cit.

• Upper arm and sholllder. Injuries appear o n the side of the impact. • 11IOmx/abdomell. Injury is d ue to a. d irect force either from inward bowing of door o n the side of the impact or fro m unn.'S tra ined passenger bein g propelled across Sl'.II .

• Pelvis/legs. Occu pants on the side of the impact a re likely to have pelvic, hip. or fe mur fractures. Injuries o f th e tho rax va ry fro m so fH issue injuries to fl ail chest, lung contusio n, pneu· mO lhorax, o r hemothorax. Abdom inal inj uries include those of so lid o r ho llow o rga ns. Pelvic inju ries may include fractu re/d isloca tion, blad· der ruptu re, and u reth ral inj uries. Shou lder g ir· die or lower extremi ty injuries are co m mo n, dependi ng o n the level of the impactin g fo rce.

Rear-Impact Collision In the most commo n form of rcar· im pact colli· sion, a statio nary car is struck fro m the rear by a mO\'ing "ehicle (Figure 1· 8). O r a slower mov ing car nlay be impacted from the rea r by a fa ster moving car. The sudden increase in accelerat io n prod uces posterio r displacement of the occu pan ts b. and possible hyperex tension of the cervical spine FIGURE 1·7 tn a tateral. impact collision, most injuries are inflictoo by if the headrest is not p roperly adjusted. Irt he scat intrusion o f the door, arm rest, side' window, or door post. (Photo back breaks and falls backward into the rear sca t, collrll'syof AmllOlIY u fliltj. NR£MT· P) there is greater chance of lumbar·spin e injury. Rapid forwa rd deceleration may also occu r if the car sudden ly strikes somethi ng in the front or if the driver applies the brakes sudden ly. Note deformity of the auto anterio r and posterior as well as interior deform ity and head rest posit ion. The potential fo r cervical· spine inju ries is srea t ( Figu re 1-9). Be aler t for associated decelerat io n injuries as well.

14 • CHAPTER' Scene Size-up

FIGURE ' -8 In a rear-impact collision, the potential exists for neck and back injury. (I'/roto cormes), of Bomric Mellt'ei)" E"rr-p)

Rollover Collision Du ring a vehicle rollover, the bod y may be impacted from any direction; thus, the potential for injuries is grea t (Figure 1- 10). The chance for axhll -loading injuries of the spine is increased in this form of MVC. Rescuers must be alert for clues that suggest the car turned over (such as roof dents, scratches. debris, and deformi ty of roof posts). Lethal injuries often occur in this form of collision because of the s rea ter likelihood of occupants being ejected. Occupants ejected frOlllth c car a re 25 times as likely to be killed.

8. Victim moves ahead while head remalns stationary. Head rotates backward. Neck extends.

b. Head snaps forward . Head rotates forward. Neck flexes.

FfGURE 1-9 Mechonism of cervical·spine injury in a rear-impact collision.

CHAPTER 1 Scene Size-up -

FIGURE 1-10 A rollover collision has a high potcntial for injury. Many mechanisms are involved, and unrestraincd victims arc frequcntl), ejectcd. (Photo (Ollrles), of BOIIII;e Melll'd); EMT-P)

Rotational Collision A rotational mechan ism is best described as what occurs when one part or lhe veh icle stops and the rest of th e vchicle rcmains in motion. A rotational collision usuall y occurs whcn a vchide is struck in the front or rear lateral area . This converts forward motion to a spin ni ng motion. The results arc a combina tion of the fro ntal-i m pact and the lateral-impact mechan isms with the same possibilities of inju ries of both mecha nisms.

Occupant Restraint Systems Restrained occupan ts arc more likely to survive a coll ision, because they are protected from much of the impact inside the auto and are unlikely to be ejected from the au to. These occupan ts are, however, still susceptibl e to certain injuries. A lap belt is intended to go across the pelvis (iliac crests), not the abdomen. If the belt is in place and the victim is subjected to a frontal deceleratio n crash, his body tends to fol d together like a clasp kn ife (Figure I- II ). The head may be thrown forward into the steering wheel or dashboard. Fllcial, helld, o r neck injuries are commoll . Abdo mimll injuries also occur if the lap belt is positioned improperly. The compressio n forces that are produced when a body is suddenly fo lded at the waist may inju re the abdomen o r the lumbar spine. The three-point restraint or cross-chest lap belt (Figure [- [2 ) secures the body much better than a lap belt alone. The chest and pelvis are rest rained. so life-th rea tening injuries are much less common. The head is no t restrained. and therefo re the neck is still subjected to stresses thaI may cause fractures, dislocations, or spinal cord injuries. Clavicular fra ctures (at the point where the chest strap crosses) arc co mmon . Internal organ damage may still occur due to organ movement inside the body. FIGURE 1-1 1 Clasp-knife effecl.

15

16 •

CHAPTER 1 Scene Size-up

Like belt restrain ts, air bags (passivc restra int s) will reduce injuries in victims of MVCs in most but not all situations. Ai r bags arc designed to inflate from the center of the steering wheel and the dashboard to protect th e fro nt -seat occupants in case of a fronta l decclcrJtio n crash. If functionin g properly, they cushion the head and chest at the instant of impact, thus effcctively decreasing injury to the face, neck, and chest. Be sure to stabilize the neck, however, until it has been adequately exam ined. Air bags deflate immediately, so they protect against only one im pact. The driver whose car hits more than one object is unprotected after the in itial collision. Air bags also do no t prevent "down and under" movement, so drivers who arc extended (tall drivers and drivers of small , low-slung autos) may still impact with their legs and suffer leg, pelvis, or abdominal injuries. It is important fo r occupan ts to wear chest and lap belts even when the car is equ ipped with air bags. Resea rchers have recentl y Air bag and three-point restraint shown that some drivers who appear uninjured after decelerat ion prevents collisions 2 and 3. crashes have been fo und to have serious internal inju ries. A clue FIGURE 1·12 Air bag and thrl"t'-poi nt restraint. to which driver may have internal injuries is the condition of the steering wheel. A deformed steeri ng wheel is just as important a clue in an auto equipped with an air bag as in those that arc not. This due may be missed , because the deflated air bag covers the steering wheel. Th us, a qu ick " lift and look" under the air bag should be part of the routine examination of the steering wheel (Figure 1-1 3). Many autos arc now equ ipped with side air bags in the doors. Some have air bags that come down from the roof to protect the head and at least one make of au to has 'Iir bags under the dash to protect the legs. These obv iousl), give much needed ex tra protect io n. Certain dangers arc associated with air bags. Small drivers who bring the seat up close to the steering wheel may sustain serious injuries as the bag inflates. Infants in car seats placed in the fronl seat may be seriollsly injured by the air bag.

FIGURE 1-13 Lift the collapsed ai r bag to note whether or not there is II deformity of the stl"t'ring wheel. (PhOlo colmes)' of Robert S. Porter)

CHAPTE R 1 Scene Size·up _ 17

In summary, when at the scene of a MVC. note t he ty pe of col lision and the clues (such as deformities o f the vehicle) that imply high kinetic energy h,IS been spent. Maintain a high index of susp icion for occ ult injuries and thus keep scene time to a minimum. These observations and clues a re esse ntial to quality patient care and must be relayed to medical direction and the receiving physician.

Tractor Accidents Another large motori zed vehicle wit h which yo u mu st be fami liar is the tracto r. Th e U.S. Na tional Safety Cou ncil reports that one· third of all farm accident fat alities in · volve tractors. T he two basic t ypes of tractors are th e two-wheel dri ve ,md th e fo urwheel d rive. In both , th e cente r of gravity is high , and thus t he tracto rs a re easily turn ed over ( Fi gure 1- 14 ). The majo rit y of fal al acc iden ts arc du e to the t r,lctor turnin g over
• Arc the rear whcels locked? • Have the fuel sitll
8. Rear overturns

b. Side overturns

•

FIGURE 1·14 TraCloraccidCl1ts.

18 •

CHAPTER 1 Scene Size-up

closer to the mid lin e of the machine. Because tractors usually overturn o n soft ground and thei r centers of gravity are tricky to determ ine. great care Illust be taken during lifting to avoid a second crush injury. Because of the tractor weight and length of time (usually prolo nged) the driver is pinned. anticipate serious injuries. Often. the patien t will go into profound shock as the compressing weight of the tracto r is removed-similar to what happens whcn antishock trousers are suddenly deflated. Rapid, safe managemen t of tractor accidents requires special exercises in lifting heavy machinery as well as good trauma management. To obta in add itional information and training opportu nities related 10 tractor incidents and other agric ultural emergencies, please refer to Append ix J in the back of th is book.

Small-Vehicle Crashes O ther small vchides that fa ll into the mot ion injury category include the motorcycle, ATV. personal wate rcraft (P\'VC). and snowmobile. The operators ofthcse machines arc not encased within them, and, of cou rse, wear no restraining devices. VVhen the o perator is subjected to the classic head-on, lateral -impact, rear-end, or rollover collision, the only form s of protection arc the following: • Evasive maneuvering • Helmet lIsage • Protective clothing (such .IS leather clothes. helmet , boots) • Use of the v(,hide to absorb kinetic energy (such as bike slide) Motorcycles: It is extremely important for motorcycle riders to wear helmets. Hel mets help prevent head injury (which causes 75 percent of motorcycle deaths). Regardless, helmets give no protect ion to the spine. The opera tor of a motorcycle involved in a crash is much like an ejected au tomobile occupant and severe injuries arc common. Injuries depend on the part of the anatomy subjected to ki netic energy. The lack of protective encasement leads to II higher frequency of head. neck, and extremity injuries. Im po rtant clues include deform ity of the motorcycle. distance of skid, and deformity of stationary objects or cars. All-Terrain Vehicles: The ATV was designed as a vehide to traverse rough terrain. The ATV was used initially by r.lIlchers, hun ters. and farmers. Unfortu nately, some people view it as a fast toy. C.1reless misuse has resu lted in an ever-increasing morbidity and mortality from acciden ts-sadly and frequently among the very young. The two basic designs arc three wheeled (no lo nger made and, so, rare) and four wheeled. The fo ur-wheel design affords reasonable stability and handl ing, bu t the three-wheeled ATV has a high center of gravity and is pro ne to roUover when turned sharply. Listed below arc the four most com mon mechanisms. • Vehicle rollover • Fall-off of rider or passenger • Forward deceleration of rider from vehicle impact with stationary object • Impact of rider o r passenger's head o r extremities when passing too dose to stationary objects (trees) The injuries produced depend upon the mechanism and the part of the anatomy that is impacted. The most frequen t injuries arc fractures, about half of wh ich arc above and halfbelow the diaph ragm. The major bo ny injuries involve thedavides, sternu m, and ribs. Be very suspicious fo r head or spinal injury.

Personal Watercraft: The use of personal wate rcraft (such as the Jet Ski, Sea 000, Wave Runner) has become popular in water recreational act ivities. O"er a million PWCs are in

CHAPTER 1 Scene Size-up _ 19

operation in the United Slates. The U.S. Coast Guard reports that after a 400 percent increase in the number of reported injuries from PWCs between 1990 and 1997 (2,860- 12,000), there has bt-en a decline in reported injuries every year since (last report 20(4). The number of reported PWC- related injuries, however, is thought to be inaccurate, because many arc never reported to law enforcement agencies. The rate of emergency department-treated injuries related. to PWC is about 8.5 times higher than the rate of that of motorboats. The death rate is about 3 times higher. These watercraft are designed to be operated by the dri\'er in a sitting, sta ndin g, or kneeling position , with o ne or more passengers located behind the driver in ta ndem. PWCs arc able to obta in high speeds quickly, but have no braking mechanism. Like motorcycles, PWCs offer no protection to the d river or passengers. Most injuries arc caused by PWC collisions, either with other watercraft or with fixed objects such as docks or tree stumps. P\·VC collisions produce injury patterns simi la r to those encountered with motorcycle-auto coll isions. Rect"l and vaginal trauma may occur whcn rear-SC
Pedestrian Injuries The pedestrian st ruck by a ca r almost
FALLS The mC(hanism ror fu lls is verrical deceleration. The types of injuries susrained depend on the following three factors, which yO li must identify and relay to medical direction. • Distance of fall • Anatomic area im pacted • Surface struck

20 •

CHAPTER 1 Scene Size-up

Force tIansmitte
Energy transmitted along the skeletal system

The p rim ary groups involved in vertical falls are adults and child ren under the age of 5 years. In children, the falls most commo nly involve boys and occur mostly in the summer m onths in urban high-risc, multiple-occupant dwellings. Predisposing facto rs include poor supervision, defective railings, and the curiosity associated with that age group. Head injuries are common in falls by child ren, because the head is the heaviest par t of th e body and thus impacts first. Adult falls are generally occupatio nal or due to the influ ence of alcohol or drugs. It is not uncommon for falls to occur during attempts to escape from fire o r crim inal activity. Generally, adults attempt to land o n their feet; thus their falls il re more CO Il t rolled. In this landing form, the Victim usually impacts initially on the feet and then falls oockwards, land ing o n the bu ttocks and outstretched han ds. Classically. this "lover's leap" fa ll m ay result in the following inj uries (Figure 1- 15). • Fractu res o f the feet o r legs • Hip and/or pelv ic injuries

Falls where victim lands on his leet often fracture the

• Axial loading to the lumbar and cervical spine • Vertical d eceleration forces to the organs

lumbar spine

• Calles fracture o f the wrists FIGURE 1-15 Axialloadillg.

T he greater t he height, the greater is the potential fo r injury. However, serious injury can occu r in a short-distance fa ll. Surface density (con crete versus sawd ust) and irregular ity (gym floor versus staircase) also influence the severity of inj ury. Relay information about distance fa llen and surface struck to medical direction with other pert inent in fo rmation.

PENETRATING INJURIES Numerous o bjects are capable of produ cing penetrating injuries. These range fro m the industrial saw blade that breaks off at an extremely h igh rate of speed to the foreign body hu rled by a lawn mower. Most high-velocity objects are capable of penetr ating the tho rax or abdomen. Common forms of penetrat ing wou nds come from the knife and gun. Knife-wound severity depends on t he anatomic area penetrated, length of t he b lade. and angle of p enetration (Figu re 1- 16). Remem ber, an uppe r abdo m in al stab WOUJld m ay cause intratho rac ic orga n inju ry, and stab wou nds below the fo urth intercostal space may have pe netrated the abd omen. Th e gold en rule wit h a ny im paled object is to stab ilize it in place. It will be rem oved at the hosp ital. Impaled objects in the cheek of the face and th ose blocking the airway are exceptions to this rule. Most penetrat ing wounds in flicted by firea rms a rc due to handguns, rifles. and shotguns. Impo rtant factors to obta in , if possible, are the type of weapo n, its caliber, and the d istance fro m wh ich the weapo n was fi red . However, remember that you treat the patien t and the wou nd, not the weapo n.

Wound Ballistics Stab WCHJnds at nipple level or below

frequently penetrate the

FIGURE 1-16 Stab wounds.

•

abdomen.

Because the kinetic energy (kinetic energy = ~ mass X veloci ty2) prod uced b)' a projectile is mostl )'dependcn t upon velocity, weapons areclas-

CHAPTER 1 Scene Size-up _ 2 1

sified as high o r low velocity. Weapons with velocities less than 2,000 fect per second are considered low wlocity and incl ude essentially all handguns and some rifles. Injuries from these weapons are much less destructive than those sustained fro m high-velocity I"eapons, such as a military rifle. Low-velocity weapons are certainly capable of lethal injuries, depending on the body area struck. More civilians are killed by low-velocity bullets, beca use they arc more often shot by low-velocity weapons. All wounds inflicted by high-velocity weapons carry the additional facto r o f hydrostatic pressure. This factor alone can increase the injury. Factors that cont rib ute to tissue damage include:

• Missile size. The larger the bullet , the more resistance and the larger the permanent tract. • /l,llissile deform il)~ Hollow po int and soft nose flatten ou t o n impact, resulti ng in the involvement of a larger surface. • Semijacket. The jacket expands and adds to surface area. • 7illllblillg. Tumbling of thc missile causes a wider path of destruction . • )'tIlV. The missile ca n oscillate verticall y and ho rizontally (wobble) about its axis, resulting in
edges if the bullet is fired fro m very close range (Figure 1- 17a ). • Exil wOl/ua. Not all ent ry wounds wi ll have exit wou nds, and o n occasion there may

be mu lt iple ex its due to fragmentation o f bone and missi le. Generall)" the exi t wound is larger and has ragged edges (Figure J- 17b ). • flllenml wOlilld. Low-velocity projectiles inflict dam'lge primari ly b)' damaging tissue

that the missile co ntacts. High -velocity projectiles inflict damage by tissue contact and transfer of kinetic energy to surrounding tissues (Figure 1- 18 ). Damage is rela ted to the follow ing: • Shock. waves • Temporary cavity, which is 30 to 40 times th c bullet's d iameter and creates im nl{'l1se tissue pressures • Pulsmion o f the temporMYcavit y, which creates pressure changes in the adjacen t tissue Generally damage done is proportional to tissue density. Highl)' dense orga ns such as bone, muscle, and liver sustain mo re dam age than less dense o rga ns such as lungs. A

ENTRANCE WOUND (Bullet -

EXIT WOUND (Bullet)

Close Range) FIGURE 1-1 7 Comparison of (a) an entrance wo und and (b) an exit wo und.

• • • • • PEARLS

Basic Ballistics Know the information offefed here, but remember: Treat the patient, not

the weapon. Caliber-the internal diametl!f of the barrel; this corresponds to the ilmmunition used for the panicul.tr weoJpon Rifling--a series of spiral grooves in the interior surface of the barrel of some W1!ilportS Ammunition--Qse, primer, powdef, and bullet &"etcons~soid ~ad a!loy; rMy have oJ full or

partial CoppeI" or steel jacket. The shipe of the nose of the bullet may be ~, flat, ccnical, or pointed. The bullet nose may also

be soft or hollow /for e~ or frilgmentationl.

22 •

CHAPTER 1 Scene Size-up

Small area 01 tissue destruction

~+-

__ Large area 01 tissue destruction

Shanered bon. ' exploded' limb

FIGURE 1 · 18b Exampll! of a high-,·dodty wOlllld o(leg. (Pltof() COllrlesy o!Roy A/SOli, AiD)

key facto r to remember is that once a bullet enters a body, its trajeclOry will no t always be in a stntight line. Any patient with a FIGURE 1-188 High-veiocilYve rsus low-velocity missile penetratio n of the head, tho rax, o r abdomen should be injury. transpo rted immediately. Personnel who have been shot while wea ring a flak vest should be managed with caut ion; be alert for possible cardiac and other organ contusio n. In shotgun wounds. inj ury is det ermined by kinetic energy at impact, which is influ enced by: • Powder charge • Size o f pellets • Choke of TllUl.zle • Distance to target Velocity and kinetic energy d issi pate rapidly as distance is traveled . At 40 yards. the velocity is o ne-half the initial muzzle velocity.

BLAST INJURIES Blast injuries in this country occu r primarily in industrial sett ings such as grain eleva tor and gas fum e explosions. Because threat of terrorist act ivity is now both common and worldwide. blast injury management also must be added to ITLS train ing and knowledge. T he mechanism of inju ry by blast/explosion is due to three factors: • Primary-in it ial air blast • Secondary-patient being st ruck by material (shrapnel ) propelled by the bhlst force • Terriary--body being Ihrown and im pacting o n grou nd or ot her object Now that terrorists are using explosives to disperse chem ica l. biological, o r radiological material, so me now classify injuries resulting from this as "quaternary injuries."

CHAPTER 1 Scene Size-up -

23

Secondary missile. elc.. being propelled

,/

/

/

"

/ /

/

/ .l

(7'. " / .

Tertiary impact hard surface multiple injuries possible

"//////

., / '

",:J

rI, '/

~- /;

Primary blast 'orce Injuries: I . Ears 2. Lungs 3. G.t Tract

FIGURE 1·19a Explosions ca n cause inju ry wilh the initial biaSI, when the victim is struck by deb ris, or by the victim being throw n against the ground or other fixed obj(.'(:ts by the blast .

Injuries due to the p rimary air blast arc almost exclusive to the air-containin g o rga ns. The auditory system usuall y im'o lves ruptured tymp
FIGURE ' ·19b Tertiary inj ury from being thrown into a ....'llll by the blast. (PiIo/1I corlrl,'SY of liD)' Alslllr, MD)

24 • CHAPTER 1 Scene Size-up

( I'ho to C

J..tT Forgn)

Dan. Joyce. and Buddy of the Emergency Transport Service (ETS) have been dispatched to a two·car collision in which one
CHAPTER 1 Scene Size-up _ 25

The mechani sm of injury of a T-bone or lateral-impact collision is stra ight deceleration for the auto hitting the side of the other auto. For the auto that sustains the lateral impact, the mechanism depends on the height of the blow. A sports utility vehicle or large truck would strike the auto higher than a passenger car and so would more likely cause upper chest, shoulder. neck, and head injuries. A passenger ca r would strike lower and. depending on how low. would be more likely to cause pelvis fra cture s, intraabdominal injuries. and rib and lower chest injuries . With major intrusion into the passenger compartment, ex.pect these to be serious injuries. All patients in shock are load-and-go.

SUMMARY Trauma is the most serious disease affecting young people. Being a rescuer is among the most importan t professions but requires great dedk atio n and continuous trai ning. Saving patients who have sustained severe trauma requires attention to detail and careful management of time. Teamwork is essential , as many actions must occur at the sa me time. At the scene of an injury. there arc certain important steps to perform before you beg;n care of the patient. Failure to perform a Scene Size- up will subject yo u and your patient todangerand may ca useyou to fail to anticipate serious injuries thai your patient may have sustained. Take standard precaulions and assess the scene for dangers first. Then determine the total number o f patients and the ne<.'CI for additional rescuers or special equipment. If there are more patients than your team can manage, report to dispatch and initiate M e l protocols. Identify the mechanism of injury and consider it as part of the overall management of the trauma patient. Ask yourself: What happened? What ty pe of energy was applied? How much energy was transmitted? What p:Jrt of the body was affected? If there is a MVe, consider the form of the crash and survc-y the vehicle's interior and extc-rio r for damage. Note that tractor accidents req uire carefu l stabi lizat io n of the machine to p revent a second inju ry to the patie nt. Falls require identification o f distance fall en. surface struck, and position of the patient upon impact. Stab wounds require knowledge of the length of the instrument as well as th e an gle at which it entered the body. \Vhen eval uati ng a shooting victim , you need to know the weapon , caliber. and distance from which it fired. Information abo ut the high·energy event (e.g ., fall s, vehicle collision) is also important to the emergency physician. Be sure not only to record your findin gs but also to give a \'erb.,1 report to the emergency department physician or trauma surgeon when you ar rh·e. With this knowledge and a high index of suspic ion. you can give your patient the greatest chance of survival.

Dan, Joyce, a nd Bud dy of the Em,er,ge,,,y' Tr;,n,; pe'",1 System (ETS) have been called to the scene of a

con struction acc id ent where a man fell from a scaffold onto a pile of lumber. Their Scene Size-up reveals that the scene is safe and there is on ly one victim. He has been pulled from the lumber pile. but ap pea rs to be pale and diaphoretic and has an obviou s open fracture of his left lower leg. He is clutching a pie ce of wood that is sUcking out of his left chest. How would you approach this paclent? What Is the

mechanism of injury? What type of assessment would you perform? What would you do first? 15 this a load-and-go situQtion? Kee p these questions in mind as you read

the chapter. Then, at the end of the chapter, find out how the rescuers comp leted thi s call.

INTRODUCTION

28

ITLS patient assessment (Primary Survey, Secondary Survey, and O ngoi ng Exam) is sistent with U.S. Department of Transportation guidelines. The ITLS Primary Survey made up of the Scene Size-up, In itial Assessment (a very bri ef exam of the level of sciousness and the ABCs), and a Rapid Trauma Survey (a rapid head- to-toc exam ) to termine if immedintely life- threatening co nditions exist and to identify those patients Surveyl should have im media te transport. The Primary Survey differs from the in that the Seco ndary Survey is an eva lua tion for all injuries, not just iir.,· ,h"'"toeni.ng, mlesj.1 The Ongoing Exam is meant to identify changes in the patient's condition. The patient with the IllOst minor-appearing inju ry will get a brief Initial Assessment fore you concentrate on the minor injury. Critical patients will get a nouo:hme)recoml,rehet0l.1 sive exam , but in each case the exam will begin in the same way (I nitial A.ssessment). Scene Size-up will set the stage fo r how you will perfo rm the rest of the ITLS Primary 'U I~'.'" If there is a dangerous generalized mechanism of inju ry (auto crash, fall from a he.ightil etc. ) or if the patient is unco nscious, you should go fro m Initial Assessme nt direct ly 1"0 Rapid Trauma Survey. You would then perfo rm intervent ions, transport, Ongoing ExI'm~ 1 and possibly a Secondary Survey en roule. If there is a dangerous focused mechanism of inju ry suggesting a n isolated inju ry let wou nd of thigh, stab wou nd to the chest, etc.), you would perform the In itial A,,;CS!11I ment but the Focused Exam would be limited to the area of injury. The fu ll Rapid T"""''''I Survey is not required. YOli would then perfo rm interventions, transport , O ngoing ''''' m~ 1 and possibly a Secondary Survey. If there is no significant life th rea t in the mecha nism of injury (e.g., sho t off big yOll wou ld do the Initial Assessment and , if normal , go d irectly to a Focused Exam o n the patient's chief complaint. The Secondary Survey wo uld not be necessary.

CHAPTE R 2 Assessment and Initial Management of the Trauma Patient _ 29

10 make the most efficient use of Lime, ITLS prehospital assessment and managemen t of the trauma patient is divided into three cxams ( Primary Su rvey, Seconda ry Su rvcy, and O ngoin g Exam), and each exam is made up of certain steps ( Figure 2-1 ). Thcse exams arc the foundation on which prchospital t rauma care is built.

• •••• PEARLS

A Systematic Approach Use the 5ame systematic /TIS

"""'" "" "" """" P""'-

PATIENT ASSESSMENT ITLS Primary Survey The ITLS Primary Survey includes a n c,'aluat ion of the scenc :lIld preparation for patient assessment and management. It begins with the Scene Size-up and theil, if the sccnc is safe to e nter, moves on to the Initial Assessment and a Rapid Trauma Surveyo r Focused Exam. Scene Size-up: On -scene t r:Hlma assessment begins with certain actions that a rc performed before you approach the patient. It cannot be s tressed too much that failure to perform prelimi n:l ry actions can jeopard i7'(" your life as well as the patient's. Perform the Scene Size-up as dcscribed in Chapter I. Once YOll begin your assessment of the critical patient , you may not have time to return to the vehicle for needed eq uipmcnt. For this reason, yOll should always carry essential medical cqu ipment with you to the patient's side. An ticipate that the following equipment may be needed for trauma paticnts.

• • • • • PEARLS

Saf"y 00 not approach the patient before doir.g a Scene ~. FooI"ISh haste IDiY subtract a rescuer and add a

,,-

• Personal protection eq uipmen t (See Chapters I and 22.) • Long backboard with effective strapping and head motion -restriction devicc • Appropria tely sized rigid cervica l extrication collar • Airway kit (separate kits or separate sections for adult and pediatric patients) • Oxygen • Airway a nd intubation equ ipm ent • Bag-v:l lve mask ( BVM) • Suction • Trauma box (scp;lrate boxes for adult and ped iatric patients) • Dressings, band ages. and he mostatic agents to aid in bleedi ng con t rol • Pleural decompression equipment • Blood pressure cuff • St('thoscope • Tourniquets Once th(' scene is safe 10 ('nler, as team leader. rou must focus on the rapid assessmen t of rour patient. All decisions on treatment req uire that you have identified life-threatening conditions. Experience has shown that most mistakes occur because the team leader stops to perform an interven tion and forgets to perform part of the assessment. If immediate interventions arc needed, delegate them to your team members while YOll continue the

assessment. Remembcr, once you begin patient assessment in the ITLS Primary Survey. only three things should cause yo u to interrupt the com pletion of the assessment. You may interrupt the assessment sequen ce if th (" scene becomes unsafe. if you must tr("at an airw:lYobstruction, or if you must treal ca rdiac arrest. ( Respiratory arrest o r dyspnea Illay be :lddrcssed by Rescuer 2 while yOll co ntinue assessment of the patie nt. ) For cri tical patie n ts, th e goal should be to have on-scene times of 5 minutes o r less. While interventions may be important, the o nly thing proven to increase survival of trauma pal ients is decreasing time to defini tive care (trauma ce nt er).

• • • • •

PEARLS

Ie.

lnternlptions The team

should delegate ~

il'ltervtntion requited during the ITl5

Primary SuNey and should no! in:errupt the completion of the

survey em·pt lor airway obstruction, cardiac arrest, or scene danger.

30 •

CHAPTER 2 Assessment and Init ial Management of t he Trauma Patient

ITLS Patient Assessment SCENE SIZE-UP Standard Precautions Scene Hazards Number of Patients Need for More Help or Equipment Mechonism of I

INITIAL ASSESSMENT General Impress ion of the Patient level of Consciousness Airway Breathing Circulation

Mechanism of Iniury?

Generalized or Unknown

localized

MOl

MOl

RAPID TRAUMA SURVEY

FOCUSED EXAM

l ood-ond-Go Situation?

FIGURE

2~1

Steps in the assessment o f the trauma palient.

CHAPTER 2 Assessme nt and Initial Management of t he Trauma Patie nt _ 31

Initial Assessment: The purpose of the Initial Assessment is to prioriti7.c the patient and to determine the ex istence o f im mediately life- threatening co nditions. The info rmatio n gathered is used to make decisions about cri tical in terventions and time of transport. Once you determine that the patient may be safely approached , assessment should proceed quickly and smoothl y. (The Initial Assessment and Rapid Trauma Survey should take less tha n 2 minutes.) As you begin , d irect Rescuer 2 (who sho uld have the cervical collar and airway equipment ) to stabilize the patient's neck (if needed) and to assume responsibility fo r the airway. Rescuer 3 will place the backboard and the trauma box beside the pa tient while yo u arc proceedi ng with your exam. This tea m approach makes the 1110st effi cient use of time and allows yo u to rapidly perform the Initial Assessment witho ut performing noni nvasive airway in terventions you rself, which ca n interrupt your thought process. The In itial Assessment is made up o f )'o ur general imp ression upo n ap proaching the patient, an evaluation o f the patient's level o f consciousness (LOC), manual stabilization of the cervical spine (i f needed ), and an assessment of the pa tient'S airway, breathing, and circulation (AllCs) .

Form a General Impression of tl.e Patient on Approacl.: You have already sized up the scene, determined the total num ber of patients, and in itiated MCi protocols if there arc more patients than yo ur team can effectively handle (see Cha pter I and Appendix I). As you approach, note the patient's approximate age, sex, weight, and general appearance. The old and the very yo ung arc at increased risk. Female patients may be pregnan!. O bserve the position of the patient, both body positio n and posi tio n in relat io n to surroundings. No te the patient 's activity. (Is the patient aware of surroundings, anxious, obviously in distress, CIC.?) Does the patient have any obvious majo r injuries o r major bleeding? Your observation o f the patient in rcla tio n to the scene and the mechanism of injury will help you pri+ oritize the pat ient. If there are m ultiple pilt ients, rapidl y triage them and begin eval uat iun o r tbe Illost seriously injured patient first. (You may have to delegate a member of your team to assess other patients until help ;lrri ves.) Evaluate I"itial Level of Consciousness WI.ile Obtaining Cervical-Spine Stabilization: Assessment begins immediately, even if the patient is being extricated. As team leader, try to approach the patient from the fro nt (f.lCe to face, so the patient does not turn the head to see you). If there is a mechanism o f injury that suggests spinal inj ury, Rescuer 2 im med iately and gently but firm ly stabi lizes the head and neck in a neutral positio n. Hold ing the head keeps the hands from being in the way when another team member applies a cervical collar later. As team leader yo u may need to initially stabilil.c the neck if there is no t a second rescuer immediately ava ilable. If the head or neck is held in an angulated position and the patient compla ins of pain on any attempt to straighten it, you should stabi lize it in the position found. The same is true o f the u nco nsciou s patient whose neck is held to o ne side and docs not move when you gently attempt to straighten it. The rescuer stabilizing the neck m ust no t release it un til he o r she is relieved o r a suitable motion- restriction device is applied. . We are here to The team leader sho uld say to th e patient , "My name is help you. Ca n you tel l me what happened?" The patien t's reply gives im mediate information about bot h the airway and the level of consciollsness. If the patient respo nd s appropriatel y to q uestio ni ng, you can assume that the ai rway is open an d th e level o f consciousness (LOC) is normal. If th e response is not appropriate (the patient is un co nscious o r awake but confu sed), make a mental note o f the LOC using the AV PU scale (Table 2- 1). Anyth ing below "A" (alert) sho uld trigger a systematic search for the causes during the Rapid Trauma Survey.

32 • CHAPTER 2 Assessment and Initial Management of the Trauma Patient

A-Alert (awake and oriented) V-Responds to Y:erbal stimuli (awake but confused, or unconscious but responds in some way to verbal stimuli) P- Responds to fain (unconscious but responds in some way to painful stimuli) U-.!J.nresponsive (no gag or cough reflex)

Assess tile Airway: If the pat ient cannot speak or is unconscious, fur ther evaluation oflhe airway sho uld follow. Look, listen, and feci fo r movement of air. The team leader or Rescuer 2 should position the airway as needed. Because of the ever-present danger of spi nal injury, avoid extending the neck to open the airway of a trauma pat ient. If the airway is obstructed (apnea, snoring, gurgling, stridor), usc an approp riate method (reposition, sweep, suction ) to open it immed iately (Figure 2-2 ). Failure to quickly provide an open airway is one of the three reasons to interrupt the pa tient assessment pa rt of the ITLS Primary Survey. If simple positioning and suctioning fail to provide an adequate airway, o r if the patielll has strido r, advanced airway techniques may be necessary immediately.

Assess Breatl.i"g: Look, listen, and feel for movement of air. If the patient is unconscious, place your ear over the patien t's mouth so you can judge both the depth (tidal volume; see Chapter 4) and mte of ventilatio ns. Look at the 1ll0wIllcni of the chest (o r abdomen), listen to the sound of air movement, and feel both the movement of air on your cheek and the movement of the chest wall with your hand. Notice if the patient uses accessory muscles to breathe. If ventilation is inadequate (less than 8 per minute or too shallow), Rescuer 2 should begin to assist ven tilat ion immediately, using his knees to restrict movement of the patient's neck and free his hands to apply oxygen or a bag-valve mask to assist ventilation (Figure 2-3). 'v\'hen assisting or providing ventilation. be sure that the patient gets an adequate ventilatory mte (one breath every 6 to 8 seconds) and an ad<"'quate volume (Table 2-2). Rescuers tend to ventilate too fas t. If you monitor ventilation with capnography (recommended), you should maintain the peo2 at about 35-40. All patients who are breathing too fast should receive supplemental high-flow oxygen. As a general rule. all patjents with multisystem trauma should receive supplemental high-flow oxygen. Assess CirClilatiOIl: As soon as you have ensured a paten t airway and adequate vent ilation,

note the rate and qualit y of thc pulses at the wrist (brachial in the in fant ). CheckiJlg the B. Since neck may be injured, do not extend the neck to open the airway.

b. Use modified jaw thrust.

FIGURE 2-2 Opening the airway using the modified jaw thrust. Maintain in-line stabilization while pushing up on the angles of the jaw wi th yo ur th um bs.

CHAPTER 2 Assessment and Initial Management of the Trauma Pat ient _ 33

FIGURE 2-3 Using your knees to maintain stabi lization of the n«k will free your hil nds to assist \·entililtion. (Photo ClJur{csy of ITLS Ourflrio, Slt'l'<' MrNt'lliy, /clillifi'r I.undgren, //lId Shayl }lIcholl )

.,

[ ,['"

Adult Sma ll child Infa nt

[

,

,

'

,

Normal

Abno rmal

10-20 15-30 25-50

<8 and >24 <15 and >3 5 <25 and >60

pu lse in the neck is not necessary if the patient is awake ,md alert or has a palpable peripheral pul se. Q uickly note wheth er the rate is too slow «60 in an adult ) or too fast (> 120), and note also its qualit y (thready, bounding, weak, irregular). If pulses arc absent at t be neck, imm ediately start C PR ( unless there is massive bl ullt t rauma ) and prepare for immediate transport. This is also onc of the Ihree reasons 10 interrupt assessment duri ng Ihe ITLS Prim,lrY Su rve)'. While at the wrist, note skin color, h.'mp('f
34 • CHAPTER 2 Assessment and Initial Management of the Trauma Patient Rapid Trauma Surveyor Focused Exam: The choice between the Rapid Trauma Survey and the Focused Exam depends on the mechanism of injury andlor the results of the Initial Assessment. If there is a dangerous gen eralized m echanism of injury (such as an auto crash or fall from a height) or if the patient is unconscious, perform the Rapid Trauma Survey. If there is a dangerous focused mechanism of injury suggesting an isolated injury (bullet wound of thigh or stab wound to the chest, for example), you may perform the Focused Exam, which is lim.ited to the area of injury. If there is no significant mechanism of injury (e.g., dropped a rock on a toe) and the Initial Assessment is normal (alert with no loss of consciousness, normal breathing, radial pulse less than 120, and no complaint of dyspnea, chest, abdominal, or pelvic pain), you may move directly to the Focused Exam based o n the patient's chief co mplaint. If you identify a priority (high-risk) patient, you need to find the cause of the ab normal findin gs and identify if this is a load-and -go patient. You have identified a priority patient if you find any of the following: • Dangerous mechanism of injury • History that reveals: • Loss of consciousness • Difficulty breathing • Severe pain of head, neck, o r torso • High-risk group (such as very young, very old, chronically iU) • Altered mental status • Difficulty breathing • Abnormal perfusio n • Any abnormality revealed during the Initial Assessment

Rapid Trauma Survey: The Rapid Trauma Survey is a brief exam done to find all lifethreats (Figure 2-4). (A more thorough assessment-the ITLS Secondary Survey-will follow later if time permits.) To begin the Rapid Trauma Survey, briefly assess (look and feel) the head and neck for injuries and see if the neck vein s are fl at or d istended and the trachea is in the midline. A rigid cervical extrication coUar may be applied at this time. Note: If the team leader elected to stabilize the neck, this duty should be t ransferred to another rescuer at this time. Now expose and look, fee l, and listen to the chest. Look for both asymmetrical and paradoxical movement. Note if the ribs rise with respiration or if there is only diaphragmatic breathing. Look for signs of blunt t rauma o r open wounds. Feel fo r tenderness, instability, and crepitation (T IC). Then listen to see if breath sounds are present and equal bilaterally. Listen with the stethoscope over the lateral chest about the fourth intercostal space in the midaxillary line on both sides. If breath sounds are not equal (decreased or absent on one side), percuss the chest to determine whether the patient is just splinting from pain o r if a pneumotho rax or a hemothorax is present. If abnormalities are found during the chest exam (open chest wound, flail chest, tension pneumothorax, hemothorax), delegate the appropriate intervention (seal open wound, stabilize flail , decompress severe tensio n pneumothorax). Very briefly notice the heart sou nds so you will have a baseline fo r changes such as development of muffled heart sou nds. Rapidly expose and look at the abdomen (distension, contusions, penetrating wounds), and gently palpate the {.,bdomen for tenderness, guardin g, and rigid ity. C heck the pelvis. Look for deformity or penetrating wounds. Feel for tenderness, instability, and crepitation by gently pressing down on the symphysis and gently squeezing in on the iliac crests. Note that tenderness is not the same thing as being unstable. T he pelvis may be tender and yet stable. If the pelvis is unstable, you can feel the pelvic ring collapse as you apply pressure. If the pelvis is unstable, do not check again!

CHAPTER 2 Assessment and Initial Manag ement of the Trauma Patient _ 35

IlLS PRIMARY SURVEY SCENE SIZE-UP Standard PrecautiOflt, Hazards, Number of Patients, Need lor Additional Help/Equipment, Mechanism of Iniury

~~ ~~~~~ ~ ~~~~~ ~ ~~~~~~ ~ ~~~~~~~~ ~ ~! ~ ~~~~~ ~~~~~~~~~~~~ ~~ ~~~~~~~~~~ INmAL ASSESSMENT General lmpreuiOfl (Age, Sex, Weight, General Appearance, Position, Activity, Obvious Iniuries/Bleeding) lOC [AVPUj Conll'ol Cervical Spine Airway (Snoring, Gurgling, Stridor, Silence) Breathing 1Present~ Rate, Depth, Effort) Radial/Carotid Pulses ll'rer.ent~ Rate, Rhythm, Quality} Skin Color, Temperature, Moisture; Capillary Refill Unconll'oIled E)(ternol Hemorrhoge~

~~ ~~~~~~~~~~~~~~~~~ ~ ~~~~~~~~~ ~ ~! ~~~~~~~~~~~~~~~~~~~~~ ~~ ~~~~~~~

:

RAPID TRAUMA SURVEY Inspecl Head and Neck (Major Facial Injuries, Bruising, Swelling, Penetrations, Subcutaneous Emphysema) (Neck Vein Distention~ Tracheal Deviation?) Inspect Chest (Asymmetry, Contusions, I'enetrations, Paradoxical Motion, Instability, Crepitation) Breath Sounds [Present? Equal?) \If unequal: Percussion) Heart Tones Abdomen (Bruising, l'enetration/EvillCeration, Tenderness, Rigidity, Distention) Pelvis (Tenderness, Instability, Crepilotion) lower/Upper ExlI'emities (Swelling, Deformity, Instability, Motor and Sensory) Place Patient on Backboard Posterior (Penetrations, Deformity, Presocral Edema) If Critical Sitvotion, Transfer 10 Ambulance 10 Complete E)(om. Baseline Vital Signs Measured Pulse, Respirations, Blood Prenure Pupils (Size? ReoctiYtl~ Equal?) [II Ahered Mental Sta tus: ) Gla:ICQw Como Scale Score Eyes, Voice, Motor, Orientation, Emotional Stole

FIGURE 2-4 The Rapid Trauma Survey as part of the ITLS Primary Survey.

Check th e ex trem ities. Assess bot h upper legs, looking fo r deformit y and feel ing for TI C. Remember that bilateral fem ur fra ct ures can produce enough internal blood loss to be life th reateni ng. Scan for obvious wounds o r deformities of the
36 • CHAPTER 2 Assessment and Init ial Management of the Trauma Patient

FIGURE 2 -5 Scoop stretchers may be used to transfer backboard patients who should not be log rolled. The newer, more rigid scoop slrclchcN (as shown) can replace standard backboards. (PllOlOs cOIlrltts),oj f.eOli Cllrpeu,ier, EMT-P)

( Ferno) p rovides stabilizat ion equal o r superior to a rigid backboard and you may sim pl y lise it instead of
SAMPLE History: At the same time as you are performing the patient assessment part of the ITLS Primary Survey (I nitial Assessment and Rapid Trauma Surveyor Focused Exam ), you o r o ne of the other rescllers should obtain a SAMPLE h istory (Table 2-3). This is especially important if )'ou must gather in fo rmation from bystanders, since they will not be going with you when you transpo rt the patient. Remember, prehospital providers are the only ones who get to see the scene and also may be the only ones who get to take a history,

"

I

'

,

"

,

'

5 -Symptoms A -8JJergies M-Medications P -fast medical history (Other illnesses?) l -Last oral intake (When was the last time there was a ny solid or liquid intake?) E -,Event s preceding the incident (Why did it happen?)

CHAPTER 2 Assessment and Initial Management of the Trauma Patient _ 37

sincc many paticnts who are initiall y alert lose consciousness before arriving at the hospital. You are not only making interventions to deliver a living patient to the hospital, you also must be the detective who figures out what happened and why. Pay special attention to the patient's complaints (symptoms) and events prior to the incident (the "S" and "E" of the SAMPLE history). A more detailed history may be taken later during the ITLS Secondary Sun'ey. The patient's symptoms ca n suggest other injuries, and this will affect further examination. It is important to know as much about the mechanism as possible. ( Was she restrained? How far did she fall? What caused her to fall ?) Look for clues to serious injury such as histo ry of loss of consciousness, shortness of breath, or pain in the neck, back, chest, abdomen , or pelvis. Critical Interventions and Transport Decision: When you have completed the In itia l Assessment and R,lpid Traum:l Surveyor Focused Exam, enough info rmation is available to decide if a critica l situ ation is present. Patients with critical trauma si tu ations arc transported immediately. Most treatment interven tions will be done during tr:lnsport. If your patient has any of the following critical injuries or conditions, tr:msporl immedia tel}'.

• Initial Assessmetlt reveals: • Altered mental status • Abnormal respiration • Abnormal ci rculat ion (shock or uncontrolled bleeding)

• Siglls discovered dur;lIg tile Rtlpid Trauma Survey of comlit;olls tllllt rapidly /('(/(I to sllOek: • Abnormal chest exam (flail chest, open wound, tension pneumothorax, hemothorax) • Tender, distended abdomen • Pelvic instability • Bil:lIera l femur frac tures

• Sigt/ificllllf mccJUlI/ism of injury (II/dlor poor get/eraf hea/I/I of patiet/t. As yOll consider mechanisms, age, general appearance, chronic illnesses, and so on, }'OU may decide that the patient is :It higher risk than the ITLS Primar}, Su rvey alone would suggest. These higher risk patients should go to a trauma center even though they might not mcct o th er criteria to go there. Remember that there are more co nsideration s than just the physical exa m of the patien t. If the patient has one of the critical conditions listed above, after the Ra pid Tra uma Surve)' or Focused Exam, immed iately load her into an ambu lance, and transpo rt mpidly to thc nearest appropriatc emergenc}' facility. When in doubt , transport early. The following procedures arc done at the scene, and most of them ca n be delegated to team members to perform while you continue the ITLS Primary Surve)'. • Manage the airway. • Assist ventilation. • Administer oxygen. • Begin CPR. • Co ntrol major external bleeding. • Seal sucking chest wounds. • Stabilize nail chest. • Decompress tension pnculllothor:lx. • Stabilize impaled objects. • Complete packaging of the patient.

• • • • • PEARLS

On-Scelle Time Critical trauma patients r.eed deMitive care i1 the ope!"ating room. limit on-scene time. SuMvaI of the critical trauma patiem is time deper.Oent Most interventions

shouIdbeperlormedinthe amb.rIance cbing trinspOrt to an

_I""".

38 • CHAPTER 2 Assessment and Initial Management of the Trauma Patient

Procedures that arc not life s;wing, such as spl inti ng, bandaging, insert ion of IV lines, or cven emergency endotracheal intubation, must not hold up transport of the critical patient.At this point, the ITLS Primary Surwy is over and the team leader may hel p the other rescuers with patient care. Be sure to call medical direction early so that the hospital is pre· pared for the patien t's arrival.

Contacting Medical Direction: When you have a critical patient , it is extremely importan t to contact medical d irection as early as possible. It takes time to gel the appropriate surgeon and the operating room team in place, and the critical palient has no time to wai t. Always notify the receiving facil ity of your estimated time of arrival (ETA ), the cond ition of the patien t, and any special needs on arriva l (see Append ix B).

ITLS Secondary Survey The ITLS Secondllry Survey is a more comprdlensivl' exam to pick li p addit ional injuries that might have been missed in the brief ITLS Prima r y Survey. This assessmen t also establishes the baseline from which Ireatm('nt decisions will eventually be made. It is important \0 record the information discovered in th is assessment. \Vhether or not to perform a Secondary Survey as well as when to perform one depends on the situation. • Crit ica l patients should have this assessment done duri ng tra nsport rather than on scene. I

If there is a short transport and you Jllust perform interventions, you may not have lime 10 do the $('condary Survey.

• If the Primary Survey does not fen'a l a critical condition, the Secondary Survey may be- performed on scene. When you perform the Seconda ry Survey, rout in ely repeal the In itial Assessment. YOll can do this as you check the vital signs. Even though the p~l tien t aplX':,l rs to be stable, if there is a dang('rous mechan ism or other dangers {such as age, poor gener:11 health, death of another passenger in the S:Hlle auto),consider e:lfly transport. "Stable" patients may beCOllle unstable quite r~lp i dl}'. Stable p:llients wi th no dangerous mechanism of injury (e.g., droPPl'd rock on toe) do not require a $(x:ondary SurvC)'. You should have obtained most of the perti nent history during tJle ITLS Primary Survey, but now you ca n obtain further information if needed . YOll shou ld perform you r Secondary Survey while yOll are obtain ing the rest of the SAMPLE history (if the patient is conscious).

PROCEDURE 00 Performing a Secondary Survey The exa m should con tain the fo llowing clements (Figure 2-6). I. Repeat the Initial Assessment.

2, Record vital sig.ns agai n. Record pulse, respi ratio n, and blood pressure. Remember, the pulse pressure is as importan t as the systol ic pressure. Many people now consider the pu lse oximetry reading one of the vital signs. It is a good tool b\lt yQU must kllOw its limi tations (see Chaplers 4 and 5). 3. Consider using monitors (card iac, pulse oximeter, CO 2 ) , These arc usually applied duri ng tra nsport.

CHAPTER 2 Assessment and Initial Management of the Trauma Patient _ 39

IlLS SECONDARY SURVEY INmAL ASSESSMENT

lOC

IAVPUJ "<Way

COfltroi Cervical Spine !Snoring, Gurgling, Stridor, Silence) &ealtllng (Pre~nt?

Rate, Depfh, Effort] Carot,d/ Radiol PUIMS !present? Rote, Rhythm, Quality] Skin Color, Temperature, Moisture; Copillory Refill UncOfllroiled El(fefnol Hemorrhoge?

------- ------------------------{-- -- ._-------------------DETAILID EXAM Potienl History {Cornpl..", SAMPLE Hi>lory) Vital Signs (Measured Pul~, Respirations, Blood Pressure) Pul:IB Oximeter, Cardiac Monitor, Blood Sugar, C02 MoniiOf GIoKOW Como Scale Score !Eyes, Voice, Movement); EmoliOflol Slate Hood !pupils, Bottle's Sign, Roc;coon Eyes, Drainage; Deformities, COflIuSiOflS, Abrasions, Penetrations, Burns, Tenderness, locerotiOfls, Swelling [OCAP.anslJ Ne<\ !DCAP.Bn5); Neck Vein Di$lentiOfl? Trocheal DeviatiOfl?

Che. {Asymmotry; Paradoxical MotiOfl; OCAP-en5; Tenderness, Instability, CrepitotiOfl [TICII Steam Sounds (PreMnl? Equol?) {II unequol: PercuSliOflJ Heart Tones Ahdom~

(DCAP.BTlS; Rigidity, Distention) Pelvis {DCAP-BnS] lower/Upper Extremities {DCAP·enS; TIC; PMS] Posterior Examine anly if nol done in ms Primary Survey (DCAP-BTlS) FIGURE 2.6 ITLS Sei:onda r), Sll rvc)' for the stab le patient.

4. Do a neurological exam. II gives important basel ine information Ihal is used in later treatment decisions. This exam should include th(' following: a. Level of COIISci(WSII('ss: If the patient is conscious, describe her orientation and emotional status. If she has an altered mental status, record her level of coma (for Glasgow Coma Scale score, sec Table 2-4). If there is altered menial status, check finger-stick blood glucose and check the oxygen saturation level. If there is any chance of narcotic overdose, give 2 mg of naloxone IV. b. Pllpils: Note size and whether they are equal or unequal. Do they respond to light? c. Motor: C m the patient move fingers and toes? d. SCI/s(/tion: Com she feci yo u when you touch her fingers and toes? Does the unconscious patient respo nd when you pinch her fi ngers and toes?

4 0 • CHAPTER 2 Assessment and Initial Management of the Trauma Patient

Eye Ope ning

Verbal Respo nse Po ints

Spontaneous To voice To pain

4 3 2

None

1

Mo tor Response Po ints

Oriented Confused Inappropriate words Incomprehensible sounds Silent

Po ints

5 4 3

Obeys commands Localizes pain Withdraws

5 4

2

Abnormal flexion

3'

1

Abnormal extension No movement

2"

6

1

'Decorticate posturing to pain "Decerebrate posturing to pain

5. Perform a Detailed (head -to-toe) Exam. Pa), particu lar attention to the patient's complaints and also recheck the injuries Ih
Begin at the he
b. Check the neck for DCAP- BTLS, distended neck veins, and deviated tr(lChe;l. c. Check the chest for DCAP-BTLS. Also check for p
CHAPTER 2 Assessment and Initial Management of the Trauma Patient -

IllS Ongoing Exam Ongoi ng asscssment and management includes the critic.11 procedures performed o n scene and during t ransport and com mun ication wi th medical d irection. The IT LS O ngoing Exam is an abbreviated exa m to assess fo r changes in the patient's condit ion. In con trast to the ITLS Secondary Survey that is performed o nly once, the Ongo ing Exam may be perfo rmed mul tiple times d uring .1 long transpo rt. In critical cascs wi th short transpo rt times, there may not be time to perform a Secondary Survey; theOngoing Exam may take its place. It should be performed and recorded no less tha n every S minutes for critical patients and every 15 mi nu tes fo r sta ble pat ients. The Ongo ing Exam also sho uld be performed: • E'lCh time the p'ltienl is Illoved . • Each time an in tervention is performed . • Any ti me the pat ient's cond ition worsens. This exam is meant to find any changes in the patient's condition , so co ncentrate on reassessing o nly those things that may cha nge. For exam ple, if you have 'lppl ied a traction splint, reassess the limb fo r decreased pain and fo r the presence of distal pulses, motor fu nction , and sensation ( PMS). On the other hand, if you decompress a chest , you Illllst reassess eV('f),th ing in the Ini tial Asscssment and Rapid Trauma Survey down through the abdo minal exam. PROCEDURE

00

Performing an Ongoing Exam

The IT LS O ngo ing Ex'lIn shou ld be performed in the fo llowing order: I. Ask t he patient if there have been an y changes in how she fee ls. 2. Reassess men tal status (LOC and pupils, recheck GCS if the patien t has an altered mental status). 3. Reassess the ABCs. a. Reassess the airway. ( 1) Recheck patency. (2) If th is is'l burn pat ient, assess for signs of inhalat ion injury. b. Reassess breat hing and circu lation. ( 1) Recheck vital signs. (2) Note skin ,ala r, condition , and temperature. (3) Check the neck for jugular venous distention (JVD) and tracheal devia tion. (If a cervic'll collar h'ls bee n 'lpplied, remove the fro nt to exa mine the neck. ) (4 ) Re,heck the chest. Notice the quality of breath so unels. If breath sounds arc u neq ual, evaluate lor splinting, pneumothorax, and hemothorax. Listen to the heart to sec if the sounds have become Illumed. 4. Reassess the abdonH.'n (if mechanism suggests possi ble injury). Note the development of tenderness, distention, or rigid it y. 5. C heck each of the iden tified injuries (laceratio ns for bleedi ng, PMS distal to all injured ex trem ities, fl ai ls, pneumothorax, open chest wOllnds, and so on). 6. C heck interven tions. a. C heck ET tube for patency and position. b. C heck oxygen lor flo w rate. c. C heck IVs for patency .md raIl.' of fluid.

41

42 • CHAPTER 2 Assessment and Initial Management of the Trauma Patient d. Check scllis o n sucking chest wounds. e. Check patency of tension pneumotho rax decompression needle. f. Check splin ts and dressings. g. Check im paled objects to be sllre they arc well stabilized. h. Check body position of p regnant pa tients. 1.

Check cardiac mon ito r, (;lpnograph, and pulse oximeter.

Accuratel y record whll! you sec and what you do. Record changes in the patient's condition during transpo rt. Record the time that you perform each interventio n. Ex teI1ulIting circumstances or significan t details should be recorded in the co mments or relllllrks section of the written report (review documen tation in Appendix C).

Dan, Joyce, and Buddy of the Emergency Transport System (ElS) have been called to the sce ne of a construction accident where a man fell from a scaffold onto a pile of lumb er. Their Scene Size-up revealed that the scene was safe to enter. There they foun d their patient who is awake and appears to be about 50 years old (high- ri sk group). The general im pression is poor, because the patient is pale an d diaphoretic and appears to be having some t rouble breathing. He is clutch ing a 2-foot piece of wood that is protruding from his left chest. In addition , the bone can be seen in an open wound of his left [ower leg. Buddy is acting as team leader on this ca ll. The team dons personal protective equipment, gathers the essential equipment, and approaches the patient. Bud dy begins his In itia l Assessm ent by introducing the team. At the same ti me, Joyce stabilizes the patient's neck by holding his head with her knees and prepares to apply a no nrebreather oxygen mask. Dan places th e long backboard beside the patient and checks the pul se in his left foot before splinting the lower leg. When questioned about what happened , the patient states he was building a concrete wa lt and was on a scaffold about 10 feet high . He was lifting a con crete block when he felt a "fluttering" in his chest and the next th ing he knew his friends were bending over him asking him what happened. His frie nd s state he was unconscious for about 2 to 3 minutes. Buddy notes the patient has a good airway but his breathing is rapid and shallow. He has a rapid, thready pulse at the wrist. Dan has applied a compress ion dressing to the open wound on the left lower leg and is applying a splint at th is time. There is no bleeding now. Because of the mechan ism of injury, Buddy chooses to perform a Rapid Trauma Survey. He has already d ete rmined that thi s is a priority patient because of the abnormal In itial Assessment and' this is also a load -a nd -go situation because of the loss of consciousness and the re spiratory difficulty. Brief exam of the head and face reveals no evidence of head trauma and Joyce notes that the pupils are 4 mm and react equally. The neck veins are nat and the trachea is

CHAPTE R 2 Assessment and Initial Management of t he Trauma Patient _ 43

midline. There is no tenderness or deformity of the neck. At th is time Buddy and Joyce choose the correct-size rigid cervical coHar and apply it while ma intaining motion restriction of the cervical spine in a neutral position. Buddy notes the 2-inch-wide piece of wood enters from the front of the left chest but does not protrude from the back. There is no paradoxical movement of the chest. The breath sounds are marked ly decreased on the left and the left chest is dull to percussion. The heart sounds are good but slightly irregular. The abdomen is negative for DCAP-BTLS and is soft and non tender. The pelvis is stable and nontender. Exam of the extremities is normal except for the left lower leg, which has an open fracture that has been splinted and dressed . The patient is able to move his fingers and toes and has sensation in all extremities. Because of the history of loss of consciousness, a brief neurological exam is done. It reveals normal level of consciousness with good PMS in all extremities. The Glasgow Coma Scale score is 15. After stabilizing the impaled piece of wood , they decide not to log roll the patient. but to carefully strap him onto a scoop stretcher. He is then immediately moved to the ambulance and transported. Dan drives while Buddy and Joyce provide patient care. Wh ile Buddy obtains the rest of the SAMPLE history and obtains baseline vital signs, Joyce starts two large-bore IVs, applies a pulse oximeter, attaches a cardiac monitor, performs a 12-lead EKG, and performs a rapid blood·glucose check. The patient states that he hurts in his chest and left lower leg and feels short of breath. He has no allergies. His past medical history is positive for hypertension but he has never had any heart disease or palpitations in the past. He takes one aspirin tablet each day (and has taken his dose today) and medication for hypertension but is not sure of the name. His last oral intake was breakfast. It is now 11:00 AM. The vital signs are blood pressure 70/ 40, pulse 130 and irregular, resp iratory rate 30 and shallow. The pulse oximeter reading is 92 percent on 100 percent oxygen, the blood glucose is normal, and the 12-lead EKG shows an acute injury pattern with frequent premature vent ricular contractions. Buddy notifies medical direction that he is transporting a patient who had syncope after cardiac palpitations and fell about 1 0 feet, sustaining a penetrating wound of his left chest and an open fractu re of his left lower leg. He also notifies medical direction that the patient's EKG shows an acute injury pattern. Buddy is ordered to give cautious small fluid boluses to try to raise the blood pressure to no higher than 90- 100 systolic, while watching carefully for signs of congestive heart failure. The trauma team and ca rdiologist are wa iting upon their arrival and the patient is taken to surgery where t he impaled wood is removed (no card iac damage from the wood) and the open fracture is irrigated and repaired. A balloon angioplasty and stent insertion is performed and the patient receives three units of blood. After a stormy course he eventually recovers.

This is a complex case in which a medical event (acute myocardia l in farction with arrhythm ia) causes syncope, which in turn causes serious traumatic injury. If the team had not carefully performed every step in the ITlS Primary Survey, they would have missed the cardiac problem. with potentially disastrous results.

44 • CHAPTER 2 Assessment and Initial M anagement of the Trauma Patient

SUMMARY p,l\icn\ aSsessment is key to trauma care, The intervent ions rcq~lircd are not difficult, but their timi ng often is critical. IfyOli know what questions to ask and how to perform thi:' exam, yotl wil l know when to perform the life-saving in tervent ions. Th is chapter has described a rapid , orderly, and thorough exam ination of the trauma p:lIient with examina· tion and treatment priorit ies always in mind. The continuo us practice of approaching the p.ltknt in the way d escribed here wi ll allow yo u to co ncentrate on the pat ien t, rather than on what to do next. Optimum speed is achieved by teamwork. lcamwork is achieved by pract ice. YO li should plan regu la r exercises in patient evaluation to perfect each team mem' ber's rotc.

BIBLIOGRAPHY I. Alam, H. B., CI al. 2005. Hemorrhage control in the battlefield: Role o f new hemostatic agents. Miliwry Medici"e 170: 63-69. 2. Krell, J. M., 1.'1 al. 2006. Comp:Jrison of the Ferno scoop stretcher with the long b:lckboard for sp inal immobilization. PreJlOspital Emerge" cy Care 10: 46-51.

46 •

CHAPTER 3 Patient Assessment Skills

• • • • • PEARLS

ITLS Pr;,t",ry SlIrvey • Do 001 approach the patient unbl you have done a Scene Size-up.

Do not kn\errupl the !ill Primary Survey except for airway obstJuctioo, carcfJaC arrest, or if the scene becomes too dangerous. Team members may perform other aitical inlel"lentions whtle you complete the SUNey. Give ~nti\ation instructions as soon as you assess airway aoel breathing. Proph)iactic hyperventilation is not re<:ommenOed for patients with deaeased lOC Use it orJy /or ~ad·i~ury patients v.+.o show SigflS of the cerebral herniation

"oorom..

PROCEDURE Short written scenarios will be used along with a model (to act as the patient). You will d ivide into tea ms to practice performi ng the Initial Assessment, critical interventions, and tran sport decision. Each member of the team must practice being team leader at leaSI once. The Critical Information represents the answers you sho uld be seekin g at eac step of the survey. The Treatment Decision Tree :It the end of the chapter represents the actions that should be taken (personally or delegated ) in respo nse to your assessment.

00

ITLS Primary Survey-Critical Information

If you ask the right questions, you will get the information you need to make th e critical decisions necessa ry in the management of your patient. The following questions are presented in the order in wh ich you should ask )'oursel f as you perform patient assessment. This is the minimum in fo rma tion that ),O ll will need as you perform each step (Figure 3- \ ).

Scene Size-up • Have I taken sta ndard precaut ions? • Do I see, hea r, smell, or sense anythi ng dangerous?

is hypoventilating Oess than 8

• Are there any other patients? • Are additional personnel o r resources needed?

breaths per minllte).

• Do we need special equipment?

• Assist ventilations in anyone who

Give oxygen to all iTl'Jftip!etrauma patients. ~ in doubt. give oxygen. Remember thai unconscious patients with no gag rellex cannot protect their airways.

Endotracheal tubes are the best method to protect the airway and ventilate the aduk patient. • Transfer the patient to the badboard as soon as the rns

Primary Su!Vey is completed. 'MIen the ITLS Primary Survey ts completed, decide if the patient is criticalor stable. • Call medical direction early if you have a critical patient. (Other physicians may have to be CClIIed from home to treat the patient) If the patient has a criticaltrauma situation, load him into the ambulance and transport (Transport pregr.ant patients with the backboard tiked slighrly to the left. Do not let them foilover onto the fIoor.1 (continued on page 48)

• What is the mechanism of injury here? • Is it generalized or focused? • Is it potentially life-threatening?

Initial Assessment General Impression • \¥hat is my general impression of the patient as \ approach? Level of Consciousness (AVPU) • Introduce yourself and sa)': "We are here to help you. Ca n you tell us what happened?" Airway • Is the airway open and clear? Breathing

• Is the patient breathing? • \"'hat is the rate and quality of respi ration? Ventilation Instructions • Order oxygen for any patient with abnorn1
• Delegate assisted ventilation if the patient is hypoventilating (less than 8 breaths per minute) o r if there is inadequate movement of air. • Hypervent ilate only those head-injury patients who are unresponsive and show signs of cerebral herniation (see Chapter 10).

CHAPTER 3 Patient Assessment Skills •

IlLS Patient Assessment SCENE SIZE-UP Standard Precautions Scene Hazards Number of Patients Need for More Help or Equipment Mechanism of I

i

INITIAL ASSESSMENT General Impression of the Palient

level of Consciousness Airway Breathing Circulation

Mechanism of Injury?

Generalized or Unknown

Localized

MOl

MOl

RAPID TRAUMA SURVEY

FOCUSED EXAM

load-and-Go Situation?

FIGURE 3·1 Steps in the assessment of the lrauma patient.

47

48 •

CHAPTE R 3 Patient Assessment Skills

• • • • • PEARLS

ITLS Primary Survey (continued) • If absolute~ ReC&SSary, certain interventions may have to be done befOfe transport. Remember that you are trading minutes of the patient's Golden Hour for those procedures. Use good iOO9""'" Indkations to decompress a tension pneumothorax: The patient rrost have signs of a tension pneumothorax and more than one of the following: respiratOf)' distress and cyanosis, loss of radial pulse (obvious shock), loss of consciousness or an obviously d&aeasing level of consciousness. Stan IVs in the ambular.ce en route urJess the patient is entrapped Of the ambulance has not arrive
Circulation • What is the ratc and quality of thc pulse at the wrist (and at the neck. if not palpable at the wrist)? • Is major external bleeding present? • What are the skin color. condition, and temperature? Decision • Is this a critical situation (Table 3-1)? • Are there interventioos that I must make now?

Ra pid Trauma Survey (See Figure 3-2. ) Head and Neck • Are there obvious wounds of the head or neck? • Are the neck veins distended? • Does t.he trachea look and feel midline or deviated? • Is there deformity or tenderness of the neck? Chest • Is the chest symmetrical? Is there paradoxical movement ? Is there any obvious blunt o r penetrating t rauma?

• Are there any open wounds? • Is there TI C of the ribs? • Are the breath sounds presen t and equal? • If breath sounds are not equal, is the chest hyperresona nt ( pneumothorax ) or dull (hemothorax)? • Are heart sounds normal o r decreased? Abdomen • Are there obvious wounds? • Is the abdomen soft, rigid, or djstended? • Is there tenderness?

__

I \ ",1 I

,I

'

'

Critical trauma situations are characterized by any of the following: • Decreased level of consciousness • Difficulty with airway or breathing • Shock or uncontrolled bleeding • Tender abdomen • Unstable pelvis • Bilateral femur fractures • High-risk group

CHAPTER 3 Patie nt Assessment Skills •

IlLS PRIMARY SURVEY SCENE SIZE·UP Stondard Precautions, Hazards, Number of Polients, Need for Additional Help/Equipment, Mechanism of Injury

-------------------------------}-----------------------------INmAl ASSESSMJ:NT GeMfollmprenion (Age, $ex, Weight, General Appearance, Position, Activity, Obvious In juries/Bleeding)

lOC (AVPU) Conlfol Cervicol Spine Airwoy

(Snoring, Gurgling, Slridor, Silence) Breothiog jPresent? Role, Depth, Effort)

Radial/Carotid Pul:les !presefll? Rate, Rhythm, Ouality) Skin COIOf, Temperature, Moisture; Capillary Refill

Uncontrolled Ex\ernol HOlTlOfrhogei

-------------------------------!-----------------------------RAPID TRAUMA SURVEY

Inspect Head and Ned: (Mojor Facial In juries, Bruising. Swelling. Penetrations, 511bc;uh;meQu5 Emphysema)

(Neck Vein Distention? Trocheal Deviation?) Insped Chesl (Asymmetry, ConllJsions, Penetrations, Paradoxical Molion, Instability, Crepitation! Breath Sounds (Present? Equal?) (If unequal: Percussion) Heart Tones Abdomen (BruiSing, Penetration/ Eviscerotion, Tenderness, Rigidity, Distention) Pelvis £Tenderness, Instability, Crepitation) lower/Upper Extremities (Swelling, Deformity, Instobility, Motor and Sen$Ory) Place Potient on Ihd:boord Posterior !penetrations, Deformity, Presacral Edema) If Critical Siluotion, Transfer to Ambulance to Campletll Exam. Bose-line Vitol Signs Measured Pulse, RespiratiOlU, Blood Pressure Pupils (Size? Reactive? Equal?) (If Altered Mental StoIuS:) Glascow Como Scale Score Eyes, Voice, Motor, Orientolion, Emotional Stole

FIGURE 3 -2 The Rapid Trauma Survey as pari orlhe ITLS Primary Sur vey.

Pelvis • Are there obviolls wo unds o r deformity? • Is there TI C? Upper Legs • Are there obvio us wounds, swelli ng, or deform ity? • Is there TI C?

49

so •

CHAPTER 3 Patient Assessment Skills

Lower Legs and Arms • Are there obvious wounds, swelling, or deform ity? • Is there TIC? • Can the patient feel/move fin ge rs and toes?

Posterior This exam is performed during tran sfe r to th e backboard. • Is there any deformity, contusions, abrasions, penetrations, burns, tenderness, lacerations, or swelling (DCAP-BTLS) of the patient 's posterior side?

Decision • Is there a critical situation? • Are there in terventions that I must make now?

History • \,\Ihat is the SAMPI.E history (ma)' have been obtained during the exa m )? Baseline Vital Signs • Are the vital signs ;lbnormal? Disability Perform th is exam now if there is altered mental statu s. Otherwise, postpone this exam until you perform the IT LS Secondary Survey. • Are the pupils equal and reactive? • What is the Glasgow Coma Scale score? • Are there signs of cerebral herniation (unconscious, dilated pupil (s), hypertension , bradycard ia, posturing)? • Does the palient have a medical identification device?

PROCEDURE

• • • • •

Short written scell
PEARLS

JTLS SecoNdary Survey • Critical patients get an IllS Secoodary Swvey en route to the ~I ~ time permits. • Stable patients may get an IllS Setondary SUNey at the scene (on tI1e backboard).

• Transport imrnediate~ ~ YOUf

Detailed Exam reveals any ofthe oiticaI trauma situations. Critical patients should 001 have traction splints apptied at the scene. They take too long.

L1J

ITLS Secondary Survey-Critical Info rmation

As a general rule, YOll should repeat the Ini tial Assessment before )'ou begin the ITLS Secondary Survey. YOLI can do this as you check the vital signs. If rou ask the right q uestion s, you will get the in forma tion )'ou need to make the critical decisions necessary in the management of yo ur patient. The following questions are presented in the o rder in which you sho liid ask ),ourself as YOli perform the Secondary Survey. This is the minimu m info rmation that you wil l need as you perform each step of the exam (Hgu re 3-3).

SAMPLE History Comple-te the SAMPLE history now if you have not alread y done so. • What is the p;ltient's history?

CHAPTER 3 Patient Assessme nt Skills •

ilLS SECONDARY SURVEY INITIAL ASSESSMENT

lDC (AVPU) Airway Control Cervical Spine (Snaring, Gurgling, Stridor, Silence) Breathing (Present? Rate, Depth, EHort) Carotid/Rodiol Pul~s (Present? Rate, Rhythm, Quality) Skin Color, Temperature, Moisture; Capillary Refill Uncontrolled External Hemorrhage?

- ----------------------------- - ~-------------------------------DflAILED EXAM

Pallent HiStory (Camplete SAMPLE History) Viral Signs (Measured Pulse, Respiratians, Blood Pressure) Pulse Oximeter, Cardiac Manitor, Blood Sugar, CO2 Monitor Gloscow Coma Scale Score (Eyes, Voice, Movement); Emotional State

Hood {Pupils, Battle's Sign, Raccoon Eyes, Drainage; Deformities, Contusions, Abrasions, Penetrations, Burns, Tenderness, Lacerations, Swelling [DCAP-8TLSlI

N~'

(DCAP-8TLS); Neck Vein Distention? Tracheal Deviation? Chest {Asymmetry; Paradoxical Mation; DCAP.BllS; Tenderness, Instability, Crepitation (TIC)) Breath So\Inds (Present? Equal?) (II unequal: Percussian) Heart Tones Abdomen (DCAP-8TtS; Rigidity, Distention) Pelvis (OCAP.BTLS) Lower/Upper Extremities (DCAP.eTIS; TIC; PM5) Posterior Examine only if not done in illS Primary Survey (DCAP·BllS) FIGURE 3-3 The ITLS Secondary Sum:T for a stable patient.

Vital Signs and Repeat Initial Assessment • What are the vital signs? • Airway • Is the airway open and clear? • Is th e sou nd of b reathing no rmal (sno ring, gurgli ng, strido r)? • Breath ing • What is the quality o f respirations? • Ci rculatio n • What is the r;lIe and q ualit y o f the p ulse? • What are the skin colo r, condit io n , and temperature (capillary refill in children)? • Is all external bleeding still controlled?

51

52 • CHAPTER 3 Patient Assessment Skills

Neurological Exam • What is the LOC? • What is the blood glucose (if altered mental status)? • Are the pupils equal? Do they respond to light? • Can the patien t move his fingers and foes? • Can the patient feel me touch his fingers and toes? • What is the Glasgow Coma Scale score (if altered mental status)?

Detailed Exam Head • Is there DCAP-BTLS of Ihe face or head? • Are Battlc's sign or raccoon eyes present? • Is there blood or fluid draining from the ea rs or nose? • Is there pallo r, cyanosis, or diapho resis?

Airway • Is the airway open and clear? • If there are burns of the face, are there signs of burns in the mouth or nose?

Breathing • What is the rate and quality of respiration? Neck • Is there DCAP-BTLS of the neck? • Are the neck veins normal, flat, or distended? • Is the trachea midline or deviated?

Chest • Is there DCAP-BTLS of the chest? • Are there any open wounds or paradoxical movement? • Arc the breath sounds present and equal? • If breath sounds are not equal. is the chest hyperresona nt or dull? • Are heart sounds normal or decreased? • If patient is intubated, is the endotracheal tube sti ll in good posi tion?

Abdomen • Is there DCAP-BTLS of the abdomen? • Is the abdomen soft, rigid, or distended?

Pelvis If the pelvis has already been exa mined during the ITLS Primary Survey, no further exam should be done. Lower Extremities • Is there DCAP- BTLS of the legs?

• Is there normal PMS? • Is range of motion normal? (optional)

CHAPTER 3 Patient Assessment Skills •

53

Upper Extremities • Is there DCA P-BTLS of the arms? • Is there normal PM S? • Is range of motion norma l? (o pt io na l)

PROCEDURE

Short written trauma scenarios will be used along with a model (to act as the pat ient). You will d ivide into tea ms to p ractice performing the lTLS O ngo ing Exam , making critical decisions and interventio ns. Each member of the team must p ractice being team leader at least once. Th e Critical Informatio n represents the answers you sho uld be seeking at each step of the exam .

00

ITlS Ongoing Exam-Critical Information

The following questions are presented in the order in which yo u should ask you rself as yo u perfo rm the Ongoing (reassessment) Exam . Th is is the minimum information that yO ll wi ll need as you perform each step of th e exam.

Subjective Changes • Arc YOll fee ling better or worse now?

• • • • •

PEARLS ITLS Ongoing Exam

Repeat the ITLS Ongoing Exam: !f the patient's condition

"""' " If

~ 'jfJIJ make an

intervention the patienl (scene to ambulMlte, ambulance to 'jfJIJ

Mental Status • What is the LOC? • Whal is pupillary size? Are they equal? Do they reacl to li ght? • If altered mental status, what is th e Glasgow Coma Scale score now? Reassess ABes • Airway • [s the airway open and cleM? • If there are burns o f the face, are there signs of inh alatio n injury? • Breathing and ci rculatio n • Wha t is the rate and quality of resp iration ? • What is the rate and qualit)' o f the pu lse? • What is the blood pressure? • Wha t arc the skin color, condition , and temperature (capillary refill in children )? • Neck • Is the trachea mid line o r dev iated ? • Are the neck veins no rmal, fl at, or distended? • Is there ill crcaslCu swelling of the neck? • Chest • Arc the b reath sounds present and equal? • If breath so unds are unequal, is the chest hyperreso nant or d ull? • Are hea rt sounds still normal o r have they become muffled? • Abdomen (i f mechanism suggests possible injury) • Is there any tenderness? • Is Ihe abdomen soft, rigid , o r d istended ? • Assessment o f identified injuries • Have there been any changes in the conditio n of any of the injuries that I have found ?

J1lOV(!

hospitalemergency deparunent) Remaincalmand think. Your knowledge, tralning, ar.d concern are the most important tools 'jfJIJ

""'y.

54 • CHAPTER 3 Patient Assessment Skills • Check interventio ns. (Ask the appropriate question for your pat ient.) • Is the endotracheal tube still patent and in the correct position? • Is the oxygen rate correct? • Is the oxygen tubing connected? • Are the IVs running at the correct rate? • Is the open chest wound still sealed? • Is the decompression needle still working? • Are any of the dressings blood soaked? • Are the splints in good position ? • Is the impaled object still well stabil ized? • Is the pregnant pat ient tilted 20 to 30 degrees to the patient's left? • Is the cardiac mon itor attached and working? • Is the pulse oximeter attached and working? • If intubated, is the cap nograph attachcd and workin g? PROCEDURE

00

Patient Assessment and Management

Short written trauma scenarios will be used along with a model (to act as the paticnt ). You will be divided into teams to practice the management of simulated trauma situations using the principles and techniques taught in the course. You will be eval uated in the same manner on the second day of thc course. You will be ex pected to use aU the principles and techniques taught in this cou rse while managing these simulated patients. To fami liarize you rself with thc evaluation procedure, you will be given a copy of a scenario and a grade sheet. Review Chapter 2 and the previous surveys in this chapter.

Ground Rules for Teaching and Evaluation 1. You will be allowed to stay together in th ree-membcr groups (different-sized groups arc optional) throughout the practice and evaluation stations.

2. You will have three practicc scena rios. Th is allows each member of the team to be team Icader once. 3. You will be evaluated as team leader oncc. 4. You will assist as a member of the rescue tea m during two scenarios in which another member of your team is being eval uated as team leader. You may assist. but the team leader must do all assessments. This gives you a total of six scenarios from which to learn: th ree practices, o ne evaluation. and two assists whilc others are evaluated. 5. Wait outside the door until the instructor Comes out and gives you your scenario. 6. You will be allowed to look over yo ur equipment before you start your exam. 7. Be sure to ask about scene safety if not provided in the scenario. 8. Be Sllre to apply your personal protective gear. 9. If you have a live model for a patient, YOli must talk to that person just as yOli would a real patient. It is best to explain what you are doing as you examine the patient. Be co nfident and reassuri ng. 10. You must ask your instructo r for things yo u can not find out from )'our patient. Examples arc blood pressure, pulse, and breath sounds. II. Wounds and fra ctures must be d ressed or splinted just as if they were real. Procedures must be done correctly (such as blood pressure, log- rolli ng, st rapping, and splinting).

CHAPTER 3 Patient Assessment Skills • 12. If you need a piece of eq uipment that is not available, ask your instructors. They may allow you to simulate the equipment. 13. During practice and eva luation, you may be allowed to go (or may be directed ) to any station, but yo u cannot go to the same station twice. 14. You will be graded on the following: a. Assessment of the scene b. Assessment of the patient c. Management of the patient d. Effident use of time e. Leadership f. Judgment g. Problem-so lving ability h. Patient interaction IS. When you finish your testi ng scenario, there is to be no discussion of the case. If you have any questions, they will be answered after the faculty meeting at the end of the course.

Initial Assessment

Action

SCENE SIZE-UP

Safety ....................•.......•...... Put on gloves, protective clothing. Remove hazards or patient from hazards. Number of patients ........••......••...... Call for help if needed. Extrication needed .......... • ...... ••...... Call for special equipment if needed. Mechanisms of injury .......••......•....... Suspect appropriate injuries (e.g ., cervical spine). GENERAL IMPRESSION ...................... Begin to establish priorities. Age, sex, weight Position (in surroundings, body position/ posture) Activity LEVEL OF CONSCIOUSNESS

Alert/responsive to voice ........ .. •..... ... Maintain cervical-spine motion restriction. Unresponsive to voice ..............•....... Modified jaw thrust prn. AIRWAY Snoring .......•• • . . . ..••. . ... .. .. • ....... Modified jaw thrust. Gurgling ... .... • ......................... Suction. Stridor ..........•........•.......• • ...... Intubate. Silence ..........•....... •• ....... • ....... Attempt to ventilate. If unsuccessful: - Reposition; extricate immediately. - Visualize. - Suction. - Consider Heimlich maneuver. - Intubate. - Consider translaryngeal jet ventilation.

55

56 • CHAPTER 3 Patient Assessment Skills

BREATHING Absent . ........ . .......• • ......•......... Ventilate twice (check pulse before continuing ventilation at 8-10 + oxygen). < 8 ................... . •..... _•. . ... . .... Assist ventilation at 8-10 + oxygen. low tidal volume .......• • . . ..••• • . . .. . .... Assist ventilation. l abored .............••• . . ... . • •.... . . ,.,' Oxygen by nonrebreather at 15liters/minute Normal or rapid ........•.. . . . . ... . ........ Consider oxygen. RADIAL PULSE

Absent .... . . . . . . . . .. .• •.... . . • ... . ....... Check carotid pulse (see below). Note late shock. Present ... .. .. . ....... • ..... . . • ....... . . . Note rate and quality. Bradycardia .......... . ..•.......• . ....... . Consider spinal shock, head injury. Tachycardia ... . ......... . ...... • . ....... . . Attempt to calm to reduce rate; consider shock. CAROTID PU LS E ......... • •......••......... Done if no radial pulse. Absent ...... . . . .......•• . ... . .••...... . . . CPR + BVM + oxygen, load and go. Quick look and defibrillate as appropriate. Monitor. Present ....... . ........•...... •• ........ . Note rate and quality. Bradycardia ............•....... _.......... Consider spinal shock, head injury. Tachycardia. . . . . . . . . . . .•.. . . . •... ... ..... Consider shock. SKIN .. . . . . . ......... . . . • ......• • . . . . . ..... Color and condition. Pale, cool, clammy .. . . . . . • ...... . •.. . . . .... Consider shock. Cyanosis .......... . ..•.• . . .. . . • .. . . . ..... Reconsider intubation/ventilation; check oxygen. MAJOR BLEEDI NG ... . ...•.......•.......... Direct pressure, pressu re dressing. Rapid Trauma Survey

Action

H EAD

Major facia l injuries .............. . . . . ....... Consider intubation. N ECK

Swelling, bruising, retracting ......•.......... Neck vein distention ............. ... ........ Tracheal deviation ... . . . ....... . . .. ... .. .... Deformity, tenderness ..... • • . ... .•••• . . .... CHEST ........ . . . ... . .... ... . • . .. . .. . . . ... Symmetrical, stable .... . . . . . ...•........... Bruises, crepitation ... . ... . ....•. . ..... . .... Penet rating wounds .....•.......• • ......... Paradoxical motion ......••......• • .........

Consider intubation. Consider tamponade, tension pneumothorax. Consider tension pneumothorax . APPLY CERVICAL COLLAR NOW. Inspect and palpate. Continue exam. Consider early cardiac monitoring. Occlusive dressing. Stabilize flail; consider early intubation.

BREATH SOU N DS

Present and equal ...... •• ......••.......... Continue exam. Unequal. ................................. Percuss chest to determine pneumothorax versus hemothorax. With decreased l OC, absent radial pulses, cyanosis, JVD, possible tracheal deviation . .... Consider needle decomp ression.

CHAPTER 3 Patient Assessment Skills •

57

HEART TONES . . ........................... Note for comparison later. Muffled with JVD and bilateral breath sounds ... Consider pericardial tamponade.

ABDOMEN, PELVIS, UPPER LEGS If tender abdomen, unstable pelvis, or bilateral femur fractures .......................... Expect development of shock.

MOVEMENT/SENSATION IN EXTREMITIES Present ................ . ................. Record. Decreased or absent ........................ Suspect spinal injury.

POSTERIOR Injuries identified .... ..... • . ......••........ Appropriate management of identified injuries. Transfer to backboard .

TRANSPORT IMMEDIATELY IF CRITICAL TRAUMA SITUATION PRESENT. SAMPLE HISTORY..

. . •.• . • . . .•.•• • . . .•..... Record.

VITAL SIGNS ...... . . ................ ...... Measure and record pulse, respirations. Auscultate and record blood pressure. Systolic < 90 with signs of shock .............. Consider IV fluid therapy en route. Systolic < 80 . . . . . . . . . . . . . . . . . . . . . . . . . . .. . IV fluid therapy en route. Systolic < 60 . . . . . . . . . . . . . . . . . . . . . . . . . . .. . IV fluid therapy en route. Pulse pressure> 60 with decreased LOC

Neurological Exam

Consider increased intracerebral pressure. Maintain systolic blood pressure of 110-120. To 8e Done If Altered Mental Status

PUPILS Unequal. ................................. Suspect head injury unless patient is alert, then suspect eye injury. Give 100% oxygen. Unequal or dilated and fixed with GCS :::;; 8 ...... Give 100% oxygen; do not let patient get hypotensive. [Target systolic BP of 110-120.) Intubation and hyperventilation (20 breaths per minute) are indicated. (Unequal pupils or dilated and fixed pupils and GSC 8 or less are suggestive of cerebral herniation.) Pinpoint (with respiratory rate < 8) ............. Consider naloxone. Dilated/ reactive (with GCS :s: 8) ............... Give 100% oxygen; consider intubation. GLASGOW COMA SCALE score (for decreased LOC) :::;; 8 ................................. Give 100% oxygen. Don't let patient get hypotensive (target systolic BP of 110-120). Intubation en route is indicated. Consider hyperventilation only if patient shows signs of cerebral herniation: -

GCS :::;; 8 with extensor posturing

-

GCS

-

s 8 with pupillary asymmetry or nonreactivity GCS s 8 with a subsequent drop of more than 2 points

ALL PATIENTS WITH DECREASED LOC ......... Check for medical identification devices. Do blood-glucose check.

Dan, Joyce, and Buddy of the Emergency Transport System (ElS) have been ca lled to the scene of a house fire. Their Scene Size-up reveals that the fi re service is present, the scene is safe. and there is on ly one victim. a young woman. She had been asleep in a back bedroom where the firefighters found her and pulled her out of a win dow. She is covered in soot and is coughing. How would you approach this patient? What is the

mechanism of injury? What type of assessment would you perform? What would you do first? Is this a load-and-go situation? Keep these questions in mind as you read the chapter. Then, at the end of the chapter, find out how the rescuers completed this ca ll.

INTRODUCTION Of all the tasks expected of fie ld teams c.1ring for the trauma patient, none is more important than th at of ai rway control. Mai ntaining an open airway and adequate vent ilation in the trauma patient can be a challenge in any setting, but it can be almost impossible in the adw rse environment of the field with its poor lighting, the Ch:IOS that often surrounds the ('wnt, the position of the patient, and perhaps hostile onlookers. Ai rway cont rol is a task th:lI YO ll must master, becallse it fn.'q uently " mnot wai t until you get to the hospital. PlItients who arc cyanotic, und(·rvcntilated. or both. are in need o f immediat e hel p-help that o nl y you can give them in the in itia l stages of their ca re. it fall s 10 you, theil , to be fa miliar with Ihc basic structure and func tion of th(' airway, to be versed in how to achieve and main tain an open airway, and to know how 1'0 oxygenate and ventilate a patient. Ikcause of the unprcdictabk nature of the field environment, YO LI will be called on to manage patien t airways in almost every conceh'able si tuation: in wrecked " Irs, dangling above ri ver», illihe middle ur i l »i.uppingccntcr, o r at the »ide of a l.IUsy hil)lm' .. y. You therefore need optiolls and altt.·rnatives from which to choose. What will help o ne pat ient may not work for ano thn. One patient may requ ire a sim ple jaw thrust to open an :lirwa)" whi le another may requi re a surgical procedure to pn!\'ent impending dea th . Wh atever the methods required, )'OU must always st:lrl with the basics. It is or lillie value--a nd in some cases it may be downright dangerous- to apply "adva nced" techniques of airway cont rol before begi nning basic maneuvers. The discussion o f airw:IYco ntrol in the traumll p:ll ient wi ll be rooted in several fu ndamental truths: Air should go in and ou t, oxygen is good, and blue is bad. Everyth ing else follows from this.

59

60 •

CHAPTER 4 Initial Airway Management

SOFT PALATE

TONSIL

ANATOMY AND PHYSIOLOGY

....t 7L NOSE

i~~;i== TEETH

MOUTH

The airway begins at the tip of the nose and the lips and ends at the alveolocapillary membratle, through which gas exchange takes place between the air sacs of the lung (the alveolt) and the lung's capillary network. The airway con~ sists of chambers and pipes, wh ich conduct air with its 21 percent oxygen con tent to the alveoli and carry away the waste carbon dioxide that diffuses from the blood into the alveoli .

TONGUE

Nasopharynx

HYOID BONE

,)f,f-- /-- -

VOCAL CORDS

I L L - - J L - - - TRACHEA

ESOPHAGUS

FIGURE 4-1 Anatomy of the upper airway. Note that the longue, hyoid bone, and epiglollis are allachcd to the mandible by a series of ligaments. Lifting forward on the jaw will therefore displace all theS(' structures anteriorly.

The beginning of the respiratory tract (the nasal cavity and oropharynx) is lined with moist mucous membranes (Figure 4~ 1). This lining is delicate and highly vascular. It deserves all the respect that you can give it, and that means preventing undue trauma by using liberally lubricated tubes and avoiding unnecessary poking about. The nasal cavity is divided by a very vascular midline septum, and on the lateral walls of the nose are "shelves" called the turbinates. These projections can get in the way when tubes or other devices need to be inserted into the nostrils. Care~ full y sliding a weJl ~ lub ricated tube's bevel along the floor or the septum of the nasal cavity will usually prevent traum a~ tizing the turbinates.

Oropharynx The teeth arc the first obstruction we meet in the oral part of the airway. They may be more obstructive in some patients than in others. in any case. the same general principle always applies: Patients should have the same /llImber and conditio/l of teeth at the end ofall airway procedure as they had at tile begirmil1g. The tongue is mostly a large chunk of muscle and represents the next potential obstruction. These muscles are attached to the jaw anteriorly and through a series of muscles and ligaments to the hyoid bone, a wishbone~like structure just under the chin from which the cartilage skeleton (the larynx) of the upper airway is suspended. The epiglottis is also connected to the hyoid, so elevating the hyoid wiUlift the epiglottis upward and open the airway furthe r.

Hypopharynx Th e epiglottis is one of the main anatomic landmarks in the ainvay. You must be famil~ iar with it and be able to identify it by sight and by touch. It looks like a floppy piece of cartilage covered by mucosa-which is exactly what it is-and it feel s like the tragus. the cartilage at the opening of the car canal. Its function is unclear, but it is nonetheless im~ port ant to you when you must assume control of the airway. The epiglottis is attached to the hyoid and thence to the mandible by a series ofligaments and muscles. In the un ~ conscio us patient, the tongue can produce some airway obstruction by falling back against the soft palate and even the posterior pharyngeal waU. However, it is the epiglottis that will produce complete airway obstruction in the supine unconscious patient

-

CHAPTER 4 Initial Airway Management _ 61

whose jaw is relaxed and whose head and neck arc in the neut ral position. In such pat ien ts the ep iglo tt is will fa ll down :lgainsl the glo ttic opening and prevent vent ila tion. It is essen tial to u ndnsl'and this crucial fact in the management of the a ir ~ wa)'. To ensu re an o pen (patent) airway in an unconscio us supi ne patient, you can displace the hyoid anteriorly by lifting forward o n the jaw (chin lift, jaw thrust) o r by p ull ing o n the tongue. Th is will lift the tongue out o f the way and keep the epiglo ttis elevated and away from the posterior pha ryngea l wall and glottic opening (Figure 4-2). Both nasotfacheal and o rotracheal int ubalion req ui re elevatio n of the epiglottis b)' a laryngoscope o r the fi ngers, by pulli ng o n the to ngue o r by lift ing fo rward o n the jaw.

Larynx On eith er side of the epiglottis is a recess called the pyriform fossn. An e nd o ~

FIGURE 4-2a The epiglottis is attached to the hyoid and then 10 the ma ndible. When the mand ible is relaxed and fa lls bac k, the to ngue falls upward and agai nst the soft palate and the posterior pharyngeal wall, while the epiglott is fa lls over the glottic opening.

!rachcOlI tube ca n "catch up" in either o ne. Pyriform fossa placement of an e n ~ dotracheal tube can be identified easily by "tenting" o f t.he skin on eit her side of the superior aspect of t he laryl/geal promil/ellce (Adam's apple) o r by t ra n s~ illumination if a lighted stylct (or " lightwand") is being used to in tubate. The vocal cords arc prot('('ted by the tl/yroill cartilage, a boxlike struct ure shaped like a "C," with the o pen part of the "'c" representing its posterior wall , which is covered with muscle. In some patients, the cords can dose ent irely in laryngospasm, prod ucing complete airway obstruction. The thyroid cartilage can easily be seen in most people on the anterio r surface of the neck as the laGlottic ryngeal prominence. Infer ior to the thyroid ca rt ilage is another part of the larynx, the crieoirl, a cartilage shaped like a signet ring with the ring in fro nt and the signet behi nd. It ca n be pa lpated as a small bu mp on the anterio r surface o f the neck inferior to the laryngeal prominence. The esophagus is just beh ind the posterior wall o f the cricoid cartilage. Pressure o n the cricoid at the fro nt o f the neck win d ose o ff the esophagus to pressures as high as I OOcm H 20. T his maneuver (t he Sellick /ll1It/ell ver, I:igure 4- 3) can be used to reduce the risk o f gastric regurgital io n d uring t he p rocess of intubatio n a nd to p revent insum at ion of air into the sto mach d uring positive pressure ventilatio n by mo ut h-toFIGURE 4-2b Extension of the head and mouth , bag-valve mask, o r fl ow. restricted oxygen-powered V('ntila to r. If lifting the chin will pull the tongue and there is any danger of cervical-spin e injury, you m ust ca refully support and the epiglottis upwa rd and forward, stabilize the neck while perfo rm ing the Sell ick maneuver. exposing the glott ic open ing and en suring Con necting th e inferior bo rder o f t he thyroid cart ilage with the superior the patent airway. In the trauma patient, only the jaw, or chi n and jaw, should be aspect o f the crico id is the cricothyroid membra lie, a very impo rt ant la n d ~ displacro forwa rd, while the head and mark through which )'O U can gai n d irect access to the airway below the neck should be kepi in alignment. cords. Yo u can palpate the cricothyroid mem brane o n most pat ien ts by find· ing the most p romi nent pa rt of t he thyroid cartilage and then slidi ng your index fi nger down u ntil you feel a second "bump" just before you r finge r palpates the last depressio n before t ht., stenwi llotch. That second bu mp is the crieoitl CIIrtilage, and at the upper edge o f t his is the cricothyroid membrane (Figu re 4 ~4). In so me p:ltients, especially those wi th a th ick neck, you may fi nd the cricoid cartilage mo re easily by goi ng fro m the sternal notch upward unt il yo u fed th e fi rst pro minent cart ilage " bu mp." Just over the ~ top" of this b ump is the cricothyro id membrane. The sternalno lch is an impo rtant la nd· mark as well beca use it is the poi nt at wh ich the cu ff of a properly placed endo t racheal tube sho uld lie ( Figure 4-5) . The sternal notch is readi ly palpa ted at the junct io n of the clavicles with the uppe r edge o f t he sternu m.

62 •

CHA PTER 4 Init ial Airway Management

FIGURE 4-3 The Sellick maneuver.

FIGURE 4-4a External vie"" of the an terio r neck, showi ng the surface landnlarks for the thy roid cart ilage (laryngeal) prominence, the cricothyro id membrane, and the cricoid cartilage.

FIGURE 4-4b Cutaway view showing the importan t la nd ma rks of the larYI!;': and upper airway: hyoid, thyroid cart ilage, cricothyroid membrane, Il nd cricoid cartilage.

Trachea and Bronchi The tracheal rillgs (C-shapcd c:lrtilaginoLis supports for the trachea ) conti nue beyond the cricoid cartilage, and the I rachea soon divides into the left and right /1/ai1l5lem brOllchi. The point at which the trachea divides is called the mrill(l. lt is import.lIl t to note that the right mai nstem bronchus takes off at an angle that is slight ly more in li ne with the trachea. As a result , tubes or other fOTi.'ign bodies usually end up in the right ma instem bronchus. One of the goals of a properly performed endotracheal intubation is to avoid a right (or left ) mai nstem bronchus int ubation. YOLI should know how fu r some of these major anatomic l:tndmarks arc from the teet h. Not o nly wil l a knowledge of these help )'ou place an endotracheal tube at the correct level, but also by remembering on ly three numbers you wi ll be able to detect a lube that is too far into the ai rway or not in far enollgh. The three numbers to remember arc 15, 20, and 25. T he first number, 15, is the d istance (in c('ntimel'ers) fro m the teeth to the vocal cords of the average ad ul t; 20 (5 cm far ther down the airway) is the stern:11notch; and 5 cm fn r-

CHAPTER 4 Initia l Airway M anagement _ 63

J;:"~~==~ Nasal Passage Sinus

~

~'=--~- Pharynx

Epiglottis

Thyroid cartilage

La""" Cricoid cartilage

Trachea

Upp."

Pleura

of rlght"'"''·.,.- ---....

Right main _~"­ ......:----~ Left main bronchus

bron
, , -------Diaphragm

-

Bronchiole

Respiratory bronchiole

"7"":::::::t

Costal cartilages

Alveolar

saos ALVEOLAR SACS FIGURE 4-5 The respiratory s}'~ t e ll\ . NOlice Ihe slernal notch. at which point the clavicles joi n the sternum. II marks the position of the tip of a well-placed endolracheallubc.

ther agai n at 25 is the carina ( Figure 4-6). These arc average distances and can va ry by several centimeters, Extension o r flex io n of the head of an intubated patient wi ll move the elldot racheal tube up o r down as much as 2 to 2.5 em. Tubes can e'lsily become dislodged, and detection of m isplacement can be difficult unless you are mo nito ring oxygen satUr:1 lion and expired CO 2, 'Ia ping the head dow n o r guardi ng against movement wi ll no t o nly

64 • CHAPTER 4 Initial Airway Management

FIGURE 4--6 Major ai rway landmarks and distances from the teeth: 15 = 15 Clll from teeth to cords, 20 = 20 CIIl from teeth to sternal notch, 25 = 25 e lll from teeth to carina.

lessen Ihe risk ofluhe displacement (even more important in children ) but will also reduce trauma to the tracheal mucosa. Less movement of the tube will resu lt in less stimulat ion to the pnt ient's airway refl exes and may result in a more stable ca rdiovascular system and intracrnnial pressure in the patient. To help protect lhe ainvilY fro m becoming blocked and to reduce the risk of aspiration, the body has developed brisk rcllcxes th at will attempt to e.xpel any offending foreign materia l from the o rophn rynx, thc glottic opening, or the trachea. These areas arc well supplied by sensitive nerves that can activate thc swallowing, gag, .md cough refl ex. Activat ion of swallowing, gagging, or cou ghi ng by st imulation of thc upper ai rway can cause significa nt cardiovascuhtr stimulation as well as elevation in int racranial p ressure. You can protect pat ients from such unwanted effects by supp ressing the reflexes thro ugh the use of topical lidocaine (sec Chapter 5).

The Lungs The IlIlIgS art' the organs through which gas exch.mge takes place. They are contai ned within a "cage" formed by the ribs, and usually fill lip the pleural space, which is the potclltia/ space between the internal chest wall and the lung surface. The lungs have only one o pening to the outside, the glottic opelling, wh ich is the sp'lCe between the vocal cords. Expansion of the chest wall (the cage) and movement of the diaph ragm downward ca use the lungs to expa nd (since the pleural space is airtight ), and air rushes in through the glol/is. The air travels down the smaller and smaller tubcs to the alveoli, where gas exchange (resp iration) takes place.

THE PATENT AIRWAY O ne of the first maneuvers essen tial to caring for a patient is ensu ring a pa/wl or open airway. vVithout this. all other care is o flittlc use. This must be done quickly, because patien ts ca.nnot tolera te hypox ht for morc than a few minutes. Th e effect of hypoxia and inadequate ventil ation on an unconscious injured patient can be devastating, and if thcse are com-

CHAPTER 4 Initial Airway Management _ 65

pounded by the absence of adequate Since ned!: may be (niured. Use modified}aw thrust. do 001 extend the neck perfusio n, the patient is in even more to ooeo the airway. difficult straits. Patients suffering fro m head trauma not on ly may have hypoxic brain damage from airway compromise b ut may also bu ild up high levels of carbon dioxide that ca n increase blood flow to the injured brain, causing swell in g and increased intracranial pressure. Ensuring an open airway in a patient ca n be a major challenge in the prehospita l selling. Not o nl y can trauma disrupt the anatomy o f the FIGURE 4-7a Opening the airway usi ng R modified jaw thrust. Maintain in-line face and airway. but it can also result stabiliz..1 lion wh ile pushing up on the angle of the jaw wi th yo ur thumbs. in bleed ing, which can lead 10 airflow obstruction and obscu re airway land marks. Add to this the risk of ce rvical-spine injury. and the challenge is readil), apparent. You must .l1so remember that some airway maneuvers, including suction and insertion of nasopharyngea l and o ropharyngeal ai rways. may stimulate a patient 's protcctive renexes and increase the likelihood of ,'omi ti ng and aspiration , cardiovascular stimulat ion, and increased intracranial pressure. The first step in provid ing a patent airway in thc un conscious patient is 10 ensure that the tongue and epiglott is :lre lifted forward :lnd maintained in that position. This is done b), either the modified jaw thrust (Figure 4-7a) or the jaw lift (Figure 4-7b). Either of these maneuvers witl prevent the to ngue from f'llli ng back\\'ard agai nst th e soft palate or posterior pharyngeal wall. Eitll('r will pu ll fo rw;ml on th e hyoid, lifting the epiglotti s up out of the way. These ar(' essent ial maneuFIGURE 4-7b Jaw lift. O'holo C(Jllrlesy of Hmltiy Dellsoll, EM·1'.. /') vcrs for both basic and ad va nced airway procedures. Done properly, they will open the airway without tilt ing the head backw.mi o r moving the neck. Constant vigilance and care are required to maintain a patent airway in your pa tiellt. Following arc essentials for this task: • Continu al observation of the patient in order to anticipa te problems • An adequate suction device with large-bore tubing and attachment • Airway adjuncts

Observation The patient who is inj ured is at risk of airway com promise e\len if com pletely conscious and awake. This is partiall y due to the fJc tlhat many patients ha"e full stomachs. arc anxiOllS, and arc prone to vomi ting. So me patients will also be bleedin g into their o ropharynx and thus swallow ing blood. In view of these facts, you shou ld constantl y observe your pa tient for ai rw'1Y problems following injury. One team member must be responsible (or bot h airway control and adeq uate ventilation for any p.lticnt who m ight be at risk of ai rway compromise.

66 •

CHAPTER 4 Initial Airway Management

The general appearance of a patient, the respiratory rate, and any complaints must be noted and addressed. In a patient who is breathing spontaneously, you must check fre· quently for adequate tidal volume by feelin g over the mouth and nose and by observing chest wall movements. Bare the chest- at least below the breasts-is a good rule to follow. Check the supplemental oxygen line periodically to ensure that oxygen is being delivered to the patient at a given flow rate or percentage. You should always imm ediately clear blood and secretions. Yo u must also be alert fo r sounds that indicate trouble. Be alert for this danger sign: Noisy breatiJing is obstructed breatiJitlg. If the patient has an endotracheal tube in place, monitor lu ng compliance and search for the cause of any change in compliance. If possible, monitor endot racheal tube position by pulse oximetry and continuous expiratory CO z monitoring. (For more on capnography, see Chapter 5.) Consider combative patients to be hypoxic until a systematic and rapid evaluation rules it out. Use of waveform capnography is strongly recommended in all intubated patients and use of pu lse oximetry is recommended in all trauma patients (see Chapter 5).

Suction All patients who are injured and who have cervical motion·restriction devices in place should be considered at high risk for airway co mpromise. In add ition, one of the great· cst threats to the patent airway is th at of vom iting and aspiration, pa rticula rly in pa· tients who have recently eaten a la rge meal washed down with large quan tities of alcohol. As a result, po rtable suction devices should be co nsidered bas ic equ ipment for field trauma care. A portable suct ion device should have the fo llowing characteristics (Figure 4·8) . • It ca n be carried in an ai rway ki t with an oxygen c}'linder and other airway equipment. It should not be separated or stored remote from oxygen; otherwise, it represents an "extra" piece of eq uipment requiring cxtra hands. • It can be hand powered or battery powered rather than oxygen driven. Hand powered is preferred. You should always have a hand· powered sllction as a backup if you use a battery. powcred suction.

FIGURE 4-8 Examples of suction apparalus.

CHAPTER 4 Initial Airway Management _ 67

FIGURE 4 -9 a The nasopharyngeal airway is inserted with the bevel slid along the septum or !loor of the nasal cavity.

• It can generate sufficient suction and volu me displacement to

remove pieces of food, blood clots, and thick secretions from the oropharynx . • It has tubing of sufficient diameter (0.8- 1 em) to handle whatever is suctioned from the patient. Suction tips should be of large bore, such as the rigid "tonsil- tip" suckers that can handle most clots and bleeding. In some cases the suclion tubing itself can be used to withdraw large amounts of blood o r gastric contents. A 6-mm endot racheal tube can be used with a conncctoras a suction tip. The tube's side hole removes the necessity for a proximal control valve to interrupt suction. Usually Rescuer 2 (sec Chapt er 2) assumes responsibility for the airway. As the VO (vom it officer), Rescuer 2 must be co nstantly ;llert to prevent the patient fro m aspirating.

Airway Adjuncts

FIG URE 4-9b The nasopharyngeal airway rests betwccn the tongue and the posterior pharyngeal wall.

Equipment to help ensure a patent airway will include various nasopharyngeal (NPA), o ropharyngeal (OPA), blind insertion airway devices (BIAD), a nd endotracheal airways. Insertion of these devices must be reserved for patients whose protective reflexes are sufficiently depressed to tolerate them. Ca re must be taken not to provoke vomiting o r gagging, si nce both occurrences are bad for these patients. Nasopha ryngeal Airways: Nasopharyngeal airways (NPAs) should be soft and of appropriate length. They are designed to prevent the tongue and epiglott is from fallin g against the posterior pharyngeal wall (see Chapter 5 for insertion technique). In a pinch, a 6-mm or 6.6-mm endotracheal tube can be cut and serve as a nasopharyngeal ai rway. With light lubricatio n and gentle insertion, there should be few problems with thi s airway (Figure 4-9). However, bleeding and trauma to the nasal mucosa are common. Mi ld

68 •

CHAPTER 4 Initial Airway Management

• • • • • PIWU.S

Puvt'nting Dt'oths • IIeccmI skIId" ~

""'"

ActIvI ~ mngemtflt is

"""""

Tht pWent IIItdlISSistince

""'' ' ' ' ' '

AA itrwJy deYic. is pI«.d

""",,<1iy All Ww¥t deYice Ihlt was pbced COI'IectIy has bKome ~ (The pulse om,eler

and CO, monitor are critial

'" "'.J

• IIecome competent in inttkatilg the trJChN. Be preptred to use I ~ Iirway (t.g~ ~'. King Lf.O'II aiJway) if you are I.nabIe to rrtubltt.

-....... "'_ -. i'TMnt ii5pimion 01 ~ eonttlllS. Suction must be

.......

",

h.w.g ""'"' .........

Fdutt to mwge the ~<MI be J fmI error.

hemorrhage fTOm the nose after insert ion of the airway is tlot an indication to remO\'e it. In fuct, it is probably better to keep an lPA in place so as not to disturb the clot or reactiva te tile bleeding. The NPA will be ocller tolerated than the oropharyngeal one and th us can usually be used in patients who still ha\'e a gag reflex. Oropharyngeal Airways: Oropharyngeal airways (OPAs) are designed to keep the tongue off the posterior pha ryngea l wall and thereby help main tain a patent airway ( Figure 4- 10). Patients who arc easily able to tolerate an oropharyngeal airway should be considered cand idates for endotracheal intubation, because their protective reflexes are so depressed that they ca nnot protect their lower ai rways from aspiratio n. Spec ial OPAs arc available. Some are designed as int ubatio n gu ides, whereas o thers have proximal ends that protrude from the lips and arc designed to be used with balloon masks that seal the mouth and nose. Blind Insertion Airway Devlc:es: Esophageal tracheal combitube (Combitube*), King LT·D TJoO ai rway, and the laryngeal mask airway ( LMA) are all blind insert ion ainyaydeviccs ( Bl ADs). These adjuncts arc not as effecti ve as endot racheal intubat ion in prevel1ling aspiration or ensu ring ven tilatio n rmd thus arc not recommended for advanced EMS providers except 3S rescue devices in cases in wh ich you are unsuccessful in intubating thc trachea (see Appendix A). Endotracheal Intubation : Endotracheal intuba tion is the gold standard of airway ca re in patients who cannot protect their airways or in those needing assistance with breath ing. Sc\'cral problems wi ll face you w hen )'Ou dc.·e idc to intubate a traUnla patiellt. Thus there are several methods used to perform endotracheal intubat ion. Intubation freque ntly must oc done under the most difficult circumstances--on the side of the road, in a crashed vehicle, or under a train. In addition, the patient's spine may need to be motion restricted, with a cervical colla r o r other equipment in place. This may so restrict movement and visualization of the airway that )'OU have to consider alternative methods of intubation. Although the original method ofinlu balion was de'lfl)' tactile o r digital, this was later changed by the invention of the laryngoscope. which allowed visuali7...uion of the upper airway and placement of the tube under d irect vision. The ,Ibili ty \0 sec the aclWl1 passage of the tube th rough the glott iC opening rendered tactile o rotracheal intubation obsolete, and its practice large1)' died o ut un til interest in it was re\'ived in the last two decades. There arc several choices to facilitat e intubation in the trauma patient. ranging from awake intuba tion using topical anesthetics to dL"Cp sedation and rapid sequence intubation (RSI). Rapid seqll('1lCt! ;11111001;011 refers \0 the lI SC o f paralytic agents to quickly facilitate' tube placement and to minimi7}.' the risk of aspiration. You must be cogni7..a nt of the fact that both deep sedation and RSI inhibit the normal muscle tone of the airway and thus may make it impossible to effectively mask·\'ent ilate the patient. In this situation, it is nec· essary to immediatel), place an endotracheal tube to achic\'e successful ventilation. For this reason, rou must be very familiar wit h the predictors of difficult laryngoscopy and intu· bation before deciding to intubate a patient who is already breathing o n his own. Remember. patients wl/O luwe sf1OIItm/!'OIIS ret illatieqllatc respiratory effort are better off tlrtlll tilt! patient who has been giVftll1 ptlrtli)'tic I1ml mil llcitiler be mllsk-venti/trtetl nor irlfubtlted. Although it is not always possible to guess e\'cry time which patien t will ha\'e a difficuh ain\'a)'. certain phYSical features allow li S to predict which patients might potentially ha\'e' difficult laryngoscopy and int ubation. The mnelllonic "MMAP" has been proposed to iden· tify these fea tures. MMAP stands for Mallampati, measurement 3-3·1, at lanto-occipital ex· tension, and pathology:

CHAPTER 4 Initial Airway Management _ 69

M - Mal/ampati. The Mallampa ti sco re ranges from I to IV and is dependen t on what structures can be viewed when thc mouth is opened Crable 4- 1). Generally, the higher the grade. thc more difficult it will be to perform laryngoscopy.

AirwfJllj Is inserled

M - Measurement 3-3-1. This measurement can also aid

in predict ing the difficult ai rway. Ideally, you should be able to fit three (3) fingers under the patie nt's chin between the hyoid bo ne and the mentum of the chin; the patient should be able to open his mouth so that th ree (3) fi ngers fi t between the upper and lower incisors; and. lastly, the patient should be able to protrude thc lower jaw such that the lower teeth are I cm (1) beyond the upper teeth.

••

A -AtJallfo-occipital jlltlctiotl. ln patients in whom cervical -spine inju ry is tlot suspected, the abil ity to extend the head at the a tl a n to~occ i p i tal ju nct ion to achieve the "sniffing position" will aid in visualizing the vocal cords.

P - PtIlllo!ogy. Finally. p.lIhology refers to
Tongue depressor

b.

As for 1I1l clin icians responsible for emergency ai rwlIY managemen t, the appropriate decision regarding whom and how to intubate wi ll ult imately be related to several factors. These include the assessment of Ihe patient and the particular clinical presentation, the skill set of the individual health -ca re p rofessionals present, and the system in which they work. An addi tional factor unique to the prehospital setting is time. Ventilation with a bag-vlI lve mask (BVM ) and immediate transport of the patient mlly be 1I bruer option in certain instances than taking the lIddit ional time required to perform RS I. Although t/ireet-visioll oro/melleal illlllba/ioll should o. brconsidered the primary method of placi ng a tubc in the trachell, the procedurc is not always easy. nor is it indica ted FIGURE 4-10 Insertion or an oropharyngeal airway. in all paticn ts. In the ma nagement of trau ma patients particu larly, o ptio ns Illu st be avai l:lble to permit successful intubat ion in even the most challenging of situations and patients. There is evidence tha t the techniquc of dirccl- vision orotrae/zcal illtubatioll result's in movement of the helld and neck. The questio n the refo re arises as to whethcr the usc of th is method presents an added risk in possible cervical-spi ne injurics. Co ntroversy exists as to whether such mo\'ement is either substant ial or of real clin ical significance. In short, the method of in tubatio n sho uld be suited to cach pa tie nt. Those with a low risk of ccrvical·spine inj ur y (an be intubated in the conventional way, using a laryngoscope. Intubation by the nasotr.ICheal rou te, the tacti le or transiJi umina tion methods, or a combination of the two

70 • CHAPTER 4 Initial Airway Manage ment

.,

I li,ii

I I

'

,

,

Mallampati Score View pharynx with mouth open and tongue not protruding. Scoring: I. Entire tonsil or tonsillar bed is visible. II. Upper half of tonsil or tonsillar bed is visible . III. Soft and hard palate are d early visible. IV. Only hard palate is visible . The higher the score, the higher the degree of difficulty.

sho uld be rese rved fo r pat ients wit h spec ific ind icatio n for alternative tech niques (see Chapter 5 il nd Append ix A). Tralls/nr)'lIgca/ jet venti/atioll (T L/V) can p rovide a quick, reliable, and relat ively safe tempo rary method of adequate ox)'genatio n and ven tilatio n when the airway ca nnot be maintained because of obstruct ion or partial obstruct io n above the cords, and access below the level of the cords is needed. A special cann ula is inserted thro ugh the cricoth),roid mem brane, and the patient is ventilated using a special manual jet ventilato r dev ice (see Appendix A).

SUPPLEMENTAL OXYGEN Patients who are injured need supplemental oxygen. especially if they arc unco nscious. It is well recognized that patients suffering from head injury arc frequently hypoxic. Supplemental oxygen can be supplied by a sim ple face Ill ask ru n at to-I2l iters per mi nu te. T his will provide the pat ient wit h abo ut 40 to 50 percent oxygen. No nrcbreathing masks with a reservoir bag and oxygen flow rates into the bag of 12-15 liters per minu te can p rovide 60 to 90 percent oxygen to the patient. These arc recom mended fo r aU trau ma patients requiring sup plemental oxygen . Nasal oxygen cannu lae are well tolerated by most p;l\ icn ts, but p rovide o nly about 25 to 30 percent oxygen to the pat ien t. They are recommended only for those patients who refu se to accept an oxygcn I11
CHAPTER 4 Initial Airway Manageme nt _ 71

VENTILATION Normal Ventilation The movement of air or gases in and out of the lungs is called vellti!lIlioll. At rest, ad ults normall y take in about 400 to 600 cc with cach brea th . This is called the titla! volllll/c. Multiplying th'lt value by the number of breaths per minutc (the respirato ry rate) givcs the milli/le I'oillme. the amo unt of air breathed in (and, of course. o ut ) each mi nute. This is an important v'llue and is no rmally 5-12 liters per minute. Normal ventilation by heal thy lungs will produce an oxygen level of about 100 ml11l-1 g and a ca rbo n dioxide level of 35 to 40 mmHg. A ca rbon dioxide !evel below 35 mmHg indicates hypervent ilation, and values greater than 40 mm Hg indicate hypoventilation. The clinical terms hYPol'clI1 i/atioll and hyperl'Cfltilm iOIl do not refer to oxygenat ion b ut to the level of carbon d ioxide maintained. It is easier for carbon dioxide to diffuse across the alveolocap ilJary mcmbrane of the lungs than it is for oxygcnto do so. This makes it easier to excrete carbo n dioxide than to oxygenate the blood. Thus, if the chest o r lungs are inju red. the body ma), be able to ma intai n normal levels of carbon dioxide in the blood and yet the cells can be hypoxic. A patient with a contused lung might have a respinltory rate of 36. a ca rbon diox ide level of 30 mm Hg, and an oxygen level of on ly 80 mmH g. Al though hyperventi lati ng, this person is still hypoxic. He does not need to b rea the faster; he needs to have supplemen tal oxygen. W hen in doubt, give yo ur patient oxygen. Dev ices to measure oxygen satura tion ( pulse oxi meters) have been ava ilable fo r several yea rs and expired CO~ mo nitors (capnographs) are now available fo r prehosp ital use. Pulse oximcters measure oxygen saturation and should be used on almost all trauma patients, while CO 2 monitors are most useful for continuously monitoring endot racheal lube placement (though they have many other uses; sec Chapters 8 and 10). These devices will be discussed in Cha pter 5.

Positive Pressure (Artificial) Ventilation Normal b reathing takes place because the negative pressure inside the (potential ) pleural space "draws" air in through the upper airway fro m the outside. In any patient who is unable to do this. or whose airway needs protecting. you ma)' need to "pump" air or oxygen in through the glottic openi ng. This is called il/termittent positive pressure I'eutilation (lPPV). lPPV in t rauma pat ients ca n take various fo rms, from mouth- la - mouth to bagvalvc-endot racheal tube ven tilatio n. NOTE: "Pumpillg" air illto thc oropharYllx is //0 gllar-

antee tllnt it will go throllgh thc glottic opellillg and illto the II/figs. The oropharynx leads to the esophagus. Pressure in the o ropharynx of greater than 25cm H20 will open the esophagus and lead to air being pu mped into the stomacil (gastric ;nsumation ). Bag-valve masks and FROPVDs can produce pressures greater than this, II'hieh is why the Sellick maneuver (posterio r pressure on the cricoid ca rtilage) is so very importa nt as a basic airway m,meuver. When you need to vent ilate a pat ient using IPPV, you should know app roximately what the delivered )'oiJmle is (how much volu me you are delivering with each breath you give). You can esti mate the minute volu me by multipl ying delivered volume by the ventilatory ra te. A flow- rest ricted oxygen-powered venti lato r device that delivers oxygen at the rale of 40 liters per min ute will have a delivered volu me of about 700 cc each seco nd that the valve is activated. Unless the Sellick man ellver is used, delivering this volume at a p ressure of 50 em H 20 will almost guarantee gastric insuffia tion and all the com pl ications resulting from it. BVM breathing is no better, because pressures generated by squeezing the bag may equal or exceed 60 em H 20. Delivered volumes are usually less with bag resuscitators than with FROPVDs. There art' two reasons fo r this. The average resuscitator bag holds only 1,800 cc of gas, which is

72 •

CHAPTER 4 Initial Airway Management

the absolute limit to the volume that could be delivered if you were able to squeeze the bag completely. Using one hand, the best an average adult can squeeze is approximately 1,200 cc. Most people will squeeze only 800 to 1,000 cc with one hand. The other reason for greater delivered volumes with flow-restricted oxygen-powered ventilator devices is that a FROPVD has a trigger that allows the rescuer to hold a mask on the face with both hands, thus decreasing mask leak. Keep in mind that these volumes, delivered from the ventilating port of these devices, equal the volumes delivered to the patient only if an endotracheal tube is in place. In other words, they do not take into account mask leak. When performing IPPY with a mask, keep the fo llowing essentials in mind: _. Supplemental oxygen must be provided for the patient du.ring IPPY. _ Suction must be immediately available . • Ventilation must be done carefully to avoid gastric distension and to reduce the risk of regurgitation and possible aspiration. You can help prevent these complications by using the Sellick maneuver. • Pulse oximetry and end -tidal CO 2 monitoring (capnography) are the most reliable methods of mo nitoring effectiveness of ventilation. The pulse oximeter measures the oxygen saturation of the blood and the capnograph measures the COz lcvcl. Use the end-tidal COz level to judge whether to increase or decrease the rate of ventilation. If you adjust your respiratory rate to keep the expired C02 1evei between 35-40, you can be sure you are neither hypo- or hyperventilating the patient. In the case of bag-mask breathing, up to 40 percent mask leak can be expected. Balloon mask designs can reduce this, and a two-person technique, in which one rescuer holds the mask iJl place with both hands wh ile a second squeezes the bag, may better ensure adequate delivered volumes. During the stress of an emergency situation, you will tend to ventilate patients at an increased rate. Normal rates should be 10 to 12 times per minute but, if the patient is intubated, the rate usually can be 8 to 10 times per minute. Your pulse oximeter and end-tidal CO 2 monito r are most important in getting the correct rate for each patient.

Compliance When au, or air contain ing oxygen, is delivered by positive pressure into the lungs of a patient , the "give" or elasticity of the lungs and chest wall will influence how easily it will be for the patient to breathe. If you are performing mask ventilatio n, a normal elasticity of the lungs and chest waU will allow air to enter the glottic opening and little gastric distension should result. However, if the elasticity is poor, ventilation will be ha.rder to achieve and gast.ric distension more likely. The ability of the lungs and chest wall to expand and therefore ventilate a patient is known as compliatlce. It is simpler to speak of "good compliance" or "bad compliance" rather than "high" or "low" compliance, since the latter terms can be somewhat confusing. Compliance is an important concept, because it governs whether or not you can adequately ventilate a patient. Compliance can become bad (i .e., low) in some disease states of the lu ng or in patients who have an injury to the chest wall. In ca rdiac arrest, compliance will also become bad, due to poor circulation to the muscles. This makes ventilating the patien t all the more difficuJt. With an endotracheal tube in place, the patient's compliance becomes a~ important clinical sign and may reveal airway problems. Keep in mind that with an endotracheal tube in place and with bag-valve ventil ation, you have a kind of "pressure-detection" device much like a tire-p ressure gauge. That is, you can "feel" with your fin gers and hand a change in compliance, either worsening or im proving. A worsening of compliance may be the first sign of a tension pneumothorax. Poor complian ce also will be felt in right (o r left) mainstem bronchus intubation-

j t

CHAPTER 4 Initial Airway Management _ 73

pullin g back on the tube will result in an immediate improvement in the ab ility to ventilate (Le., bette r co mpli ance).

Ventilation Techniques Mouth to Mouth: Mouth -to-mouth ventilation is the most reliable and effective method, with the advantage of requiring no equipment and a minimum of ex perience and training. In addition, delivered volumes are co nsistently adequate because mouth scal is effectively and easily maintained. In addition, com pliance can be "felt" more accurately, and high oropharyngeal pressures are therefore less likely. This method is almost never used because of the fear of disease transmission. However, it is appropriate for many patients, especially those with whom you are familiar (such as famil y members). Beca use of its effectiveness and universal availability. you should be familiar with the technique. Mouth to Mask: Though not qui te as effective as mouth -Io-mouth ven tilation. mout hto-mask ventila tion can overcome the slight danger of disease transmission by interposing a face mask between your mouth and that of the patient. Commercially designed pocket face masks, which fold into a small case that can be ca rried in your pocket. are particularly suited fo r the initial ventilation of many types of patients. Some have a side port for supplemental oxygen. Pocket ventilating masks have consistently been shown to deliver larger volumes than bag-mask devices and do so with a grea ter percentage of oxygen than mouth -to-mouth vent ilation. Mouth-to-mask ventilation has sign ificant advantages over bag-mask devices, and should be more widely used (see Chapter 5). Flow-Restricted Oxygen-Powered Ventilating Device: In the past, the highpressure, oxygen-powered ventilators (demand valves) were considered too dangerous to use in multiple-trauma patients. Experience with the newer flow-restricted oxygenpowered ventilator devices (FROPVDs) that meet American Heart Associ.llion guidelines (oxygen flow rate of 40 liters per minute at a maximum pressure of 50 ± 5 cm H 20 ) suggests that these may now be the equal of bag-valve devices for ven tilation (Figure 4- 11 ). They have the advantage of delivering 100 percen t oxygen and allowing use of two hands while using fa ce-mask ventilation. FROPVDs are no worse than BVMs at producing gastric distention. However. because it is more difficult to fee l lung compliance when ventilat ing with the FROPVD. there is still some cont roversy about its use. FoUow your medical director's advice on the usc of a FROPVD. Bag-Valve Mask: The bag-valve mask, a descendant of the anesthetic bag, is a fixed-volume ventilator with an average delivered volume of about 800 cc. With a two-ha nded squeeze. over I liter can be delivered to the patient. It should be used with a reservoir bag or tu bing. Plain BVMs without reservoir bag or tubing can only del iver 40 to 50 percent oxygen and thus should be replaced with reservoir bags. The most important problem associated with the bag\'alve mask device is the volume delivered. Mask leak is a serious problem, decreasing the volume delivered to the oropharynx by sometimes 40 percent or more. In addition,old masks of conventional design have significant dead space beneath them. thus increasing the chal1enge to provide an adequate volume to the pat ien t. The newer balloon mask has a design that eliminates dead space beneath the mask and provides an improved seal over the nose and mouth. It has been

FIGURE 4-11 The flow-restricted oxygen-powered ventilation device. This valve delivers a set flow of 40 liters per minute at maximum pressure of 50 ± 5 em HzO. Do no t use it unless it meets these standards and you r medical di rector approves.

74 • CHAPTER 4 Initial Airway Management

FIGURE 4-12 The inflated balloon mask has been shown to red ucc mask Icak and providc greater vol umes during \"cntilation with bag-mask devices. (Plroto COllr/I'5), of /Jlldd)' 1)e1l501l, EMT-P)

show n in mannequin st ud ies to decrease Illask leak and to improve ventilation. It is recommended particularly for trauma patients (Figure 4-12 ). A better seal can somet imes be obta ined, ilJld larger vol umes delivered, in either the balloon o r conventional mask, with the usc of ex tension tubing aUached to the vent ilating po rt of the bag-valve device. Th is permits the mask to be better seated on the face wit hout a levering effect from the rigid ventilating port connector that tends to un sellt the mask. \"'i ,h the extens ion in place, the bag can be more easily comp ressed, eve n ag'linst the knee or thigh, thus increasing the delivered volu me and overcoming any mask leak ( Figure 4-13). Effective ventilation wi th a BVM requires a high degree of skill and is no t without problems. Prehospital personnel must be prepared for situations where mask venti lation is difficu lt and be able to respond to these challenges. Predictors of difficult mask ventilation can be remembered usi ng the "BOOTS" mnemonic. B -13e(lf(ls

0-

Obesity

0-

Older paticllts

TS-

Toollt'essl1ess Snores or stridor

All t hese signs suggest that the p;lIien t will not be easy to ventila te. Facial hair and the hICk of teeth make mask seal more difficult. Obesity increases both lung lind chest co mplian ce. In older patients and in those in whom cervical-spine cont rol is essential , it is more difficult to get proper head and neck positioning. Finally. the presence o f snoring or st ridor should alert the rescuer to the presence of airway obstruction . FIGURE 4-13 A \'entilllting port extension attached to a If unable to ven tilate a patient using a BVM, the first ventilating bag permits a better mask sClll and therefore greater step sho uld be to reposition the airw;IY and consider the del i\'crcd volumes. When the bag is compressed against thl' thigh, use of an OPA or N PA. If you are still unsuccessful, the as shown he re, delivered volullles ma y be increased furt her. next step is to initiate two-person BVM ventilation with (Pholo courtcs), of BJldd)' DeI/SOli, fA'IT-P) ext ra em phasis o n the jaw- thrust maneuver to maximize airway opening. Continued problems with mask ventilation should prompt the consideratio n of ain"ay obstruction as a potential cause, - Reposi tion ~ Ul timately. the placemen t of II 13lAD or endotracheal tube may be required to > - OPNNPA definitively ventilate the patient in the worst-case scenario ( Figure 4-14).

~..

- Two-per~ bog

"

- Consider obstruction

c

·, .5 7 -SIAD V

. Laryngoscopy arid intubation

FIGURE 4-14 Response 10 difficult bag-mask \·cntilation.

Airway Equipment The most important rule to follow in regard to .lirway equipment is that it should be in good worki ng order and immediately ava ilable. It will do the patient no good if you have to run back to the amb ulance to get the suction apparatus. In other words, be prepared. This is not difficult. Five basic pieces of equipment arc necessa ry for the initial response to all pre hospital trauma calls.

CHAPTER 4 Initial Airway Management _ 75

• Personal p rotection equ ipment (see Chapter I) • Lo ng backboard with attached head mot io n-restriction device • Appropriately sized rigid cervical extrication collar • Ai rway kit (see below) • Trau ma box (see Chapter 1) The airway kit should be com pletely sel f-con tained and should contai n everything needed to secure an airway in any patient. Eq uipment now available is lightweight and portable. Oxygen cylinders are aluminum , and newer suction devices arc less bu lky and ligbter. It is no longer acceptable to have suctio n units Ihal arc bulky and stored separa tely from a sou rcc of oxygen. Suction unitssbould be contained in a ki t with oxygen and other essen tial airway lools. A ligh tweight airway kit should consist of the followi ng (Figure 4- 15): • Oxygen D cylinder, preferdbly aluminum

FIGURE 4-15 An airway ki t containi ng the essentials for airway management. Note thai portable suction is included in this dcsign. The to tal .....cight (with aluminunl " I)" oxygen cylinder) is app roxi mately 10 kg (22 lb), about the samc as a slee' ''E'' cylinder.

• Portable b,ltlery- powered and hand-powered suction units • Oxygen cannulae and masks • Endotr
(Co m bil u be~ ),

• Bag-valve mask venlilatingdevice (with reservoi r b,lg) • Pocket mask wil h supplemental oxygen intake • Pulse oximeter

• C02 1l10nitor • Translaryngeal oxygen cann ula and manual vent ilator The contents of the ai rway kit are cri tical. Check all equipment each shi fl ,lnd have a ca rd attached to be in itialed by the person check ing it.

Dan , Joyce, and Buddy of the Emergen cy Transport Syste m have been called to the scene of a house fire. Their Scene Size-up reveals that the fire department is present, the scene is safe . and there is only one victim. She had been asleep in a back bedroom and the firefighters pulled her out of a window. The general impression is poor because the patient is covered in soot, she is coughing, and she appears to be having some troub le breathing. Buddy is acting as

76 • CHAPTE R 4 Initial Airway Management team leader. The team dons personal protective equipment, gathers essential equipment. and approaches the patient. Buddy begins his initial assessme nt by introducing the team, while Joyce prepares to apply a nonrebreather oxygen mask. When questioned about what happened , the young woman states she had some food simmering on the stove and decided to take a brief nap. When she awakened, the room was full of smoke, and when she opened the bedroom door the hallway was engulfed in flames. She slammed the door and was trying to climb out the window when the fire department arrived. She denies any history of asthma or lung disease and does not smoke. She complains of headache, persistent cough, and some dyspnea. Buddy notes she has a hoarse voice and her breathing is rapid and shallow. She has a strong rapid pulse at the wrist. Dan has the stretc her ready, and the patient climbs onto it. Because of the mechanism of injury, Buddy chooses to perform a focused exam for burns and ahway injury. He has already determined that th is is a priority patient because of the abnormal init ial assessment. This is also a load ·and·go situation because of the respiratory difficulty. A brie f exam of the head and face reveals erythema and blistering of the face and lips. Her hair is singed. There is also soot in the nose and mouth with singed hairs in her nose. There are no other burns but there is erythema (but no blistering) of the skin of the neck and exposed surfaces of her arms, with so me singeing of the hair. The breath sounds are present and equal bilaterally but there is a slight expiratory wheeze. The patient is immediately moved to the ambu lance and transported. Dan drives; Buddy and Joyce provide patient care. While Buddy obtains the rest of the SAMPLE history and vital signs, Joyce starts a saline lock IV. applies a pulse oximeter. and performs a 12-lead EKG (reveals sinus tachycardia). The patient states that the oxygen helps her dyspnea, but Buddy notes that her voice is hoarser. She has no allergies . Her past medical history is negative for any serious illnesses and she takes no medications. Her last oral intake was noon. (It is now 6:00 PM.) Vital signs are blood pressure 120/ 70. pulse 130, and respiratory rate 36 with expiratory wheezing. The pulse oximeter reading is 100 percent on 100 percent oxygen, but Buddy realizes that the pulse oximeter is not reliable in this situation. Buddy notifies medical direction that he has a patient who was asleep in a closed space with smoke and was briefly exposed to flames. She is now dyspneic and coughing with bilateral expiratory wh eezing and a hoarse voice. She also has a headache. Joyce has already given a nebulized bronchodilator treatment with only slight improvement. Buddy requests permission to intubate because of the danger of losing the airway. This is accomplished using nasotracheal intubation because the patient sti ll has a gag reflex. After arrival at the emergency department, the patient is found to have a carboxyhemoglobin level of 25 percent and also upper airway burns. She req uired several days of endotracheal intubation until her airway swelling decreased.

This is a case of upper airway burns and smoke inhalation. The carbon monoxide poisoning can be treated with 100 percent oxygen; hyperbaric oxygen can be used if available. Protecting the airway and maintaining oxygenation are the keys to recovery. The pulse oximeter is worthless in this situation, as it does not recogni ze carboxyhemoglobin or cyanide poisoning and will give falsely high readings. Unless you have the capability to perform rapid sequence int ubation. you will usually have to perform nasotracheal intubation in this situation.

C HAPTER 5 Airway Ma nageme nt Ski lls •

BASIC AIRWAY MANAGEMENT PROCEDURES

EiJ

Suctioning the Airway

I. Attach the suctio n connecting t ub ing to the portable suction machine. 2. Turn the device o n and test it.

3. Insert the suct io n tip th rough the nose (soft o r whistle tip) or mou th (soft or rigid) withou t activating th e suction. 4. Activate th e suctio n and withdraw the suction tube.

S. Repeat the procedu re as necessa ry. NOTE: Al tho ugh the intent is to suction fore ign matter, air and oxygen are also bei ng suctioned oul o f the patient. Never suction for greater than 15 seconds. After suctioning, reoxygenate the patient as soon as possible.

00

Inserting the Nasopharyngeal Airway (NPA) The nasopharyngeal airway (NPA) is made to go into the right nostril. Do not use it if the patient has facia l fractu res or racoon eyes. 1b insert the NPA into the patient's right nostril: 1. C hoose the appropriatc sizc. It should be as large as jXlssiblc bu t still fi t easily through the patient's cxternal nares. The size of th e patient's little fi ngcr c.ln be used as a rough guide.

2. Lu bricate the lu be wi th a watcr-based lubrica nt.

3. Insert the tubc straight back th rough the right nostril with thc beveled edge of the airway toward the septum. 4. Gent ly pass it into the posterior pharynx with a slight rotating motion until the flange rests against the narcs.

To insert the NPA into the left nostril: I. Tu rn the airway upside down so that the bevel is toward the septum.

2. Insert st raight back th rough the nost ril until you reach the posterior pharynx.

3. Turn the airway over 180 degrees and insert it down the pharynx. NOTE: I f the tongue is occlud ing the airway, a jaw thrust or chin li ft mus t be done to allow the nasopharyngeal airway to go under the to ngue.

EiJ

Inserting the Oropharyngeal Airway (OPA)

l. C hoose the app rop riate-size O PA. The d istance from the corner of the mo uth to the

lower part of t he external ear is a good est imate. 2. O pen the airway.

a. Scissor maneuver b. Jaw lift c. To ngue blade 3. Insert the airway gently without push ing the tonguc back into the pharynx. u. Insert the ai rway under d irect vision using a longue blade. Th is is the preferred method and is safe fo r adults o r ch ildren. b. Insert the airway upside down or sideways and rotate into place. This method sho uld no t be lIsed fo r children. 4. If the oroph aryngeal airway causes gagging, removc it and replace it wi th an N PA.

79

80 •

CHAPTER 5 Airway Management Skills

f:!J

Using a Pocket Mask with Supplemental Oxygen

J. Stab ilize the patient's head in a neutral position.

2. Connect the oxygen tubi ng to the oxygen cylinder and the mask. 3. O pen the oxygen cylinder and set the flow rate at 12 liters per minute. 4. Open the airway. 5. Insert an O PA or NPA . 6. Place the mask on the face and establish a good seal. 7. Ven tilate mou th-to-mask with enough vol ume (about 800-1,000 cc oxygen) to causc adequa te chest rise. Ventilate at a rate of 8 to 10 breaths per minute. The inspiratory phase should last 1.5 to 2 seconds. Let the patient exhale fo r 1.5 to 4 seconds.

f:!J

Using the Bag-Valve Mask

I. Stabilize the patien t's head in a neutral position. 2. Connect the oxygen, co nnecting tubing to the bag-valve system and o},:ygen cylinder.

3. Attach the oxygen reservoir to the bag-vah'e mask. 4. Open the oxygen cylinder and set the flow rate at 12 liters per minute. 5. Select the proper size mask and attach it to the bag-valve device. 6. Open the ;li rway. 7. Insert an OPA (or an NPA, if the patien t has a gag reflex). 8. Place the mask on the face and have your partner establish and maintain a good seal. 9. Using bot h hands, ventilate with about 800 to 1,000 cc oxygen at a rate of 8 to 10 breat hs pcr mi nute. 10. If you are forced to ve ntilate without a part ner, use one hand to maintain a face seal and the other hand to squeeze the bag. This decreases the volume of vent ilation because less volu me is produced by only one hand squ eezing the bag.

The Pulse Oximeter A pulse oximeter is a non invasive photoelectric device that measures the arterial oxygen satu ration and pu lse rate in the peripheral circulatio n. It consists of a portable monitor and .. sensing probe that d.ips onto the patien t's finger, toe, or ea rlobe (Figure 5- 1). The device displays the p ulse rate and the arterial oxygen saturation in a percentage value (% SaO!) . This useful device shou ld be used on all patients wi th any type of respiratory compromise. The pulse oximeter is useful to assess the patient's respiratory status, the effectiveness of oxygen therapy, and the effectiveness of BVM o r FROPVD ventilation. Remember that the device measures percent of SaO!, not the arterial partial pressure of oxygen (Pa02) ' The hemoglobin molecule is so efficient at carryi ng oxygen that it is 90 percent saturated (90 percent SaOJ ) whell the partial pressure of oxygen is only60 mrnHg ( 100 is normal). If you are used to th inking about PaO l (where 90- 100 mmHg is norma l), then yo u may be foo led into thinking that a Sa02 reading (pulse oximeter) of 90 percent is normal when it is actually critically low. As a general rule, any pulse ox.imeter reading below 92 percent is cause for concern and requires some sort of intervention (such as o pening the airway, suctio n, oxygen, assisted ventilation. intubation, d ecompression of tension pneumothorax ). A pu lse oximeter reading be low 90 percent is critical and requires immediate in tervention to ma.intain adequa te tissue oxygenation. Try to maintain a pulse oximeter reading o f9 5 percent or higher. However, do not withhold oxygen from a patient with a pulse oximeter reading above 95 percent who also shows slgns and symptoms ofhypoxia or difficulty breathing.

CHAPTER 5 Airway Management Skills •

FIGURE 5-1 Portable pulse oximeler. (Plloro (ol4rfesy a/David FJJroll. MD)

The followin g arc condi tions that make the pulse ox imeter reading unreliable. • Poor peripheml perfl/sion (shock, vasoconstrict ion, hypotensio n). Do nol attach the

sensing probe onto an injured extremity. Try not to use the sensin g probe on the sa me arm that you are usi ng to monitor the blood pressure. Be aware that the pulse oximeter rcading will go down while the blood pressu re cuff is infla ted. • Severe anemia.

• CarbOIl monoxide poisoning. Th is wi ll give falsely high readings because the sensing probe ca nnot distin guish between oxyhemoglobin and ca rboxyhemoglobin. • H),potllCrmia.

• Excessive patie1Jt /1/ovemelll. • High ambiellt light (bright sunlight , high-intensity light on area of the sensi ng

probe).

• Nail polish or a dirty fi/lgernail if yo u arc usin g a finger probe. Use acetone to clean the nail before attaching the probe. '10 use the pulse oximeter, turn on th e device, d ea n th e area that you are to monilor (earlobe, finge rnail, or toenail), and attach the sensing cl ip 10 the area. Remember that while very useful , the pulse oximeter is just anolher tool to help you assess the patient. Like all tools, it has limitations and shou ld not replace ca reful physical assessment .

ADVANCED AIRWAY MANAGEMENT Preparations Wha tever th e method of intubation used, both patients and rescuers should be prepa red for the proced ure. The follow ing equipment is considered basic to all intubation procedures (Figu re 5-2).

• Gloves. Latex or nit rile examining (not necessaril y sterile) gloves should be worn for all intubation procedu res.

81

82 •

CHA PTER 5 Airway Management Skills

FIGURE 5-2 An intubatio n wrap contains the essentials for carr yi ng out endotracheal intuhat ion. The ki t fo lds on itself and is compact and portable. When opened. it provides a clean .....orki ng surface.

• Eye prorcction. Providers mu st we;lr goggles or mce sh ield. • Oxygclla/ioll. All patient s should be ventilated or should breathe high- l1ow oxygen ( 12 liters per mi llLltc ) fu r severill m illu tcs priu r tu the ill tc ll lPt.

• Equipment. Check all equipmen t, and keep at hand in an orga ni zed kif. For

laryngoscopic in tubation , the en dotracheal tube should be held in a "field hockey stick" or o pen "I" shape by a mallea ble stylet t hai is first lubricated and inserted until the distal end is just proxima l to the side hole of the endotracheal tube. C heck the cu ff of the endotrache;ll tube by inl1at ing it with 10 cc of air. Completely remove the air and leave the syringe filled with ai r attached to the pilot tube. Lubricate th e cuff and distal cnd of th e tube. • Slie/ioll. Suct ion must be immediately at hand .

• Assistant. An assistant should be ava ilablc to help in the procedure and may apply the Sellick maneuver d uring vent ilat ion and the subsequent intubat ion attempt. The assistant may also help hold the head and neck in a neutral posit ion. Some int ub:l\ors like the assi sta nt to cou nt aloud to 30 during the intubation procedu re. Yo u may prefer to sim pl y hold yo ur breath (when you need to breathe. the patient really needs a breath ) while performing in tubat io n.

• UdoCllille. 'Jopicallidocai ne sprayed in to the posterior pha rynx before in tubation attempts ca n decrease the adverse cardiovascular and in tracran ial pressure effects of the in tubation proced ure.

Laryngoscopic Orotracheal Intubation For laryngoscopic orotracheal in tu bation, the upper ,lirway and the glottic opening are visualized and the tube is slipped gently through the cords. 'J'he advan tages of th is method include the ability to see obstructions and to visualize the accu rate placemen t of the tu be. I! has the d is.1dvantage o f requiring a relatively relaxed pa tient without anato mic distortion and with mi n imal bleed ing or secretions.

CHAPTER 5 Airway M anagement Skills •

83

Equipm ent: • A straight (Miller) or curved (Maci ntosh) blade and laryngoscope handle, all in good working order (checked da ily) • A tra nsparent endotracheal tube, 28 to 33 cm in length and 7, 7.5, o r 8 mm in internal d iameter for the adult patient • A stylet to help mold the tube into a fi eld hockey stick shape • A water-sol uble lubrica nt-no need for it to contain a local anesthetic • A 100r 12ccsyringe • • • • •

Magill force ps Ta pe and tincture of ben win o r endotracheal tube hol der Suction equipment in good working order Pu lse ox imeter and CO! detector or monitor If ava ilable. a bougie for difficult intubations

PROCEDURE O'J Laryngoscopic Orotracheal Intubation In tubation in the trauma patient di ffers from usual endotracheal int ub;lIion in tha t the patient 's neck must be stabilized du ring the procedu re. Followi.ng ventilation and ini tial prepa ratio ns, the fo ll owing steps should be carried out (Figure 5-3; Scan 5.1 ). I. An assista nt holds the head. performs the Sellick maneuver, and coun ts slowly aloud

to 30 (if yo u request). 2. Pull down on the chi n and slide the blade into the right side of the patient's mou th . Push the tongue to the left and " inch" the blade down along the tongue in an attempt to see the ep iglottis. A key maneuver must be perfo rmed here: The blade must pull fo rward on the tongue to lift up the epiglottis and brin g it in to view. 3. Usc the laryngoscope blade to lift the tongue and epiglot tis up and forward in a straight line. " Levering" the blade is a com m O il error with 1l00'ices and can result in broken teeth and other trauma. The laryngoscope is essentially a "hook" to lift the tongue and epiglottis up and out of the way so that the glottic opening can be identified. 4. Advance the tube along the ri ght side of the oropharynx o nce the ep iglo ttis is seen. When the glottic opening (or even just the arytenoid cart il ages) is identified, slip the tube th rough to a depth of about 5 cm beyo nd the cords. 5. While the tubc is still held firmly, remMe the stylct, infla te the Cliff, attach a bag-valvc device, and check the tubc for placemcnt lIsi ng the immediate confirmation protocol given in the paragraphs that follow. 6. Begin vent ilat ion using adequate oxygen concentrat ion and tidal volume. For difficult in tubat ions where YO ll cannot see the cords o r where the angle is slIch that it is difficult to get the tube through the cords, a bougie can be very helpful. Insert the bougie thro ugh the cords and then slip the tube over the bougie and slide it down through the cords (Sca n 5.2 ). Then remove the bougie and perform steps 5 and 6 above.

Vocal cord

FIGURE 5-3 Lnndmarks du ring intubation.

84 •

CHAPTE R 5 Airway Management Skills

II

Ventilate the patient with 100 percent oxygen.

D

Position the patient's head. The trauma patient would have his neck stabilizad from below.

D

Prepare to insert laryngoscope blade.

II Assemble, prepare, and test all equipment.

o

A second rescuer should perform the Sellick maneuver during intubation to prevent vomiting and improve visualization of the cords.

o

Lift the tongue out of the way.

C HAPTER 5 Airway Management Skills •

o

Insert the blade (curved blade into vallecula; straight blade under epiglottis) and lift to bring the glottic opening into view.

o

Insert endotracheal tube with stylet.

D

85

Visualize the cords and glottic opening.

m

With tube held firmly, remove the stylet and inflate the cuff with 5-10 cc of air.

m Attach a bag-valve unit or other ventilation device to tube.

(cot/ tillued flex t p(lge)

86 •

EEl

CHAPTER 5 Airway Management Skills

Perform immediate confirmation of tube placement.

m

If correct placement is confirmed, secure the t ube in

place.

. . Bougie. (Photo courtesy of Roy A/son, MD)

EI

Inserting the bougie into the trachea. (Photo courtesy of Roy A/son, MD)

CHAPTER 5 Airway M anagement Ski lls •

87

Nasotracheal Intubation The nasot racheal route of endo tracheal intubation in a prchosp ital setting m ay be justified when you can not open the adult patient's mouth beca use of clenched jaws and when )'O U cannot ventilate the patient by other means. The greatest disadvantage o f th is method is its relat ive di fficu lty, depend ing as it docs upon the appreciation of the intensity of th e breath sounds of sponta neously breathi ng patients. It is a blind procedu re and as such requires ext ra skill and care to successfull y perfor m proper intratracheal placement. Guidance of the tu be through the glottic opening is a question of you perceiving the intensity o f the so und of the pat ient breathing out. You can. with so me diffi culty, gu ide the tube toward the point of maximu m intensit y and slip it through the cords. YO ll can better hear and feel the breath sounds with your ear placed agai nst the proximal opening of the tube. Commercial adaptors are now available to do this without contaminating yourself or your equipment ( Figure S-4). The success o f this method will also depend upon an an terior curve to the tube that will prevent its passing into the esophagus. Prepa re two tubes prior to carrying out the intubat io n attempt. Insert the distal end of the 7- mm tube into its proximal opening. thus mold ing it into a fo rmed circle. Preparing two tubes allows the immediate use of the second, more rigid tu be should the first plastic tube become warm with body tem perature, th us losing its anterior cu rve. Displaci ng t he longue and jaw fo n vard may also help in ach ieving placement, since this maneuver lifts the epiglotlis anteriorly o ut of Ihe way of the adva nci ng tube. PROCEDURE

£iJ

Nasotracheal Intubation

I. Perfo rm rout ine p repa rat ion procedu res.

2. Lubricate the cuff and d istal end o f a 7-mm or 7.S- mm endotrachealt ubc. With the bevel against the floor o r septum of the naS.ll cavity, sl ip the tube distally th rough the largest naris. Insert alo ng the floor of the nasal cavity (at a 9O-degree angle to the face).

(-m.rrO

D

The bougie going between the cords and throug h the glottic opening . (Photo courtesy of Roy A/son, MO)

II!

Sliding the ET tube over the bo ugie and into the t rachea. (Photo courtesy of Roy A/son, MO)

88 • CHAPTER 5 Airway Management Skills 3. When the tube tip reaches the posterior phnryngeo l wall , take great care o n "roundin g

the bend" and then direct tl1(.' tu be toward the glottic opening. 4. By watching the neck at the laryngeal prominence, you ca n judge the approximate placement of the tube; tenting of the skin o n either side o f the prominence indicates th,lt the tube is caught up in the pyriform fossa, a pro blem solved by sli ght wi thdrawal and rotation of the tube 10 the midli ne. Bulging and anterior displacement of the laryngeal prominence usually indicate th.1t the tube has entered the glo ttic o pening and has been correctl y placed. At this point the pat ient , especially if not deeply coma tose, wi ll cough , st rai n, or both. T his may be alarming to the novice intubato r, who might interpret Ihis as laryngospasm or m isplacement o f the tube. The temptation may be to pull the tube and ventilate, sin ce the patient may not breathe immed iately. Hold ing your hand o r car ove r the opening o f the tube to detcct airtlow may reassure ),Otl that the tube is correct ly placed , and you may inflate the cu ff and begin ventilation.

••

S. Confirm tube placement lIsing th e immediate confirmatio n p rolocol below.

Immediate Confirmation of Tube Placement O ne of the greatest challenges of intubatio n is ensuring the correct intratracheal placement of endotr.lCh eal tubes. An un recognized esophageal intubation is a lethal complicat io n o f this life-savi ng procedure. ever)' efforl must be made to avoid this catastrophe, and a st rict protocol m ust be followed to reduce the risk. Although the most reliable method of ensuring proper placemelu is aCluall ), visualizing the tube passing throu gh the glottic opening, even this is not 100 percent sure. The gold b. standard for confirm ing and monitorin g endotracheal tu be FIGURE 5-4 ( 0) Exa mple of a commercial nasotrachcal placement is waveform capnogra phy (sec discussio n starting tubl.' auscultation device (Burden nasoscope) used to on page 90). If you do not have capnography ava ilable, the fol(b) better heur brcuth sounds while inserti ng the nasolowing protocol can be used but is not reliable. When you u S(' tracheal tube. (Photos co rmi'S), of Hmllf Hur(/;m. £M'J'-P) this protocol, you should recogni ze the unreliable nature of auscultation as the sole method of confirmin g intratracheal placement. Correct intrat racheal placement should be suspected from the followin g initial signs. • All allterior displacement of tile laryngeal promilletlce as the lube is passed distally • Coughillg, IlI/ckillg, or simillillg oll the p.lrt o f the patient. Note; Phonation-a ny noise made with the vocal cords-is absolute evidence that the t ube is in the eso phagus, and the tube sho uld be removed immcd iatcl r

• Breath cOllliellSdtioll

011 til l' II/be

wilh each ven li/flliol l -ll 01 100 percent reliab le, but

vef)' suggestive of inlr
C HAPTER 5 Airway Management Skills •

89

• NQrmal colllpli(IIICC witll b(lg vCtltilatiOtl. (The bag does not suddenly "collapse," but rather there is some resilience to it and resist.mce 10 lung inOation. ) • No ClIff le(lk after illflatiotl. (Persistent leak indica tes esophageal intubation until proven otherwise.) • Afle'll/ate cflest rise with ('acl! velltil(lt ;011.

The following procedure should then be carried out immediately to prove correct placement. PROCEDURE

00

Immediate Confirmation of Tube Placement

I. Auscult ate th ree sites as shown in I:igure 5·5.

a. Epigastrium-the most im port ant ; should be silen t, with no so unds heard

FIGURE 5·5 Sites to ausc ultate when performing immediate confirmation ofET lube placement.

b. Right and left midaxiJIary lines 2. Inspect for full movement of the chest with ventilation. 3. Check position using suction bu lb or syringe o r one of the CO! detecti ng devices. 4. Watch fo r any change in the patient's color or in the pu lse oxillleter reading. Also observe the EKG monitor for changes. Commerciul suction bulbs or syringes arc available for confirm in g tube placement (Figure 5·6). They arc almost as reliable as capnogra phy for confirming initial tube place· l11enl. (Ca pnography is superior for constant monito ring of tube posi tion.) To u:'>c a bulb detector. sq uee.....e the bulb and insert the end into the IS- Illill adapter on the endot racheal tube. Release the bulb. If the tube is in the trachea, the bulb will expand immediately. If the hlbc is in the esophagus, the bulb will remai n collapsed. If yOlI arc using the detector syringe, )'Otl wi ll be able to withd raw the sy ringe plunger easily if the tube is in the trachea, but you will not be able to withd t;\w the plu nger if the tube is in the esophagus. Commercia l COl detectors arc also available to attach in·line be .....,rccn the endotracheal tube and the I3VM or FROPVD. Three differcnt k in d s,,~ ay<\ilable. • Qualitative (colorimetric) CO! dctectors • Quantitative CO 2 monitors • Qua ntitative waveform COL monitors

FIGURE S...tta Esophageal intubation detector de\'ice, bulb slyle.

FIGURE 5-6b Esophageal intubation detector device, syringe style.

90

CHAPTER 5 Airway

Manag em ~t

Skills

$<.'l' thl' detailed dis(:ussion of thl'.:S(' monitors ill the follm"'ing sl'ction. "Usi ng Capnomdry and Capnograph}t to Cunfirm.llld )\lonitor ET Tube Position." Apply the protocol for confirm.ilion of tubl' plal~' n1{'nt immt'diatdy follow in!Z. intuhJ tion. If rou art' using il tjll,Ult itative COl monitor or quantit,il i\'e w,l\"rform CO.! monitor, t1u:n yOll m a}, continm' monitoring. ET tube positio n with th~ devi..:t:.'i. If you are not using onf' of t1H.'S{' device;, then rqx'at the- I:T tulx: position reconfi rmation prowo(;ol after St'veral m inutes of \'entilation. 'nlCTt' aftl'T. rl'peat the Tt"Confirmation protocol after mO\~' m ent of the patit'nt from th" grou nd to th~, stretcher, aftl'r load ing onto the olmbul.mce• ....ilt'll you perform the rll$ Seconda ry Survey and Ongoing Exams. and im ml'd i,lte~ prior to arrival .It the hospital.

PROCEDURE ~ Reconfirming ET Tube Position I. Auscultatl' six sites as shown ill j.:igurl' 5-7.

a. Epigastrium- it shou ld bt' sift.'n l with no sounds heard b. Right and left apex

c.

Ri~t

and h.'ft midaxillary li m'~

d . St("rnal notch- "traclll'al ~ sou nds should be n'adily heard h('lX'

2. Insp(,,:t t il(' dH'st for full movcment of the (;he:.t with w·nt Hation, 3. Genl ly palpatt.' the t ubi..' cuff in thl' sternal notch while mmpn-ssing the pilot balloon bNwet.'n the index ling,cr and thumb. A preSSUTt' W"'dn' :.holl id be fdt in the ste-rnal notch.

4.

U~ adjuncts .\ouch placemellt.

,IS

a suction bulb Or CO2 dek'ctors to help ..:oniirm

Any time placem ent is still in doubt in spite of thl' al)(w(' protocol. vi:.ua liLCdirectly or n'lllo,'e the t uhe. l'evi..'r as."mnll' tha t thl' tube is in the right place-'dlway!' IX' sure a nd rt'(:ord that tht! protocol has bt'cn carefully followl'J.

UsJng Capnometry and upnography to Confirm and Monitor FIGURE 5-7 Sites to auscultate when pt>rfonlling reconfirmation of ET tube placement,

(

ET Tube Position: Capno ml'try rt'prCS<'nts a major clinic-.ll upgrade in the 3ssessml'nt. d i .l~nosti cs. and n:'nt ilatory status in thl' monit(lTing of PJ~ !iena, It is importdnt for you to und~'rst and the difTen:m'("S bt:tw(','n simple detection of cud-tidal CO~ ( ETCO:) calkd colorillH't ric or clualitative capnomt'lry. quantitative cnpnometry (a \~d l ue without ,I ....-aveform), and tht· m osl us;.·fu l a nd diagnostic fo rm known 0 .0; (IUanlildtin' w.wt"forlll capnography, Colorimetric COl detectors (q ualitative capnolllNry) are simple devices designed to detc(:t ETC0 1 (Figure 5·8), They do not accurdtd} mea,sure the dmOUn! of CO z. l~T'ically. these- devices use a spt.'cial pi e of "litm us pa~'r" that changes color from purple to yellow as it detecb COl ' If a devin' of this typo: is USt-cl as a confirming device, rot! must be awar e o(th.. lolluwing.: • It mdY not be accurate in poor perfusion states, such as shock or ca rdiac arrest, due 10 ,'ery small am o u nts o f CO 2 returning to the Ju ng,s. In these c-ases, another confirminl:t device is lloct'SSM),. In Col:"CS of cardiac arrest. hest rcs uh$ w ill he nht,lin ed if good

FIGURE

s.a

Colorimetric CO; detK lor.

comprl'Ssions are heing dOll(' at the time the dl'\'ic(' is ust'd.

CHAPTER S A irway Manageme nt Sk ills •

• You IllUSt bag s ix breaths th rough it before using it to co nfirm the CO 2 as being fro m the t rachea. It is a fact that COl ca n be detected from the esoph:lgus, and it would take about six breaths to pu rge it. • If t he device gets wet, it will not be usefu l. • O nce intubated , the device can be used for spot checks onl y, as it will stay )'ellow aft er a few minut es of continuo us use, not changing colo rs with each breath. • Since the device onl)' detects ETC01 , it ca nnot be used as a mo nito r of ven tilation. Qua ntitative capno metry actu.lIly measures the amou nt of COl in expired air (ETCO z). More than just detectio n, the device can be used to mon itor the adequacy of ventilations and help the provider to accurately "titrate" the ETCOl levcis in patients where C01 levcls are critical, such as those with closed head injuries. They are o ft en combined with a pulse oxi meter (Figure 5-9). Q uantitat ive capnometry means ETCOl measurement without a wavefor m. If these devices arc used to confirm lube placement , rou must be aware o f the following li mitations. • In poor perfusion states or ar rest, the nu mbers will be very low, .md may take li p to 30 seconds to display a nu mber. If th is is the Case, it may not be usefu l to in itially confir m ; rather, it could be used to monito r the tu be after th at.

FIGURE 5-9 Combined quantitative CO! monitor and pulse oximeter. (11 /11)11) CDlIffCSY of Norlill Jvktlim/. IIIc. )

• As in colo rimet ric devices, these devices can also detect esophageal COl' so six brea ths arc necessary to actually confir m t racheal CO2 • • In cases of cardiac arrest, best results are obtained if good co mpressions arc being

performed while t he device is being used. Q uanti tative waveform ca pnography is the ult imate confirma tion device and is a slan -

doud of care in su rgical suites and many EMS systems. These devices not only detect and measure the ETC01 , but they also provide you wi th a diagnostic waveform that ca n con fi rm (by the shape of the wavefo rm ) endotracheal placement even in low perfusio n states. These waveforms will appear within 2 seconds of the actual b reat h. Furthermore, these deviccs can be bu ilt into existing cardiac monitors, which will alto\\' you to co nti nuously monito r the waveform and v.llue (Figure 5- 10). They also will allow )'OU to print out a realtime waveform that is time and date stamped fo r absolute documentation of correct tube placement. Capnography has many other uses tn no nin tubated patients, including perfusion monitor, airway monito r, and ventilatio n mo nitor. In usi ng capnognlphy to confi rm endotr.lCheal tube placemen t, )'Oll mu st be aware of the following limitatio ns. • Like ;111 CO: detection devices, low perfusio n states will result in low CO2 readings and subsequently sTllall waveforms (Figure 5- 11). In arrest situatio ns, good comprcs.<;ions sho uld be do ne as the wavefo rms arc bei ng evaluated . This will increase the size of the waveform.

FIGURE 5-10 Quantitative waveform COl monitor incorpora ted into cardiac monitor.

91

92 • CHAPTER 5 Airway M anagement Skills

FIGURE 5· 11 Small capnography waveform means poor perfusion or severe acidosis.

• To use the devices in conjunction wi th your cardiac monitors, you must enable the waveform display on the monitor screen before intubation. A delay of 10 to 30 seconds for warm-up (depending on the monitor) will ensue if you wai t to activate it after placing the tu be. For best results, have the cap nography waveform defa ult when the moni tor is turned on. PROCEDURE

DJ

Confirming and Monitoring ET Tube Placement with Capnography

I. Prepare all equipment for intubat ion. Turn on mon itor and attach capnography fil te line or wires to the monitor. (This will va ry depending on the brand of capnograph.) 2. Place the end otracheal tube and inflate the cuff. In cases of arrest, compressions sho uld not be in terrupted to perform this proced ure. 3. Attach the capnography airway adapter on the endotracheal tube and then attach th BVM to the airway adapter. 4. Ventilate the patient and observe th e waveform. The presence of a "square" pattern confi rms tracheal placement (Figure 5-12). Print out the waveform, jf possible (for documentation ). If the wavefo rm is nonexistent, or appears in gross and irregular waveform patterns, the tube is possibly in the esophagus or hypopharynx.

101: _1165131 3IJInII1 11:11:16 . :19 E\IlI2II11'1111).:31'28 II

_ CO2 _ I

FIGURE 5·12 "Square" waveform is normal.

CHAPTER 5 Airway Management Skills •

s.

93

Listcn fO I" breath so unds midaxillal"Yo n each side to rule out right ma instelll intubation .

6. Secure the tube and con tinually monitor the waveforms d uring transport.

1. On arrival at the receiving facility, print out another waveform ( if available) to prove conect placement at the time of patient transfer. s. O n )'ou r run report, document the visualizatio n of the vocal cords. attach the waveform pri ntout(s) or document the presence, and document equa l breath sounds. Troubleshootin g while mo n itor ing:

• Loss of waveform completely: apnea, or tube is d islodgcd o r obstructed • Waveform s alld vailles getting smaller: hyperventilation (check t h e depth and rate 0 f ventil ation) or hypo perfusion (shock, or loss o f pulses)

Anchoring the Tube Anchoring a tube can be a frustrati ng exercise. Not only does it requi re some fine movements of thc hands when we appear to be all thumbs, but it is difficult to perform wh en vcn tilatio n, movement , o r extr ication is being carried o ut. Keep one th ing in mind: The re is no s ubstitute for the human anchor. That is, Rescucr 2 should be held responsible fo r ensuring that the tube is held fast and that it does not migrate in or out o f the airway. To lose a tube ca n be a carastrophe, especially if the patient is rather inaccessible or the intubation was a difficult one to begin with. Fixing the endotracheal tube in place is important for severnl reasons. First, movement of the tube in the trachea will produce more mucosal damage and may increase the risk of postintubation compl ic.1 tions. In addition, movement of the tube will stimulate the patient to cough , strain , o r both, lead ing to ca rdiovascular and int racranial p ressure changes that could be detrimental. Most importan t, there is a grea ter risk in the prchospital setti ng of dislodging a tube and losing control of the ai rway if it is not anchored solidly in place. T he endotracheal tube can be secured in place by either lalX' or OJ co mmercially avai lable holder. \Vh ile taping a tube in place is convenient and relatively easiJy done, it is not a lways effcctive. There is often a problem wi th the ta pe sticki ng to sk in wet with rain, blood, airway secreti o ns, or vomitus. If yo u arc usi ng tape , severa l principles should be fo llowed: • Insert an oropharyngeal airway to prevent the patient from b iting down o n the tube. • Dry the p at ient 's fuce and apply t inct u re o f benzoin to bettcr ensure proper ad hesion of the tape. • Carry the tape right around the patient's neck when anchoring the t ube. Do not move the neck. Do no t tie it so tight that it occl udes t he external jugu lar veins. • An cho r the tube at the corner of the mouth, not in thc midline. Because of the difficulty of fixing the t ube in place with tape. it Illay be better to use a com mercial endotracheal tube holder that uses a s trap to fi x the tube in a p last ic holder, which also acts as a bite b lock (Figure 5- 13). Because nexioo or extc nsion of the patient's head ca n Illove the tube in or out of the a irway by 2 o r 3 cm . it is good p ractice to restrict head and neck movemcnt of any patie nt who has an endotrachcal tube in p lace (even more im portant in child ren). If the paticnt is sp in alm o tio n -rest rictcd because of t he risk of cervical-spi ne inju ry, ncxion a nd extens ion sh o uld be less of a conccrn .

FIGURE 5-13 A commercial endotradleal tube holder.

Dan, Joyce, and Buddy of the Eme rgency Transport System eETS) have been called to a bar where a patron has been stabbed. The Scene Size-up revea ls that the police are on scene, have cleared the bar, and are questioning bystanders outside. There is a single

(Photo (OUrl esy o f Hoy Aison. MO )

male victim who is sitti ng in a chair and ho ldi ng his chest. Si nce the scene is safe and the mechan ism of inj ury (stab wound) is read ily apparent, the team dons personal protective equipment. As they approach the patient. each carries essential trauma care equipment. How would you approach this patient? What type of

assessment would you perform? What would you do first? Is this a load-and·go situation? Keep t hese questions in mind as you read the chapter. Then. at the end of the chapter, find out how the rescuers completed this cal l.

INTRODUCTION Major thoracic injury may rl'sult from l\·I VC", fa lls, gunshot wou nds, crush inju ries, stab wounds, or o ther IllIXhanisms. Of all trauma patients, half of those with mUlt iple injuries have an associated thoracic inju ry. Of ali traullla deaths, 25 percent arc due ent irely to thoracic injuries. Of all patients wi th potentia lly fatal thoracic injur)" two-thirds are aliV{' when they re.lCh the emergency d{.'partmcn t, b ut onl)' 15 p('rct'nl of Ihem req uire surger)'. T his suggests that patien ts with potenfi.111y fata l thomcic injuries can usually lx' saved by good prchospital and emergency department C;lre. T he goal of th is cha pt er is to enable you to recognize tbt, signs and sym ptoms of such inju ries and to provide the appropriate emergency treatment.

ANATOMY OF THE CHEST The thor.lx is a bo ny cavit y t hat is formed by 12 pairs of ribs, which join posterio rI), with the thoracic sp ine a nd an teriorly with the stern um. Th e intt'rcostal neurovascular bu ndle runs along the infe rior surface of each rib ( I:igure 6-1 ). The inner side o f the tho racic cav ity and the lung itsel f arc lined with a t h in [.lyer of tissue, the pieura. T he sp'Ke between the two plcu ralla}'crs is no rmall y on ly a potential space. However, a pneumothorax is formed wht'n this space is occupied by air. A hemotho rax is fo rmed when it is filled with blood. Thi s po ten tia l sp.Ke can hold 3 liters ofnu id on e;lch side in an adu lt . As shown in Figure 6- 2, one lung occupies each th o racic cavity. Between t he two chest cavities is the med iastinum, which con tains the heart , 'lorta , superior and inferio r vena cava, t rachea, majo r bronchi, and esophagus. The spinal cord is protected by the vertebr,11 column. Th e diaphragm separates the thoracic o rgans from the abdominal cavit y. The upper abdominal organs, includ ing the spleen, liver, kidneys, pancreas, and stomach , arc

95

96 •

CHAPTER 6 Thoracic Trauma

- - Rib

The intercostal vessels ~Hil-t-- and nerves are located

at the inferior borders of the ribs.

-,<+ --t- Heart and major -

blood vessels

Rib

l ungs

lung

Parietal pleura

--. --

FIGURE 6-1 Rib with intercostal vessels and nerw.

" EARLS

Penetra,ing Clrest

Wo.mds Patients ....too hm penetrating che5t trauma and shod are at the top of the list 01 \oad.and~ patienb. Nothing should delay transport.

FIGURE 6-2 Thorax.

protected by the lower rib cage (Figure 6-3 ). Any patient with a penet rating thoracic wound at the level of the nipples (fourth intercostal space) or lower shou ld be assumed to have an abdom in al injury as well as a thoracic injury. Si mil arly, blunt deceleration injuries, such as steering wheel injuries, often affect both thoracic and abdomin al st ructures. Penetrating wounds that traverse the mediastinum have a particularly high poten tial for life-threatening injury because of the vital ca rdiovascular and tracheobronch ial structures with in th is area.

PATHOPHYSIOLOGY

Kidneys

When evaluatin g a patient with probable thoracic trauma, always follow the ITLS Primary Survey (Chapter 2) to avoid missing life-threatening injuries. During the ITLS Primary Survey, search for the most da ngerous injuries first to give your patient the best chan ce for survival. As with any trauma patien t, the mechanism of inju ry is very important in caring for the thoracic trauma pa lien!. Thoracic injuries may be the result of blunt or penetraling trauma. With blunt trauma, the fo rce is distributed over a large area, and visceral injuries occu r from deceleration, shearing forces, comp ression, or bursting. Penetrating inju ries, usually gunsho t wu unds or stab wounds, d istr ib ute the

FIGURE 6-3 Intrathoracic abdomen.

forces of injury over a smaller area. However, the rrajectory of a bullet is often unpredictable, and all thoracic struclures arc at risk.

CHAPTER 6 Thoracic Trauma _ 97 The common end point in thoracic injury is tissue hypoxia. Tissue hypox ia may result from the following: • • • • •

Inadequ ate oxygen delivery to the tissues secondary to airway obstruction Hypovolemia from blood loss Venti lation/perfusion mismatch from lung parenchymal injury C hanges in pleural pressures from tension pneumothorax Pump failure from severe myocardial injury

EMERGENCY CARE OF CHEST INJURIES The major symptoms of chest injury are shortness of breath and chest pain. The signs indicative of chest injury found on inspection include hemoptysis, cyanosis, distended neck veins, tracheal deviation, asymmetrical chest movement , incl ud ing pa radoxical motion , chest wall contusion, open wounds, subcu taneous emphysema, and shock. In addition , palpat ion may reveal tenderness. instabil ity, and crepilation (TI C). Listen to the lung fields for the presence and equal ity ofbrealh so unds. Using the ITLS Primary Survey, includi ng the Rapid Trauma Survey, wi ll guide you in an organized fas hion 10 discovery of these in juries (Figure 6-4). Life-th reatenin g thoracic injuries should be identified immediately during the ITLS Primary Survey. Major th oracic injuries to identi fy are listed below ,lI1d may be remembered as the "deadl y dozen." • The follo wing injuries must be detected and treated during the ITLS Primary Survey: I. Airway obstru ct ion 2. Open pneumothorax 3. Flail chest 4. Te nsion pneumotho rax 5. Massive hemothorax 6. Cardiac tamponade • Life-threateni ng injuries that are more likely to be detected du rin g the IT LS Secondary Survey or during hospital evaluation a re the fo llowi ng: 7. Myocardial co ntusion 8. Traulllatic aortic rupture 9. Tracheal or bronchial tree injury 10. Diaphragmatic tears J J. Esophageal injury 12. Pulm o nary conl'usion

Airway Obstruction Airway management remains a major challenge in the ca re of any multiple-trauma patient. Hypoxia seconda ry to airway obstruction (foreign bod y, tongue, aspiration of vom itus, or blood) is a common cau se of prevent able trauma deat h. Manageme nt of the airway has been discussed in Chapter 4, so nothing furth er will be added here other th an to stress its importance.

Open Pneumothorax An open pneumothorax is caused by a penetrating th oracic injury and may present as a sucking chest wound. The signs and symptoms are usuall y proportion al 10 the size of the chest wall defect (Figure 6-5 ).

98 • CHAPTER 6 Thoracic Trauma

ITLS PRIMARY SURVEY SCENE SIZE-UP Standard Precautions, Hazards, Number of Patients, Need For Add itional Help/Equipment, .Mechanism of Injury

-------------------------------! -----------------------------INITIAL ASSESSMENT General Impression [Age, Sex, Weight, General Appearance, Pasition, Activity, Obvious Injuries/Bleeding)

lOC (AVPU) Control Cervical Spine Airway [Snoring, Gurgling, Stridor, Silence) Breathif19 [Presen t? Rate, Depth, Effort) Radial/Carotid Pulses (Present? Rate, Rhythm , Quality] Skin Color, Temperature, Maisture; Capillory Refill Uocootrolled External Hemorrhage?

-------------------------------}-----------------------------RAPID TRAUMA SURVEY In$peet Head and Nec:k [Major Fociallnjuries, Bruising, Swelling, Penetrotioos, Subcutaneous Emphysema) [Neck Vein Distention? Tracheal Deviation?) Inspect Chest [Asymmetry, Contusians, Penetrations, Paradoxical Motion, ln5tabi lity, Crepitatioo) Breath Soonds [Present? Equal?) [II unequal: Percunion) Heart Tones Abdomen [Bruising, Pene tration/Evisceration, Tenderness, Rigidity, Distention) Pelvis (Te nderness, Instability, Crepita tion) l.ower/Upper Extremities [Swelling, Deformity, Insta bility, Motor and Sensory) Ploee Patient on Backboard Pasterior [Penetra tions, Deformity, Pres.ocral Edema) II Critical Situation, Transfer ta Ambulooce to Complete Exam. Baseline Vital Signs Measured Pulse, Respirations , Blood Pressure Pupils [Size? Reodive? Equoli) (If Altered /'o.f\ental Status:) Gloscow Como Scale Score Eyes, Voice, Motor, Orientatian, Emotional Stote

FIGURE 64 ITLS Primary Survey.

Normal venti lat ion involves a negative pressure being genera ted inside the chest by di aphragmatic contraction . As air is drawn through th e upper airway, the lungs expand , With a large open wound of the chest (larger than the trachea or aboutlhe size of the pa tient's little fin ger), the path o f least resistance for airflow is through the chest waUdefect. Air going in and ou l of this o pening makes a sucking sound (from which the term "sucking chest wou nd " comes), and b ubbles o n ex piration, This air will enter only the pleural dead space. It will no t enter the lung and therefore wi ll not contribute to oxygenation of the blood. Ventilatio n is impaired and hypoxia results, An open pneumothorax may be identified during the JTLS Primary Survey (Figure 6-6).

CHAPTER 6 Thoracic Trauma _ 99

a. Inspiration

b. Expiration

FIGURE 6 -5 Open pneumothorax. If the wo und is larger than the opening 10 the trachea, air will preferentially go into dead space rathl'r than the lung.

OPEN PNEUMOTHORAX PROCEDURE 00 Management of Open Pneumothorax 1. Ensu re an open airway. 2. Promptly close the chest wall defect by any

availab le means. YOLI may initially accom plish this with yo u r hand and then with a defibrill atio n pad . Vasci ine gauze. rubber glove. o r plastic dressing. However, using an occlusive dressing carries the risk of a tensio n pneumothorax. To circumvent this problem , tape the occl usive dressing 011 three sides to produce a fl utter valve, which w ill allow air to esca pe from the chest but not enter it (Figure 6-7) . A commercial chest seal with a one-way valve is now ava ilable (Asherman Chest Scal* ) and is currently the best device with wh ich to close an open cbest wound (Figure 6-8). A chest t ube will be needed ultimately. followed by operative closure of the chest wall defect. 3. Ad minis ter h igh - fl ow oxygen. 4. Insert a la rge-bore IV. 5. Monitor the heart and note heart to nes for compariso n later. 6. Monitor oxygen satu ration with a p ulsc oximeter. 7. Transport rap idly to th e approp ri ate hospital. 8. Noti fy m edical d irection earl y.

SCENE SIZE-UP Is the scene SAFE?

--------------------i--------------------INITIAL ASSESSMENT lOC Ponibly decreased Airwoy Possibly gurgling Breathing Rapid and shallow, possibly labored, b..rr olter. poor Of NO tidal volume

Pul$e$ Ropid/threody 5k.in cool/clommy; cyanaric

--------------------i--------------------RAPID TRAUMA SURVEY Neck. Veins flat Troc:hea Midline Chest Asymmetricol with penetrotionls! Breath Sounds Decrea...d on oFfected side Heart Tones Note lor comparison loter Abdomen Where did the penetrating obiect go?

"'"

Where did the penetra ting obiect go?

FIGURE 6 ·6 An open pneumothorax ma y be identified during the ITLS Primary Survey.

Flail Chest Flail chest occurs wh en th ree or more adjacent ri bs are fractu red in at least two pl aces (Figure 6-9). The result is a segm ent of t he chest wall that is no t in conti nu ity with th e thorax. A late ral flail chest o r an teri o r fl ail ches l (sterna l separat io n ) may result. Wit h posterio r rib fra ctures, the heavy m usculat ure lI sually p revcnts the occurren ce o f a n;li l

100 • CHAPTER 6 Thoracic Trauma 8. On inspiration, dressing seals wound. preventing air enlry

COllapsed _ _ _7< lung

b. EKpiration anows trapped air to escape through untaped section 01 dressing

••

b.

FIGURE 6·8 Sealing a sucking chest wound with Asherman Chest Seal • . FIGURE 6 ·7 Treatment of s ucking chest wo u nd.

segment. If the patient is breat hing spo nta neo usly, the fl ail segment moves with para· dox ica l mot ion relat ive to the rest of the chest wall ( Figures 6-10 and 6-1 1). The force necessa ry to produce th is injury also bruises the underlying lung tissue (pulmo nary co ntusion). which will con tr ibute to the hypox ia. Th is pat ien t is at risk for the development of a hemothorax o r pneumot hora x. With a large fl ail segment, the pa tient may be in marked respi ratory distress, and probably will have very li ttle tidal volume, so will require ven tilatory assistance and , at some poi nt , intubation. Pain from the chest wall in· jury exacerbates the al ready impaired respiration from paradoxical moti on a nd the underlying lung contu sion . Palpation of the chest wall may revea l crepitation in addi· tion to the abnormal resp iratory motion (Figure 6- 12). Flail chest may be identified d uring the ITLS Prima ry Survey (Figure 6- 13).

CHAPTER 6 Thoracic Trauma _ 101

.... -

PEARLS

Rib Fractures Multipfe nb fractures with or without flaif chest can cause hypoxia from mechanical ~ntifatory problems as welf as pulmonary contusion. The patient, especially the older patient, must be closely monitored for hypoKia and respiratory failure. Monitoring with poise oKirnetry and capnography is ~ry hefpful.

FIGURE 6·9 Flail chest occurs when thrct' or more adjacent ribs fracture in two or more places.

a. Inspiration

b. Expiration

FIGURE 6· 10 Pathophysiology of flail chest.

PROCEDURE

00

Management of Flail Chest

1. Ensure an open airway.

2. Assist venti latio n. 3. Admin ister high-flow oxygen. 4. Initially. stabilize the flail segment with manual pressure. Then stabilize it with bulk dressings taped to the chest wall (Figure 6-14 ). However. this is usually not necessary

102 • CHAPTER 6 Thoracic Trauma

Cyanosis Respiratory diHiculty

Severe pain at site of injury

l n~lralion

Ribs rise

Paradoxical chest wall

Flail section

","" ;0

Obvious deformity and crspit over fractu ribs

FIGURE 6·12 Physical findin gs of fl ail chest.

FLAIL CHEST SCENE SIZE· UP T-bone collision? Intrusion of door?

------------------ i -----------------INmAl ASSESSMENT lOC Often unconscious Airwoy

FIGURE 6·11 Paradoxical motion.

Possibly snoring or gurgling Breathing Apneic, or shallow and guarded; ohen NO lidal volume Pubes Rapid/thready Skin cool/clammy; cyonolic

------------------i-----------------RAPID TRAUMA SURVEY Neck Veins f lat Trochea Midline Chest Asymmetrical with poradollical molion on affected side Breath Sounds Usually decreased on offected side (moy be heard on both sides)

Abd_o Pain of brolr.en ribs may mask abdominal tenderness Check carefully

FIGURE 6·13 Flail chest may be identified during the ITLS Primary Survey.

CHAPTER 6 Thoracic Trauma _ 103 untiJ the patient is placed on a backboard. Remember that trying to maintain manual pressure o n a fl ail segment while performing a log roll can compromise a stable spine. S. Load a nd go. 6. If shock is present, use care to prevent flui d overload. which cou ld worsen hypoxemia. 7. Consider intubation early in o rder to provide positive endexpiratory pressure (PEEP). Continuous positive airway pressure (CPAP) could be used here if available. 8. Monitor oxygenation with puJse oximeter and ex piratory CO 2 wit h capnography (if available). 9. Tra nsport rapidly to the appropriate hospital. 10. Notify medical directio n ea rly.

Tape pad in place. extending tape to both sides of chest

Inlubation and positive pressure ventilation is the best stabilization

FIGURE 6·14 Stabilizing nail chest.

Remember that intubation and positive pressure ventilation is the best way to stabilize a fla il chest. but this may be very difficult in the fie ld if the patient still has a gag reflex. Also keep in mind that a pneu mothorax is commonly associated with a fl ail chest; be alert fo r develo pment of tension pneumothorax.

Tension Pneumothorax

PEARLS

Tension Pneumothortlx The diagnosis of tension pneumothorax requires several tir.dings. Patients with simple til fractures but no pntumothorax have decreased breath sounds on the affected slde due to splinting to reneVi' tile pain. Never decornpms I chest unless the aiteria lot

wi.

A tension pneumothorax is an injury that occurs when a one-way valve is created from either blunt or penet rating trauma. A.ir c an ente r but not leave the pleural space (Figu re 6- 15). This causes an increase in the intrathoracic pressure, which will collapse the affected lung and

de
breath sounds, hyperresonarlCe to percussion on Jffected side,

Iocreaslng cyanosis, air hunger (ventilation severely - - - - - - ' impaired)

and deaeased lung compIiaoce if intubated. Traclleal deviatioo is a late

hypotension, distended ned:; veins,

-----c::}.------ Distended neck veins

',"~~_-=:::::",,-<~_ Tracheal displacement

Possible SlJbcutaneoos - -/-: . . - - - emphysema

-;

toward uninjured side

Hyperresonant

-.

Shock; skin

- --.\-- /-----+ percussion note;

"'~=="".". l

FIGURE 6-15 Physical findin gs of tension pneumothorax.

breath sounds or absent

I +

sign and is more often seen on Hay than clinically.

104

C HAPTER 6 Tho racic Trauma

TENSION PNEUMOTHORAX SCENE SIZE-UP S&at b.l1~ stooo'iog wr-ee?

.------- ! -------INITIAL ASSfSSMENT

lOC Doc,,,,,,",,

""- of a;'~ "-'" Rapid/ shallow, 1oI:x:..,d ""Weal:/lfvoody .. AbseN rt:d'o/l Opori

MoYMl"IIWl!

Slin cod./ c.fcr'lfflY' c.yonot<,

RAPtO TRAUMA SURVEY

FIGURE 6-16 'Ille t<'nsio n pnt.,\lmothorax mal' ~ idt"ntifie,1 tiudnll the ITLS Prilllilry Survey.

w ill th<"n exert pre:-SUft' on thl' media:.tillum. This pre<;sure will {'\"l'nluall~' CI)lIap:'><.' tll(' supt.'rim and in fl'rio r wna cay·it. re,sult ing in a loss of Ye'nOli.:. r('t u rn 10 the hl'art. A shift of the traliled and mediastinum a"~d\ trom the :.idl· of tlw IC'nsion pnl'ulllothorax will .l.l<;() com prom ise \ 1:';11lilation of til(' Ol her l u n~, itlthou!!h th is i~ a late phl'llom enon and U:.U ally canllOI he- deh.·.... h.·d (''\C<''I'I by:<-r3)'. Clinic,11 Sipb of a tl' nsiOll r neumothorax includl' d y'plll.'a. an:d ely, tachrpnl'a, d istl'J1d{'(1 nt"C"k willS. a nd possihty Irachl'al d('\'ialion away from til(' aITt"cted side. Auscultation will rewal diminished hrl.'ath sounds on the am.'ct("(1 sidl' and ....ill he 'Kcomp;mit'.t by hvper rt'l>On:lIlC(' \\'ht"n percU5sl'd. Sho(k with hypotension will follow. In a re, il'w of !fI8 fi d d patients d iagnoS\.';j ,,-ill1 tl"Jlsio n pneumothora..'C and rl'llui ring Iwt'dlc de ....o m pn.,ssion, none Wl.'rt· n'l,:urd.,d as ha\'ing-i ~k \' i ,lH'd trachea. The dl'\'e!opnwnt o f dt:'crl'a!>I,'d lun~ compliann' (d ifficuhy in squl'C'l'i ng t he h,lg-\',lI\"c dl'Yic..) in tht' intubatrd patient s.hould al wars ,I\('rt you t( l tilt' possibility of a tension Pllcul1lollwrax. Intub:Itt'd p:n i.'nts ~~'i th ;1 history of d u onic o hslrtlctin' pulmon;u y .liSl"llSt' (COP D ) or .lSth m3 Mi.' at inne,lS<'d risk for d l'\"dopnH"IH of tensio n pneuillot hor,lx fmm po:.iti\"(' rressu rt' '·l'ntilat ion. '11l<' It'll:.ion pneumothor,lJ: may be.' id(.·ntifi ....d durin),! tilt' ITL5 Pri l1 1 ar~ Sun'c¥ ( r igurl' 6- 16)_

PROCEDURE ~

Management of Tension Pneumothorax

I. Establish an opt'n it ir\\ d} .

2. Administer high Ilow oX:yv;('n.

3. Dl"c(lmprl,'ss till' aITt.'CIt"l1sidl' of tht' chl"st, ii ind icated. TIlt' indicat ion for pt'rforming l'nwrgl'ncy d('l,om prl"ssion is the pf('-.encl" of a It'n~io ll PIWUll1ot horax with d('compt'n s.'li()1l a,~ eddl'nn'd by mor(' than ont.! of Ihl.' followi ng: a. Hespiratory

distre,~

dnd C)~itllo:.i:-.

h. Lo:.s of Iht" rad ial pul<.c (Ia lt' shock) c. I)n:-reasi ng It·\,(,1of COIl..ciou:-lll':..s -4, Load a nd go.

s . Ra pid ly

tr
to til\' appropriate ho:.pititl.

6. .'.'ol ify Illt'dical JiT('("1 i(:m

<' aTl }".

If ro u arl' not authoril'ed h) dt'(omprcs'i the (·hl'5t. t lw patient Illu:.t bl'transportNI rapidl)" 10 the hospilal
Massive Hemothorax Blood in the p!t'llfal spitct' is a ht'llIotllOr.llI, ( I:igurl' 6 - Ill_A m.lssiw hemothor.u: occurs d !> a re:.u lt o f a ll{'asl a 1,500 C( bllx)(i lo:.s in ll) til(' thOr:.lCic ca\·it}'. Each thorack cayit}' mit)' ("(m tain u p 10 .\.000 n." of blood . !\Ias:.i\"(' IWlllothorax i:. mor(' often dUl' to rellt,traling tra u ma than til blunt trauma, h UI I,'ither iniury I1MY d i,rupt 11 major pulmonary or systemic \'i.'~<;t'L A:. blood accu m ulat(':. within tbe r leural :.pac('. Ihe lu nF- Oil t h(' alTm("(1 side

CHAPTER 6 Thoracic Trauma

Cyanosis - - - - - - - -

Neck veins Ilat - - - - - - - - - /-

''''.r- - - -Respiratory difficulty as a lale symptom

Breath sounds absent; dull to percu ssion

'

-ct"''-'-- - - -#-'-

--ll~Jf-----------'\rI--k-----\- Shod<

FIGURE 6 -'7 Physical findings of massive hemolhorax.

is compressed . If enough blood accumulates ( rare), the mediastinum will be shi fted away from the hem oth o rax. T he inferior and superior vena cava and th e cont ralateral lung are compressed. Thus, the ongoing blood loss is com plicated by hypoxemia. Signs a nd sympto ms o f massive hem otho rax arc produced by both hypovolem ia and respirato ry compromise. T he patient may be hypotensive fro m b lood loss and compression o f the hea rt o r great vein s. An xiety and confusio n are p roduced by hypovolemia and hypoxemi a. Cl inical sign s o f hypovolemic shock may be apparent. T he neck ve ins arc usually fl at seconda ry to profo und hypovolemia, b ut may very rarely be d istended due to m ediastinal compressio n. O ther signs o f hemothorax include decreased b reath sounds and dullness to percussio n o n the affected side. Sec Table 6- 1 fo r compariso n o f tensio n pneumotho rax and massive hemothorax.

~ Manag e m e nt of M assiv e H e mothorax 1. Secure an o pen airway.

2. Apply high -fl ow oxygen. 3. Load and go. 4. Notify medical directio n early. 5. Treat fo r shock. Replace volume ca refull y a fter IV inse rt ion en ro ute. Try to keep the blood p ressu re just high en o llgh to m aintain a peripheral pulse (90-100 mmH g systolic). While the majo r problem in massive hem otho rax is usually hem o rrhagic shock. elevatin g th e b lood pressure will in crease the bleed ing into th e chest. 6. O bserve closely for the possible development o f a tension hemopneumo thorax, which wou ld require acute chest d ecompression .

_

105

106

CHAPTER 6 Thoracic Trauma

Te nsion Pne umot horax

Massive Hemothorax

Scene Size-up

Seat belt? Steering wheel?

Scene safe? Penet rating vs. blunt trauma?

l ever of consciousness

Decreased

Decreased

Breathing

Rapid/shallow; labored

Rapid/shallow; labored

Pulse s

WeakJthready; absent radials

Weaklthready; absent radials

Skin

Cool/c lammy/diaphoret ic; cyanotic

Cool/ clammy/ diaphoretic: pale / ashen

Neck

Neck vein d istension; raro t racheal deviation

Ned< veins flat; trachea mid line

Bre ath sound s

Decreased or a bsent breath sounds on affected side

Decreased or absent b reath sounds on affected side

Hyperresonant to porcussion on affected s ide

Dull to percussion on affected side

(LOC)

Cardiac Tamponade Cardiac tamponad\' is usually d Ul' 10 penetratin~ iniury. The p"ricardial sac L;; an ind astic membrane tha t surrounds the ht'a rt. IfblOl.xi colh.,,(ts rapid ly belw~n the- ht"arl and I)('r i ~ cardium from a card iac injury. the H.'nlridi..'S of the- h car! w ill he comrressed. A snmll alllou nt of pericardia l blood m ay compromise cardiac filling. As lh\." compression of the n~ n tricl es increases, th{' heart is less ahle 10 rdill and cardiac o utf' ut f.llk Diagnosis of (;lrdiac tamponade d.a!OSicalJy relics UIX lfl the triad of hypott:nsion. di:. ~ h'nded neck veins, an d m umed Iwart sou nds (lkck"s triddl . '\ lufl1\.-d heart sounds may he \'ery diffic ult to .lppn'Ci.lt{· in the prt'hosrilal setlin~, hut if you briefly listen 10 tht' heart wh{"n p(."rfo rlll in~ t h~ primary :.urn'y YOLI Illd)' notic"".l changt' lalt"r. T he palienl may hdn." d par.ldoxical pulw. If the patiellt loSl..'S his peripheral puls{' during in:, ~'ira l i o n, this is sug~ gestiw of a pa radoxical puiS(." and the prt"St"nce of cardiac lamponadi.". The m ajor d itferen~ lial d iagno:,is in Ih(' fidd is tension pneumothorax. With cardiac t ..un ponade. t he piltil'"nt will lx' in shock with a m idli ne t rachea a nd \.'4ual brl..lth sounds ( fi gure fl~ 18 ). unless th\.'re i:. an 6~ 19).

PROCEDURE Ell Management of Cardiac Tamponade I. blsure an open airway"

2. Administer high- fi ow oxygeu.

3. Load aJld go!

CHAPTER 6 Thoracic Trauma _ 107

Distended neck veins _ _ __ __ _ _ _ _--' r

Blood In the pericardial sac compresses the heart and impairs

---::=-;I--- Trachea midline

.:r-~-'---"""o:-- ThIs results In a low

ventricular filling

cardiac output and high central venous

pressura A reflex tachycardia attempts to (but cannot) compensate lor a low ootput

- - - -- \-

Normat breath

sounds Tamponade Is diagnosed

by distention of neck

veins, hypotension, and nafr'OW9d pulse ptessure

FIGURE 6-18 Pathophys iology and ph ys ical findin gs of card iac tamponade.

4. Transport rapidly to the appropriate hospital. 5. Notify medical direct ion early. 6. Monitor the heart early, especially with chest pain or an irregular pulse. 7. Trea t for shock. An IV infusion of electrolyte solu tion (en ro ute) may increase the filling of the heart and increase ca rdiac o ut put. However. since there may be associated infra th o racic bleeding, give o nly enough fluid to maintain a pu lse (90--100 mmH gsystolic). 8. Treat dysrhythmias as they present. 9. Watch for ot her complicat ions, including hemothor.l.x and p neum otho rax.

Traumatic Aortic Rupture A traumatic aortic rupture is the most common cause of immediate death in mo tor-veh icle collisions o r fu lls from heights. Ni nety percent of these patients die immediately. For the survivors. salvage is feasible with prompt diagnosis and surgery. Traumatic thoracic aort ic tears usually arc due to deceleration injury with the heart and aortic arch moving suddenly anteriorly (third coUision), transecting the aorta where it is fixed at the ligamentum artcriosum. In the 10 percent of patients who do not exsanguinate promptly, the aortic tear will be contained t em ~ porarily by surrounding tissues and the adventitia. However, this will usually rupture within hours unless surgically repaired .

CARDIAC TAMPONADE SCENE SIZE-UP Troumo (blunt or penerrotiog) to anterior chest~

-----------------i-----------------· INInAL ASSESSMENT lOC Decreased Ikeathiog Ropidhhollow

PulMs Weak/thready ~ Absent rodiols Possi ble paradoxical pvlW! Slr;in Cool/ clammy/ diaphoretic

-----------------i-----------------· RAPID TRAUMA SURVEY Head/Neck Neck vein distention; trochea midline Chest Sternol contusion or frocrure~

Pen.troting wound

~

chelf?

Breath $OUnds usuolly preMn! ond equol

May be unequal if onocioied pnetJmothorox or hemothorox Heor1 Sounds

Muffled (may develop over time) FIGURE 6·19 The cardiac ta mponade may be identified dur ing the ITLS Primary Survey.

108 •

CHAPTER 6 Thoracic Trauma The diagnosis of a co ntai ned thorac ic aortic laceration is impossible in the fie ld and may be missed even in the hospital. The history fro m the scene is crit ically important, since many of th ese patients have no obv io us signs of chest trauma. Information about damage to the car or steering wheel with a deceleratio n injury o r the height from \vhich the p.lI ient fell is vital. Infrequen tl y, the patient may present with upper extremity hypertension and d iminished lower ex tremity pul ses. PROCEDURE

t!J I.

2. 3. 4. 5. 6.

Management of Potential Aortic Tears Ensure an open airway. Admini ster high-flow oxygen. Rapidly transport to the appropriate hospita l. Establ ish IV access. Monitor the heMt. The mechanism of inju ry is the same as for myoca rdial co ntusio n. Notify medical direction early.

Tracheal or Bronchial Tree Injury Tracheal or b ronch ial tree injuri es may be the result of penetrating or blunt trauma. Penetrating upper airway injuries often have associated major vascula r injuries and extensive tissue dest ruction . Blun t trauma may present with subtle findin gs. Blunt inju ry usually ruptures the trache:l o r mainstem bronchus nea r the cari na. Presenting signs of blunt or penetrating injury include subcu taneous emphysema of the chest, face. o r neck or an associated pneu mothorax or hemothorax. Securing th e airway in the patient wi th a laT)' ngeal or trache.t1 injury may cha llenge th e Illost experienced ca re provider. Ideally, a cuffed endotracheal tube shou ld be passed beyond the site of th e rupture. However. this Illay not be possible, a nd emergency sur· gical interve ntion may be needed to obtain an airway. Thu s, prompt tra nsport to the hosp it al is impo rtant. Observi ng the pat ient for signs of a pneumothorax or hemothorax is also necessary.

Myocardial Contusion Myocardial contusion is a potentially lethal lesion resulti ng from blunt chest injury. injury to the anterior chest is transm itted via the sternum to the heart, which lies immedi· ately posterior to it (Figure 6-20). Cardiac injuries from this mechanism may include valvular rupture, pericar· d ial tampon.lde, o r cardiac rupture. but contusion of the right atrium and right ventricle occurs most corn· monly (Figure 6-21 ). Th is bruising of the heart is basi· call y the same inju ry as an acute myocardial infarction and likC'ovise prescnts with chest pain, dysrhyth mias, or cardiogen ic shock (rare). In the field, cardiogenic shock cannot be distinguished from cardiac tampo nade. The chest pain may be difficult to differentiate from the as· sociated musculoskeletal discomfor t that the patient also suffers as a result of the injury. All patients with blunt :mterior chest trauma should be prcsu med have a myocard ial con tusion. The management is the FIGURE 6·20 Pathophysiology of myocardial contusion. same as for cardiac tamponade above.

CHAPTER 6 Thoracic Trauma _ 109

FIGURE 6 -21 Myocardial cont usion most frequently affects the right atriun\ and "entride as they collide with the sternum.

Diaphragmatic Tears Tears in the diaphragm may result from a severe blow to the abdomen. A sudden increase in intra-abdominal pressure, such as a seat -belt inju ry or kick to the abdomen, may tear the diaphragm and allow herniation of the abdominal organs into the thoracic cavity. This occurs more commo nl y on the left than the risht, si nce the liver protects the right hcmidiaphragm. Blunt trauma produces large rad ial tears in the diaphragm. Penetrat in g trawna may also produce holes in the diaphragm. but these tend to be small. Trallmatic di aphragmat ic hernia is di fficu lt to diagnose even in the hospital. The herniation of abdominal con tents in to the thoracic cavity ma}' cause marked respi ratory distress. On examination, the breath sounds may be diminished and, infrequently, bowel sounds may be heard when the chcst is auscultated. The abdo men may appear scaphoid if a large quantity of abdo minal co ntents is in the chest.

PROCEDURE ~ Management of Diaphragmatic Rupture I. Ensure an open airway.

2. Assist ventilation as necessary 3. Administer high-flow oxygen. 4. Transport the patient to the app ropriate hospital. 5. Treat shock. Insert an rv en route. Associated injuries are common and hypovolemia may occur. 6. Notify medical directio n carl)'.

Pulmonary Contusion Avery common chest injury resulting from blunt trauma, a pulmonary contusion takes hours to develop and rarely develo ps during prehosp ital care, un less very long transport

110

CHAPTER 6 Thoracic Trauma

o r ddaye<1 disco\ery oflhe \'ictim occur,. Cmltu~i on of the lung may produc~ marked h)'poxt'l11ia, 1\ lalMgement consists of intub.1tion and/or as."isted n:n l ilalion if indicOlll'tl. oxygen adm inislroltio n, transport, and IV inSi..-rl ion .

Other Ch. st Injuri• • Impaled Objects: PelwlrOi tillg obj\."C1I>.1>llch ,1<;.1 kni fl', mav CdU!;t' impal,'lIwlll iniuries of the chest. As in other areas of the bod). the object sho uld n OI be r~m o\ed in the field. S~ · bilize the ob ject. en1>U rl' an ain\,IY, inSut an IV, and 1r.l llSport the poItiC!'n t. TraumAtic Asphyxia;: Traum,lIic 'hphyxia b ,Ill important !;d of p hysiml finding~. I low· ('\'N , thr- term lmunral i(' asphyxlJ~ i~ a misnomer, becolll5e t he condition i~ not cau5c.'d bv a,'phyxia. T lw synd rome resuhs from a 1>{'\,ere co m p rt~ ..... ioll injury to the chest. such as from ;a sh.'t'rins whet'l, co n\'eyor bd t. o r h avy object. The .:;udd('11 c(l m pri.·~ion of the heart and mt"di pat ien ts .app<-a r similar 10 thoS(' of 5t r.lllgul.ltion. with cpnosis ano sw('lIing of the h Cild and n ~k. The tongo~ ,md h~ are ; ; .... 01len. and conjunct i ~1 h emo rrhage is t'\'idenl. The skin bdow tht~ len'l of the cru!>h injury to Ihe ch c~ t will be p ink un k' ~ Ihert" are other probl(,I1l~.

Tr;.lUlllalk a!>phyxia ind icale!> that tnt' paticnI has sulTerl·d a 1>t.'n.'re' blunI thorad.. injur'\', and major thoracic injuries arC' likdy to be present. Management includes a i ~OIy nl.li ntt'nance, IV access, treating o theTinjurI(,s., and rapid transport.

• • • • •

PfAtU

.mplr PnrumetltonIX

--1**1:1--.,...

........,. pw.-poy;

I'

oi

.~~c.C4*

PI

••

.,.-..on

J I M - - nepulM ....... .

'"''''''''-

Simple Pneumothonlx: SimplC' pneumothorax milv result fro m blunt or penetrating trauma. Fract ured rib::. art' the u~u.ll C3US(' ill blunttrOltlma. Pm'umothor;u: L;; cau5e(i by dCcumulation of air within the potC'ntiaJ spacC' be1"'et'n thC' vi.scernJ and pari(1al ple-ura. 1 M lung may be totally or p.trtiallv collap..~.'d Ihe ai r con li nul'S 10 at'crue in the thoracic cavity.ln a healthr patient this ;;;;hould nol acutd r compro mi~ \'entilation, if a tension pnnJ l11othorax does nol ('\'oln'. Pa lit'nt." wit h Ie-55 rl'Spiratory rCSt'rye illay not tolerate.' e\'en a simple pneumothorax. Dj,lgnosis of .t pneumothorax i.. bilM.-d o n plcuntic chl'::.l r.t in, drSpnt'.I. dec-rea!><;"d breat h sounds o n tht> afT('Cted side, and hypertympan)' 10 percu<;sio n. Clost" o bst'n 'ation is rl.'quired in anticipation of the patient deyeloping a tensio n pneumothorax. Sternal Fr.rturH: Sterna l fracturt':) aJso indicate that 'he patient has s ufferffl marked blunt tr.J.IIIll;! to tht' anterior chol. Th,'!><;" patients sho uld bl~ pn-sum ...d to ha\'e d lII}ucard ial con tu~ion . Di.tgnoslS o f ~tern.lI fr~cfllrC' m.IY\)(' ma
CHAPTER 6 Thoracic Trauma _ 111

Dan . Joyce. and Buddy of the Emergency Transport System have been called to a local bar where a patron has been stabbed. The Scene Size-up reveals that the police are on-scene and have cleared the bar and are questioning bystanders outside. There is a single male victim who is sitting in a chair and holding his chest. Since the scene is safe and the mechan ism of injury (stab wound) is readily apparen t. the team dons personal protective equipment and each carries their essential trauma care equipment as they approach the patient. The patient. a male in his twenties, states that he was stabbed twice in the left chest but has no other injuries. He states that during an argument his drink.ing buddy stabbed him twice in the left anterior chest before bystanders could tak.e the knife away from him. The patient denies falling or any other injuries. Joyce is acting as team leader and as she begins the initial assessment, her general impression is good. The patient is sitting in a chair and is awake and answering appropriately. He does not appear to be in any distress. Respiration appears to be fast and shallow and when his hand is removed from his left chest. there are two stab wounds. One of the wounds is small but the other is about 5 cm long and obviously sucks when he inhales. The radial pulse Is rapid but strong. Joyce Immediately asks Dan to apply a nonrebreather oxygen mask and then clean the chest and apply an Asherman Chest Sea l®. Because of the nature of the injury she decides to do a focuse d exam. Exam of the airway is normal, with good movement of air and a normal speaking voice . The neck veins are flat and the trachea is in the midline. The breath sounds are not present on the left (except for the sucking sound) but are normal on the right. Respiration is rapid and shallow. The two wounds (no longer bleeding) are as mentioned above. Percussion of the chest reveals dullness to percussion on the left. Heart sounds are normal but rapid. The abdomen is soft and nontender. There are no other wounds . Vital signs are pulse 140. respiration 36 / minute. blood pressure 90/ 60. As soon as Dan seals the sucki ng chest wound , the patient is placed on a stretcher (no backboa rd or packaging) and moved to the ambulance. He is treated with 100 percent oxygen by nonrebreather mask. Two large-bore IVs are started during transport but, because the blood pressure is not below 90 mmHg systolic. Joyce keeps the flow rates just fast enough to keep the veins open. She is concerned about causing worsening of any intrathoracic bleeding. The history reveals: 5 - Pain in left chest, shortness of breath, and weakness A - None M- None P - No history of serious illness. l - Ju st ate some Slim jims and pickled eggs; admits to drinking "three beers"

E - States he was drinking with his friend, who became upset when they got into an argument over fo otball. In a snit. his friend stabbed him with a large pocketknife. His friend is now outside talking to the police and is crying and protesting that he never meant to hurt the patient.

(Photo oourlesy of

Roy Alson, MI)

112 • CHAPTER 6 Thoracic Trauma Buddy applies a ca rd iac monitor and a pulse oxim ete r (98 percent on 100 percent oxygen). Joyce notifies medical direction that t hey will be arriving in 5 minutes with a yo un g male with a sucking chest wound, a hemothorax, and early shock. She is told to watch the vital signs but not to give a bolus of saline unless the blood pressure drops below 80 mmHg systolic. Joyce performs the Detailed Exam and finds everyth ing norma l except what was noted on the Focused Exam. The ITlS Ongoing Exam was not performed, si nce they arrived at the emergency department before she had ti me to do one. While in th e emergency department . the patient had a chest tube inserted and 1,000 cc o f blood evacuated. There was no further bleeding. so the patient did not have to go to surgery. He was in t he hospital for 5 days and had an uneventful recovery.

This is one of th e few examples of a Focused Exam being adequate for a trauma patient. Note that even a Focused Exam requires that both the chest and the abdomen be exam ined because the diap hragm rises so high in the chest that a midchest stab wound may go through the diaphragm and cause abdomi nal injuries. A sucking chest wound can be closed using an occlusive dressing taped on only three sides so that ai r can escape (preventing development of a tension pne um otho ra x) but ai r cannot enter the chest. The co mm ercially avai lable As herm an Chest Seale has a bui lt·in flutter valve and is currently the best way to seal a sucking chest wou nd. or the decompression needle for a tension pneumothorax. Studies have found that for penetrating wounds of the chest, the pneumati c antis hock garment or IV fluid s may signi fi ca ntly worsen surviva l (Chapter 8). Thu s, the PASG is contraindicated and IV flui ds shou ld only be used to maintain sufficient perfusion to keep the patient alive to reach the trau ma ce nter.

SUMMARY Chest injuries are co mmon and often life th reatening in the multiple-tra um a pa tient. If you follow the ITLS Primary Survey, you will identify the injuries. These are o ften loadand-go pat ien ts. Primary goals in treating the patient with chest tra uma arc the fol lowing: l. Ensu re ;In upen ;Iirway whi le pro tecting the cervical spine.

2. Admin ister high-fl ow oxygen and ventilate if necessa ry. 3. Stabilize flail segments. 4. Seal sucking chest wou nds. S. Decompress the chest if needed. 6. Load and go. 7. Noti fy medical direct io n ca rl}'. 8. O blain IV access. The thoracic inju ries discussed are life threatening, but treatable by p rompt intervenlion and transport to the app rop riate hospital. It is mandatory that the inju ries presented are recognized in tbe field and treated appropriately to salv,lgt' these pat ients.

CHAPTER 6 Thoracic Trauma _ 113

BIBLIOGRAPHY l. American College of Surgeons Comm ittee on Trauma. 2004. Ativancetilrtlilma life support.

Chicago: American College of Surgeons, 103-15. 2. Eckstein . M., D. Suyehara. 1998. Needle thoracostomy in the prchospital setting. PreJlOspital EmergellCY Care 2(2): 132-35. 3. Leppaniemi. A.• R. Haapiainen. 2003. Occult diaphmgmaric injuries caused by stab wo unds.

/ormlfl i of Tmrmw 5S: 646-50. 4. McGwin G.• J. MctLger, S. Moran, et al. 2003. Occupant- and collisio n-related risk facto rs for blunt thoracic aorta injury. lormral ofTrmmlfl 54: 655-63. 5. Spodick, D. 2003. Acute carditlc tampontlde. Ne w Englalld /ormltfl of Medicine 349: 684-90. 6. Vies, w., F. Veen, J. Roukema, ct al. 2003. Consequences of d elayed diagnoses in trau ma patients, a prospective study. 101mral of II,e America" College of Surgeons 197: 596-602.

CHAPTER

CHAPTER 7 Thoracic Trauma Skills •

CHEST DECOMPRESSION Indications As with all advanced procedures, this technique must be ,Iccepted local protocol and you must obtain medical direction befo re performin g it . The conservative ma nagement of tension pneumothorax is oxygen, ventilatory assistance, and rapid transpo rt. The indication fo r perfo rming emergency deco mpressio n is the presence of a tensio n pneumotho rax with deco mpensation as evidenced by more than one of the followin g:

• Respiratory d istress and cyanosis • Loss of the radial pulse (late shock) • Decreasing level of consciousness

Complications • i"'lcemtion of the intercostal vessels lllay cause hemorrhage. The intercostal artery and vein run around the inferio r margin of each rib. Poo r needl e placement can lacerate o ne of these vessels. • Creation of a pneumothorax may occur if not alre;ldy present. If your assessment was incorrect, you may give the patient a pneumotho rax when you insert the needle into the chest. • Laceration of the lung is possible. Poo r technique or inappropriate insertion (no pneumothorax present ) can cause laceration of the lung, with subseq uent bleeding and an air leak. • Risk of infection is a consideration. Adequate skin preparation with an antiseptic will usually prevent this.

PROCEDURE Performing a Chest Decompression

00

I. Assess the patient to make sure that his condi tion is due to a tension pneumotho rax.

a. Decreased level of consciousness (LOC) b. Open airway

c. Rapid shallow respiration ; respiratory distress d. Weak/thready pulses; possible absent radial pulse e. Skin is cool, clammy, diaphoretic; pale o r cya notic f. Neck w in distention (may not be present if there is associated severe hemo rrhage) g. Possible tracheal deviation away from the side of the injury (almost never present) h. Absent or decreased breath sounds on the affected side Tympany (hyperresonance) to percussion on the affected side 2. Give th e patient hi g h ~ flow oxygen and ventilatory assistance. I.

3. Determine that ind ications for emergency decompression are present. Then obtain medical direction to perform the procedure. 4. Identify the second o r third in tercostal space on the anterior chest at the midclavicula r li ne on the same side as the pn eumothorax. This may be do ne by

115

116 •

C HAPTE R 7 Thoracic Trauma Skills

1-1-1 l- - - - - - - - - 2nd rib

'f,j~I==~-----The intercostal vessels and nerves ~ are located at the inferior borders of the ribs.

To avoid damaging the Intercostal - - - - - - - - - neurovascular bundle with needle or catheter, follow the upper border 01th e 3rd rib in entering the pleural space.

3rd rib

i pleural space

Lung -

J - --

Heart - - - '

_ -

L - Ribs

- - - Diaphragm - - PI,,"",II ""'"

FIGURE 7-1 Needle decompression of a tension pneumothorax.

feel ing for "angle of Lo uis," the bump loca ted on the ste rnum aboll t a quar ter of the wa y fro m the suprasternal notch ( Figure 7- 1). Th e anterio r site is preferred becau5C th e supi ne patien t has a better chance of having accumu lated air in the pleural space removed when deco m pressing at the m idcJav icular a rea as opposed to the midaxillary area. Monitoring of the si te is also easier if performed in the a nterior site because the cat heter is not as li kely 10 be u ni n tentionally dislodged when the patient is moved. However, if there is significa nt an terior chest tra uma, t he alt ernate site may be used: the midaxil1ary li ne, fo ur th or fifth intercostal space d irectly above the fifth or sixth rib (the ni pple is over t he fifth rib). 5. Q ukkly prepare the area wit h a n an tisept ic. 6. Remove the plastic cap from a 2-i nch (5-cl11 ) large·bo re catheter, T h is allows air to exit the needle as it passes into the pleural space. Use a cathet<'r that is IOllg enough to en le r the pleural space. O ne study fou nd that t he chest wall th.ickness in the anterio r chest var ies fro m 1.3 cm to 5.2 cm, with a mean of 3.2 cm . The m in imu m ca theter length should be 5 cm. Insert the needle into the skin over the superio r bo rder of the thi rd rib, midclavicu la r line, and di rect it into the jJlIercostal space at a 90-degree a ngle to the third rib ( Figures 7- 1 a nd 7-2) . Direction o f the bevel is irrelevan t to successful results. As the needle ente rs th e pleural space, t here will be a '·pop." If a tensio n pneumothorax is present, there will be a hiss of air as the

CHAPTER 7 Thoracic Trauma Skills •

FIGURE 7· 2 Needle decompression by the anterior approach. (Photo collr/(!$Y of lere IUllrill'llI, MD)

pneumothorax is decompressed. If using an oveHhe· needle catheter, adva nce the catheter into the skin . Remove the needle and leave the catheter in place. The catheter hub m ust be stabilized 10 the chest with tape. 7. Place a o ne·way valve o n or over the decompressing needle. The Asherman Chest

ScallZ will go over the needle and provide a o lle·way valve. Other o ne·way valves ca n be made but sho uld be tested before using (a needle through the fin ger o f a rubber glove will not work as a one·way valve). You ng healt hy patients willioleratc hav ing no valve at all on the decompressing needle. 8. Leave the plastic catheter in place until it is replaced by a chest tube at the hospital. 9. Intubate the patient if indica ted. Monitor closely for recurrence of the tension pneu mo thorax.

BIBLIOGRAPHY American College of Surgeons Commi ttee on Trauma. 2004. Adl'(lIIced trallllla life Slippor/. Chicago; American College of Surgeons, 127. 2. Eckstein, M., D. Suyehara. 1998. Needle thoracostomy in the prchospital setti ng. PrcllOspital EmergellCY Cllre2 (2): 132-35. I.

117

Dan, Joyce, and Buddy of the Emergency Transport System have been called to the scene of a high ·

What injuries might they anticipate in a coJlision of this type? Would the victim likely develop shock? What type of inteNentions might they likely have to make? Keep these questions in mind as you read the chapter. speed side· impact auto collision.

(I'lmloSf'oll'h C C raig lacksonl In 1he J);uk Pholography)

Then, at the end of the chapter, find out how the rescuers completed th is call.

INTRODUCTION The management of shock has bccn the subject of intensive research for decades and, as a result, changes have been made in the recommendations for prehospital treatmcnt of the patient with hemorrhagic shock. The experience of the United States and the United Kingdom in the Ir'lq war has k-d to new thinkiJlg in the management of exsanguimlting hemorrhage. This chapter will review the present knowledge ;lbout the pathophysiology and tre;ltment of shock in the traumatized patient and in patients with various other shock states.

BASIC PATHOPHYSIOLOGY The normal perfusion of body tissues requires four int act compo nents. • An intact vascular system to deliver oxygenated blood throughout the body: the blood vessels • Adequate air exchange in the lungs to allow oxygen to enter the blood: oxygenation • An adequate volume of fluid in the vascular system: blood cells and plasma • A fun ctioning pum p: the heart It is important to remember that blood pressure requ ires a "steady state" acti vity of all of the above factors. The he;lrt must be pumping, the blood volume must be adequate, the blood vessels must be intact, and the lungs must be oxygenating the blood . An impo rtant formula rega rd ing the maintenance of blood pressure should be fresh in the mind of every emergency medical provider: Blood Pressure = Cardiac Output x Peripheral Vascular Resistance In addition , the formu la for ca rdiac output is written as follows: Heart Rate x Stroke Volume = Cardi;lC O utput Thus, if cardiac output fall s (either due to falli ng heart rate or lowered stroke volume) or if peripheral vascular resistance falls (such as in the dilated arteries that occur in neurogenic shock), then blood pressure will fall.

119

120 • CHAPTER 8 Shock Evaluation and Management

• • • • • PEARLS

Basic Rules Shock kills. Look for early signs of M and manage it appropriate~. The basic rules of shock management are: Maintain the airway. Maintain oxygenation and ventilation. Control bleeding where possible. Maintain circulation through an

adequate hean rate and intravascular volume.

The preservation of these compo nents can be related to the basic rules of shock management, which are: maintain the airway, maintain oxygenation and ventilation , control bleeding where possible, and maintain circulat io n through an adequate heart rale and intnwascular volume. The term sllOck describes a condition that occurs when the perfusion of the body's tissues with oxygen, electrolytes, glucose, and fluid beco mes inadequate. Several processes cause this drop in perfusion. The loss of red blood cells in hemorrhaging pat ients results in less oxygen transport to the body tissues. Decreased circulating blood volum e leads to lowered glucose, fluid volu me, and electro lytes to the cells. These circulato ry disturbances result in the cells of the body becoming "shocked ," and grave changes in body ti$Sue begin 10 occur. Eventuall y, cell death follows. Deprived of oxygen, cells begin to use "backup" processes that utilize energy sources less effi ciently. producing toxic by- products such as lactic acid . Although these backup (anaerobic) processes may postpone cellular death for a time, the lack of oxygen is compo unded by these toxic by-products because they ca n poison certain cellular function s, such as the production of energy by mitocho ndria. Eventually, accumulating lactic acid in the blood and o rgans creates a system ic acidosis that furth er disrupts cellular activity. Respiratory muscle fun ction also weakens, and respiratory failure develops, which worsens hypoxia. In response to inadequate oxygen delivery, the body respo nds with increased acti\'it)' o f the sympathetic nervous system (called "increased sympathetic tone" ), resulting in the increased release of circulating catecholamines (epinephrine and norepineph rine). These hormones increase both the rate and strength of the heart's cont ract ions and constrict peripheral arterial blood vessels. The midbrain responds to the progressive hypoxia and acidosis with an increase in the respiratory rate. As you can see, shock is a conditio n that begins with an injury, spreads th roughout the body as a multisystem insult to majo r organs, and results in specific sympto ms that you can detect ;11 the bedside as the patient becomes progressively sicker. Thus, shock is a cellular process with clinical manifestatio ns. The patient with shock may be pale, diaphoretic, and tachycardic. At the cellular level, the p
ASSESSMENT AND SHOCK

• • • • • PEARLS

Hypolemion Shock is poor perfusion, not just hypotension. Hypotension is alate fincfng. after the compensatory

mechanisms have failed.

When first considering the concept o f shock, you must understand that shock produces signs and symptoms that you can observe during patient assessment. T he initial diagnosis of the shock state can often be made from the physical assessment findings. Altho ugh blood pressure sho uld be monitored frequentJy to help determine whether organ perfusio n is adequate. remember that assessment tools o ther th an measuring th e blood pressure must also be used to recognize shock in the trauma patient. Humans vary as to the blood pressure req uired to maintain adequate perfu sio n. The question " How low ca n you go?" whi le maintaining adequate perfusion has not yet been answered . We know that the healthy )'oung patient can often ma intain adequate perfusion in the fJce of hypotension whereas older patients, hypertensi\'e patients, and those wi th head injury often cannot tolerate hypotension for ('ven short periods. It is vita l that you work wit h your medical director to stay lip to date on recommendatio ns for shock management as new research is completed. Although this text is about trauma , shock is a clinical condition associated with more med ical problem s than just trauma. Following is a discussion of shock syndromes, many

CHAPTER 8 Shock Evaluation and Management _ 121

of which are caused by traumatic conditions. The take-ho me point. though. is that the shock state is one of low tissue perfusio n (from many causes) in which the body usuall y demonstrates similar signs of its response to th is perfu sion -deprived condition. The body may not always demonst rate similar signs. See, for example, the discussion of high-space shock that fo llows. Therefore. the stabbed and bleed in g patienl in hemorrhagic shock oflen shows many of the same signs as the burned or dehyd rated pat ient with low blood volume that is NOT due to hemorrhage.

Compensated and Decompensated Shock Generally, the onset of the symptoms and signs of hypovolemic shock (includ ing hemorrhagic shock) occur in the fo llowing order. Compensated Shock

• Weakness (l nd liglltllcadcdl1es.r-caused by decreased blood volume • Tltirst--
• Pal/or (pale, white color of the skin )--caused by catecholamine- induced vasoconstriction and/or loss of circulating red blood cells

• Tachycardia-
• Diaphoresis (sweati ng)--
• Decreasc(llIri1lflry olltput--ca used by hypovolemia. hypoxia, and circulating catecholamines (important to remember in intcrfacility transfers)

• Weakelled I,eripllcral pulses-the "thready" pulse (thread y means "threadlike," meaning the arteries actua lly shrink in width as intravascular vo lu me is lost); caused by vasoconstriction, tachycardia, and loss of blood volume NOTE: The sympto ms and signs listed above are in the order of progrcssive"compensation," as the bod y attempts to deal with the cause of shock. Begi nning with the next item, hrpotension , the body is no lo nger able to maintain perfusio n, and the shock condi tion is now "decompensated." Decompensated Shock

• Hypotcflsioll-ca used by hypovolemia, either absolute or relative (see later paragraphs for a discussion of relative hypovolemia ), and/or by the dimini shed cardiac outpu t seen in "obstructive" or "mechanical" shock • Allered mel/tal slaWs (confusion , restlessness, combati veness, unconsciollsness)-

caused by dec reased cerebral perfusion, acidosis, hypoxia, and catecholamine stimulation

• Cardi(lC"rresl-caused by critical o rgan failure seco ndary to blood o r fluid loss, hypoxia, and occasionally arrhythmia caused by catecholamine stimulatio n and/o r low perfusion To summarize, man)' of the symptoms of shock of any etiology, including the classic hemorrhagic shock picture, are caused by the release of catechola mines. When the brain senses that perfusion to the tissues is insufficient, it sends messages down the spinal cord to the sympathetic nervous system and the adrenal glands, cau sing a release of catecholamines (epinephrine and norepinephrine) in to the circ ulation. The circu lat ing catecholamines cause the tachycardia, anxio llsness, diaphoresis, and vasoconstriction. The vasoconstrictio n in the arterioles shunts blood away from the skin and in testines to the

12 2 • C HAPTER 8 Shock Evaluation and Management hearl, lungs, and brui n. Close mo nitoring early in the shock syndrome may allow you to detect a n in itial r isc in the blood p ressure due to this shunting. though this does not always

happen. There will almost always be all initial narrowing of the pulse pressure because vasoconst riction rai5('S the diasloJjc prcssurc mo re than the systolic. The shunting of blood from th e skin and th(' loss of circulating red blood cells caliSc the pallor o f shock. Decreased perfusio n ca uses weakn ess and thi rst in itially. and then later, an altered level of conscio usness (confusion, restlessness, or comba tiveness) and worsen in g pallor. As shock continues, the prolo nged tissue hypoxia leads to worsening addos is. This acidosis can ultimately ca use a loss of response to c;ltt'Chola mines, worsening the drop in blood pressu re. T h is is often the po int at wh ich the pat ient in "co mpensated " shock sudden ly "crashes." Eventually, the hypoxia and acidosis cause cardiac dysfun ction . includin g ca rdiac arrest, and ult ima tely dcath. Although the individual respo nse to post- traumatic hemor rhage may vary, many pat ients wi ll have the fo llowing classic patterns of "early" and " late" shock .

• Early siwek (loss of approxim,a tely 15 to 25 percent of the blood vol ume), enough to stim ulate slight to moderate tachycardia, pallor, na rrowed pul se pressu re. thirst, weakness, and possibly delnyed capilla ry refi ll. In "early s hock," the body is "compensating" for the p hysical insult that is cau si ng the problem (hemorrhage, deh ydration, tension pneumo thorax, and so on ) .

• Laic sIwek (loss of approxi mately 30 to 45 percent o f the blood volu m e), eno ugh to cause hypo tension as well as the o th er sym ptoms of hypovolemic shock listed earlier. When " late shock" has occurred, th is mea ns that the body's abilit y to com pensu te fo r the physical insult has fa iled. As men tion ed above. hypotension is th e first sign of " la te shock." The hypotensive patient , then , is nca r death, requiri ng aggress ive assessmen t and management by the provider to prevent dea th of tile piilient.

. -.. -

PEARLS Tachycn,dia Apersistently elmted pulse filta wh.1e at rest isAJ.WAYS an indiaticw'I of _t/W,g mol"", ""'" "'" the pa~1, including the possilifrty of """" t.mom.,..

Note that du ring the in itial Assessment, early shock presen ts as a fast pulse with pallor and d iaphoresis, while late shock Illay present as weak p ulse or loss of the peripberal pulse. O ne usefu l tip is to remembe r that the radial pu lse appears at a sys10lic pressure of abo ut 80, the fe moral p ulse appears at a systolic pressure of abou t 70, and th e C;lro tid pulse "ppc.lrs at .1 systolic pressure of about 60. Th us, if yo u had iIla ry bed in the skin and thus cause ab normal result s. Measurement of cap illary refill is u seful for small children in who m it is difficult to get an accurate blood pressure, but it is of little lise for detecting early shock in adults.

Evaluation of Tachycardia O ne of the first signs of illn ess, and arguably o ne of the most co mmon, is th at of tachycardia. You wi ll frequently be confronted with the patient with an elevated pu lse rale, and you mllst make some so rt of distinc tion as to the cause.

CHAPTER 8 Shock Evaluation and Management -

123

First, f('member that yo u must always attem pt to ex plain why ,1 pa tient has tachycardia. An eleva ted pulse r,He (generally considered to be above 100 in an adult and higher at )'ounger ages) is never normal. Hum,lIl s call tra nsienti)' raise thei r pulses in the sell ing of anxiety. btl t stich elevatio n quickl y returns to normal or fluctua tes in rate dependi ng Oil the waxing and wa ning of Ihe anx iety slale. Second . remember Ihat an elevaled pu lse rale is o ne of the first signs o f shock. Any adult tfilUma pa tient with a sustained pulse rate above 100 mu st be suspected of having occult hemorrhage until proven o therwise. However, du ri ng the ITLS Primary Surve}', a pulse rate greater than 120 should be a red fl ag for possible shock. Finally. so me pat ients who arc in shock may not develop a tachycardia. It has been rt"po rtt"d th;1I a " relat ive bradycard ia" 1ll;IY develop in pa tien ts with traum atic hypotension. So, the absence of tachycard ia in an injured patient docs not rule out that the patient is in shock.

Capnography The heart d el ivers oxygen and nutrien ts to the cells of the body by way of blood vessels. The cells "burn" the nutrients in the presence of ox}'gen to produce energy, water, and carbon d iuxide.' (CO l )' Till' w,lIn and CO 2 muve.' ill to thl' bloodstream. the.' CO 2 be.' ing Cilrrit."d to the lu ngs by the red blood cell s fo r excretio n durin g ex halat io n. CO 2 then is the exha led by-prod uct of metabolism. Put another way, the levcl of exhaled CO 2 ind icates how brightl}' the ti re of metabolism is burn ing in the cells. Whe n m('asured moment to moment at the airway, the level o f CO 2 being excreted may be graphed as;1 waveform. Devices arc now co mmonly ava ilable either separately or on EKG monitors that measure waveform cap nography. The typ ical exhaled COl is approxima tely 40 mmHg. Fall ing me;I.'\lI red CO! indicate.'\ ei ther th,lt the patient i ~ hyperven tilating (fro m anxiety or acidosis) o r that theamount of oX}'gen bci ngsupplied to the cells is fa lling. You might say it this way: A fa lling exhaled C0 2 levei suggests that the fire of metilbo lism in the patient Illily be bu rn ing low. Pat ients in shock h,we decreased oxygen bei ng suppl ied to their cells. Thus, if you arc monitori ng ,1 pa tient who appears to be in shock or at risk of going into shock. monitor the level of exhaled COl ' A level of exhaled CO 2 that fa lls much under 4O---cspeciaUy if it fa lls in to the 20s o r below-ma), be an indication of circu lato ry coll apse and thus can be an additional warn ing sign of worseni ng shock (sec Chapter 5, Figures 5-11 and 5-12 ).

The Shock Syndromes Al though the most co mmo n shock state seen in trauma pat ients is associa ted with hemorrhage and the acco mpa nying hypovolem ia, th ere are actu ally three major classificatio ns of shock. These "types o f shock" relate directly to the blood pressu re equatio n d iscussed ('"rlier in th is chapter (Blood Pressu re = Cardiac Output x Peripheral Vascul ar Resistance). These three shock states can be categorized acco rding to their causes as fo llows: • LOIV- voll/me slwck (absol ute hypovolemia ) is caused b}' hemorrhage o r ot her majo r

body fluid loss (diarrhea, vomiting. and "thi rd spacing" d ue to burns, peritonit is, and other causes). • Higll-sp(/ce shock (relative hypovo lemia) is caused b)' spinal injury, vasovagal syncope. sepsis, and certain drug overdoses. • Mcdulllim/slwck (ca rdiogeni c shock. also known as obstructive shock) is ca used by pericardial tam ponade. tension pneumotho rax, massive pulmo nary embolism, o r co nditio ns weakening the heart muscle. stich as myocard ial contusion or in farc tion. Th ere arc notable differences in the appearan ce of patients with these condit io ns, a nd it is criticalth;lI you be aware of the signs and symptoms that ;lCcompany each o ne.

••••• PEARLS

Ctlpnogmpl.y FaDing wa\li!form capnography may be one of the first incfators thaI a patient is going into ashod state.

1 24 • CHAPTER 8 Shock Eval uation and M anagement

ABSOLUTE HYPOVOUMIC SHOCK SCENE SIZE-UP

Is the

K&rIfI

wn

-----------------}-------------- --INmAL ASSESSMENT

lOC Possibty decreo.sed Airway

Possibly snoring 8reamlng

Ropid Clnd shallow Pul$8s Ropid/lhreody Skin coollclommy ond pole Possibly unconrrolled hemorrhoge

-----------------}------------ -- --RAPID TRAUMA SURVEY

NeG" Veins F~,

T."""", Midline Chesr May be normal Possibly contusions CIt penerroring injury Bream Sounds Normal or unilaterally diminished wilt! chillness to percussion Abdome,

Possibly lender/rigid/ distended PeiY" Moy be unsroble or poinfut

ExlJemilles Possibly femur froclur&s

Low· Volume Shock (Absolute Hypovolemia): Loss of blood fro m injury is called post-trlllmUltic lIemorriwge. In addition t o head inju ry, hemo rrhagic shock is the number-one cause of preventable death fro m injury. The amount of vol ume that the blood vessels can hold is many liters mo re th a n that wh ich actually flows through the \"asculature. T he sympathetic nervo us system keeps the vcsscls constricted, red uci ng their volume and 1ll;lintain ing blood pressu re high e no ugh to perfuse vital organs. If blood volume is los.t. "sensors'" in the major vessels signal the adre nal gland and th e nerves of the sym pathetic ne rvous system to secrete catt.·c.holamines, wh ich cause vasoco nstriction a nd th us further shrink the vascular space an d maintain perfusio n pressure to the brain a nd hea rt . If th e blood loss is minor, thc sympa thetic syste m ca n shrink th ... space e no ugh to mai nta in bl ood pressure. If the loss is severe, t he vascula r s pace ca nnot be s hru nk down e no ugh to mainta in blood pressure, and hypoten sion occurs. o rma lly, Ihe blood vessels arc elastic an d arc distended by the volu me that is in the m . T h is produces a radial artery pulse th;1I is full :md wide. Blood loss ;ll1ows the a rtery to sh rink in wid th . becoming more th read like in s ize; hence the term "'th rcad)'" pulse in shock, as discussed previo usly. H ypo\'olem ic shock victi ms usually have tachycardia, are pale, and ha\'e flat neck \'eins. So, if you come upon a tra uma victim who is pale, tacil),ca rdic, with weak radial pulses, and fl at neek veins, this patien t is proba bly bleeding from sollle inj ury. Absolute hypovole mic s hock may be identified in )'o ur palient during th e ITLS Primary Survey (Figure Sol).

High-Space Shock (Relative Hypovolemia): As mentioned ('arlier, the vol ume that the blood vessels ca n hold is many liters Illo re th a n the blood volum e in the blood vessels. Aga i n, it is the stt'ady-state act io n of the sympathct ic nervous syste m t hat kecps the arteri o les o f the vascula r bed constricted in the normal s tate in o rde r to maintain perfu sion to the nCOlr t and bmin . Anything that interrupts the o Ul now from the sym pathetic ne rvous system a nd ca uscs the loss of th is no rmal vasoconst rict io n allows the vascular space to dilate, becom ing much "too la rge" fo r the ;Hllount o f blood in the vascular system . If blood vessels d ilate, the S liters or so of blood fl owing thro ugh the normal adult's vascula r space m ay not be sufficien t to m aintain blood p ressure and vital tissue perfusion . The condi tion causi ng Ihe vascular space to be too large fo r a no rmal amount of blood has been called high-space s hock or relative hypovolemia (also known as " ,'asodilatory shock" ). Although severnl causes o f high-space shock ex ist ( such as sepsis syndrome a nd dru g overdose), ne u rogenic s hock, commo nly called spit/", siwek. isadd rcssed here because it m ay be caused by Irau ma. T he nerves of the sympathetic !len'o us system come off o f the spinal cord in the thoracic (chest) and lumbar area. T his is why the sympathet ic ne rvous system is often called the "tho racolumba r a uto no mic nervous system ." 'e urogenic shock occurs most t )'p icall y after a n injury to the spinal cord. An injury to the spinal cord in the neck can prevent th e b rain from bcing a ble to send out lhesy mpathetic nervous syste m signals. Thus, a cervical spinalcord injury can p revent the b wi n fro m ra is ing the pu lse ra te, frolll raising the stre ngth of t he hea rt's contractio n, or from constricti ng th(' peripheral arterioles (the vessels that main· tain blood pressure). Although circulating catccho l;lInines alread y present in the blood·

FIGURE 8-1 Absolute hypo\'ole mic shock may be iden tifi ed du ring the ITLS I'rimtlr y Survey.

CHAPTER 8 Shock Evaluation and Management _ 125

stream may preserve the blood pressun.' lor a short time, the disruption of the sYlllpathetic nervo us system o utflow from the spi nal cord results in loss of the no rlllal vascular tone and in the inabili!), of the body to compensate for an)' accompan)'ing hemorrhage. The clinical presentation of neurogenic shock differs from hemo rrhagic shock in that there is no catecholamine rele;lse, thus no pallor, tachycardia, or swe;lI ing. The pa tien t will have a decreased blood pressure, but the heart rate will be normal or slow, and the skin is usually warm, dr)" and pink. The pat ient may also have accompan)'ing paralysis and/o r senso ry deficit corresponding to Ihe spi nal-cord injury. You may also see a lack of chest lIIall movement and o nly sim ple diaphragmatic movement when the patient is asked to take ;1 deep breath , seen as prot ruding of the abdomen during inspiratio n. The imporlant point is that neurogenic shock does not have the typica l picturt' of hemo rrhagic shock, even when associated with severe bleedi ng. The neurologic assessment is therefore very important , and you sho uld not rely on typical shock s)'mptoms and signs to suspect internal bleeding or accompan)'ing hemorrhage-associated shock. Neurogenic shock patients may " look better" than their act ual condition reall )' is. PEARLS Certain drug overdoses ilnd chemical ex posures can also result in shock from vasod iMechanical or High latation lind relative hypovo lemia. Very often injuries result aft er such intoxication, and Space SI.ock their effect o n t)'l)ical clinical signs and symptoms (l ike neurogenic shock ) should be look for signs of mechanical or high. considered. Examples of drug overdoses and chemical exposures that may produce the relspace shock. especia!~ if there is no ative hypovolemia syndrome include nit roglycerin, calciu m channel blockers, antihyperbleeding. tensive medic;ltio ns, and cyanide. Whereas neurogenic shock (due to spin al-cord injury) is bradycardic, pink, and has flat neck veins, the other form s of high-space shock (drug overdoses, cyanide, sepsis) typicall y RELATIVE HYPOVOLEMIA arc tachycardic, pale or flu shed, and have nat neck vein s. SCENE SIZE·UP Relati ve hypovolemia d ue 10 neurogenic (spinal ) shock Is the Kene SAFE? may be identified in your patient during the ITLS Primar), ------------------~- ---------------Surve)' (Figure 8-2).

•••••

Mechanical (Cardiogenic or Obstructive) Shock: The heart is a pump. Like any pump, it has a "power" stroke and a stroke. just like a piston moving up ;lIld down in the cylinder of a mOlor. In the normal adult's restin g state, the heart pumps oul aboul 5 liters of blood per minute. Th is means, of co urse, that the heart also must take in about 5 liters of blood per minute. Therefore, any traumatic or medical cond ition thaI slows o r prevents the venOllS return of blood (an cause shock by lowering cardiac o utp ut and thus oxygen delivery to the tissues. Likewise, anyth ing that obstructs the fl ow of blood to or through the heart can cause shock. The following arc traumatic co nditions [hat can cause mechanical shock. ~ fil1in g"

• Tel/ sio/J PIIClllllo /homx is so named because of the high

air lensio n (pressure) that may so metimes develop in lhe pleural space (between the lun g and chest wall ) due to a lung injury. Th is very high positive pressure collapses the low-pressure superior and inferio r vena cava, prevent ing the return of venous blood to the hea rt. Shi fti ng of mediastinal structures Tlla y also lower veno us return by impinging on the superi or and inferior vena cava, also causing a deviation of the trachea away from the affected

INmAl ASSESSMENT lOC Possibly decreosed Airwoy Possibly snoring Br~thin8

Possibly diaphragmotic only Pulses Normol or slow rate W~,

Skin color norma l without diaphOfesis

------------------~----------------RAPID TRAUMA SURVEY Neck Vein$ Flat Trachea Midline Chest >'".-\oy be normal Breath Sounds Norma l Extremities Absent motor/sensory (usually from neck or upper chest down) FIGURE 8-2 nd
126 - CHAPTER 8 Shock Evaluation and Management

ApprehensiOn, agitation Increasing cyanosis, air hunger (ventilaUon severely - -Impaired)

Possible subcu!aneotJs emphysema

Shock: skin

---'

'-------'1--- - - -- -

Distended neck veins

··~fP11 .:~.,j~:::,~---=:::,"_;;c_- Tracheal displacement ~ toward uninjured side --f~--­

f""""'~::::,J~==;-;:-~'-----f

Hyperresonant

j

percussloo note: breath sounds or absent

oo~.

FIGURE 8-3 Physical findings of tension pneumothorax_

side_ Decreased venous return results in lower cardiac output and the development of shock. (Sec Figure 8-3 and Chapters 6 and 7 for a complete description of the signs, symptoms, and treatment of tension pneumotho rax, ) • Cardiac (mupol/(lde (or "pericardial tamponade") occurs when blood fiUs lhe "potential " spaCe between the heart and the pericardium, squeezing the heart and preventing the heart from fillin g (Figu re 8-4). This decreased filling of the heart causes cardiac output to fall , resulting in the development of shock, Pericardial tamponade may occur in Illore than 75 percent of cases of penetrating cardiac injury, The signs and symptoms of tamponade have bccn labeled as " Beck's triad," consisting of shock, muffled heart tones, and distended neck veins, On-scene in terventions should be avoided if th e diagnosis is suspected, beca use any time wasted on-scene cou ld result in death of the patien t, Definitive surgical care in the nearest approp ri ate facility for pericardial deco mpression may be the only life-saving measure available. Using in t ravenous l1u ids to increase filling pressure of the heart Tllay possibly be of some value, but IV l1uids could also worsen the condition if there is an additiona l internal exsangu inating inju ry, Usc of IV l1uids in this situation should be during transport and on ly on the order of medical direction . (See Chapter 6 for a morc complete discussion. ) • Myocardial cOlllus;OIl ca n result in diminished ca rdiac output because thc heart loses pumping ab il ity due to direct injury to the heart muscle (Figure 8-5 ) and/o r cardiac dysrhythmias (Figure 8-6), Myocardial contusion often cannot be differentiated from cardiac tamponade in the field. Therefo re, rapid transport, supportive care, and cardiac monitorin g are the mainstays of therapy.

CHAPTER 8 Shock Eva luation and Management _ 127

Distended neck veins

------------t,

Blood in the pericardial sac compresses the heart and impairs ventricular lilling

A reHex tachycardia attempts to (but cannot) compensate for a low output

r---c=''---- Trachea midline

,-------'=0...,-- This results In a low cardiac output and high central venous pressure

-----'1- Norma! breath sounds

Tamponade is diagnosed by distention of neck veins, hypotension, and narrowed pulse pressure

FIGURE 8-4 Pathophysiology and physical findings of c.1Tdiac tamponade.

FIGURE 8-5 Myocardial contusion most frequ ently affects the right atriulll and ventricle as

they co llide with the sternum.

128 •

CHAPTER 8 Shock Evaluation and Management

A word of caution is impo r ta nt here. Pat ien ts with shock fro m m echan ica l causes can be vcry nC:lr death. Delay o n the scene ma y preven t salvage of t he pati ent. For exa m ple, o ne urb'lIl stud y has sugges ted that , in applicable cases, the t ime fro m d evelopmen t of a tampo n'ld e to ci rculato ry arrest may be as litt le as 5 to FIGURE 8-6 Myocardial contusion may cau$(' vent ricular 10 min utes . Survival fo llowing t raum atic ci rcu latory « topy. arrest, even in the best of t rau ma sys tems, is rarely achieved if su rge r y is not performed with in 5 to 10 minutes. MECHANICAL (OBSTRUCTIVE) SHOCK Mechanical shock is caused bY'1 dimin ished ca rd iac output rather than SCENE StZE-UP Sect belt? Steering wheel? Is the scene SAFE? blood loss; t hus, these pat ients usually have a d ifferent appearan ce at the bed------ -------------------{----------------- --------side than hemorrhagic shock pat ients. tNITIAL ASSESSMENT Since the Cilrdiac Ollt'Put is diminished, LOC t he blood backs up into the venous sysPossibly decreosed tem, result ing in distended neck veins. Breothing Rapid and labored T he lungs arc not being perfu sed well, Pulses causin g the patient to become cyanotic. Weak/threody; ponibly irregular; ponibly absent radials Because the patient is in shock with an Skin Pole/cool/diaphoretic; possibly cyanotic intact spi nal cord, catcchola mines are rcle'lsed and the pat ient de\'elops pallor, ------------------------- ic ------------------------tachyc
MANAGEMENT AND TREATMENT General Management of Post-Traumatic Shock States Ma rl:lgel11en t of post-traumatic shock sla t('s includes the following:

-- ---

PEARLS

Hemorrl,age

Control hemorrhage. If it cannot be done in the field, the patient needs to be in the operating room as soon

MP"'ibI<.

I. Comrol bleedillg. Red blood cells arc necessa ry to c:lr ry oxygen. Control of bleed ing must be obtained ei ther by di rect prl.'ssure o r rapid tra nsport to surgery.

2. At/minister high-flow oxygell. Cyanosis iS :ln ex tremely la te sign of hypoxt'mia and may not occur at all if there has been extensive blood loss. Indeed, a p:lt ien t has to have 5 grams of deoxygenated he mog lobin per 100 cc of blood for cya nosis to occur. Someo ne bleed ing to dea th , literally, may not have eno ugh hemoglobin a ro und 10 man ifest C)'anosis. G ive high- flow oxygen to all patients at risk for shock. Try to maintain a pulse oxi meter reading greater Ih;m 95 percent.

3. Load ami go. Trauma pat ients in shock fro m :m y ca usc :lrc considered to be in the load-and-go ca tegory. Transport as soon as you fin ish the ITLS Primar y Survey

CHAPTER 8 Shock Eval uat ion and Management _ 129

(Initial Assessment and Rapid Trauma Survey). Almost all critical in terventions should be done in the amb ulance (see Chapter 2).

Treatment of Post-Traumatic Hemorrhage Specific prehospital management of the patient in shock remai ns both cont roversial and th e subject of o ngoi ng resea rch. Th ere is no question of the need for control of hemorrhage, supplemental oxygen, and early transport, but the indications for most other therap ies arc still being debated . For example, the Natio nal In stitutes of Health is sponsoring a major international clinica l trial <\t th is time to determine the op timal treatment for hemorrhagic shock due to trau ma (and traumatic brain injury) in the prehosp ita l environme nt. Since the early days of modern shock treatment (about the middle of the 20th centu ry), intravenous crystalloid sol ut ions (and sometimes colloid ) have been tested and/or utilized to reverse the effects of hypovolemia. In addition, it has been previously proposed that intra-abdominal and pelvic bleeding may possibl}' be diminished by use of the pneumatic 'lIltishock garme nt (PASG; o r military antishock trousers, MAST). Research showed that the PASG seemed to cause a worsening dea th rate when the garment was applied to p.llients with un controlled bleeding. Indeed, current rescn rch into the management of hemo rrhagic shock due to trau ma suggests a modified approach. Patients in hypovolem ic shock due to hemorrhage may be generall y thought of as fall ing into one of the following two categories: those with bleeding that you ca n co ntrol (such as many ext remity injuries) and those with bleeding that you can no t control (such as internal inju ries ). Hemorrhage That Can Be Controlled: A patient with controllable bleeding is fairl y eas), to manage. Most bleedi ng ca n be stopped with direct pressure. In some si tuations (usually blast or tactic'll injuries) there mn)' be exsnnguinating hemorrhage thnt )'ou cannot control with direct pressure. In these most ex treme circumstances you should not hesitate to apply a tourn iq uet. A tourniquet is rarely needed but when it is needed, it should lx, applied q uickly. If the pat ient has clinical evidence of shock that persists after direct co ntrol of the bleeding, you should take the steps described below.

PROCEDURE

[iJ Managing Shock When Bleeding Has Been Controlled I. Put the patient's body in a horizontal or slightly head-down position. 2. Admi nister high-flow oxyge n, preferably using a nonrebreather mask wi th a reservoir. 3. Transpo rt immediately and in a sa fe, rapid manner. 4. Obtain IV access wi th large-bore cat heters ( 16 gauge or greater). Co nsider in traosseous vascular access if the patient is critical and you are unable to estnblish an intravenous line. S. Using normni saline, give a bolus of 20 mLlkg IV mpidly and then repeat the ITLS Ongoing Exam. If shock symptoms persist, continue to admin ister fluid in boluses and reassess. Jn some cases of vcr)' severe hemo rrh age, because of the substantial loss of red blood cell s and markedly impaired oxygen dctiver)' to the tissues, shock symptoms and signs mily persist despite hemorrhage con trol and IV volume infusion. These patients need the rapid transfusion of blood and/or blood products.

• • • • • PEARLS

IV Access Do not waste scene time to lmabrtsh IV itCCeSS. Consider the use of intraosseous mcular access if the patient is critical and you cannot obtain lV access.

130 • CHAPTER 8 Shock Evaluation and Management

6. Place the patient

011

an EKG monitor early during evaluat ion and treatment.

7. Apply pulse oximetry and, if available, waveform capnography. 8. Perform Ongoing Exams. and observe clOSel)f, especi'llly for any return of bleeding.

Hemorrhage That Cannot Be Controlled Extenrnl Hemorrhage. A patient with external hemorrhage that is not controlled by di rect pressure must be rapidly transported to an app ropriate fuciJi tywhere necessa ry procedures to gai n surgical hemostasis can be perfo rmed. Although most physicians advocate fluid resusci tation to treat hemorrhagic shock, you must also remember that elevating blood pressu re can incre,lse uncontrolled hemorrhage. To 1ll,IIl;lgC thi:; patient , you :;huuld takt: the following steps. PROCEDURE

Fj3 Managing Shock Due to Exsanguinating External Hemorrhage That You Cannot Control 1. Apply dirc'Ct pressure on the bleeding site (c.g., femoral artef)', facia l hemorrhage). Substantial pressure may be req uired. Releasing of direct pressure may result in the con tin uat ion of bleeding. 2. Put the patient's body in a horizontal o r slightly head-down position. 3. Apply tourniquets to a bleeding ext remity only as a critical attem pt to stop severe bleedin g that ca nnot be otherwise controlled (d iscussed earlil,.'r). 4. If you cannot stop severe bleeding with pressure and cannot use a tourniquet (groin, axilla, neck, face, sca lp), you should use one of the hemostatic agents such as Qu ikClot 1st Response or Celox (see Chapter 14). Pack the hemostatic agen t in the wound and hold firm pressure. 5. Admin ister high -flow oxygen th rough a nonrebreather Illask with a reservoir. 6. Transport immediately and in a rapid, safe manner. 7. Gain IV access when en route. Consider in traosseous vascu lar access if patient is critica l and you are unable to establish an in travenous line. a. Give only enough normal saline to maintain a blood pressu re high enough for adeq uate peripheral perfusion . Maintaining peripheral perfusion may be defined as producing a peripheral pulse (such as a radial pulse), maintain ing consciousness (assuming a traumatic brain injury is not also present), and maintaining an "adequate blood pressure." The definition of an adequate blood pressure (" How low can YO li go?") remains controversial and will continue to be subject to change based upon ongoing research . Certai nly most young patients can maintai n adequate perfUSion with a blood pressure of 80 to 90 mmH g systolic, but some experts now advocate even lower pressures. Keep in mind thaI a higher systolic pressure m,IYbe required in the sett ing of head injury with increased intracerebral pressure (sec Chapter 10) and in patients with a history of hypertension. Rely o n local medical direction fo r guidelines in this area. b. Early blood transfusion is the most im po rtant flu id replacement in severe cases. c. Finally, substa ntial research into the use of hypertonic saline for uncontrolled hemo rrhage suggests promising evidence th,lt small volumes of concentrated sali ne may suppOrt the vascular staws or the bleedi ng patient by pu llin g in terstitial flu id into the vascular space. It is unclea r at this time whethe r hypertonic saline is safe for use via intraosseous access. Also, early work at th is

CHAPTER 8 Shock Evaluation and Management _ 131

time indi cates a potential role in the future fo r artificial bl ood products that carry oxygen 10 the tissues. 8. Mon ito r the heart, and apply pu lse oximetry and waveform ca pnography ( if ava ilable ) . 9. Perfo rm IT LS O ngoing Exa ms, and observe closely. NOTE: If assistance is not avai lable, co ntrol of hemorrhage, even if m in imal, shou ld remain the priorit y. Other procedu res become secondary if they interru pt attempts to maintain hemorrhage controL In the case o f woun ds with exsanguinat ing hemorrh age, the military has changed the initial assessment fro m ABC (ai rway, b reathing, and circula tion ) to CAB, making control of the hemorrhage the first priority. illtertUlI Hemorrhage. T he patient with uncontroll ed internal hemorrhage is the classic critical traum;1victim who will almost certainly die unless you promptly transport to an appropriate faci lity where rapid operative hemostasis can be obtained . The results of the most current medical research on the management of patients with exsan guinating internal hemorrhage is that there exists no substitute for gaining surgical control of bleed ing. Recent work on the adm in istration of IV fluid s and the use of lhe PASG (pneumatic antishock garment ) in shock patients with presumed internal hemorrhage suggests the foll owing:

• Use o f the PASG in the sett ing of uncont rolled internal exsa nguination due to penetrating inj ury may increase mortalit y, especiall y in Ihe setting of intrathoracic hemorrhage. The PASG ra ises blood pressure, and rai sing blood p ressure in the setting of bleeding vessels within the thorax, abdomen, and pelvis prob,lbly increases internal bleed ing, raisin g the chance of death due to exsanguin;ltio n. • Likew ise, the use of large amounts o f IV fl uids in the setting of uncontrolled internal hemo rrhage may also increase internal bleeding and mo rtality. IV fluid s increase the blood pressure (li ke the PASG), but fluids may also d ilute clotting fac tors. Furthermore, IV fluids carry almost no oxygen and are not a replacement fo r red blood cells. Ea rly blood transfusion is vcry important in severe cases of hemorrh agic shock. • Any del ay in providing rapid transport of such patients sho uld not occu r u nless absolutely unavoidable, as in the case Of :l patient requirin g prolo nged extricatio n. Always document such circumstan ces carefully in th e P;ltient Care Repo rt. • i\'loribund tra uma patients (o nes in ver)' deep shock wi th blood p ressures under 50 mml-Ig systolic, i.e., non palpable pulses) usuall y die, but fluid administ rat io n may be ind icated to ma in tain some degree of circulation. Treat ment of this ext reme amount of hemorrhage may o verride the concerns for increased hemorrhage secondary to the use o f these interventions. However, this approach is still controversial. Local medical directio n sho uld guide such therapy pend ing furth er research. The recommendations, therefo re, fo r a patient with probable exsan guinating internal hl'morrhage secondary to penetra tin g injuries arc d escribed below.

PROCEOURE

EiJ Managing Shock Due to Internal Hemorrhage 1. Transport immediately and in a rapid, safe mann er. 2. Put the pa tient's body in a ho rizontal or slightly head -down position. 3. Adm inister high-flow oxygen.

132 • CHAPTER 8 Shock Eval uation and Management 4. Gain IV access with large-bore catheters. Consider int taosseous vascula r access if unable to establish an in tra\'enous line.

s.

Administer sufficient no rmal sali ne to maintain peripheral perfusion. Local medical direction should guide what is acceptable practice in this setting. Ma ny experts now recom mend that flu id resuscitation be kept to a mi nimum until hemorrhage cont rol is obtained (operat ive in tervention ). Hemostatic agents can no t be used for internal hemorrhage. Aga in , substantial research into the usc of hypertonic saline for uncontrolled hemorrhage suggests prom ising evidence tha t small volu mes of co ncentrated saline may support the vascular status of the bleed ing patient by pulli ng interstitial fluid into the vascular space. Research into the li St' of artificial blood products conti nues.

6. Monito r th e heart, and apply pul se oximetry and waveform capnography (where available) . 7. Perform ITLS Ongoin g Exams, and observe closely. Current published research has not yet adequately addressed the treatment of the patient with presumed internal hemo rrhage in the setting of blunt inju ries (MVCs, fa lls, and so on ). This creates a di lemma because many patients with blunt injuries can lose a significa nt amount of blood and Il uid from the in travascular space into the sites of large-bone fractures (hematoma and edema ). This loss can be eno ugh to calise shock, and yet the blood loss fro m these fractures is usually self- limited, wi th the exception of pelvic fra ctures. Pelvic fractures can result in exsanguinatio n and death. In theory, this situation should be treated with oxygen and in travascular vol ume expansion (IV flu ids). However. if the blun t inju ry patient has a tear of ,I I:lrge in ternal blood vessel or a lacera tion or avulsion of an internal organ, raising the blood pressure prior to surgical intervent ion rna)' also result in accelerated bleedi ng or a second,lry hemorrhage. Therefore. if an internal hemo rrhage is not suspected (patient is alert and o riented and has no apparent chest. abdom inal. or pelvic injuries). fl uids may be used judicio usly for fra ctu res and externally controll ed hemo rrhage. In the case of a severe mechanism of injury and/o r in ability to assess the patient, use fluid s judiciously. Administer enough fluids to maintain peripheral perfu sion. Remember that early blood transfu sio n, when available. is the most app ropria te flu id rcplacemen t of severe blood loss. Frequent pat ient assessments and local EMS medical direction should gu ide therapy.

Special Situations in Hypovolemic Shock Head Injury: The pat ient with severe head injury (Glasgow Coma $calc score of 8 o r less) and shock is a special situation (see Chapter 10). These patients do not tolerate hypotensio n. Therefore, if necessary, adults with suspected hemorrhagic shock in add ition to head inju ry shou ld be fluid resuscitated to a blood pressure of 120 mmH g systolic to main tain a cerebral perfusion pressure of atle,lst 60 mmH g. Nonhemorrhagic Hypovolemic Shock: The patient who has low-vol ume shock syndrome not due to hcmorrhage can generall y be manilged in the same man ner as a pat ient with shock due to bleeding thai can be con trolled. An exam ple of this type of patient wo uld be one with shock due to fluid loss from burns o r severe diarrhea. Low-volume shock is the usual cau se of death in these patients. Since the loss of volu me in this case is

CHAPTER 8 Shock Evaluation and Management _ 133

not from an injured vascular system, it is reasonable to treat such patients with aggressive volume replacement to restore vital signs to\vard no rma l. lust beware: Hemorrhagic shock d ue to a bleed ing internal o rgan (such as a bleedi ng ulcer or a ruptured ectop ic pregnancy) may be rapid ly lethal , and the bleedi ng may no t be at all apparen t from the physical examination. So, if you see signs of shock present , follow the basic rules of shock management until you have ex plai ned the ca use. For example, an unconscious, pale young woman of childbearing agc is bleeding to death from a ruptured ectopic pregnancy until proved o th erwise.

Treatment of Nonhemorrhagic Shock Syndromes Treat ments for the o ther shock syndromes, na mely, mechanical (cardiogenic) and highspace (relative hypovolemia ) are somewhat different All patients require high -fl ow oxygen, rapid transpo rt , shock positioning, and IV line placement (usually en route). Mechanical Shock: The patient with mechan ical shock must first be accurately assessed to determine the cause of the problem. The patient with tension pneumothorax needs prom pt deco mpression or the elevated pleural pressu re. (See Chapter 7 for indicat io ns and procedure fo r decompression.) The patient with suspected pericard ial tamponade must be rapidly transported to an appropri ate facil ity, beca usc the time from o nset of tam ponade to the time of cardiac arrest can be a matter of minu tes. \Vhile anecdotal su pport ex ists in the li terature fo r usc of an intravenou s volu me challenge in such patients as a temporizing me:lsure, no clear evidence exists that such treatment will improve su rvival. Use of IV flu ids in this situation should be d uring tra nsport and only o n the o rder of med ical direct ion. Obtaini ng IV access certainly should not delay direct transport or ai rway/oxygen in terventions. Consider int raosseous vascu lar access if unable to establish an intravenous line. Bear in mi nd that Imuma is not the on ly cause of tamponade. Metasta tic cancer and other diseases resulting in pericardial effusion may also cause tamponade. Myoca rdial contusion rarely causes shock. Recent reports indicate that most contusions cause li ttle or no clin ical findin gs. However, severe contusio n may cause acute heart fa ilure, manifested b),distended neck vei ns, tachycardia, cya nosis, and possibly arrhyth mias. These are the same signs seen with pericardial tam ponade. These patients require rapid transpo rt (or proper care. Give high-flow oxygen and perform cardiac monitoringon the patient with suspected myocardial contusion. IV flu ids may cause worsening of the patient's condition. High-Space Shock: High-space shock, in th eory, resembles contro lled hemorrhage, in that there is relative hypovolemia with an "i ntact" vascular system (no "leaks"). Therefore, initial management includes IV tluid boluses. Consider intraosseous va.scular access if the patien t is critical and you are unable to establish an int ravenous line. In the absence of a head inju ry, the patient's level of consciousness is a useful monitor of the success o r fa ilu re of resuscitat ion. Be alert fo r possible occult in ternal injuries, and keep in mind that raising the blood pressure may increase internal bleed ing in that situation. An argument can be made for the use of vasopressors in patients with vasodilator), shock, such as in calcium cha nnel blocker overdose o r sepsis.

134 • CHAPTER 8 Shock Evaluation and Management

(Photogra ph C Craill J~ckstmf In tht Da rk I'hotography)

Dan, Joyce, and Buddy of the Emergency Transport System have been called to the scene of a single vehicle, high-speed, side-impact auto collision. They are informed that a rescue truck is on-scene and attempting to extricate the driver. Whi le driving to the scene, they decide that Buddy will act as team leader on this call. On arrival Buddy gets the trauma box and cervical collars and begins the Scene Size-up. Dan gets the oxygen and airway equ ipment and Joyce gets t he backboard. Buddy notes that the police are on-scene and they signal that the scene is safe. The team dons personal protective equipment, and each carries his or her part of the essential equipment as they approach. The driver of the car had lost control on a wet road and hydroplaned. The car rolled over several times and then side-impacted a tree, finally coming to rest on its left side. The driver has been extricated but is dead on·scene. The restrained front-seat passenger is alert and oriented but complains of chest and abdominal pain. After extrication, Buddy's Rapid Trauma Assessment reveals facial lacerations but an open airway, tender lower ribs (no crepitation) on the right with a tender abdomen. He also has deformity and instability of the right thigh. Breath sounds are present and equal and the pelvis is stable and nontender. The patient has a strong regular pulse and a normal respiratory rate with good air movement. Because of the tender abdomen, they quickly package the patient and immediately load and go. In the ambulance the vital signs are pulse 110, respiration 22, BP 120/90. The patient states he has no allergies, takes no medications, and has always been healthy. Last food was about 4 hours ago. After applying a traction splint to the right leg, Dan starts two large-bore IVs of normal sa line at a KVO (keep vein open) rate. Buddy cails his on-line medical direction (OLMO) and reports that he is transporting a patient who has been in a high-speed MVC in which the driver was killed. He suspects that the patient has rib fractures, intraabdominal injuries, and a fractured femur. OLMD instructs them to lim it IV fluids un less the palient becomes hypotensive and then only give enough to mai ntain systolic BP of 90 mmHg. They are to transport the patient to the local level-one trauma center. OLMO also instructs the team to monitor waveform capnography, and the cu rrent reading on exhalation is 40 mmHg. The ITLS Ongoing Exam performed 5 minutes later re veals that the patient's condition has changed. The pulse has increased to 140, the blood pressu re has dropped to 70/40 with an absent radial pulse, and the waveform capnography is now 25 on exhalation. The abdomen has become distended and rigid. The lungs are still clear. Buddy gives 250-cc boluses of normal sa line until the systolic blood pressure is 90 mmHg and a radial pulse returns. The trauma team is mobilized and waiting when they arrive. The patient is found to have a fractured right femur and a lacerated liver, but no other major injuries. His liver la ceration is repaired and he receives six un its of blood, but recovers uneventfully.

CHAPTER 8 Shock evaluation and Management _

The mechanism of injury in this scenario is both rollover and lateral impact, with the driver recei ving the brunt of the forces from the lateral impact. The driver died from major chest inju ries. The passenger received se rious injuries but was saved because he was restrained. Though his vital signs were good when EMS arrived, they recognized the tender abdomen was suggestive of internal injuries and were prepared for the development of hemorrhagic shock. IV fluids were given to maintain perfusion to vital organs but they did not try to raise the blood pressure to normal levels because of the danger of increasing intra-abdomina l bleeding. The fractured femur was also a factor here, as there is usually a loss of one or two units of blood into the soft tissue of the thigh after a femur fracture. Falling waveform capnography provided addit iona l verification of the patient's worsening shock state.

SUMMARY A patient with shock must be diagnosed early. The early signs and sympto ms of shock may be subtle, and when the later signs such as hypotension develop, the palie nt may be near death. The importance of ca reful assessment and reassessme nt ca nnot be overemphasized . You must understand the risk of any of the shock states to yo ur patient. Further, yO li need to study and memorize the shock syndromes, especially in regard to the rapid provision of the proper treatment for such conditio ns as internal hemorrhage, pericard ial tam ponade, and tension pneumothorax. Finally, you should be aware of the controversy on the lI SC of [V flu id resuscitation for cases of uncontrolled hemorrhage. Rely on your local medica l d irection to help keep you current on the standard of ca re in these areas.

BIBLIOGRAPHY I. Bickell, W. H., rv!. J. Wall, P. E. Pcpe,et al. 1994. Immediale versus delayed fluid resuscitation for hypotensive patients with penetrating torso injury. Nell' Englanlllollfll(li of A'fedicine 331 ( Oc~ tober); 1105-9. 2. Champion, H. 2003. Combat fluid resuscitation. Supp/ellll'lIIto the IOllr1ll1l ofTrtllIlIIlI 54 . 3. Chiara, 0., P. Pelosi, L. Brazzi, el al. 2003. Resuscitation fro m hemorrhagic shock: Experimental model comparing normal s.1Iine, dextran, and hypertonic sa line solutjons. Critiml enre !'>'fedicine 31: 1915-22. 4. Demetriades, D., L. S. e h,lIl, P. Bhasin, et 011.1998. Relative bradycard ia in patients with trau matic hypotension.lol/rn(ll ofTmlllll(l45(3); 534-39. 5. Kow31enko, '1'., S. Stern, S. Dronen, X. \Vang. 1992. Improved oufCome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine mode. lolln/a/ ofTrmwlII 33: 349-53. 6. Mapstone, J., I. Roberts, P. Evans. 2003. Fl uid resuscitation st rategies: A systematic review of an imal trials. Journ(ll ofTrmlll/{/ 55: 571-91. 7. Mattox, K. L., W. H. Bickell, P. Pepe,et al. 1989. Prospecli\·e ~'I AST study in 911 patients.lournal

ofTmlllll(l29: 1104-12. 8. ~\'Ioore, E. 2003. Blood substitutes: The future is now. 10llr1llll of t/ie American College of SlIr-

geons 196: 1- 16.

J. IJaraff. 1991 . C lpi!huy refill- Is it a useful predictor of hypo\'Olemic slates? Al1l1(1ls of Emergellcy Me(lieille 20: 60 1- 5.

9. Schriger, D. L., L.

135

CHAPTER 9 Fluid Resuscitation Skills •

137

CANNULATION OF THE EXTERNAL JUGULAR VEIN The externa l jugular vei n ru ns in a li ne from the angle of the jaw to thej unction of the mcd ial and middle th ird o f the clavicle (Figure 9-1 ). This vei n is usua lly easily visible through the skin; pn.'ssin g on it just above the clavicle wi ll make it more prominent. It runs in to the su bclav ian w in . lndie.l tion for cannu lation of th e ex ternal jugular vein is the pediat ric or adult patient who needs IV access and in whom no suitab le peri pheral vein is found.

FIGURE 9-1 Anatomr of the external jugular vein.

PROCEDURE

~ Performing External Jugular Cannulation

1. Thc patien t must be in the supine position, preferably head down, to distend the vein and to prcvent air embol ism.

2. If no slIspicio n of cervical-spine inju ry exists. turn the patien t's head to the o pposi te side. If thcre is a dangcr of cervical -spine inju ry, one rescuer must stabilize the head (it must not be tu rned ) whi le the IV is being sta rted. The cervical collar shou ld be opened o r the fro nt removed du ring the procedure. 3. Q uickly prepare the skin with an antiseptic and thcn align the cannula with the vcin. The needle will be poin ting at the clavicle 'It the ju nclion oflh(' middlc and medial thi rds. 4. With one finge r, press a ll the vein just above the clav icle. This sho uld make the vein marc promincnt. S. Insert the needle into the vei n at about the m idportion and can nulate in thc usual way. 6. [f not already done, dr.lw a 30 cc sa mple of blood and store it in the appropriate tubes. 7. 111pe down the line securely. [f there is dangcr of cervical -spine injury. a cervical collar ca n be applied over the [V site.

INTRAOSSEOUS INFUSION The techn ique of bone marrow infllSion of fluid and drugs is not ncw.1t was fi rst described in 1922 and was used com monly in the 1930s and 1940s as an alt('rnative to IV infusio n of crystalloids. drugs, and blood. The tech nique was "rcd iscovered" in the 1980s, and studies haw confir med it to be a fast, safe. and effective route to infuse medications, fluid s, and blood. Intraosseous (10 ) infusion can be used for giving med ications in both adults and children, b ut becaus<.' the flow rate is not as rapid as pcripheral vcnous infusio ns, it ca nnot be used for rapid volume replacement in adults. Newer techniques for 10 insertion may prove to o ffe r adcquate flow rates for ad ult volume resusci tation. ln lraosseous infus ion has the adv,lIllage of being quick and sim plc to perform wh ile providing a sfil ble (anchored in bonc) access that is not easily dislodged during transpo rt.

Indications Indications for the usc of intraosseous infusion include the pedi.lIric or adult palicnt who is in cardiac arrest and in whom rou ca nnot quickly obtain peripheral ve n OliS access, and thc hypO\'olcm ic ped iatric palien t who has a prolon£cd transport (you do not need an IV if the transport is short ) and in whom you arc unable to quickly obtain peri pheral venous access.

138 • CHAPTER 9 Fluid Resuscitation Skills

• • • • • PEARLS

b,tr(JO$srous lnflls;o" ~ in~ltration occurs (rarel, do oot reuse the same bone. Anothef site must be selected because fluid will leak out of the original hole made in the bone. ~ this CICC\fi, .apply a pressure dressing and serure with an elastic bandage. Ne'ler place an r.traosseous line ina fr
Potential Complications Stud ies have shown that the follow ing complications a re rarc. However, good aseptic technique is important, just as it is wit h I V therapy. Po te nti al com plicatio ns of 10 infusion includ e: • Subpe riosteal in fusion due to imp roper placement • Osteomyelitis • Sepsis • Fal em bolism • Ma rro w damage • T ibial fracture if needle is too large

00

Performing Intraosseous Infusion in a Child

(See Appendix A for the technique of adu lt 10.) 1. Determine the need fo r this procedure; obtain permissio n from med ical d irectio n if

required. 2. Havc all needed equ ipment ready prior to bone penet ratio n. a. 16-18 gauge int raosseous needles

b. 10 cc syringe c. Antiseptic sol ut ion to prep the skin d.

rv tubi ng and

IV flu ids

e. Tap e and dressing material to secure the 10 needl e f. BP cuff o r commercial pressure device to infuse flu id lmder p ressure

3. Identify the sile, which is proximal tib ia, one fin gerbreadth below the tibial tuberosity either midi inc o r slightly medial to the mid line ( Figure 9-2). 4. Prep the skin with an appropriate antiseptic (very important ). 5. O btain the proper needlc. The needle must have a stylct so that it docs not become

Tibial

plugged with bo ne. Wh ile 13-, 18-, and 20-ga ugc sp inal needles wi ll work, they are difficult and uncom for tab le to grip d uring Ihe insertio n process. Long spinal needles lend to bend easily, so if you use spinal needles, try to ob tain the short o nes. The preferred needle is a 14- to 18-ga uge intraosseolls needle, b ut bo ne marrow needles ca n also be lIsed. 6. Using aseptic techn ique, insertlhe needle into the bone

Femur

Epiphyseal plate

FIG URE 9· 2 Insertion site for intrao~ us infusion needle in the proxi mal tibia.

marrow cavity. Insert the need le perpendicular to the skin, d irccted away fro m the epip hyseal plate (Figure 9-2), and advance to t he periosteum. Penetrate the bo ne wi th a slow bo ring or tw istin g motio n until you feel a s udden "give" (decrease in resistan ce) as th e needle enters the marrow cavity. Th is can be confirmed by removing the stylet and aspirating b lood and bo ne m ar row (Figures 9-3 and 9-4).

7. Attach standard IV tubing a nd infuse flui d and/or medicatio ns (Figure 9-5). Yo u may havc 10 infuse flu id

CHA PTER 9 Fluid Resuscit ation Skills •

139

Remove

stylet Check placement by aspirating marrow and !hen nushing

FtGURE 9-4 To check needle placement, aspirate a pproximatel y I cc of bone marrow.

FIGURE 9·3 Remove stylct (rom the needle and au ach syringe.

under pressure (BP cuff blown up around IV bag) to o btain an adequate infusion ratc. 8. Tape the tubing to the skin and secure the bone marrow needles as if to secure an impaled object (gauzc pads taped around the insertion site).

LENGTH-BASED RESUSCITATION TAPES

FIGURE 9·5 int rilOSK'OUS m'Ct!lc in child's tibia being used for flu id infusion. (1)llOto COIlrtesy of Bob Page. NREM T. P)

Calcu latio n of the volume of fl uid resuscitation or the dose of an IV medication for the pedia tric patient depends on the patient 's weight. In an emergency situatio n the age and weight of a child may not be know n. The weight of a child is directly related to his length , and resuscitatio n tapes (Broselow " Ipe or SPARe system) have been developed that estimate a child's weight by measuring his length. These ta pes contain precalcula ted doses of IV Ouids and emergency drugs fo r each .....eight range ( Figure 9·6). They also include the correct sizes of emergency equ ipmenl and supplies for each weight range.

140 •

CHAPTER 9 Fluid Resuscitation Skills

PROCEDURE

00

Estimating a Child's Weight with a Length-Based Resuscitation Tape

I. Place the patient in the supine position.

2. Using the tape, measure the patient from the crown to the heel. Place the red end wi th an arrow at the crown of the child 's head , and stretch the !npe 10 the child 's heel (see Figure 9-7). 3. Note the box on the lape al which the child 's heel falls. With the SPARe system , match the color of the tape at which the child 's heel falls with the snm(' colo red nre:l of the booklet. 4. If the measurement fa lls on a line, the box or colored panel proxi mal to the line is used to generate the fluid ll nd dru g doses and the size of eq uipment needed fo r resuscitntioll.

s.

T he tllpe m a), be disin fected if it becomes contaminated.

FIGURE 9-6 SPARe system has color-coded tape and booklet of

pn.'calculated doses of fluids and mooicatiolls. (PholO courtesy of Kyee HUll, MOJ

FIGURE 9 -7 Measure the patient from crown to heel 10 read precalculated doses of fluids and

medications.

Joyce, Dan, and Buddy have been dispatched to a private home where a man has fallen off of a

(Photo cou rlCliY of Roy Alson. MO)

la dd er. As they respond, they decide that Joyce w ill be team leader. When they arrive, they find a small group of people huddled around a 40-yea r-old man who was taking down Christmas decorations and slipped off the ladder, landing on his head. The scene is sa fe and he is the only patient. His fall was w it nessed by his w ife who , with tears in her eyes (s he insisted that he remove the decorations that day), says that when his foot sli pped, it ca ught in the rung of the ladder and he swu ng like a pendu lum , st riking his head on the concrete driveway. He was unconscious for a few minutes and she was sure that he was dead. Now he can not remember go in g up the ladder at alL She says he is in good health, takes no medications, and has no allergies . She prepared him lunch (hambu rgers) about 2 hours ago. He com plains of a headache and nausea and says his neck hurts.

you suspect from a mechanism such as this? Keep

What injuries would

th is question in mind as you read

the chapter. Then, at the end of th e chapter. find out how the rescuers completed t his ca lL

INTRODUCTION Head injuries or, more specifically, trau matic brain inju ry (TB I) is a major cause of death and dis..1.bi lity in multiple trauma patients. Forty percent of multisystem trauma patients have a central nervous system (eNS) injury. These patien ts have a death rate nvice as high (35 percent versus 17 percent) ;lS that of patien ts without eNS inj uries. Head injuries ac· co unt for an estimated 25 percent of all trau ma deaths and up to one· half of alll11olorvehicle fatalities. Worldwide, the cost of TBI is staggeri ng, in terms of lives lost, fa milies destroyed, and money spent for care. Preventio n remains the most effective treatment. You can help reduce th is major ep idemic by encouraging the lise of helmets and restrain t devices in vehicles. You may be called upon to ma nage head inju ries that can range from the trivial to the immed iately life threat ening. By recogn izing those inju ries that need immediate interven tio n and providing transport to the appropriate facility, )'OU can significa ntl y im prove the chances for a patient having a good outcome. Because it is not possible to perform a field clearance of th e cervical spine in a pa ti ent wit h altered mental status and because head injury often results in th e alterat ion of conscio llsness, ),O ll must always assum e th at a serious head injury is a((omplmied by an injury to the cervical spine and spinal cord .

142

CHAPTER 10 Head Trauma _

Beginning with the third edition of this text , !Haterial included in th is chapter has been based upon the recommendation s of the Bra in Trauma Fou ndat ion (a multidisciplinary organiza tio n d ed icated to improving care of TB I victims by use o f evidence-based treatment ).

ANATOMY OF THE HEAD edge of the basic anatomy and physiology of the head and brain. The head (excluding the f;\Ct, and f
Pia mater

oort6)(

Cerebellum Medulla oblongata

FIGURE 1 0 -1 Anatomy of the head.

- . --.

PEARLS

To m ost effectively manage the head -injured patient, you should 11:1\'e a working knowl-

-,I=:::::~~L

143

Spinal oord

Cervical-SpitJe ltJjury Mways anticipate a cervical-spine injury in the head-injured patient

144 • CHAPTER 10 Head Trauma (called simply the arachlloid), which lies underneath the dura and in which are suspended both arteries and veins; and the very thin pia mater ("soft mother"), which lies underneath the arachnoid and is adherent to the su rface of the brain. The cerebrospinal fluid (CSF) is found beneath the arachnoid and pia mater. The intracranial volume is composed of the brain, the CSF, and the blood in the blood vessels. These three completely fi ll the cranial cavity. Thus the increase of anyone of these is at the expense of the other two. This is of great importance in the pathophysiology of head trauma. Following injury. the brain . like all injured tissue. will sweU. Because of the fixed space, as the tissue swells and the volume of fluid inside the skull increases. so does the pressure. Cerebrospinal fl uid (also called spillal flllid ) is a nutrient fluid that bathes the bra in and spinal cord. Spinal fluid is continua lly created within the ventricles of the brain at a rate of 0.33 mUmin.1t is reabsorbed by the aracll lloid membrane that covers the brain and spinal cord. Anything obstructing the flow of spi nal fluid will cause an accumulation of spi nal fluid within the brain (hyd rocephalus) and an increase in intracerebral pressu re (lel').

PATHOPHYSIOLOGY OF HEAD TRAUMA Primary and Secondary Brain Injuries Head injuries are either open o r closed. depending on whether the object responsible for the injury compromised the skull and exposed the brain. Brain injury can also be divided into h vO components, primary and secondary. Primary brain injury is the immediate damage to the brain tissue that is the direct result of the injury force and is essentially fixed at the time of injury. Management of primary brain injury is best directed at prevention with such measures as better occu pant restraint systems in autos, the use ofhclmcts in sports and cycling, firearms education. and so forth. While penetrating wounds to the brain always cause primnry injury, most primary injuries occur either as a result of external forces applied again st the exterior of the sku ll or from movement of th e bra in inside the sku ll In deceleration injuries the head usually strikes an object such as the windshield of an a utomobile. which (;l llseS:1sudden d('Celeralion of the skull. The brain co ntinues to 1110ve forward. impacting first against the skull in the original direction of motion and then rebounding to hit the opposite side of the inner surface of the skull (a "fourth n collision). Thus, injuries may occu r to the brain in the area of original impact ("coupn) or on the opposite side ("contracoup"). The interior base of the skull is rough (Figure 10-2), and movement of the brain over this area may cause various degrees of injury to the brain tissue or to blood vessels supporting the brain. Good prehospital care can help prevent the development of secondary brain injury. Secondary brain injury is tllC resuit of hypoxia or decreased perfusion of brain tissue. Secondary inju ry is the result of th e brain's response to th e primary inj ury. with swelling causing a decrease in perfusion, or from complications of other injuries (hypoxia or hypotension ). The initial response of the injured brain is to swell. Bruisin g or injury causes vasod ilatation with increased blood flow to the injured area, and thus FIGURE 10-2 The rough inner base of the skull. an accumulation of blood tha t takes up space and exerts pressure

CHAPTER 10 Head Trauma _ 145

o n sur ro und ing brain tissue. There is no extra space inside the sku ll. Swelling of the in· jured area increases in tracerebral pressure and eventua lly decreases blood flow to the brain that causes furth er brain injury. The increase in cerebra l water (edema ) does not occur im mediately, but devel ops over hours. Ea rly efforts to maintai n perfu sion of the brain can be li fe·saving. The brain normally adjusts its own blood flow in response to metabolic needs. The au · toregu lation of blood flow is adjusted based on the level of carbon dioxide (C0 2 ) in the blood . The normal level of CO 2 is 35 to 40 mmHg. An increase in the level of CO 2 (hy· povcntilation ) promotes cerebral vasod ilatation and increases ICP, while lowering the level of CO! (hyperventilat ion) causes vasoconstriction and decreases blood flow. In the past, it was thou ght that hyperventi latio n (lowering of CO 2) in the head-injured patient wou ld decrease brain swelling and thus improve cerebral blood flow. Research has shown that hyperventilation actually has o nly a slight effect on brain swelling. bu t causes a significant decrease in cerebral perfusio n from vasoconstriction, which results in cerebral hypoxia. The injured brain does not tolerate hypoxia. Thus. bo th hyperventilation and hypoventilation call causc cerebral ischemia and increased mo rtality in the T BI patient. Maintaining good ventilation (not hyperventilation ) at a rate of about o ne breath every 6 to 8 seconds (8 to 10 per minute) with high-flow oxygen is very important. Prophylactic hyperventilation fo r head injury is no lo nger recom mended.

INTRACRANIAL PRESSURE 'Within the skull and fibrou s coverings of the brain arc the brain ti ssue. cerebrospin al fl uid, and blood. An increase in the volu me of anyone of these co mponents must be at the ex pense of the other two because the adult skull (a rigid box) ca nnot expand. AJthough there is some give to the vo lume of cerebrospinal fluid , it accounts fo r little space and cannot offset rapid brain swelling. Blood supply cannot be comprom ised, for the brain requires a co nstant supply of blood (oxygen and glucose) to survive. Thus. since nOlle of the supporting components of the brain can be compromised, brain swelling can be rapidly catastroph ic. The pressure of the brain and contents with in the skull is termed ;lIfracra l/;al press1Ire (lCP). This pressure is usually very low. Int racranial pressure is considered dangerous when it rises above 15 mmH g; cerebral herniation may occu r at pressures above 25 mmHg. The pressure of the blood flowing through the brain is termed the cerebral perfusioll pressure (CPPJ. Its value is obtained by subtracting the intracranial (intracereb ral) pressure fro m the mean arterial blood pressure (MAP). MAP = Diastolic BP

+ 1/3 (Systolic BP -

Cpp

~

Diastol ic UP )

MAP - ICP

If the brain swells or if bleeding occurs inside the skull , ICP increases and the perfusion pressure decreases. resulting in cerebral ischemia (hypoxia). If the swelling of the brain is severe enough, the ICP equals the MAP and blood flow to the brain ceases. The body has a protective refl ex (Cushing's response or refl ex) that attempts to mainta in a co nstant perfusio n pressure. Whenlhe IC]> increases, the systemic blood pressure increases to try to preserve blood flow to the bra in. The bod)' senses the rise in system ic blood pressure and th is triggers a drop in the pulse rate as the body tries to lower the blood pressure. With scvere injury andlor ischemia, the pressure with in the sku ll continues in an upward spiral until a critical point at which the ICP approaches the MAP and there is no cerebral perfusion. All vital signs deterio rate, and the patient dies. Because CPP depends on both the arterial pressure and the Ie p, hypotension will also have a devastating effect if the Ie p is high .

••••• PEARLS Hypoxia ami Hypote:tlSiotl

Patients with serious head i~uries cannot tolerate hypoxia or hypotension. Give high·fIow oxygen and monitor oxygenation with a pulse oximeter. • Usual~ pediatric patients have a better recovery from ml. ~ an adult and a child have the same injury, the child has a much better char.c:e of recovery. However, hypoxia and hypotension appear to eliminate any neuroprotectiw! mechanism normally afforded by age. ~ the child with a serious brain injury is allowed to become hypoKic or hypotensiYe, the rnar.c:e 0/ recovery is even worse than an aduh with the same injury.

146 • CHAPTER 10 Head Trauma

As stah.'d above, the injured brain loses the abilit), to autoregula te blood fl ow. In this situatio n perfusion o f the brain is directl y dependen t on t he C PP. You Illllst maintain a cerebral perfusion pressure of at least 60 mmH g (see earlier formu la), which requircs maintaining a systolic blood pressure of at least 110 to 120 mmH g in the patient with a severe head inj ury. T his will rarely be a problem, as hypotension o nly occurs in about 5 percent of patients with severe T BJ (GCS of < 9). Aggressive attempts to maintain CPP above 70 mmHg with flu ids and presso rs (dopam ine, epinephri ne) should be avoided because of the risk of adu lt respiratory dist ress syndrome (ARDS).

Cerebral Herniation Syndrome

• • • • • PEARLS

Brain Injury A. patient who, after correction of

hypoxia iII!d tr,-polension, shows rapid progression of brail injury (e.g., \.WIf~ with cilated pupil; decet-Knte posn.ing; or drop .., GCS score of >2 with an ioitiaI GCS score of < 9) should be toosported rapidly to a tr.tuma center capable of IT\iI'oaQing sevete rnI patients. This is the only situation .., -Mlich hypetwntIlation is d flclicated (see Table 10-1). ttyperventiation, while krown to cause ischemia, maydeaelSl! brain

swelling temporamy. Although a despeme measu-e, this might 00y enough tine to get the patient to surgery thai migflt be r~e-saving. 1Ia60 ahead so that a nelXOSllgeotl CiIIl be available and the oper.Iting room prepared by the tine )'OU arrive at the hospital.

Whenl he brain swells, pa rticularly after:t blow td the head, a sudden rise in IC P may occur. This may force portions of the brain downward , obst ru cting the flow of cerebrospinal fluid and applying great pressure to the brain stem. T he classic find ings on exam. in this li fe- threatening situation, arc a decreasing level of consciou sness ( LOC) tha t rapidly progresses to co ma, di lation of the pupi l and an o lltward-downward devhltion of the eye on the side of tile injury. paralysis of the arm and leg on the side opposi te the injury, o r decerebrate posturing (arms and legs extended). As the cerebral hern iation is occurring, the vital signs frequently reveal increased blood pressure and bradycardia (Cushing's response). The patient may soon cease all movement, stop breathi ng, and d ie. Th is syndrome often fo llows an acute epidural or subd ural hemorrhage. If these signs are developing in a head-injury patient, cerebral hernia tion is imminent and ilggressive therapy is needed. As noted earlier, hyperve ntil ation will decrease the size of the blood vessels in the brain and briefl y decrease IC P. In this situation the danger of immedia te herniation ou tweighs the risk of cerebral ischem ia that can follow hyperventi lation. The cerebral hern iat ion s)'ndrome is Ihe only situatio n in which hyperventilation is still indicated. (Vou must ven tilate every 3 st.·conds /20/min l for adults, every 2 ~ seconds [25/min J for children, and every 2 seconds [30/m in l for infants.) -10 simplify knowing when to hyperventilate in the fiel d , the cli nical signs of cerebral herniation in the patient who has h:ld hypoxemia and hypotension corrected :1fe any one (or more) of the following: • T Bi patient wit h il GCS < 9 wi th extensor posturing (decerebrate posturing)

• TI3l patient wit h a GCS pu pi ls

< 9 with as),mmet ric (or bi lateral ), d ilated, Or nonreactive

• T BI patient wi th an ini tial GCS 2 points

< 9 who then drops his or her GCS by mori,.' than

For the above, "asymmetric pupils" means 1 mm (o r more) difference in the size of o ne pupil, "fixed " means no response « 1 mm ) to bright light. Bila teral di lated and fixed pupils usually arc a sign of b rain stem inj ury and arc associated with 91 percent mortality. A unilateral dilated and fixed pupil has been associated wi th good recovery in up to 54 percent

Age Group

Normal Ve ntilation Rate

Hype rve ntitation Rate

Adult Children Infants

8-10 breaths/ minute 15 breaths/minute 20 breaths/minute

20 breaths/ minute 25 breaths/minute 30 breaths/minute

I!

CHAPTER 10 Head Trauma _ 147

of pa tients. Remember that hypoxem ia, orb ital t ra uma, d rugs, ligh tning stri ke, and hypo therm ia also afTect pu pillary reaction , so take t his in to accou nt befo re begin ning hyperventi lat ion. F];ICcid par;llysis usually means spinal injury. If t he pat ient has signs of hern iatio n as listed above and the signs reso lve with hypervent ilatio n, you shou ld d iscontinue the hyperventi latio n.

HEAD INJURIES Scalp Wounds The scalp is hi ghl y vascular and oft en blt'eds briskly when lacerated . BeC:luse many of the small blood vessel s arc suspended in an inelasti c mat rix of support ing ti ssue, the norn1
• • • • • PEAlU.S

Shock Arly unexplained shod in a patient with heild injury is hypovolemic until

proven otherwise. Treat hypotension.

Skull Injuries Skull inju ries can be li near nondisp laced fractures, depressed fra ctures, o r com pou nd fra ctures ( Figu re 10-3). Suspect an underlying skull fractu re in ad ults who have a large con tusion or darkened swel ling of the scalp. T here is very li ttle that can be done for skull fractu res in the field excepllo avoid placi ng direct pressu re upon an obvious depressed or compound skull fra cture. The real con cern is forces that can cause a skull fra ct ure can also cause a bra in injur)'. Treat t he brain injury wit h adequate Linear ox),gena tion and main tain perfu sion. Open skull nondisptaced fractu res sho uld have Ihe wo und dressed , b ut avoid cxccss pressure when controlling bleed ing. Penetrating objects in the skull sho uld be secured in place ( nol removed ) and the pa lient t ransported imm cd i.ltel),. lfyour patient has a gunshot wound to Ihe head, u nless t here is a clear entra nce and ex it wound in a perfectly linear path , assume that the bullet ma)' have ricocheted and is lodged in the neck near the spinal cord . You should co nsider child ab use when )'ou fi nd a chi ld with a head inju ry and no clear explanatio n o f th e cause. Suspect possible ab use if the stor), abo ut t he inju ry is inconsistent wi th the in jury o r the respo nsible adu lt suggests t he child perfo rmed an activi t y tha t a ch ild of th is age is nol ph ysicall y capable of performi ng. Pa), part icular atten tio n to the setti ng fro m which you rescued the ch ild . Request po li ce o r social service assistance if the circumstances are suspiciolls for child abuse. FIGURE 10-3 Types of skull fractures.

Depressed

Impaled object

148 •

CHAPTER 10 Head Trauma

Brain Injuries Concussion: A concussion im plies no structu ral injury to the brain that can be demonstrated by curren t imaging techn iques. There is a brief disruptio n of neural function that often results in toss of consciousness, but many peopte will have a concussio n without a loss o f co nsciousness. Classically there is a history o f trauma to the head with a variable period of unconsciousness or confusion and then a return to normal consciousness. There may be amnesia follow ing the inju ry. This amnesia usually extends to some po int before the injury (retrograde short -term amnesia), so oft en the patient will not remember the events leading to the injury. Short- term memory is often affected, and the pat ien t may repeal questions over and over as if he hasn't been paying attention to your answers. Patients may also repo rt dizziness, headache, ringing in the ears, andl or nausea. Cerebral Contusion: A patien t wit h cerebral con tusion (bru ised brain tisslle) wi ll have history o f prolonged unconsciousness or serio us al teration in level of consciol1sness (e.g., profound confusion, persistent amnesia, abnormal behavior). Brain swelling may be rapid and severe. T he patient ma)' havc focal neu ro logical signs (weakness, speech problems) and appear to have suffered a cerebrovascular accident (stroke). Depending upon the location of the cerebral contusion, the patien t may have personality changes such as inappropria tely rude behavior or agi tation.

II

Subara chnoid Hemorrha ge: Blood Clln enter the suba rllchnoid space as a result either of trauma or a spon taneous hemo rrhage. The subarachnoid blood causes irri tation that results in int ravllscular fluid "leaking" in to the brain and causing more edema. Severe headache, coma, and vomiting from thc irritation arc co mmon. These pa tients may have so much brai n swelling that they develop the cerebral herniation syndrome. Diffuse Axona l Injury: A diffuse axonal injury is the most coml11o n type o f injury as a result of severe bl unt head traUlllll. The brain is inju red so diffusely that there is general ized edema. Usually, there is no evidence of a structural lesion. In most cases the patient presents unconscious, witho ut focal deficits. Anoxic Brain Injury: Injuries to the b rain from lack of oxygen (e.g., card iac arrest, airway obst ructio n, nellr-drowni ng) affect the brai n in a serious fashio n. Following lin anoxic episode, perfusion of the co rtex is interrupted because of spas m that develops in the small cerebral arteries. Aft er 4 to 6 mi nutes of anoxia, restoring oxygenation and blood pressure will not restore perfusion o f the cortex ( no- reflow phenomeno n), and there will be continuing anoxic injury to the brain cells. If the brai n is without oxygen fo r a period greater than 4 to 6 minutes, irreversible damage almost always occurs. Hypothermia seems to protect against this pheno menon, and there have been reported cases of hypothermic pa tient s being resuscitated after almost an ho ur of anoxia. Cu rrent research is directed toward finding medications that ei ther reverse the persisten t postanoxic arterial spasm or protect against the anoxic injury to the cells. Intracrania l Hemorrhage: Hemo rrhage ca n occur bel\'I'een the skull and dura (the fib rous coverin g o f the brain ), between the du ra and the arachnoid, ordirectty into the brain tissue.

Awte Epidural Hemato"m: An acute epidural hematoma is most often ca used by a tea r in the midd le men ingeal artery that runs along the inside of the skull in the tempora l region. The arterial injury is often caused by a linear skull fractu re in the temporal o r parietal re-

CHAPTER 10 Head Trauma _ 149

gion (Figure 10-4). Because the bleeding is arterial (although it may be veno us from one of the du ml sin uses), the bleed ing and rise in ICP can occu r rapidl y, and death may occ ur qu ickl y. Sym ptoms of an acute epid ural hematoma incl ude a history of ht'ad trauma with in itial loss of consciousness oft en fo llowed by a period during which the pat ient is conscio us and coherent (the " lucid interval"). After a pemeningeal riod of a few m inu tes to several ho urs, the patient will deartery velop signs of increasing ICP (vomiting, headache, altered FIGURE 104 Acute epidural hematoma. This hemorrhage mental stat us), lapse into unco nscio usness, and d evel op may foll ow injur y to the extradu ral arteries. The blood collects body paralys is on th e side o pposite of the head injury (see betwl't'n the fibro us dura and thc periosteum. earlier section o n cereb ral herniation syndrome). There is often a dilated and fi xed (no respo nse to bright ligh t) pupil o n the side of the head injury. These signs arc usually fo llowed rapidly by death . The classic exam ple is the boxer who is knocked unconsciolls, wakes up, and is allowed to go home, o nly to be fOlln d dead in bed the next PEARLS morni ng. If the u nderlying brai n tissue is not injured, surgic;ll removal of the blood and Altered Mental Status ligat ion o f the ruptured blood vesst'! often allows full recover)'. Remember that hypoglycemia,

• • • • •

Awte Subdural Hematoma: Th is is the result of bleedi ng between th e dura and the arachnoid and is associated with inj uf)' to the underlying brain tissue (Figu re 10-5 ). Because the bleed ing is veno us, intrac ranial p ressure in creast's more slowly, and the d iagno sis often is not appa rent unt il hours or days after the injury. The signs and sympto ms include headache, flu ctuat ions in the level of co nsciousness, and foca lncurologic signs (e.g. , weakness o f one extrem ity or o ne sidc of the body, altered deep tendo n refl exes, and slurred speech ). Becallse o f underl ying brai n tissue injury, prognosis is often poor. Mortality is vcry high (60 percen t- 90 percent) in patients who are comatose when found. Always suspect a subdural hematoma in an alcoholic wit h any degree o f altered mental status fo llOWi ng a fall. Eld erly pa tient s and those taki ng ant icoagulants are also at hi gh risk fo r th is inju ry.

hypoxia, cardiac dysrhythmias, and drugs can also cause altered mental status. \'Alen narcotic abuse is a pOSSIblity,
/"tracerebml Hemorrhage: In tracerebra l hemo rrhage is bl eedi ng with in the brain tissue (Figure 10-6). Traumatic in tracerebral hemo rrhage may rt'suit fro m bl un t o r pe n e ~ trati ng injuries o f the head . Unfo rtu nately, surgery is o ften no t hel pfu l. The signs and sympto ms d epe nd upon the regions involved and th e degree of injury. They occur in

Superior sagitlal sinus

FIGURE 10-5 Acute subdural hematoma. This usually occurs following the rupture of du ral veins. Blood collects and oft en SC"ereJy com presses the brain.

FIGURE 10-6 Intracerebral hemo rr hage.

150 •

CHAPTER 10 Head Trauma

patterns si mi lar to those that accompany a stroke; sponta neous hemorrhages o f this type may be seen in pa tients with severe hypertensio n. Alteration in the level of consciousness is co mmonly seen, tho ugh awake pa tients may complain of headache and vomiting.

EVALUATION OF THE HEAD·TRAUMA PATIENT Determining the exact lype ofT I31or hemorrhage canno t be done in the fi eld, as it requi res imaging techniques, such as a CAT scan. It is more important that you recognize the presence of a br3in injury and be read)' to provide su pportive measures while transporting the patient. T BI pa tients may be difficult to manage because they arc often uncooperative and may be under the inl1uence of alcohol or drugs. As a rescuer, )'OU must pay extraordi nary attention to detail and never lose your patience with an uncooperative patient.

ITLS Primary Survey Rt:rncmbcr that ewrytrallma patient is initiallyevaillatcd in the same sequence (Figure 10-7).

Sce ne Size-up: The results of lhe Scene Size- up will begin to determine if yOll have a load-and-go pa ticill. Dangerous generalized mechanisms (M VC, fall from a height ) will require a complete exami nation (Rapid Trauma Survey). Dangerous focused mechanisms (hit in head wi th baseb:t ll bat ) will allow you to "focus" your exam (A BCs. wit h head and neurological exams) rather than ha\' ing to perform a complete exam.

• • • • • PEARLS

Vomiting PatitnlS with head trauma frequently vomit. You must (emain alert to prevent aspiration. ~ the patient is lKICOnSCioos, with loss of protective rrlle~~,

roo should in5ert an

erdotrilCheallube.~, k~

mechaniaI suction avaWe and be prepMed to Iog-roI the patient onto M side (maintaining motion restrictiot1 of the spine).

Initial Asseument: Tilt, goals of the Initial Assessment are to determ ine if this is a priority patient and to find imnH.'diate li fe -threats. The Initial Assessmen t in the head -trauma patient is to determi ne quickly if the patient is brain injured and, if so, if the patient's condi tion is deterio rating. Obviously, a pa tient wi th a history and physical examinat ion that indic;Jte a loss of consciousness fo llowing a lucid period postinj ury (possible epidural hematoma) should be transported with more urgency than one who is alert and oriented after bei ng knocked out (possible concussion). It is vcr)' important that alJ observatio ns be recorded (but do not interrupt patient care to do this), because later t reat ment is o ft en dictated by detection of the deterioration of cl in ical stability. All patients wi th head or facial trauma and an :tltered level of consciousness shou ld be assumed to have a cervical-spine injury until proven otherwise. Because of the alteration of LOe. it is often not possiblc, in this si tU. Control of the airway cannot be overempha ... ized. The ... upine. restrained. and unconscio us patient is prone to airw"y obstruction from the tongue, blood , vomit, or other secret ions. Vom iting is very common wit hin the first hour following a head injury. Protect the airway of the unco nscious patien t with no gag rel1ex by endotrachcal intubation or by placement of an o ral or nasal airw"y and frequent suctioning. Perform endot rachea l intubation of the unconscious head -i njured patient as rapid ly and

CHAPTER 10 Head Trauma _ 151

ITLS PRIMARY SURVEY SCENE SIZE-UP Sklndard Precautions, Hazards, Number of Patients, Need lor Additionol Help/Equipment, Mechanism of Iniury

-------------------------------t-----------------------------(Age,

Se~,

INITIAL ASSESSMENT General Impression Weight, General Appeorance, Position, Activity, Obvious In juries/Bleeding) lOC jAVPUj Canlrol Cervical Spine Airway {Snoring, Gurgling, Stridor, Silen<:el Breathing {present? R.ale, Depth, Effort) Radial/Carotid Pulses (Present? Rate, Rhythm, Quality) Skin ColOf, Temperature, Moisture; Capillary Refill Uncontrolled External Hemorrhage?

-------------------------------}-----------------------------RAPID TRAUMA SURVEY

Insped Head and Neck (Mojor Faciollniuries, Bruising, Swelling, Penelrotions, Subcutoneous Emphysema) {Neck Vein Distention? Tracheal Deviation?l Inspect Chest (Asymmetry, Contusions, Penetrations, Paradoxical Mollon, Instability, Crepitation) Breath Sounds (Present? Equal?) (If unequal: Percussion) Heart Tones Abdomen {BruiSing, Penetration/Evisceration, Tenderness, Rigidity, Distentionl Pelvis (Tenderness, Instability, Crepitotionl Lower/Upper E~lremities (Swelling, Deformity, Instability, Motor a nd Sensory) Place Patient on Backboard Posterior {penetrations, Deformity, Presocrol Edemal If Critical Situation, Trons/er to Ambulance to Complete Exam. Baseline Vitol Signs Measured Pulse, Respirations, Blood Pressure Pupils (Size? Reactive? Equal?) (II Altered Mental Stotus:) Gloscow Cama Scale ScOfe Eyes, Voice, Motor, Orientolion, Emotional Stote

FIGURE 10-7 The ITLS Primary Survey.

smooth ly as possible in order to avoid pati en t agitatio n, straining, and brea th-hold ing that may contribute to elevated intracranial pressure. Use of intraveno lls lidocaine when intuba ting head-inju red patients is no longer recommended. Head- inj ured patients may seize from their injury (if hypoxic) o r have their teeth and jaws clenched , making intubation difficult. Attempting to force an artificial ai rway into this patient may cause additional injury. Nasotracheal intubation or use o f rapid sequence intubation (RSI) should be co nsidered in this situa tion, if permitted under local protocols. Before begin ning in tuba tion, vent ilate (do not hypc rvc ntilate) with high -fl ow oxyge n. Do not allow

152 •

CHA PTER 10 Head Trauma

the head-i njured pa ti ent to become hypoxic. Even one brief ep isode of hypox ia can in crease mort:!li ty. As staled above, it is important to note the patient's bils ic neurological status prior to RS J, as the medicatio ns give n ca n prevent a com plete neurologic:!1assessment in the hospital. Ra p id Tra uma Survey: All pat ients with an abno rmal level of consciousness get il Rapid Trauma Survey (see Chapter 2). Head: Once the ini tial exam is co mpleted, continu e with the exam guided by the mechanism of inj ury. Begin with t he scal p and qu ickly, but carefu lly, examine for obviolls inju ries such as b cemtions or depressed o r open skull frac tures. The size of a laceration is often misj udged because of the difficult y in assessment through hair matted with blood.l:ecl the scalp gentl y for obviolls unstable areas of the sk ull. If none arc present , you may safely applya pressu re dressi ng or hold direct pressure upon a bandage to stop scalp bleeding. A basil ar sku ll fr actu re may be ind icated by any of th e fo ll owi ng: bleed ing from the ear or nose, de;lr or serosanguin eous fluid ru n ni ng fro m the nose or ear, swell ing and/or discolorat ion behind the ear ( Batt le's sign ) (Figure I 0-8a), an d/o r swell ing and discoloration around both eyes (raccoon eyes) ( Fi gure 10-8b). Raccoon eyes arc a sign of anterior basilar sk ull frac ture that may go thro ugh the thin cribr iform plate in the upper na sal cav ity and allow sp inal fluid a nd /or blood to leak out. Raccoo n eyes with or withou t drainage from the nose are an absolute co ntrai ndicat ion to in sertin g a nasogastric tube o r nasotracheal intubation. The tube can go through the fractured cribrifo rm plate and into th e brain.

Pllpils: Thc pup ils (Figure 10-9) arc co ntrolled in part by th e third cranial nerve. This nerve takes a long cou rse through the skull and is easily co mpressed by brai n swel ling, and thus Illay be affected by increasi ng [CPo Followi ng il head injury, if both pupils are dilated and do not react to light, the pa ti ent probabl y has a brain stcm injury and the prognosis is grim. If the pup ils arc dilat ed but st ill react to light , the injury is often still reversi ble, so cvery effort should be made to tran sport the patient q uickly to a fal.: il ity ca pable of trea ting a head injury. A unilaterally d ilated pup il that rema ins react ive to light may be the e:lrl iest sign of increasing [CP. Th e development of a uni laterally dihlled, nonreactive pu pil (" blown pupil ") while YO ll arc observi ng the co matose pat ient is an cxtre me emergency and manda tes rap id transport and hyperventila tio n. Ot her Gluses of dilated pupils that mar or ma)' not react to light include hypo therm ia,light-

FIGU RE 10-8a Battlc's sign-c"idence of a posterior basilar skull fracture. (Pholo colI,ll.'s)' of/)(lvid f:ffroll. MD, FACEP)

FIGURE 10 -8b Raccoon cye.s----cvidcllcc of an anferior basilar

skull fra cture. (IlllOlo fOllrll's), of /J1lI'i(l Effron. MD, f-'ACEP)

CHAPTER 10 Head Trauma _ 153

ning strike. anoxia. optic nerve injury, drug effect (e.g., atropine), or direct trauma to the eye. Fixed a nd d ilated pupil s signi fy increased intnlcra n ia[ pressu re only in patients w ith a decreased level of co nsc iousness. If th e p.ltient has a normal level of consciousness. the dilated pupil is not from head injury (m o re likely due to eye trauma or drugs such as atropine). Fluttering eyelid s are o ft en seen with hysteria. Slow lid closure (like a curtai n fa ll ing) is rarely seen with hysteria. Testing for a blink response (corneal reflex) by tOllching the cornea with the edge of a gauze pad or cotton swab. or by applying o\'erly noxious stimuli to a patien t to test for response 10 pain. are techniques that arc unreliable and do not contribute to prehospita[ assessment.

Constricted pupils

u tremities: Note sensation and motor fUllc tion in the extremities. Can the patient feel yO Li touch her hands and feet? Can she wiggle her fingers and toes? If the p:ltien t is Ull conscious, Ilote her response to pain. If she withdraws or loca[izes to the pinching o f her finge rs and toes, she has grossly intact sensation and motor fun ction. This usually indicates that there is normal o r only minimally impaired cortical funct io n. BOlh decorticate pos\'urin g or rigidi ty (arms flexed, legs extended) and decerebrate postur ing o r rigidity (a rms and legs extended) arc ominous signs o f deep cerebral hemispheric o r upper brain stem injury (Figure 10-10). Decerebrute postu ring is worse and usually signifies cerebral hern iation. It is one of the indicat io ns for hyper ventilat ion. Flaccid paralrsis usuall y denotes sp inal-co rd inju rr.

Dilated pupils

Unequal pupils FIGURE 10-9 Exami nation of pupils.

Neurological Exa m: To apply the Revised Trauma Score and other field triage scoring systems (see Append ix F), rOtL sho uld be familiar wi th thc Glasgow Coma Scale score (GCS), which is imple, easy to lise, and has good prognostic value fo r eventua l outcome (Table 10-2) .l n the Ttll patient, a Glasgow Co ma Scale score of8 or less is co nsidered evidence of a scvere brain injury. The GCS sco re that is determined in the fi eld servcs as the baseline for the patient; be sure to reco rd it. Record th e score for each PJrr of the GCS, not just the total score. You should perfo rm a finge r-stick glucose on all patients wi th altered mental stat us. Vital SigtlS: Vita l signs should be obtained by another te3m member whi le YOll are performing the exam. They are extremely important in fo llowing the course of a patient with head trau ma. Most important, Ihey can indicate changes in Ie p (Table 10-3). Observe and record vital signs at the end of the illS Primary Survey, durin g the l)ct;liled Exa m, and each time rou performlhe IT I$ Ongo ing Exam .

FIGURE 10-10 Decort icate and dcccrebnltc posturing.

• Respimtion Increasing intracranial pressure ca uses the respiratory rale to increase, decrease, andlor to become irregular. Unusual respira tory pa tterns may reflect the [cvc[ of bra in or brain stem injury. Just before de:l th, the patient rna)' develop a

154 •

.,

CHAPTER 10 Head Trauma

.,'

Eye Opening

Verbal Respo!'\se Points

Spontaneous To voice To pain

4 3 2

None

1

Motor Response Point$

Points Oriented Confused Inappropriate words Incomprehensible sounds Silent

5 4

Obeys commands localizes pain Withdraws

5 4

Abnormal flexion

3'

Abnormal extension No movement

2"

6

3 2 1

"Decorticate posturing to pain "De<erebrate posturing to pain

rapid, noisy respiralory pattern called central neurogen ic hyperventilation. Beca use respiration is affected by so ma ny facto rs (e.g., fear, hysteria, chest injuries, spinalcord inj uries, diabetes), it is not as useful an indicator as are the other vital signs in moni toring the course of head injury. Abnormal respiratory pa tterns may indicate a chest injury or other problem Iha t co uld lead to hypoxia if untreated .

• Pulse. Increasing ICP ca uses the pulse rale to decrease . • 8/001/ pressure. Increasing ICP causes increased blood pressure. This hypertension is usually associated wi th a widening of the pulse pressure (systolic minus d iastolic pressure). Other causes of hypertension include fea r and pain . Hypotension in the presence of a he:ld injury is usually caused by hemorrhagic or neurogenic shock and should be treated as if ca used by hemorrhage. It is a rare (5 percent) findin g in the patient with a severe T BI. The injured brain does not tolera te hypotension. A single instance of hypotensio n (Ill' 90 mmHg systolic) in an adult with a brain injury may increase the morlality rate by ISO percent. The increase in mortality rate fo r hypotension and a severe T61 is even worse in child ren. Give IV fluid s to main tain a blood pressure of at least 11 0 to 120 mmHg systolic in the adult patient wit h a severe head injury (GCS 8 or less) even if the patient has associa ted penetratin g trauma

Shock l evel of consciousness Respiration

Decreased Increased

Pulse Blood pressure Pulse pressure

Increased Decreased Narrows

Decreased Varies but frequently decreased Decreased Increased Widens

CHAPTER 10 Head Trauma _ 155

with hemorrhage. As noted above, the goal is to mai ntain cerebral perfusio n p ressure (C PP) above 60 mmH g. Children with severe TDI sho uld have their blood pressure mai ntained at the normal r
ITLS Secondary Survey Head-trauma patients with altered mental stat us arc load-and-go situations. The IT1.5 SecondarySurvey (see Chapter 2) will bedonedufing transport (or not at atl. if a short transport).

ITLS Ongoing Exam Each time you perform the ITLS Ongoi ng Exa m. record the level o f co nsc iousness, the pupi l size and reaction to light. the Glasgow Coma Scale score, and the developmen t (or improvement ) of focal weakness or par.llysis. This, along with the vital signs, provides enough information to monito r the conditio n of the head -injured patient. Decisions on the management of the head-trau ma patient arc based on the changes in all lhe parameters of the physical and neurological exami nation. You are establi shing the baseline from which hIler judgments must be made; record your observations.

MANAGEMENT OF THE HEAD-TRAUMA PATIENT Your job is to prevent secondary b rain injury. It is extremely important to make a rapid assessment and then transport the patient to a facili ty capable of managing head trauma. Appropria te triage of the pa tient to facilit ies capable of managing TBl com have a significant impact on the outcome of the pat ient. The important points of managemen t in the prehospital phase are listed here. Brain Trau ma Fou ndation Guidel ines arc classified as follows: • Levell recommendations, supported by Class I scientific evidence (formerly called Standards) • Level II recom mendations. supported b)' Class II scientific evidence (formerly called Guidelin es) • Levcl ill recommendations, supported by Class III scien tific evidence (formerly called Options) PROCEDURE

00

Managing the Head-Trauma Patient

1. Secure the ai rway and provide good oxygenation. The injured brain docs not tolerate

hypoxia, so every TBI p.lticn t should receive 100 percent oxygen. If possible, monitor the ux)'!)ell s;lIurilliun with a !Julse lJximl"leL Do nol alluw the SilO! tu \;t:CO IllI: less than 90 percent (l.evel ll ). It is best to maintain a ie\'c1 abo\'e 95 percent.

• • • • • PEARLS

Seizures Seizures in TBI patients afl~ usually caused by hypoxia. Kthe patient has an open airway Mid yr:JJ are already ventilating with 100 percent oxygen, yoo may be ordered to administer IV medication to control the se;zures. Seizures should always caU!>e YOO to rlKhed the aU'way, ~ation, and oxygenation of your patient.

156 •

CHAPTER 10 Head Trauma

• • • • • PEARLS

HyperVfmtifatio" We tend to assist respiration al too fa5t a rate. Use of an end·tidalCO2 monitor can prevent this.

Mainta in good ventilation (not hypervent ilation ) with high-fl ow oxygen at a rate of about o ne brea th every 6 to 8 seconds (8 to 10 breaths per minute). Studies have found that we tend to hyperventilllte the critical pat ient without realizing it. You can prevent this if you have an end-tidal COl monitor. Try to keep the CO2 between 35 and 40 mmH g. Endotracheal intubation is stil l recommended fo r adults if the airway cannot be maintai ned o r if you cannot maintain adequate ox ygenat ion wit h supplemental oxygen. There is no reason to routinely in tubate patient 's who arc maintaini ng their air way and have a normal oxygen satumtion. Some studies have fo und a dec reased su rvival rate fo r TBl p.ltients who have been intubated in the field. Possible causes of this are unrecognized hyperventilation and/o r unrecognized esoph ageal intubation. Usc of capnography will prevent both of these problems (see Chapter 5). Brai n Trauma Foundat io n guidelines recommend cap nography. pulse ox imetry, and BP monitoring as critical monitoring procedures fo r all intubated TBI patients (Level II I).

There is no ev idence to support out -of- hospital endotracheal intubation over bag-valve mask venti lation of ped iatric patients with TBI (Level l!). Because head-injured patients are pro ne to vomiting, be prepared to log- roll the motion-restricted pat ient and to suction the o ropharynx, part icu larly if an endotmcheal tube has not been placed. Try to llvoid use of antiemetics, as some may decrease the LOC. 2. Stabil ize the pat ient on a backboard. Restrict motion of the neck in a rigid collar and a padded he.ld mot ion -restriction device. 3. Agitated and combative patients fight ing against restraints o r vent ilatio ns Gm raise their le I', as well as place themselves at risk for fu rther cerv ical-spine injury. Consider sedation in this situat ion; though be aware that sedation will complicate the neurologica l evaluation of yo ur pat ient. Careful use ofbenzodiazep ines can decrease agi tation without d ropping blood pressu re. An added benefit of the usc of ben zodiazepines is that they prevent seizures. Seizure prophylaxis in the head-injured patient should be in it ia ted on the recommendation of medical direction. Other agents suitable for use include phenytoin. Do not lIse ba rbit urates. as they ca n cause hypotension. 4. Record baseline observ:ltio ns. Record vital signs (describe rate and pattern of brea th ing). the level of conscio usness. the pupils (size and react ion to light ). the Glasgow Coma Scale score, and the development (o r improvement ) of foca l weakness o r paralysis. If the patient develops h},potensio n, suspect hemorrhage o r spinal injury. Every patient with altered mental status should have a fin ger-stick glucose checked and recorded. S. Continuously mon itor the observa tions listed in step 4. Record them every 5 minutes. 6. Insert two large-bore IV catheters. Fluid resuscitatio n (crystalloid ) in patient wit h TBI sho uld be admin istered to avoid hypo tension and/or limit hypotensio n to the shortest du ration possible (l.evel l!). In the Pllst it was though t th at fluids sho uld be limited in head-injured patients. It has been fou nd that the danger of increasing brain swelling by giving fluid s is much less than the danger of allowing the patient to be hypotensive. Hypervent ilation is recommended for use in treating the patient with signs of cerebral herniation after correcting hypotension and/or hypoxia (Lcvel lll ).

CHAPTER 10 Head Trauma -

If you have capnography available, try to maintain the CO! level at about 25 mmH g during hyperven tilat ion. Further research is needed on the utility of hypertonic saline solutions over current crystalJoids for treatment of hypotension in Tl3l patients. Routine administra tion of steroids fo r TBI has not been shown to improve outcomes.

Joyce, Dan, and Buddy have been dispatched to a private home where a 40-year-old man has fallen off of a ladder. The man's wi fe teUs Joyce, the team leader on this call, that when his foot slipped, it caught in the rung of the ladder an d he swung like a pendulum, striking his head. He was unconscious for a few minutes. He is now awake but cannot remember going up the ladder. His wife says he is in good health, takes no medications, and has no allergies. She prepared him a hamburger at lunch about 2 hours ago. He complains ofa headache and nausea and says his neck hurts. Joyce introduces the team and cautions the patient not to move while they are examin ing him. Her initial impression is cautiously good, but she is worried by the dra inage from his nose. Dan stabilizes the patient's neck while Joyce begins the exam and Buddy brings the backboard. The airway is open because the patient can speak normally. He responds appropriately to questions but has amnesia for the event. He has a strong, regular pulse and his respiration is normal. Because of the mechanism, Joyce performs a Rapid Trauma Survey and finds a hematoma on the right side of the head in the temporal area. The pupils are S mm and equal and there are ecchymoses of both upper eyelids. There is dried blood in both nostrils and a thin, serosanguineous drainage from the right nostril. The face feels stable. There is tenderness an d spasm of the neck but no palpable deformity. The neck veins are flat and trachea is in the midline. The chest is normal to inspection wi th no tenderness, and breath sounds are present and equal. Heart sounds are easily heard. The abdomen is nontender. The pelvis is stable and nontender. The extrem ities are nontender with normal PMS. A cervical collar is placed on the patient and he is logrolled onto the backboard (the back is normal) and packaged. Joyce decides to transport immed iately. so he is transferred to the ambu lance. Buddy drives. While Dan obtains the vita l signs, Joyce does a neurological exam. The patient is awake and oriented with a retrograde amnesia. He has a GCS of lS (E-4 , V-S, M-6). His pupils are still S mm and react equally. He has good sensation and movement in his fingers and toes bilaterally. The vital signs are pulse 95, respi ration 12, BP 140/ 80, and pulse oximeter 100 percent on oxygen by nasal cannu la at 3 liters per minute. Joyce notifies medical direction that they have a patient with a probable anterior basilar skull fracture with a spinal fluid leak and are taking him directly to the local trauma center.

157

158 •

CHAPTER 10 Head Trauma

Joyce starts a saline lock IV while Dan attaches a cardiac monitor. The patient begins to get restless and becomes more confused. He tries to pull out his IV and then vomits the hamburger he had for lun ch. Joyce immediately performs an ITlS Ongoing Exam. Exam of the head reveals no change in the temporal hematoma. but the right pupil is now 8 mm and poorly reactive. The left pupil is still 5 mm. The neck, chest. and abdomen are unchanged. Noted now is a sl ight difference in strength on the left side compared to the right. The vital signs are pulse 70 . respiration 8, BP 170/80. and pulse oximeter 95 percent on oxygen by nasal cannula at 3 liters per minute. Dan begins to assist respiration at a rate of 8 to 10 breaths per minute with 100 percent oxygen by bag-valve mask. The patient is no tonge r restless but is now tess reactive. He stililocatizes to pain. He opens his eyes to verbal stimuli but his speech is mostly unintelligible sounds and cursing. His GCS score is now 11 (E-3, V-3. M-5). Joyce notifies medical direction of the change. and she has the trauma team meet them at the ambulance. The patient is taken straight to CAT scan, where a right epidural hematoma is revealed. He is then taken directly to surgery, where the bleeding right middle meningeal artery is ligated and the hematoma evacuated. After surgery, x-rays reveal a nondisplaced fracture of the fifth cervical vertebra. He recovers completely from his injuries and returns home.

The mechanism of injury, coupled with the sp inal fluid draining from the nose, alerted Joyce that the patient had an anterior basilar skull fracture. The mechanism was also suspicious for spinal injury. The patient was packaged for transport. As is common with an injury of this type, the patient initially looked good but began to deteriorate soon afterwards. He developed symptoms of an ep idural hematoma with increased lCP but never deteriorated enough to requ ire hyperventilation. If endotracheal intubation had been needed, the nasotracheal route would have been contraindicated because of the basilar skull fra cture. Joyce was wise in bypassing lower levels of care to go to a trauma center where he would receive immediate eva luation and life-saving surgery before he reached the point of cerebral herniation. He was in danger of developing meningitis from the basilar skull fracture from which the spinal fluid was leaking_ He was lucky that it sealed and healed without any infection developing. He could easily have had a spinal-co rd injury in this situation but his cervical-spinal fracture was stable and healed without further surgery.

SUMMARY Head injury is a serious complication of tra uma. In order to give yo ur patient the best chance o f recovery. you should be familiar wi th the important anatomy of the head and central nervous system and understand how trauma to the various areas presents clinically. The most important steps in the m'lI1agement of the h ead~i nj ured patien t are rapid assessment , good airway management , prevention of hypotension, rapid transport to a trauma center, and frequent ITLS Ongoing Exams. In no other area of trauma care is the recording of repeated assessments SO important to futu re man:lgemc nt decisions.

CHAPTER 10 Head Trauma _ 159

BIBLIOGRAPHY 1. The Brain Trauma Foundation. 2006. GII;(/clines for pre/tospillli management of traumatic bmi" injllry. 2nd ed. New York. 2. The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. 2000. Hyperventilation. Jourllal of Nellro/mllltla

17(6),5 1:>--20. .t Chest nut. It ~L L F. Marshall. M. R. Klauber. and others.I993. The role of secondary brain injury in determining oUlComc from severe head injury. !ollmal o/Tr(/lIm(/ 34: 216-22. 4. Cruz, J., G. Minoja, K. Okuchi. 2001. Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: Arandomized trial. NCllrosurgery49(4): 864-71. 5. Davis, D., D. Hoyt, M. Ochs. et al. 2003. The effect of paramed ic rapid k'que nce intubation on outcome in patien ts with severe traumatic brain injuT)" !oumal ofTmllma-llljury /,,/cC/ioll do Critical Girl! 54(3): 444-53. 6. Davis. D. , J. Du nford, J. Poste, et al. 2004. The impact of hypoxia and hyperventilat ion on outcome after paramedic rapid sequence intubation of severely head-injured patients. Journ(/I of "[mrllllll 57( I ): 1-8.

7. Davis, D., J. Du nfo rd, M. Ochs, ct al. 2004. The use of quantitative end-tidal capnometry to avoid inadvertelll seveTC hyperventilatio n in patients with head injury after paramedic rapid sequence intubation. JarmUlI ofTrmmUl-llljllry IttJcetioll do Crit;CtI/ Care 56(4): 80S-14. 8. McKeag, D.B. 2003. Understanding sports+rcJatcd concussion. Coming into focus but sti ll fuzzy. JAMA 290: 2604-5. 9. Pigula, F. A., S. L. Wald, S. R. Shackford, and others. 1993. The effect of h)'J>otension and hypo.'(ia on children with severe head injuries. JOllrnal of Prdiatric SlIrgl!ry 28: 310- 16. 10. Wang, H., A. Peitzman, et al. 2004. Out-of-hospital endo tracheal intubation and outcomc after traumatic brain injur),. Antrals ofEmag!!rrcy Melliej,,!!44: 439-50.

Dan, Joyce, and Buddy have been called to a public swimming pool. They are told that there has been a diving injury. What injuries should they expect with a mechanism

of this

(Pholo 0 IkJb Kri~t/ CO Rltl S)

type? Is a spinal injury likely? What other emergency may be associated with a diving injury? Keep these questions in mind as yo u read the chapter. Then, at the

end of the chapter, find ou t how the rescu ers completed this call.

INTRODUCTION Spinal-cord injury is a devastati ng and life-th reatening result of modern trauma. If a patient with a spinal-cord injury survives, he could lose his independence
THE NORMAL SPINAL COLUMN AND CORD Spinal Column It is important to differentiate the spin al column from the spinal cord. The spinal column is a bony tube co mposed of 33 verteb rae (Figure II - I). II supports the body in an up righl position , allows the use of ou r ex tremities, and protects the delicate spinal cord. The co lunlO's 33 vertebrae arc identified by their locatio n: 7 ce rvical (the C-spine), 12 thoracic

161

162 •

CHAPTER 11 Spinal Trauma

(the T-spine), 5 lumbar (the L-spine), and the remainder fu sed together as the posterior portion oflhe pelv is (5 s
Cervical vertebrae

'"""""

vertebrae

Lumbar

vertebrae

Sacrum

FIGURE 11 -1 Anatomy of the spinal column.

Spinal Cord The spinal cord is an electrical conduit that serves as an extension of the brain stem. It is continuous down to the level of the first lumbar vertebra and attha! point separates into nerves. The cord is 10 to 13 mm in diameter and is suspended in the midd le of the vertebral forame n (Figure 11-2). The cord is soft and flexib le like a cotton rope, and is surrounded and bathed by cerebrospinal flu id along its en tire lenb>1h. The fluid and the flexib ility provide some protection to the cord from injury. The co rd is composed of specific bund les of nerve Inlcts that arc arranged in a predictable manner, much as a rope is composed of individual strands offiber. The spinal cord passes down the vertebral canal and gives off pairs of nerve roots thai exit at each vertebral

Anterior Arachnoid Pia mater

1.--1-__ r

Body

Spinous procoos

I <

Transverse

process

Vertebral foram(lfl

FIGURE 11·2a Vertebra viewed from above. The spinal cord passes through the vertebral foram en.

Epidural spaoo

FIGURE 11 -2b Vertebra with spinol cord in place.

CHAPTER 11 Spinal Trauma _ 163

level (Figure 11 -3). The roots lie next to the intervertebra l discs and the lateral part of the vertebrae, making the nerve roots susceptible 10 injury when trau ma occurs in these a reas (Figure 11 -4). The nerve roots carry sensory signals (ro m the body to the spinal cord and then 10 Ihe bra in. The roots also carry signals from the brain to specific muscles, causing them to move. These signals pass back and forlh rapidly, and some arc strong eno ugh to ca use aclions on their own, called reflexes. Th is refl ex system can be demonstrated by tapping the patella tendo n below the knee, causing the lower leg to jerk. If you accidentally put your fin ger on a hal burner, yo ur reflex system causes your hand 10 move even before your brain receives the warning message. Stro ng signals also can overwhelm the spinal cord's abi lity to keep signals moving separately to the brain. This is why a tra uma patient with a fractu red hip may complain of knee pain o r a patient with a ruptured spleen may complain of shoulder pai n. The integri ty of sp inal-cord fun ctio n is tested by motor, sensory. and refl ex functions. The level of sensory loss is most accurate fo r predicting the level of spinal-co rd injury. Muscle strength is ano ther fun ction that is easy to asscs..~ in the conscious pal ien!. Refl exes are hel pful for disti nguishing complete frOIll partial spinal-cord injuries. but are best left for hospital assessment. The spinal cord is also an integrating center for the autono mic nervous system, which assists in controlli ng heart rate, blood vessel tone, and blood fl ow to the skin. Injury to this component of the spinal cord result's in neurogenic shock (common ly called spit/al shock), which is discussed laler. FIGURE 1'-3 The spinal cord isa continuat ion of the I:entral nervous system o utside the skull. The Spinal Cord Sympathetic trunk

--+,

/ ., .',,, cord

Spinal ganglion "'e:::::;~ PI, mal•• ' '---~r:I---F

2~'i1 ~~o--_ Ante rior rool

process of vertebra Spinal nerves Body 01ve rtebra Intervertebral disk ganglion process of vertebra

FIGURE 11--4 Rela tionship of the spinal cord to the ve rtebrae. No te how the nerve roots exit betwccn the ve rtebrae.

164 • CHAPTER 11 Spinal Trauma

SPINAL INJURY A normal healthy spinal column can be severely st ressed and ma inta in its integrity Wi 111 out da mage to the spinal cord . However, cerlain mechan isms of trauma ca n overcom c lhc protective defenses, injuring the spi nal column and cord. The most coml11on mechanisms arc hyperex-Iellsion, hyperfl exion, com pressio n, and rotatio n. Lcss commo nly, lateral st ress or dist ractio n w ill injure the cord. These m echa nisms and their subseq ue nt injuries are illustrated in lable II - I.

Mechanisms of Blunt Spinal-Column Injury The head is a relatively large ball perched o n top of the neck. Sudden movement of the head or trunk will produce strcsses th at may damage the bony o r connectivc t issue com ponen ls o f the spinal colu mn . Injury to the spinal column is like injury to an y other bo ne in Ih e body. It requires a significant a moun t of force , un less Ihere is a preexisting weakness or defec i in the bone. For that reason, the elderly a nd those with severe arth ritis are at higher ris k fo r spina l inju r ies. Like othe r bo ne inju ries, pain is the most common symptom , but it may be unnoticed by the patient. This is especially true if the plltie m has o ther pai nful injur ies. At the site of a bone injury. loca l muscle spas m m ay occur. Inju ry to indi vidual nerve roots can result from bony spinal-col umn injury, with resulting localized pain , paralysis, or sensory loss. Therefore, signs th at may ind icate spinal injury include back pa in, te nde rness ,liang thc spinal column, pai n w ith movement of the back, o bvious defo rmity o r wounds of th e back , paral ysis, wcakness, or paresthcsia ( tingling or burning feeli ng to the skin ). Forlullil tcly, spinal column injury call occu r w ithout inju ring the spina l cord. Statisticall y, o nl y 14 percent of a ll col umn injuries have evide nce of spina l-cord damage. In the cervical spine region it is mu ch more com m o n to have cord injury, with a lmost 40 percenl of column injuries havin g co rd damage. The co nverse is also possible. in that cord injurics ca n OCCUf in the absence of obvious spinal-col umn damage. T his is particularly t rue in children. O nl y 63 percent of spinal-cord injuries have evidence of spinal-column da m age. The unconscio us trauma patient car ries a high risk ( 15--20 percent ) of spinal column injury. The injuries afe freq uen tly in m o re than one place, and the reforc SMR should be perform ed immediately on the unconsc io us tra uma patient.

Mechanisms of Blunt Spinal-Cord Injury Spin al-cord injury is devastat ing and occurs m ost commonly in young ad ults. As the po pulation ages, so has the med ian age of the victims. Currently about 11 percent of spin al-cord injuries occur in patients o ver age 50. T here are approximatel y 11 ,000 new spinal -cord injuries in the Uni ted States each year---48 percent involve MVCs (incl uding pedestrians ), 23 percent fa lls, 14 percent penetrating wounds, 9 percent recreational activities, and the rem ain ing 6 percent are from all other Clluses. Under ase 8. the relatively large size of the head m akes the llpper end of the cervical cord Ihe m ost co mmo n site of injury. wh ich ca n be extremely devastating. Spinal -co rd injury results in a defect ive signal -conducting funct ion, prese nt ing as a loss o f motor funct io n and refl exes, loss or c ha nge in se nsation, a nd/or ne urogenic shock. The delicate st ructure of the spinal cord's ne rve tracts makes it ve ry sensit ive to any form of trauma. What is te rmed primM)1 dnmage occurs at the time of t he trauma itself. Primary damage res ults fro m the cord bcing c ut , lorn , Dr crushed o r by its blood supply being cut off. Th is damage is usually irreversible despite the best trauma carl'. Secondary (I{I//Iage occurs fro m hypotension, generalized hypoxia, injury to blood vessels, s\velli ng,

CHAPTER 11 Spinal Trauma _ 165

Excessive posterior movement of the head or neck

Face into windshield in MVC Elderly person falling to the floor Football tackler Dive into shallow water Rider thrown off horse or motorcycle Dive into shallow water

of head or pelvis driven into stationary neck or torso

Dive into shallow water Fall of greater than 10 to 20 feet onto head or legs

Rotation Excessive rotation of the torso or head and neck, moving one side of the spinal column against the other

Rollover MVC Motorcycle crash

Lateral Stress Direct lateral force on spinal column, typically shearing one level of cord from another

HT·bone- MVC Fall

Distraction Excessive stretching of column and cord

Hanging Child inappropriately wearing shoulder belt around neck Snowmobile or motorcycle under rope or wire

166 • C HAPTER 11 Spinal Trauma

or compression of the cord fro lll surrou ndi ng hemorrhage. Emergency efforts are di· rected at p revent ing secondary damage through attent ion to the ABCs, medica tio ns, and careful packaging of the patient.

• • • • • PEARLS

High -Space Shock Irfrt to the spinal coed can produce high-spact !>hod. with the patient experiencing hypotension. normal skin color I!lC' temperature, and an inappmpMte~ b hnn lite.

Neurogenic Shock Injury to the cervical or thoracic spinal cord can produce high-space shock (see C hapter 8). Neu rogenic shock results from the malfunction of the aulonomic nervous system in regu· lating blood vessel tone and cardiac output. Classically, neurogenic shock in the injured patient results in hypotension, with normal skin color and temperature and an inappropri· ately slow heart rale that contrasts with hypovolemic shock. In the healthy patient, blood pressure is maintained by the controlled release of catecholamines (epinephrine and norepinephrine) from the adrenal gla nds. Sensors in the aor· tic and carot id arteries monitor the blood pressure. Catecholam ines cause constriction of the blood vessels, increase the heart rate and the strength of heart contraction, and stimulate sweat glands. The brain and spinal cord signal the adrenal glands to release catecholamincs to keep the blood pressure in the normal range. In pure hemorrhagic shock, these sensors detect the hypovolemic state and compensate by constricti ng the blood vessels and speeding the heart ra te. The high levels o f catecholamines cause pale skin, tachycardia. and sweating. The mechanism of shock from spinal -cord injury is just the o pposite. There is no sig· nificant blood loss, but the injury to the spinal cord destroys the ability o f the brain to reg. ulate the release of catccholamines from th e adrenals ( the spinal cord cable is out), so no ca techolam ines arc released . When the levels of catecholamines drop, the blood vessels di· late ca using the blood to pool. This drop in preload causes the blood pressure to fall. The bra in cannot correct this because it cannot gettne message to the adrenal glands. The pa tient with neurogenic shock can not show the signs o f pale skin, tachyca rdia, and sweating beca use the cord injury prevents release of catecholam ines. Intra-abdom inal injury is d ifficult to eval uate because the patient with neurogenic shock usually has no sen· sat ion in the abdomen. The multiple-trauma pat ient may have both neurogenic shock and hemorrhagic shock. Neurogenic shock is a diagnosis of excl usio n, aft er all other potenLial ca uses of shock have been ruled out. In the prehospital setting. neurogenic shock is treated in the same way as hemorrhagic shock (sec C hapter 8).

ASSESSMENT AND MANAGEMENT OF THE TRAUMA PATIENT Assessing for Possible Spine Injury

• • • • • PEARLS

Motor and Sensory

Function Pctionn bnef motor and $eI\SOIy cheW il the upptf and lower e~ before and Ifte( mooMg 1IyY patient

All trau ma patients are evaluated in the same manner using the ITLS Primary Survey, of which evaluation of spinal-cord function is a pa rt. Clues to spinal-cord injury are given in Table 11 -2. Parts of the neurologic,ll exam are performed during the ITLS Primary Sur..-ey and the remainder of the neurological exam is performed during the ITLS Seco ndary Sur· vey. This is frequently done after the patient is loaded into the ambulance. The pat ient who requires extrication is a special situation. Before begin ning ext rica· tio n, you should check sensory and motor function in the hands and feet, and document these findin gs later in the written report. Not only docs this pre-extricatio n neu rological exa m alert you to any spinal inj ury, it also provides documentat ion o n whether o r not t here was loss of fUllctio n lxfore extric,ltio n was beg ull . Sadly, then: "re" few reports of patiellU who have claimed that their spinal injuries were caused by their rescuers. You will not have time to perform the pre-extrication neurological exam on the patient who requ ires Emer· gency Rescue ilnd you may not have time on those requiring Rapid Ext rication.

CHAPTER 11 Spinal Trauma _ 167

Mechanism of Injury • Blunt trauma above the clavicle • Diving accident • Motor vehicle or bicycle accident • Fall • Stabbing or impalement anywhere near the spinal column • Shooting or blast injury to the torso • Any violent injury with forces that could act on the spinal column or cord Patient Complaints • Neck or back pain • Numbness or tingling • Loss of movement or weakness Signs Revealed During Assessment • Pain on movement of back or spinal column • Obvious deformity of back or spinal column • Guarding against movement of back • loss of sensation • Weak or flaccid muscles • loss of control of bladder or bowels • Erection of the penis (priapism) • Neurogenic shock "The -dues· listed are indicators that the spine may have been injured. These patients may require $MR. (Please refer to Figure 11-8.)

The neurological exa m is described in more detail in Chapters 2 and 10, but we will review Lhe exam of the peripheral nervous system here. The JTLS Primary Survey must be time efficient. If the conscio us pal"ient can move his fingers and toes, the mo to r nerves are int3Ct. Anything less than normal sensation (tingling or decreased sensation ) is suspicious for cord injury. The unco nscious patient may withdraw if you pinch his fin gers and toes. If so, you have demonstrated int act motor and sensory nerves and LhllS an intact cord . However. this docs not mean SMR is not needed. All unconscious trauma patients should ha\·c SMR. Flaccid paralysis and no reflc.xes o r withdrawal, even in the unconscious head injury patient , usuaUy means spinal-co rd injury. Document these important findings.

Managing the Trauma Patient Minimizing Spinal Movement: Based on the mechan ism of injury, it is appropriate to place the head and neck in a neutral position as you first evaluate the patient. The purpose ofSMR is to minimize spinal movement to avoid aggravating any spinal-cord o r column injury. Preparation for managingspinal· cord or column injury ca n begin when yO li are dispJtched 10 the scene of a motor-vehicle collision, fall , explosion, head injury, or neck injury. There arc two types of situations that require modificatio n o f the usual SMR. The pa tient who is in immediate danger of dealh in a hostile environment or in an immediate lifethreateni ng positio n in a structu re o r vehicle may "-"'quire emergency rescue. An example ...."Quld be the patiellt who is in an MVC and , when you arrive, the aulO is on fire. In cases

168 • CHAPTER 11 Spinal Trauma

where even a few seconds may mean the difference between life and death , you are justified in saving the patient in any way possible. Anytime this manner of rescue is used, you should document the reason and req uest a review of the chart by medical direction. Some examples of situations that might require emergency rescue arc when Scene Size- up identifies a condition that may immediately endanger you or the patient, such as: • Fire o r immediate danger of fire or explosion • Hostile environment , gunfire o r o ther weapons • Danger of being carried away by rapidly moving water • Structure in immed iate danger of collapse • Continuing immediately life-threatening toxic exposure

.. - . -

PEARLS Emergency Rescue

Emergtney Rescue is reseNed for those situations ~ then is inrned-'ate (within seconds) environmental threat 10 the rife of the victin and/OI rescuet. PJtienu should be mewed to a safe area in a manner that places the rescuer at the least risk.

R.,;d _

""'*I t.

consKItred for patients whose ~ conditions 01 situations requile fast intervention (one 01 two rninutes-but not seconds) 10

"""" """

- ... -

PEARLS TrQc,jon Do not apply traction 10 the head iInd ned. Maintain n.ine stabiWtion of the head, ned, iInd spine.

The second situation that requires modification of usual SM R is for patients whose ITLS Primary Survey indicates a critical degree of ongoing danger that requires an intervention within I o r 2 minutes. Indications for rapid extricatio n are the foll owing: • Airway obstruct ion that cannot be relieved by modified jaw thrust or finger sweep • Ca rdiac o r resp iratory arrest • Chest or airway injuries req uiring ventilation o r assisted ventilation • Deep shock or bl eeding that cannot be controlled Rapid extrication requires multiple rescuers who remove the patient alo ng the long axis of the body, usin g their hands to minimize spinal movement (see skills in C hapter 12). When the rapid extrication technique is used, the written report sho uld also be carefull y reviewed to ensure appropriate documentation of the techn ique and its indication. The most easily applied and readily available method of cervical-motion restrictio n is with your hands o r knees. Your hands should be placed to stab ilize the neck in relation to the long axis of the spinal column ( Figure 11 -5). "Pulling traction" is not a prehospital 0p· tion, and the term traction is not an app ropriate descriptio n fo r motion restriction of the spine. Traction will usually result in further instability of any spinal-column injury. The correct approach is stabilization , without pulling on the neck. When packaging the body on a backboard, the neutral in-line position allows the most room for the spinal cord, so that is the optimal posit ion for SM R. You can place an appropriately sized cervical-spine extrication collar on the patient as airway assessment is bein g done. Commerc ial cervical motio n-restriction devices may be left in place o n the backboard. These one· or !'ovo-piece collars are not definiti ve devices for restricting cervical-spine motion. but should be used only as a reminder that SM R is necessary and to prevent gross neck movement. The rescuer's hands can be removed o nly when the patient (head and body) has been strapped on a backboard with an attached head motion -restriction device. Fo r the conscious patient. positioning the head and neck in a position of comfort is a good guideline. Adequate strappi ng must secure the head , to rso. and upper legs to the backboard. Inadequate strapping will to rque the neck aga inst the body if the patient moves, rolls, is d ro pped. or is rotated. Placin g and strapping a patient on the board effecLively eliminates the patient's ability to protect the airway; therefore , the rescuer is responsible. Once the patient is secured to the board, a rescuer must be present and capable of rolling the board if the patient begins to vomit or loses his airway. This rule continues in effect in the emergency department, where an emergency depanment staff person must assume responsibility for airway protect ion. Definitive SM R occurs when the body is strapped securely to the board with cushions, blanket , or towel roils, maintaining the head, cervical spine, torso, and pelvis in line. In the past, sandbags have been used for motion restriction of the head and perform well when the patient is kept supine. However, if the board is tilted or the patient and the board are

CHAPTER 11 Spinal Trauma _ 169

8.

"

c. FIGURE 11· 5 Neut ral spinal positioning fOf infant, child, and adult patients. (a) Due to the large heads of younge r children, yo u nla y need to raise the shoulders with padding. (b) In older children, obtain neutral positioning with shoulders and head on a nat surface. (cl With adults, elevate the head I to 2 inches.

170 • CHAPTER 11 Spinal Trauma

..

b.

o.

FIGURE 11 -6 (a ) Ree\'es slccve; (b ) fo.·liller body splint ; (cl ped iat ric SM R device; (d ) Kend r ick ext ric;uioll device; (el shorl backboard; (f) Shorl backboard app lied 10 scaled pal ien t.

.... -

PEARLS

Neulral Alignmenl PlOper padding is ohtn le:juiled 10 obtain and milntaln nel.Itf1I aligrunenl oIlIle patient's rervical spine when you periorm spiMl motion reslriction.

rotated (to prevent aspi ration when the patient \'om its). the weigh t of the sandbags ma)' calise a dangerous ilmount of head movement. Therefore sa ndbags are an extremely poor option for prchospital SMR. Ligh ter-weight bulky objects, such as towel rolls. blan ket rolls, or head cllshions, are better tools for this job, When applied properl )', these devices allow r,'moval of the fro nt portion of the cervical coUil r ilnd obS('rviltion of the neck, as in the patient with open neck wounds. T here are some patien ts (frig htened child ren and patients with altered menta l stat us) who will stfllggle so violent ly that they defeat )'O Uf attem pts to di minate spinal movement. Th('re may be no good solution to this. T he Reeves sleeve ( Figure 11-6) may be the best de-

CHAPTER 11 Spinal Trauma _ 171

I d.

••

t.

FIGURE 11-6 (continued )

vice to restrict sp inal motion in the combative adult patient. You should always carefully documen t those situations in which tht· pat ienl refuses to cooperate with SMR. A trul y neutra l ccn' i cal ~s pin(' position for an adult is lIsually obtained with the lI SC o f 1102 inches of occipital padding on a long backboard. This slightly elevates the head and brings the neck into a neu tral position th:lI tends to make the pal ient more comfortable and also makes endotracheal intubat ion easier if needed. This is accomplished. with Ihe head pad o n a cerv ical mo tion resiriClion device or thc padding that is uSc.--d with many backboard devices. Elderly patients whose necks ha\'c3 natural flexed posture wil l require more padd ing. Children, because thei r heads are proportionately larger. usually req uire padding under the shoulders to pre\'ent neck flexion on the backboard. In cerlain si tuations, once the patien t is packaged o nto Ihe backboord, the boa rd and patient may have to be rolJed up o nto his side (Figure 11-7). Ca refu l slrapping can prevent lateral movement of the spine in this situation , bu t usc of the vacuum backboard is far superior for this. Women who arc more than 20 weeks pregnant should al\\'3ys be transported with the backboard tilted 20 to 30 degrees to the patient's left side in o rder to keep the uterus off the inferior vena cava. Patients wit h airway problems who arc not intuba ted arc better transported on their side. This is especially cri tical when there is FIGURE 11 -7 Palienl in vacuum backboard uncont rolled bleed in g in to t he airwa), or if there is massivc facc or turned on side. Nolin' thai the body is mai ntai ned nt'(k tra uma. In t hese sit uat io ns gravit), helps dra in fluid s O ll l of Ihe in a siraight line. 4

172 • CHAPTER 11 Spinal Trauma

••••• PEARLS

Protecting tile Airway A patient in spinal motion restriction is at risk for aspiration and other problems. You are responsible IOf

checking and maintaining the airway.

airway and may prevent aspiration if the pat ient vomits. Beca use of the danger of voron iting and aspiration. unconsc ious patients who arc not intubated shouJd be transported rolled to the side. The Log Rol! : The log-roll technique is used for moving a patient onto a backboard. It is commonly used beca use it is easy to perform with a minimum number of rescuers. As yet no movement technique has been devised that maintains complete spinal immobilization while moving a patient onto a backboard. Properly performed. the log-roll tech nique will minimize movement of the spinal col umn as well as any other technique. The log-roll technique moves the spinal column as a single unit with the head and pelvis. It can be performed on patients lying prone or supine. Using three or more rescuers-
CHAPTER 11 Spinal Trauma _ 173 Recent stud ies have documented circulllstances under which spinal-column or co rd

injury is very unlikely, and therefore the patient can be managed without SMR. These stud ies have resulted in a clini cal pathway referred to as the Maille Protocol for Spitml MOlion Restrictioll and was written by Peter Goth, MD ( Figure 11-8). This protocol is su pported by the Natio nal Association of EMS Physicians (sec Table 11 -3 for NAEMSP's position paper on spinal motion restriction). You must assess the mechanism of injury, interview and e.xamine the patien t, then use this informa tion to determine which pat ients need SM R. From the Scene Size-u p, histo ry, and assessment come the clues tha t identify those patients who do not need SM R. Under the Maine protocol, the rescuer first assesses the mechan ism of injury. SMR is not requi red if there is no mechan ism of injury that would damage the spine (foo t crushed by a ca r). If the mechanism is a high -risk event, SM R is performed regardless of other clin ical find ings. These high-risk situations include high-speed MVCs, fa lls of greater than three times the patient's height, penetrati ng wounds in to or ncar the spinal column , sports injuries to the head or neck, divin g accidents, and any trauma situation in which the patient remains unco nscious. If the danger of spinal injury is uncertain (ground -level fall, low-speed "fender bender") , the rescuer should manually stabili1'£ the spine and then assess the patient for signs of spinal injury. The patient must be reliable enough to understand the EMS provider and answer the q uestions accurately, so child ren and patients with altered mental status or acu te st ress reactions are excluded. The patient is assessed for evidence of intoxication or distracting injuries that may not allow the patient to clearly feel the pain associated with a spinal injury. The patient is asked ifhe has pain in the area of the spinal column. If no pain is present in the ncck or back, and no other inj uries are so painful as to distract thc patien t fro m comprehending back or neck pain, the rescuer then carefu lly examines the spinal col· umn and performs a neurological exa m. If there is any tenderness on palpat ion of the spinal column area or if the patient co mplains of midline pain when asked to move his back, SMR is perfo rmed. SM R is also perfo rmed ifthere are alterat ions in the motor o r scnsoryexam. If the patient has no high-risk mechanism of injury, no alterat ion of mcntal status, no distracting injuries, is not intoxicated, has no pain or tenderness along the spine, and has no neurological deficits, the p;ltient may be treated and transported without SM R. This protocol has proven effcctive in research studies but, like all medical protocols, mllst be approved for local usc by medical direction and fol lowed up with a qual ity assurance program.

Spinal motion restriction is indicated in prehospital trauma patients who sustain an injury with a mechanism having the potential for causing spinal injury and who have at least one of the following clinical criteria. • Altered mental status • Evidence of intoxication • A distracting painful injury (e.g., long bone extremity fracture) • Neurologic deficit • Spinal pain or tenderness 'See reference 6 in this chapter's Bibliography.

• • • • • PEARLS

Spinal Motion Restrictiotl • SpiN! clearance i$ not a priOOty in the patient suffering from multiple trauma; spinal motion restriction i$. Protocols havtl been developed to dow you to properly choose I'Ihich trauma patients need SMR. using mechanism of injury ar.d

careful evaluatioo.

174 •

CHAPTER 11 Spinal Trauma

Initial Assessment of Spinal Injury Clinical Criteria Mechanism of Injury

Positive Mechanisms: • •

Uncertain • •

•

•

Apply Manual Stabilization Until Exam

•

High-Speed MVC

FaU~ > Three TImes Potient's Height Axial Load Diving Accidents Penetrating Wound In or Near Spinal Column Sports Injuries to Head or N",k Unconscious Trauma Patient

SPINAL PAIN OR TENDERNESS?

MOTOR AND SENSORY EXAM Reliable Patient Is: • • • •

Ca lm Cooperative Sober Alert

•

W ithout Dijlrocfing Injurif)j

RELIABLE PATIENT? Unreliable Patient Has: • • • • •

Note: If ony doubt exists ...

Acute Stress Readion Head/Brain Injury Altered Mental Status Intoxicotion with Drugs/ Alcohol Other Distracting Injuries

Spinal Motion Restriction

FIGURE 11 ·8 Decision tree (or spinal motion restriction. (Rl'pritlll't/ by ~nlljssioll o/Pt!ter Goth, MIJ)

CHAPTER 11 Spinal Trauma _ 175

Airway Intervention When the rescuer performs SMR in any manner, the p.ltient loses some of her ability to main tain her own airway. As men· tioned earlier, the rescuer must then assume this responsibili ty until the patient has a cont rollt.'d airway o r has the sp inal col· umn cleared in the emergency departmen t and is released from the motion· reslricling equ ipment (Figure 11·9). This is particula rly critical in children, who ha\'e a greater potential for vomiting and aspiration after a traumatic injury. Airway manipulations in the trauma patient require careful applica tion. Current research indic.1tes that any airway intervention will cause some movement of the spinal column. In · line manual stabilization is the most effective manner fo r minim izing this movement. Nasotracheal, o ro tracheaJ, o r cricothyroid intubat ions all induce some bony movement. Your ITLS Primary Sur\'cy should include manual stabilil..1tion, then the use of the airway control method that )'Oll are most skilled at perform ing. When weighing the risks and benefits of each aim'3Y procedure. recall that the risk of dying whh an uncontrolled aim'3)' is greater tha n the risk of inducing spinal·cord damage using a ca refu l approach to intubation.

Special SMR Situations You must be prepa red to stabilize the spinal col umn of all patients who sustain major trauma . In some patients (sec below), traditional techniques must be modified to pro\·ide safe and effective SMR.

FIGURE 11·9 You are responsible (or the patient's airway once the patient is st rapped to a backboard.

Closed· Space Rescues: Closed ·space rescues are performed in a manner appropriate for the clin ical cond ition of the pa tient. The o nl y general rules that ca n be appli ed to these rescues arc to prevent gross cerviGll· spine movement and to move patients in line with the long axis of the body (Figure 11 · 10). Sa fety of the rescuer is of prime impo rtance in all dosed. space rescues. Asphyxia , toxic gases, and structure collapse are dangers of closed ·space rescue and may require the use of emergency rescue. Ne\'er ente r a closed space unless you are properl y trained. eq uipped (air pack, sa fety line. and so on ), and sure of scene safety. Water Emergencies: You can perform wa ter rescues by movins the pati ent in line, thereby preventing gross cervica l movement. When the rescuers are in a stable position for performin g SI\'IR, the backboard is floated under the patient , and thl' patient is then se· cured and removed from the water (Scan 11.1 ). Sa fety of both rescuers and patients is of pa ramoun t impo rtance. If you are no t trained in water rescue, do not anempt to reSClle victims in hazardo us situations such 3S deep or swift water. Prone, Seated, and Standing Patients: Prone. seated, and sta nding patients arc sla· bilized in a manner that minimizes spinal column movement , e nding with the patient in the co nventional supine position . • PrOlle patients are log-rolled on to a backboard, wi th the careful coordinatio n of head and chest rescuers.

176 • CHAPTER 11 Spinal Trauma

FIGURE 11 -10 Paticnl enlrapped in Irench cave-in being lifted out along the long axis of the bodr. ( Photo (lIIIr/NJ' /If Ror A/SOli, A/I))

• Scatcn patiellts may be stabilized llsing short backboa rds o r their commercial

adapt:l tions. Used appropriatel)', short backboards provide ini tial stabiliza tion of tht:' cervical and thoracic spine and then facili tatc the movement of thc patient onto a long backboard . • SWI/{/illg pmiclIIs may be placed against the long bo;ud while upright and then

strappcd in place. The board is then gently lowered to the supine position.

FtGURE 11 -11 "·Iost chiJdrc'l requi re pudding under bock and shoulde rs to keep the cervical spine in a neut ral position. (Courlcs), of Hob t"'g<', NREMT·P)

Pediatric Patients: It is best to provide initial SMR of the pediatric patient with your IWllds, and then usc cushions or towel rolls to help secure the child on an appropriate board or device. Some pediatric trauma specialists suggest padding beneath tht., b:lCk and shoulders on the board in .1 ch ild under the age of 3 years (see Figures 11 -5 and II-II ). These children normally have a rcl:ltively huge head that flexes the neck when placed on a straight board . Padding under the back and shoulders will prevent this flexion and also make the ch ild morc comfortable. Chi ldren who are involved in an i\'IVC while rest rained in a child safety sca t but have no apparent injuries mil}' be packaged in th e safety se;1\ for transport to the hospital. Using towel or blan ket rolls, doth tnrc, :lnd a little renssurance, YO li can secm!;' the chi ld in the sa fet y seat a nd then belt the scat into the ambulill1ce ( Figure 11-12 ).

1 Splint head and neck wi th arms.

2 Roll patient over.

3 Ensure airway and breathing . • Patient not breathing: Begin rescue breathing using a pocket mask, and rescue from water as soon aa possible . • Patient breathing: Slide backboard under patient.

• Apply a rigid extrication collar.

178 • CHAPTER 11 Spinal Trauma

FIGURE 11 -12 Infant sc.'Cured in car seat. (Ccurlesy of Davif/ Effro rt. MD. PACEP)

• • • • • PEARLS u,rSeuts Infants and ~U dJildrefi involved in MVCs can be transported in their car seats as long as they haw 00 apparent injury and the device is not

damaged.

Th is technique mi nim izes movement of the chi ld and provides a secure method for ch ild transport in the ambulan ce. When the child is in a ca r seat th at is damaged , or in a builtin child-restraint seat that cann ot be removed, the child must be removed fo r SMR. Children in such situa tion s will have to be carefull y extricated o nto a backboard o r another pediatric SMR device, using ma nual s tabilization . For the child who is frightened and stru ggling. there may be no good way to obtain SMR. Carefu l reassu rance, the presence of a comforting famil y member, and gentle management will help prevent more complications and furth er struggling.

Elderly Patients: Elderly pa tients require fl exibility in packaging techniques. Many elderly patients have arth ritic changes o f the spine and very thin skin. Such pat ients wiII IX' very uncomfortable when placed on a backboard. Some arthritic spines are so rigid that the patient cannot be laid straight on the board, and some elderly patients have rigid fl exion of the neck that will result in a large gap between the head and the board. Yo u can make use of to wels, blankets. and pillows to pad the elderly patient and preven t movement and discomfort on the backboard (Figure 11 - 13 ). This is a situation in which the vacuum backboa rd (which co nfor ms to the shape of the patient ) works very well (see Figure 11 -7).

FIGURE 11 ·13 Additional padding, such as rolled blankets o r towels behind the head, may be needed to keep the head in

a neutral, in-line po~it i Qn .

Patients in Protective Gear: Large helmets used in spo rts and cycling Illust be removed at some poin t to permit complete assessment and care. Helmets used in d ifferent sports present different management problems for rescuers. Football and ice hockey he]mets arc custom fitted to the individuaL Unless special ci rcumstances exist, such as respiratory distress cou pled with an inabi lity to access the airway, the helmet should not be removed in the prehospita l setting. Ath letic helmel design will generally allow easy airway access once the face guard is removed. The best way 10 remove a face guard is with a screwdriver (cordless screwd river is best) and onc should be o n every response vehicle, but

CHAPTER 11 Spinal Trauma _ 179

••

b.

FIGURE 11-14a The face guard of football helmets ca n be remO\'cd wit h

it

screwdri ve r o r pru ni ng sh ears. (Phoro COII(/I'S),

0fk!l HiIlS/UlW, M S. PA-c' NRbHT-P)

FIGURE 11-14b Alwil p run ing shears (Icfl ) or it face m ~lsk ext ractor (ri ght) CHII be used to remove it footba ll helmet face gua rd. (Pholo courlcsy of k fJ Nil/sha\\', A'IS, I'A- G NREMT-P)

somctimes the sc rew sial st rips o u t a nd the [.lee gu,lrd w ill have \0 be cut off. There is all excellent dev ice made specifiCillly for cutt i ng ofT t he four fiKe guard mount ing strips (face mask exlrm,:lu r by Culli ns Sports l\kd iljm: ), but a t this Ii lilt: it is I:xtrL'llldy npl: llsive. T he next best choice is to lI SC anvil pruning shears ( Figure 11-14 ), Pick one of these devices, train with ii, ,lTld k now how to use it app ropriately when the time comes. Rescue sc issors have been advocated in the past but studies have found them to be unsui table for this task. The athlete wearing shoulder pads has his neck in a neut ral position when on the backboa rd wi th the helmet in place. If the hdmet is removed, paddi ng mu st be in se rted under the head to kct,p t he neck from extending ( Fi gure 11 - 15). Afte r arrival at t he tmergcncy fa c ili t}'. the cervical spi ne em be x-rayed wi th th e he lmet in plan'. Once the spine is evalua ted, the helmet ca n be removed b}, stab il izi ng the head and Ili;'ck, removing ,he cheek pads, releas ing the air inflation system, and then sli ding tht, hl'l m et o rf in the usua l manner.

b.

FIGURE 11-15 (a ) P,ltients wi th shoulder pad s a nd helmets arc usua ll y best im mobili7.ed wit h th e helmet in pl3Ce. The sp ine is m lli n ta ined in a neu tral positio n with a minim um of m ovemen t. ( PI,oto ,wnrsyofBol! Pag ... N REMT-P) (b ) Pat il' nts ..... it h sho uld er pads must have paddin g u nder the head to maintain a neutral posit ion if the helmet is relllo\'ed.

180 •

CHAPTER 11 Spinal Trauma

For prehospital providers, field removal of an athletic helmet is a last-d itch p rocedure but it must be entertained in certain u nique patient -care situations. The four main reasons to consider fi eld hehnet removal arc as follows: • Face mask cannot be removed in a timely fashion • Ainvay cannot be controlled due to the design o f the helmet and chin strap • Hel met and chin straps do not hold the head securely • Helmet p revents stabilization for transpo rt in an app ropriate position 'When removing an athletic hel met, it is imperative to cut the chin strap and not to at tempt unsnapping o r unbuckling the device. Sho ulder pad removal is often linked to helmet removal in the athletic setting. Not o nly is this d one routinely with helmet removal, but also when faced with the inability to main ta in neutral cervical -spine align ment (o ft en d ue to ill-fitti ng shou lder pad s), when yo u are unable to secure the athlete to the spine board, and when you need access to the chest fo r resuscitation effo rts. Most shoulder pads can be remov(.'
FIGURE 11-16 Full-face helmets obstruct access to the patient's airway. Notice that tht: hd m d Ot:M."S tl u; nt:d: in .. pa tk nt w ho

(Courtesy of Bob Page, NREMT- P)

i~

no t ",'Ca ring sh oulder pads.

CHAPTER 11 Spinal Trauma _ 181

ions or towel rolls to stabilize the spine. In cold-weather climates, patients in bulky warm clothing will need to be snugl y secured to prevent excessive movement. Patients with Neck Wounds: Pat ients with penetrating or disfiguring wounds of the neck or lower face must be continually observed. Cervical collars will prevent continued examination of the wound site and may comp romise thc airway in wou nds wi th expand ing hematomas or subcutaneous air. If th e mandible is fra ctured . Ihe collar may again CJ use airway compromise. T herefore, for pat ients with these injuries, it may be wise to avoid collars, and use instead manual stabil ization and head cushion devices or blanket rolls for cervical motion restriction. Tra uma patients with paralysis or neurogenic shock have lost vascular control and thus cannot co ntrol blood flow to the skin. They may lose heat rapidly, so it is important for you to prevent hypothermia.

Dan. loyce, and Buddy have been called to a public swimming pool for a diving injury. Dan is the team leader on this call. When they arrive on scene, they are told the patient had been chaSing some friends and dived into the shallow end of the pool, striking his head On the bottom. He was briefly dazed but not unconscious and d id not suffer near-drowning because his friends immediately pulled him from the shallow water. However, it is clear that they did not take spinal precautions while doing so. The patient complains of severe pain in his neck with weakness in both arms and inability to move his legs. A Rapid Trauma Survey reveals tenderness along the cervical spine with spasm of the cervica l spina l muscles and he is breathing with his d iaphragm only. The patient is managed gently, meticu lously packaged on a long backboard, given 100 percent oxygen to breathe, and transported to the level I trauma center. Vital signs just before lift-off are normal. On arrival at the emergency department. he is found to be able to flex his arms at the elbow but cannot move his trunk or legs. His blood pressure has dropped to 80/ 50 with a pulse of72. He is treated for neurogenic shock. A CAT scan reveals a compression fracture of the fifth cervical vertebra, causing cord compression. The patient will require spi nal decompression and stabilization surgery and months of physical therapy in order to regain some use of his arms and legs. He eventu ally is able to walk with a cane and is able to return to school.

Diving injuries or falls in which the victim lands on his head cause axial loading of the spinal column and can cause compression fractures of the cervical spine and cervical spinal-cord injury. In most trauma cases bystanders have learned to wait for EMS personnel to move the victim, but in the case of diving accidents there is such a concern

(PhQHI C lIoh Krist! CORBIS)

182 • CHAPTER 11 Spinal Trauma for the person drowning that bystanders will us ually immediately pull the victim from the water. People unt ra ined in EMS rarely think of s pinal in jury in this s ituation and most do not know how to protect the s pine when getting someone out of the water (see Scan 11.1). As in this case, even if there are already s igns of s pin a l injury, you s hould carefully package the patient to prevent secondary injuri es and give the patient the best chance at a good re covery. There are profound lifelong implications of s pinal-cord injuries.

SUMMARY Spinal-cord injury is a devastat ing co nsequcnce of modern-day trauma. Unst,lb1c or incomplete damage to the spinal col u mn o r cord is not completely predictable; thcrefore, tra uma patients who arc unconsciOllS o r have any dangero us mechanism of injury affecling Ihe head , neck, or trunk shou ld have SMR. Those trauma patients with un certain mechanism s may nol require SMR if they meet the physical exam crite ria. Special trauma cases may require special SMR tech niques. O nce SMR is perfo rmed , the patient loses some ability to co ntro l his :lirway; so. YOll musl be prepared at all times to intervene should the patient vomit o r have cv idence of airw3}' compromise.

BIBLIOGRAPHY 1. Aprahamian, L. 1994. Experimenta l cervical spine inju ry model: Evaluation of ai rway management and splinting t ~h niq u cs. Allllals of EmergclICY Medicine 23: 584. 2. Augustine, J. 2004 . Failure on thc board. EMS 33: 52- 53. 3. Brit ish Trauma Socicty. 2003. Guidelines fo r in itial management and assessment of spinal injury. Injl/ry, Im cf/la/iolla/lol/ fIIal of tile I/ljl/red 34: 405-25. 4. Cordell, W. H., J. Hollingsworth, el al. 1995. Pain and tissue-interface pressures during spi neboa rd inllllobiJiz.1tion. Annals of Emerg/'llCY Medici/Ie 26: 3 1-36. 5. Cross, D. A., J. Baskerville. 200 1. Comparison of percei\'ed pain with different immobilization techniques. Prelwspiwl Emergency Carl! 5: 270--74. 6. Domeier. R. M. 1999. The Natio nal Association of EMS Physicians Standa rds and Clin ical Practice Committee. PrellOspital Emerge/Jcy GIrl! 3: 25 1- 53. 7. Domeier, It '\"1., R. Evans, et OI l. 1999. The reliability of prehospital cl inical evaluation fo r potential spinal injury is not affcclt.>
8. Dun n, T. M.,A. Dahon , T. Dorfmil n, W. Dunn. 2004. Arc emergency medical technician-basic.s able to usc a sek'(:tivc immobiliz..1tion of the cervical spine pro tocol?: A preli minary report. Prt'iwspital Emerge/ICY Care 8: 207- 11. 9. Goth, P. C. 1994. Spine injury, clin ical criteria for assessment and management. Augusta, ME: Medical Care Developmcnt . 1- 36. 10. Hauswald, M.,e. Ong, D.l~llld bc rg, Z. Omar. 1998. Out -or-hospital spinal immobilization: Its effect o n neurologic injury. Academic t:mergl!lICY Medicinc 5: Z14-1'J . I I. Johnson, D. R., M. Hauswald, C. Stockhoff. 1996. Comparison of a vacuum splin t device to rigid backboard fo r spinal immobilization. American 100m/(11 of Emergency Mt'dicinc 14: 369- 72.

12. Kleiner, D. M ., A. Pollak, C. ~1cAdam . 2001. Helmet haz:lrds. Do's and don'ts of foo tball helmet remO\'al. JEMS26: 36-44, 46-48. 13. Krell, J. M., el al. 2006. Comparison of the Ferno scoop stretcher with the long backboard fo r spinal immobilization. Pre/wspiwl Emergellc), Care 10: 46--51. 14. Majernick, T. G. 1986. Cervical spine movement during o rotracheal intubation. Anllals of EmergellCY Medicine 15: 41 7.

184 •

CHAPTER 12 Spine Management Skills

ESSENTIAL COMPONENTS OF AN SMR SYSTEM The five essential components of a fu ll spinal motion-restriction (SMR) s),stem are:

• l111ckboarri. The purpose of the b ackboard is to keep the sp inal column from moving. Several types arc available.

• Cenl;cai collar. Though cervical collars do not immob ilize the neck, they provide some support and ca n serve to remind the patient to keep the nl'Ck still. $everal types are available.

• Head motioll-restriction device. These devices attach to the backboard and are used to restrict movement of the patient 's head after the patient's body has been strapped to the backboard. When the head motion- restriction device has been applied. th e cervical collar may be removed if necessary. There are several different types of these devices.

• Straps. St rapping systems are used to b ind the p.ltient's body to the backboard in order to restrict movement o f thc spinal column. The straps should be positioned to decrease patient movement from side to side and from sliding up and down o n the backboard. Several different systems are availab le. • Airway 11Itl11tlgellle1l1 kit. When you strap someonc's body and head to a board, you m ust assume responsibi lity fo r his or her airway. You m ust have the airway kit immediately available and you must have t he skills to use it. Airway management is a priority consideration with in SM R; thus airway management skills and equipment are necess,lry components.

APPLYING SPINAL MOTION RESTRICTIONS (SMR) Patients Requiring SMR

• • • • • PEARLS

The Short Backboard When placing the straps around the legs on a male patient, do not catch the genitals in the straps. Do not use the short backboard as a "handle" to mewe the patient. Move patient and board as a unit.. Many short backboard devices come with built-in handles. These are not to be used AlONE to ~ a patient. • You may need to mod'lfy your strapping tedtniques, depending

on injuries.

The goal of spinal motion rest rictio n (SM R) is to limit movement of the spine a nd thus prevent further harm. Sec Figure 12- 1 fo r indications for SMR. Patients requiring St-.·IR must have it done before t hey arc moved at all. In the case of an automobile collision, you must stabilize the spine before removing the patient from the wreckage. More patient movcment is involved in extricat ion than at any other ti me. so you mllst carefully stabilize the neck and spine before beginnin g ex!"rication. Remember: Traction can ca use permanent paralysis. You are stab il izing the spine, not pull ing on it. Except in situations requiring Emergency Rescue and sometimes Rapid Ext rication , always t ry to document sensation and mo lar fun ction in the ext rem ities before you move the patient.

SMR with a Short Backboard T hcshort backboard is used for patients who are in a position that does not permit use of the long backboard (such as in a moto r vehicle). There are several diffe rent devices of this type. Some have strapping mechanisms different from th e o ne explained here. Become fa m iliar with your equipment (practice, practice, practice) before employing it in an emergency.

PROCEDURE

00

Applying a Short Backboard

Remember that the priorities of eval uation and managemen t are d one before an SMR device is applied. To a pply a short backboard, follow the steps listed o n the next pages (Scan 12.1 and Scan 12.2).

CHAPTER 12 Spine Management Skills •

Initial Assessment of Spinal Injury Clinical Criteria Mechani $m of Injury Positive Mechanisms: • • • • • • •

Higi>-Speed MVC Falls> Three Times Patient's Height Axiallood Diving Accidents Penetrating Wound In or Near Spinal Column Sports Injuries to Head ()( Neck Unconscious Trauma Patient

SPINAL PAIN ORTENDERNE SS?

MOTOR AND SENSORY EXAM Reliable Patient Is: • • • • •

Calm Cooperative Sober Alert Without Distrocting Injuries

RELIABLE PATIENT? Unreliable Patient Has:

Note: If any doubt exisb ...

• • • •

Acute Stress Reaction Head/Brain Injury Altered Mentol Status Intoxication with Drugs/ Alcohol

•

Other Distrocting Injuries

Spinal Motion Restriction

FIGURE 12· 1 Decision tree for spinal motion restrict ion. (Reprimt'd b)' permissiorl ofPett'r Gotll, AiD)

185

186 • CHAPTER 12 Spine Management Skills

D

Stabilize neck and perform ITLS Primary Survey.

o Position the short backboard behind the patient. Coordinate all movement so that movement of the spine

EI

Apply a semirigid extrication collar.

o

Apply straps and tighten securely.

is kept to a minimum.

I. One rescuer must, if possible, statio n himsclf behind the patient, place his hands on either side of the patient's head, and stabilize the neck in a neutral posi tion. This step is part of the ABCs of evaluation . It is done;\I the same time that you begin evaluation of the airway. 2. When rou have finished evaluating the neck in the Rapid Trauma Survey and have checked ext remities for movement (document findings later), you should apply a scmi rigid ext ricat ion collar. If you have eno ugh people, this can be done while someone else is doing the ABCs of evaluation and management . If you have limited

CHAPTER 12 Spine Management Skills •

187

(•.,ufa ",')

D

Turn the patient carefully. Then lower the patient onto the backboard.

iii

Slide the patient on the short backboard up into position on the long backboard. Loosen the straps and allow the legs to extend out flat. Then retighten the straps. Secure the patient and the short backboard to the long backboard . Apply a padded SMR device to secure the patient's head and neck.

help, apply the colla r aftl'r fini sh ing the Rapid Trauma Survey, but before tra nsferrin g the patient to the backboard. 3. Position th e short backboard behind the pati ent . The first rescuer continues to stabilize the neck while the short backboard is being maneuvered into place. The patient may have to be moved forward to get the backbon rd in position; grea t care must be taken so that moves are coordinated to suppo rt the neck and back. 4. Secure the patient to the board. Th ere arc usually three straps for this. Place the short st rap under the armpits and across the upper chest as an anchor. Bring each long strap over a leg, down between both legs, back a round the outside of the sa me leg, and across the chest. Then attach them to the upper strap opposite that which was brought across the shoulders a t the midclavicular position. s . Tighten the strap s until the patient is held secu rely. If the patient is conscious, ask her to take a deep breath while placing your fingers under the straps to ensure that the stra ps have not been tightened to the point that it impedes breathing. 6. Secure the patient's head to the board by wide tape or elastic wraps around the forehead. Apply paddi ng under the neck and head as needed to maintain a neutral posit ion. 7. Transfer the patient to a long backboard. To do so, turn the patient so that her back is to the opening through which she is to be removed. Someone must suppo rt her legs so that the upper legs remain at a 90-degree angle to her torso. Position the long backboa rd through the opening until it is under the patient. Lower the patient's back onto the long bac kboard and slide her and the short backboard up into posit ion on

188 •

CHAPTER 12 Spine Management Skills

. . Stabilize the neck and perform the ITLS Primary Survey.

lEI

Apply semirigid e xtrication collar.

D

o

Tighten the chest straps.

Position the device behind the patient. Coordinate all move ments to restrict spinal motion . Position the chest panels up weH into the armpits.

the long backboil rd . Loosen the straps 0 11 the short boa rd and allow the patient's legs to extend out {Iat, and then rct ighten thc straps. Now secu re her to the 10ll g backboard wit h stfilPS, and secure her hl'ad wi th a padded motion-rl'str ictioll device. Wh('n she is secured in this way, it is possible 10 tUTn the whole board up on its side if Ihe patient has to vomit. The patient should remai n securel y strapped , wilh Jillk or no IllCWCll1cnt.

CHAPTER 12 Spine Management Skills •

D

loosen each leg strap around the ipsilateral (same side) leg and back to the buckle on the same side. Fasten snugly.

D

189

Apply firm padding as needed between the head and the headpiece to keep the head in a neutral position. Bring the head flaps around to the side of the head and secure firmly with straps, tape, or elastic wrap.

III

Turn the patient and the device as a unit. Then lower the patient onto a long backboard. Slide the patient and the device up into position on the board. l oosen the leg straps and allow the legs to extend out flat. Finally, retighten the straps and secure the patient and the device to the backboard.

190 •

CHAPTER 12 Spine Management Skills

Emergency Rescue and Rapid Extrication Patit'llts left inside vehicles following a collision .m~ usually stabilized 0 11 .1 short backboard (or extrication device) and then transferred onto a long backboard. Although this is thC' best way to extricate anyone with a possible sp inal injury, there arc certain situations in which a more rapid method must be used. Note: International Trauma Life Support (ITLS) offers a one~ day course called "'Access" on basic cxtrication from Illo tor vehicles using basic h.md tools. C.a Il 888-495-48S7 fo r information (international calls: 630-495-644 2).

Situations Requiring Emergency Rescue: This procedure is used only in situations in which the patient's life is in immediate danger. In so me oflheS(' situations you Illay not have time to use any techn iquc other than pulling the patient to safety. This is an examplC' of "desperate situations demanding desperat e measures." Usc good judgment. Do not sacrifice your life in a dangerous siWation. Whenever you tl SC this procedure, it should be noted in the written report , and you should be prepared to defend you r actions at a reviC'\\' by your medical director. Perform Emergency Resc ue if the Scene Size- up identi ft es a condition that may imIllcd iillety ( within seco nd s) enda nger yo u and/o r the pa tien t, such as th e follo wing ( Figure 12-2): • Firc or immediate d.mger of firc or explosion • Hostile env ironment , gunfire or other weapons • Danger of being carried away by rapidly moving wa ter • Structure in immed iate dang{"f of collapse • Continuing immedia tely life-threill cning toxic exposure

Situations Requiring Rapid Extrication: You sho uld perfo rm Rapid Extrication if your ITLS Primary Survey of a pat ient identifies a critical degree of ongoing danger that

FIGURE 12-2 Example of a situRlion in which you may have to perform emergency rescue. (Gwrll'$), of HOI/II;!' Mellt'"I},. EA'IT- I' )

CHAPTER 12 Spine Management Skills .

191

requires an interven tion within I to 2 minutes. You must act immediately and rapid ly, bu t you have time to stabilize the patient to some degree as )'ou extricate him. Example situalions that may require rapid extricatio n are as follows: • Airway obstructio n that you cannot relieve by jaw thrust or fin ger sweep • Cardiac or respirator)· arrest • Chest or ai rway injuries requiring ventilatio n or assisted ventilation • Deep shock o r bleeding that you cannot control

PROCEDURE ~

Performing a Rapid Extrication

The following steps are illustrated in Scan 12.3 . 1. One rescuer must, if possible, station himself behind the patient, place his hands on either side of the patient's head , and stabilize the neck in a neutral position. This step is part of the ABCs. It is do ne at the same time that you begin evaluation of the airway. 2. Do a Rapid Trauma Survey. T hen quickly apply a cervical collar. (You should have the collar with you when you begin.) 3. If your ITLS Prima ry Survey of the patient reveals o ne of the situations listed above, go to the Rapid Extrication technique. This requires at least fo ur, and preferably fi ve o r six, persons to perform well. 4. Immediately slide the long backboard onto the scat and, if possible, at least slightly UndtT the patient's buttocks. S. A seco nd rescuer stands d ose beside the open door of the vehide and takes over control of the cervical spine. 6. Rescuer I or another rescuer is positioned o n the other side of the front seat ready to rotate the patient's legs around. 7. Another rescuer is also positioned at the open door by the patient. By holding the upper torso, he works together with the rescuer hold ing the legs to turn the patient carefull y. 8. The patient is turned so that his back is toward the backboard . His legs are lifted and his back is lowered to the backboard. The neck and back are not allowed to bend during this maneuver. 9. Using teamwork, the patient is carefu lly slid to the full length of the backboard and his legs are carefully straightened. 10. The patient is then moved immediately away from the vehid e (to the ambulance if available), and resuscitation is begun. He is secured to the backboa rd as soon as possible.

• • • • • PEARLS The Lotlg Backbo(lrd ~)'OU are ~ tht!.W« horizontal strap around a woman,

pOO "" """' """ .... !.. bl'easts and I.Ilder ilef arms, not across the breasts. When )'OU at! applying the Iow!r horizontAl $trap on I pregnatlt woman, pOO it across the pelvis and not iK10SS the utffUS. • You mz.J need to mocify)'OUr Strapping tedriQues. depend'~ on~

SMR Using the Long Backboard One of the most important ways to apply SMR to a suspected spine-injured patient is to secure him from head to toe to a long backboard . Bllt moving the pa tient onto the backboard must be accomplished in a careful , coordinated way that protects him fro m any fu rther injury. That procedure is called a log roll.

• Seate the patient well enough 50 that ~ttIe 01 no motion 01 the spine d occur if the board is turned on its sideo. Do notmake straps 50 tight tNt they interlere

,.;;, bre...,.

192 • CHAPTER 12 Spine Management Skills

II

D

Stabilize the node and perform the ITLS Primary SUNey.

Slide the longboard onto the seat and slightly under the patient.

II Apply a semirigid extrication collar.

o A second rescuer stands beside the open door of the vehicle and takes over control of the ceNical spine.

CHAPTER 12 Spine Management Skills •

D

Carefully supporting the neck, torso, and legs, the rescuers turn t he patient.

193

D

The legs are lifted and the back is lowered to the backboard .

o The patient is immediately moved away from the vehicle and into the ambulance, if available. Secure the patient to the backboard as soon as possible,

D

Carefully slide the patient to the full length of the backboard.

194 • CHAPTER 12 Spine Management Skills The Supine Patient

PROCEDURE

00

Log·Rolling the Supine Patient onto a Long Backboard

The fo llowin g steps are illustrated in SCiln 12.4. J. Rescuer I stabilizes the head and neck in a neutral position , but docs 'lOt apply tractio n. He shou ld grasp the patient's shoulders at the neck and gently positio n the pat ient's head between your forearm s. Another rescuer should apply a semirigid extrication collar. Even with the collar in place, Rescuer I mus t maintain the head and neck in a neutral positio n unt il the log4 rolling maneuver is completed. 2. The pat ient is placed wit h her legs extended in the normal manner and her arms (palms inward) extended by her sides. The patient will be rolled up o n one arm with that arm p roviding pro per spacing and acting as a splint for the body. 3. The lo ng backboard is positioned nexi to the body. If one of the patient's arms is

injured , place the backboard on the injured side so that the patient will ro ll upon the uninjured arm. 4. Rescuers 2 and 3 kneel at the patien t's side o pposite the board.

S. Rescuer 2 is pos itioned at the midchest area and Rescuer 3 is by the upper legs. 6. With his knees, Rescuer 2 holds the patient's ncar arm in place. He then reaches across the patient and grasps the shoulder and the hip, ho ldin g the patient 's far arm in place. Usuall y, it is possible to grasp the patient's cloth ing to help with the roll if it is nol loose fillin g. 7. With o ne hand. Rescuer 3 reaches across the patient and grasps the hip. With his other hand, he holds the fect together at the lower legs. 8. Wh en everyone is ready, the rescuer at the head (Rescuer I ) gives the o rder to logro ll the patient. 9. Rescuer I carefully maintains a neu tral position of the head and neck

(anteroposteriorly as well as laterall y) during the roll. 10. Rescuers 2 and 3 roll the patient up on her side toward them. The patient's arms are kept locked to her side to maintain a splinting effect. The head, sho ulders, and pelvis are kept in line during the log roll. Additional suppo rt may be provided by b raci ng the patient aga inst the legs of Resc uers 2 and 3. I), When the patient is on her side, Rescuer 2 (or Rescuer 4, if available) quickly examines the posterio r surface fro m occi put to heels fo r inju ries.

12. The backboard is now positio ned next to the patient and held at a 30- to 4S·dcgree angle by Rescuer 4. If there are only th ree rescuers, the board is p ulled into place b}' Rescuer 2 o r 3. T he board is left flat in this case. 13. When everybody is ready, Rescuer I gives the order 10 log-roll the patient onto the backboard. This is accompl ished by keepi ng head , sho ulders. and pelvis in line.

CHAPTER 12 Spine Management Skills .

Log-Rolling

d

195

Supine Patient

D

Rescuer 1 maintains the neck stabilized in a neutral position.

D

The long board is positioned beside the patient.

D

D

D

D

Rescuers 2 and 3 assume their positions at the patient's side opposite the board.

Quickly examine the patient's posterior surface for injuries.

The patient is carefully rolled upon her side.

If another person is available, he positions the backboard next to the patient at a 30- to 45-degree angle.

(colllillued " ext page)

196 • CHAPTER 12 Spine Management Skills

SCAN 12.4 (_1irtuaI

D

If no other help is available. Rescuer 2 or 3 positions the backboard and leaves it flat.

D

D

At Rescuer 1's order, the patient is rolled onto the backboard. All movements are coordinated so that the spine is kept straight at all times.

l og roll completed.

The Prone Patient: The status of the airway in a prone patien t is crit ical for decisions about the order in which the log-rolling procedure is done. There are three dinical situations th:1I d ictate how you should proceed .

• The patient who is not breathing or who is in severe respiratory d iffic ulty must be log-rolled immediately to ma nage the airway. Unless the backboard is al ready positioned, you must log-roll the patien t, manage the airway, and then transfer the patient to the backboard (in a second log-rolling step) when ready to transport. • The patient with profuse bleeding of the mouth o r nose must not be turned to the supine position. Profuse upper airway bleeding in a supine patien t is a guara ntee of aspiration. This patient will have to have careful SMR and be transported prone or on his side, allowing gravity to help keep the airway dea r. The vacuum backboard could be very useful in this situation (sec Chapter II, Figure 11-7 ). • The patient with an adequate airway and respiration should be log-rolled directly on to a backboard.

CHAPTER 12 Spine Management Skills .

00

197

Log-Rolling the Prone Patient with an Adequate Airway onto a Long Backboard

1. Rescuer 1 stabilizes the neck in a neutral position.

When plncing the hands on the head nnd neck. the rescuer's thumbs always poi nt toward the patient's fa ce ( Figure 12-3 ). Th is prevents hnving the rescuer's arms crossed \"hen the patient is log-rolled . Initial assessmen t and exam of the backside is done, and a semirigid extricat ion collar is applied. 2. The patien t is placed with his legs extended in the normal manner and his arms (palms inwa rd) extended by his sides. The patient will be rolled up o n one arm, with that arm act ing as a splint fo r the body.

FIGURE 1 2-3 When slabilizing the neck of the prone (or su pi ne) patient, your thumbs always point toward the {ace {not the occiput). This pre" ents having yo ur arms crossed when the patienl is rollt-d m·er.

3. The long backboard is positioned next to the body on the side of the fi rst rescuer's lower hand. ( If the fi rst rescuer's lower hand is on the patient's right side, the backboard is placed on the pat ient's right side.) If the arm next to the backboard is injured, carefully ra ise the arm abm'e the pat ient's head so he does not roll on the injurt'd arm. 4. Rescuers 2 and 3 kneel at the patient's side opposite the board.

S. Rescuer 2 is positioned at the midchest area, and Rescuer 3 is by the upper legs. 6. Rescuer 2 grasps the shoulder and the hip. Usually. it is possible to grasp the patient's clothing ( if not 100 loose) to help wi th the roll. 7. Rescuer j grasps the hip (holding the near arm in place) and the lower Jegs (holdi ng them together). 8. When everyone is ready, Resc uer I gives the o rder to log-roll the patient. 9. Rescuer I carefully keeps the head and neck in a neutral position (an teroposteriorly as well as laterally) during the roll. 10. ResCliers 2 and 3 roll the patien t up o n his side away from them. The patient's arms arc kepi locked to his side 10 maintain a splinting effect. The head. shoulders, and pelvis are kept in Ji ne during the roll. 11. The backboard is now positioned next to the p,u iell t and held :II a 30- to 45-degree angle b y Rescuer 4. If there arc onl y three rescuers, the boa rd is pulled into p/;l(C by Rescuer 2 o r 3. The boa rd is left flat in this case. 11. When e\'eryone is readr, Rescuer I gives the order 10 roll the patient onto the

backboard. This is accomplished by kct"ping the hea d. shoulders, and pelvis in line. 13. Now. com plete the Rapid Trauma Survey. Special Considerations: When log-rolling the patient with chest or abdominal injuries, try to roll him on to his uninj ured side. The roU should be executed quickly enough to not compro mise lung expansion. When log-rolling a patient wi th injuries to the lower extrcmitics, position Rescuer 2 at the feet of the pat ien t to provide in-line support to the injured leg(s) during the log roll. Again try to roll onto the uninju red side. The side to which ),OU turn the patient during the log-roll proced ure is not critical and can be cha nged in situations where rou ca n only place the backboard on Olle side of the patient.

--~----------- -

198 • CHAPTER 12 Spine Management Skills

The log- roll technique is useful for most trauma patients, but for those patients with a frac tured pelvis it may aggravate the injury to roll their ' ....eight onto th e pelvis. If the pelvic fractu re appears stable, the log roll should be carefully performed, turning the patien t o nto the uninjured side (if it ca n be id entified ). Patients with obvio usly unstable pelvic fract ures should not be Jog-rolled but lifted carefull y onto a board using four or more rescuers.

The scoop stretcher (see Chapter 2, Figure 2-5) is a supplemental device that Illay help move the patient onto the backboard when specific injuries complicate log- rolli ng. Some newer scoop stre tchers have been found 10 provide equal or superior stabi li7..alion when compared to the long backboard (see reference 3 in Bibliography for Chapter 11). Such scoop stretchers can be used in place of a long backboard.

Securing the Patient to the Backboard There are several different methods of securing the patient using straps. As with all equipment, you should become familiar with your strapping system before using it in an emergency situation. Two examples of commercial devices for full body immobilization me the Ree\'eS sleeve and the Miller body splint. The Reeves sleeve is a heavy-duty sleeve into which a standard backboa rd will slide. Attached to this sleeve are the fo llowing: • A head motion-restriction d evice • Heavy vi n),l-coated nylon panels that go over th e chest and abdomen and are secured with scat-belt -type straps and qui ck-release connectors • Two full- length leg panels to secure the lower extremities • St raps to hold the arms in place • Six handles for carrying the patient • Metal rings (l,SOO-lb strength ) fo r lifting the patient b)' rope When the patient is in this device, he remains immobilized when li fted horizon tall)', vertically, or even carried o n his side (like a suitcase). This device is excellent for the confused, combative patient who must be rest rained for his safety (Figure 12-4). The Miller body splint is a combination backboard, head immobili 7.er, and body immobil izer (see Chapter I I, Figure 11 -6b). Like the Reeves sleeve, it does an excellent job of SMR with a minimum o ftim e a nd effort .

00

Applying and Securing a Long Backboard to a Standing Patient

I. Rescuer 1 sta nds in front of the patient and stabilizes the head and neck in a neutral position. Rescuer 2 applies a semirigid ccn'ical collar while Rescuer I con tinues to maintain the neck in a neutral position. 2. Rescuer 2 places a long backboard against the patient's back. 3. Rescuer 3 secures the patient to the board using n)'lon straps. These must incl ude an anchor strap high on the ch est as well as ones that cross over the shoulders and the pel vis and legs to prevent movement when the boa rd is tilted down. 4. Rescuer 3 places padding behind the patient's head to maintain a neutral posi tion, and applies and secures a bla nket roll or commercial head motion-restriction device using elastic wraps or wide tape. S. Rescuers 2 and 3 carefull), tilt the board back on to a st retcher and secure the legs.

CHA PTER 12 Spine Management Skills •

199

FIGURE 12-4 Patient restrained in a Rccyes 5Icc\'e. Combative pal icnu can haye their ar ms enclosed within the paneb and the st rops.

Specia l Consid e ra tions for the Head a nd Neck: Stabilizing the head and neck in a neutral posit ion sometimes cannot be accompl ished safel y. If the head or neck is held in an angula ted position and the patient compla ins of pai n 011 any al'lempt to straigh ten it, you should stabilize it in the position foun d. The same is true of the unconscious pa tien t whose neck is held to one side and does not easily st raighten wit h a gentle attempt. You cannot use a cervical collar or commercial head motion-restriction device in this situation. You must use pads o r a blanket roll and ca reful tap ing to stabilize the head and neck inlhe posi tion found.

• • • • • PEARlS Prot~ctiv~

HELMET MANAGEMENT PROCEDURE

00

Removing a Motorcycle Helmet from a Trauma Patient

To remove a motorcycle helmet from a patient with a possible cervical-spine injuf)" take the following steps (Sca n 12.5). I. Position yoursel f above or beh ind the patient. Place your hands on each side of the he/met and stabilize the head and neck by holding the helmet and the patient's neck. 2. Your pa rtner positions hi mself to the side of the patient and removes the chin strap. Chin straps can usually be remo\'ed easily wit hout cu tting them. 3. Your partner then assumes the stabilization by placing one hand under the neck and the occiput and the other hand on the anterior neck with the thumb pressing on one angle of the mandible and the index and middle finge rs pressing o n the other angle of the mandible.

Eqllipmetlt Patients wearing both helmets and shoulder pads usual~ can have their spines malntained in a more neutral position by leaving the helmet in piKe and padding and tapng the helmet 10 the

bodboo". Patients wearing helmets but no Y-.ouldtr pads usually can have their spines ma~lained in a lTIOfe neutral position by removir.g the helmet Face guards on helmets can be removed w'th screwdrivers Of pruning shears. Ful).face motorcycle-type helmets must be removed 10 evaluate and manage the ailway.

200 •

CHAPTER 12 Sp ine Management Skills

. . One rescuer applies stabilization by placing hands on each side of the helmet with fingers on the patient's mandible. This prevents slippage if the strap is loose.

EI

D

D

The second rescuer places one hand on the mandible at the angle, thumb on one side, long and index fingers on the other.

A second rescuer loosens the strap at the D·rings while stabilization is maintained .

With the other hand , the second rescuer holds the occipital region. This maneuver transfers the stabilization responsibility to the second rescuer. The rescuer at the top removes the helmet in two steps, allowing the second rescuer to readjust his hand position under the occipital region. Three factors should be kept in mind: (a) The helmet is egg·shaped and therefore must be expanded laterally to clear the head. (b) If the helmet provides full facia l coverage, glasses must be removed fi rst. (c) 1f the helmet provides fu ll facial coverage, the nose will prevent removal. To clear the nose, the helmet must be tilted backward and raised over it.

CHAPTER 12 Spine Management Skills •

o

Throughout the removal process, the second rescuer maintains in-line stabilization from below in order to prevent head tilt.

D

After the helmet has been removed, the rescuer at t he top replaces his hands on either side of the patient's head with his palms over the ears, taking over stabilization.

D

Stabilization is maintained from above until SMR is completed.

4. You now remove the helmet by pulling ou t laterally on each side to clear the cars and then up to remove. Tilt full -face helmets back to clea r the nose (tilt the helmet , not the head). 5. If the pat ient is wearing glasses, remove them through the visual opening before removing the full -face helmet. Your partner maintains stabiliz.ltion of thc neck during this procedure. 6. After removal of the helmet, yo u 'lgain assume stabili7.ation of the neck by grasping the head on either side. wi th your fin gers holding one angle of the jaw and the occipu t. 7. Your partner now applies a suitable cervical collar. PROCEDURE Alternative Procedure for Removing a Helmet This alternative has the adva ntage of one person maintaini ng stabili7.ation of the neck throughou t the whole procedure (Scan 12.6). Note that this procedure does flol work well with full -fa ce helmets.

00

I. Position yourself above or behind thc patient and place your hands on each side of

the neck at the base of the skull. Stabilize th e neck in a neut ral position. If necessa ry, you may use your thumbs to perform a modified jaw thrust whi le doing th is. 2. Yo ur partner posit ions himself over to the side of the patie nt and removes the chin strap. 3. Your partn er now removes the helmet by pull ing o ut laterally on each side to clear the ears and then up to remove. You main ta in stabi lization of the neck during the procedure. 4. You r partner now applies a suitable cervical collar.

201

20 2 •

CHAPTER 12 Spine Management Skills

D

Apply steiloy stabilization in neutral position.

II

o

Remove the helmet by pulling gently on each side.

o Apply a suitable cervical-spine extri cation collar and secure the patient t o a long backboard.

Remove the chin strap.

BIBLIOGRAPHY I. Johnson, D. It , M. Haus"~Jl d , C. Siockhoff. 1996. Comparison of a vacuum splinl device 10 rigid backboard fo r spinal immobilization. American /ourl/o/ of Emergency Medicil/e 14:

369-72. 2. Kleiner, D. I\-\.. A. I'ollak, C. McAdam. 200 1. Hclmci haz,1rds. Do's and don'ls of foo lhall hclmet removal./EMS 26: 36-44,46-48. 3. Krdl, J. M" cl al. 2006. Comparison of Ihe Ferno .~oop sl retcher wilh the long backboard for spinal immobilizat ion. I'reilOspif(l/ Emergency Care 10: 46--51.

Dan, Joyce , and Buddy of the Emergency Transport System (ETS) have been called to the sce ne of a si ngle moto r-ve hicle co ll ision in which the auto ran into a tree. The male vic tim is

s till in the a uto . He is restrained and currently awake. What other information about the scene and the patient would be valuable? What injuries would you expect from a mechanism

of th is type? Keep these questions in min d as you rea d the chapter.

Then, at the end of the chapter, find out how the rescuers co mpleted this call.

INTRODUCTION Injury to the abdomen can be a difficuh condition to evaluate in the hospital. In the field it is usua lly even more so. Nevertheless, because in tra -a bdominal injury is one of the major causes of preventable traumatic death, t he possibility of int ra-abdom inal injury must be recognized, documented, and addressed im mediately. Penetrating abdominal injuries obviously need im mediate surgical atten tion; blu nt injuries mOl)' be more subtle, b ut potentially are just as deadly. Whether the result of blllnt o r penetrating tra uma, abdominal injury presents two life-threatening dangers: hemorrhage and infectio n. Hemorrhage has immediate co nsequences, and thus you must be alert to the danger of early shock in all abdo m ina l-injury patients. Infectio n, which presents late, may be just as deadly, but does not require field in tervention beyond prevention of gross contamination. T he role of prehospital prov iders in the m,lIl agement of abdo minal t wuma has been the subject of some controversy. Studies in the mid -1980s demo nstrated that appropriate and timd)' intervent ion b)' well-trai ned paramedics could improve the hemodynamic statu s o f cri tically injured pa tients with wounds to the abdomen. More recent studies haw suggested that pneumatic antishock garment ( PASG ) applicat ion aJld/or vigorous IV fluid reSLIscitatio n in Ihe prehospital setting may do more harm tha n good for patients with penetrating abdominal trauma (sec C hapler 8 ,\Od the Bibliography for this chapter). The effects of nuid resuscitation in blun t trauma arc less well studied. In the field. rapid pat ient assessment and early t reatment of shock is critic.,1 in the management of the patient wi th abdominal trauma.

ANATOMY OF THE ABDOMEN The abdomen is t raditionally divided into three regio ns: the thoracic abdomen, th(' I'ruc abdomen , and thc ret roperi toneal abdomen. T he tho racic portion of the abdomen is located u nderneath a th in sheet of muscle, the d iaph ragm, and is enclosed by the lower ribs ( Figure 13 ~ I). It co ntains the liver, gallbladder, spleen, sto mach. an d tra nsverse colon. In-

204

CHAPTER 13 Abdominal Trauma _ 205

Duodenum Small in testine

----\-Q!li;

Large Intestine Bladder _-;""'L_~

FIGURE 13-1 Intrathoracic abdomen.

FIGURE 1 3·2 Trueabdomen.

jury to the liver and spleen is most colllmon in blu nt trauma and can result in li fe- threatening hemorrhage. The true abdomen contains thc small intestines and the bladder (Figu re 13-2). Damage to the in testi nes can result in infeclion, peritoni tis, and shock. In a female patient, the uterus, fallopian tubes, and ovaries are considered to be pa rt of the pelvic portion of Ihe true abdomen. The retroperitoneal abdomen lies behi nd the thoracic and true portio ns of the abdomen (Figure 13-3). Th is area includes the kidn eys, urelers, pan creas, posterior duoden um, ascending and descending colon, abdo min al aorta, and the inferior vena cava. Because of its locatio n away from the body surface, injuries here are difficult to eva luate. While hemorrhage in the true abdomen may cause the anterior abdom inal wall to become distended, hemorrhage severe eno ugh to ca use shock may occur in the retroperito neal space without this d ramatic sign. In th e pelvic pa rt of the retroperitoneal abdomen are the iliac vessels. These vessels and their branches may be damaged by abdo minal trauma or pelv ic fracture. injury to them ca n cause exsa nguinating hemorrhage with no early symptoms.

Intraperitoneal abdomeo

o

Retroperitoneal

abdome n

Spleen

Aorta

FIGURE 1 3·3 Retroperitoneal abdomen.

TYPES OF INJURIES Injuries to the abdomen are usuall y categorized as blunt or penctrating traullla, but a combi nation of thc two also occurs. Blunt trauma is the most common mechan ism of abdominal injury and has relatively high mortality rates of 10 to 30 percent. The reason for this is likely related to the frequency of accompanyi ng injuries to the head , chest, or an ext remity(s) in as Ulan y as 70 percellt of MVC victims. Blunt abdom in al injury Illay be from direct compression of the abdo men, with frac ture of solid organs (spleen/live r) and/or blowout of hollow organs (intestines). Injury may also arise from deceleratio n forces, with learing of organs and their blood vessels. The patient who has suffered blunt trauma may have no pain and little external evidence of inju ry, which may give you a false sense of security. Pat ients with multiple lower rib fractures are notorious for having severe in traabdomin al injuries witho ut significa nt abdom ina l pain. The severe pain from the rib

206 •

CHAPTE R 13 Abdominal Trauma

- -- --

pJ!AJUS

Abdominal Injury

• 'Nhen rnechani5ms of trauma or lSSOC'iated ~ like lower ~ fractures or gluteal penetrating wounds suggest possible inu')abdominal ~ury, do not be fooled by the patient's lad: 01 abdominal pain or teodemess. Be rxepared to IJeM 1I)1XMl1emic shock from ocnlt intrrabdorrWl bio.
"'""""""" "" .....

abdominalIJittlma and is ely to

'"""" M .,;dJy I_ i

vital signs are inilialy roorma!). Load and go, preparing to treat "" ..._ of """"""'" shod: en route to the hospital

fract ures becomes a d istracting injury for the less noticeable abdominal pain. As a result, th is patient may bleed to death because abdominal injuries are not recognized. Most penetrating injuries arc caused by gunshot or stab wounds. Gunshot wounds to the abdomen may incl ude direct tra uma to an organ and vasculature through penetration from the bul let, its fr ... gments, or the energy transm itled from Ihe bullet mass and '-elocit y. As a rule, most gu nshot wounds will be trealed in the operati ng room. These pat ients have mortal ity rates of between 5 and 15 percent . These rates arc much higher tha n those of stab wounds because o f greater incidence of inju ry to abdominal viscera from the higher energy imparted to the intra-abdominal o rgans (see Chapter I). Th~ mortality rate from abdom inal stab wounds is relativel y low (1-2 percent). Unless the knife penetrates a major vessel o r o rgall , such as the liver o r spleen. the pat ient may not initially appear to be in shock at the scene. However, some of these patients can de"elop li fe-threatening peritonitis over the next few hours to days. These wounds need to be carefully evaluated in the hospital because approximately one-third of these patients require surgery. You sho uld remember that the path of the penet rating object migh t not be readily apparent from the wound location. Any penetrating wou nd of the chest may penetrate the abdomen, and vice versa. The cOllfse of a bullet Illily pass through numerous structu res in d ifferent body locatio ns. It is important to look at the pa tient's ent ire posterior surface beC:luse penetrating trauma in the gluteal area (iliac crests to the gluteal folds, includ ing the rectum ) is associated wit h up to a 50 percent incidence o f significant intraabdominal injuries. In the prehospital phase. with both blunt and penetrating trauma, you must be most concerned about intm-abdomi nal bleeding with hemorrhagic shock.

ASSESSMENT AND STABILIZATION Scene Size-up You ca n glean much important information from the scene by noting the circumstances surrounding the patient's injury. An accurate but rapid assessment of the scene will usuall y tip yOll off to the possibility of abdom inal trauma. Do circumstances on the scene suggest that the vict im has fall en from a height or been hit by a passing vehicle? Has there been an explosion that co uld have hu rled the victim against immobile objects or transmitted blast pressure to orga ns inside th e abdomen? Has the victim of an automobile crash had the shoulder st rap u nder the arlll rather than over the shoulder? Or was the lap belt worn too high over the soft true abdomen instead of correctly across the pelvis? Any of these mecha nisms can lead to abdominal injury. If the patient was involved in a moto r-veh icle crash, as you do your Scene Size-up, quickly observe the damage to the \'ehicle. such as passenger compartment intrusion, airbagdeplo)'lllent, broken windows, bent steering wheel/steering column , and location of occupants. If the palient needs to be extricated , note the location of the safety belts; although they certai nly save lives, incorrectly worn safety belts can cause blunt abdominal inju ries by compressi ng the int ra-abdomi nal organs against the spine. Remember that lap belts alone. especially in the young 'Idolcscent ag~ group may. iron ica.lly, predispose an in· dividual to in tra-abdom inal injuries. T he perso n who is stabbed or shol may be able to give }'Oll some idea as to the size of Ihe instrument or IrajeCl"ory of the bullet. With gunshot wOll nds, it is also important 10 know Ihe caliber. the range from wh ich it was fi red , and the number of rou nds that were fired. A bysta nder or the police may be able to proVide such informat ion. When you arrive at the hospital (optimally a trauma center), be sure to report any mechanism that suggests

CHAPTER 13 Abdominal Trauma _ 207

abdominal injury. However, while at the scene. it is im portant nol to spend a great deal of time attempting to obtain a histo ry. The major cause of preventable mortality in abdomina l t ra uma is delayed diagnosis and t reat ment.

Patient Assessment As in treating any other t raumatic condition, the patient sho uld first u ndergo the ITLS Primary Survey. If the mechanism fo r abdomin al injury is p resenl and the patient has signs o f shock. you should assume that abdo mi nal injury is present and possibly the cause of the shock. T he essence of the prehospital abdo mina l exam inatio n in the ITLS Prim ary Survey is rapid visual evaluation and palpation. Observe the to rso for deform ities, contusions, abrasions. and punctures (DCA P), evisceration, and distentio n. Note any tenderness o r tenseness. The chest is only one thin muscle sheet (the d iaphragm ) away from the abdominal cavity, so injury to both is not uncom mon. T he presence of a scat-belt sign, or large abrasion over the abdo men (see the Case Study pho to at the begin n ing of this chapter) andlor upper neck. is indicative o f int ra-abdo minal injury in approxima tely 25 percen t of Cil.SCS. Be mindful that splenic inju ry may present with referred left posterior shoulder pain , and liver inju ry may present with referred right posterio r shoulder pain. Distention of the abdom en sho uld be interpreted as a sign of severe hemorrhage as should tenderness o r tenseness over the abdominal willI. Gentle palpatio n o f the iliac crests (pelvic wings) and pubis of the pelvis may reveal the tenderness o r bo ny crepitatio n associated with fractures. Pelvic frac tu res frequently result in hemorrhagic shock. Signs of intra-abdo m inal injury usually do not appear early, SO if signs o f intra-abdom inal injury are present in the prehospital phase. there is usually significant injury. Shock may be imminent (see Chapter 8). Abdo minal tenderness o r distentio n is an ind icatio n fo r immed iate transport to the hospital. But remember that lack of tenderness does not rule out injury in a patient with all. altered mental status andl o r spinal inju ry at o r above the level of the abdomen. Auscultatio n or percussion in the field loses critical time and little useful info rmation is gained. Abdominal wounds should never be probed with yo u r finger o r with an instrument. If clothing must be removed to visualize injury, t ry to preserve im portan t potent ial legal evidence by cutting aro und ( rather than thro ugh) areas that have signs o f possible penetration.

Stabilization Significant abdo minal t rauma cannot be stabilized in the field . Interventions sho uld follow the IT LS Primary Survey o utlined in C hapter 2. They sho uld proceed in the same order in which assessment occurred: airway (A), breathing (8 ), and circulatio n (C). This means that even if a patient has only an abdomin al injury, supplement:ll oxygen by mask or endotracheal tube should be delivered th rough a confirmed o pen airway. Breath ing should be verified to be adequate or the patient treated to ensure adequate ventilation . Then, and only then. should the consequences of hypovolemic shock fro m abdominal injury be addressed as part of the circulatio n assessment. Apply oxygen at 12 to 15 liters per mjnutc by mask o r at 5 liters per minute by nasal cannula (see Chapter 4). Sta rt two large-bo re TV lines in the uninjured upper extremities infusing normal saline begu n at a KVO (keep vein open) rate. Do th is en route to the hospital unless it can be done o n scene without delaying t ransport (during extrication or waiting fo r arrival of the ambulance). The patient should be readied for rapid transport. If the patient's blood pressure drops below 90 mmH g systolic with signs of im pend ing shod:., then the IV fl uids should be given at a rate to maintain the systolic blood pressure at 90 to 100 mmHg (see Chapter 8). It is thought that aggressive flu id resuscitation m ight dislodge protective dots and d ilute dotting fa ctors, which would lead to worsening hemorrhage.

208 • CHAPTER 13 Abdominal Trauma

Caring for an Evisceration

II

Remove clothing from around the abdominal wound.

EI

Cover the wound with a sterile dressing soaked with normal saline.

D

Cover the moistened dressing with a sterile occlusive dressing to prevent evaporative drying.

Gentl y cover any organ or visccr:l protruding from a wound wit h Solllle moistened with s.1linc or watrr. If you have a long transport time. )'Ou can apply a nonadherent material, such as plastic wrap or aluminum foi l, to prevent drying of the gaule and intestines (Scan 13.1 ). If the intestines are allowed to dry, they Illay become irreversibly damaged. Do not en.'r push any abdominal contents protruding from a wound back into the abdomen. Similarl y, if a foreign body (such as a knife or glass shard ) is impaled in the abdomen, do not attempt rCllloval or manipulation as this may precipitate uncontrollable hemorrhage. Ca refully stabilize the object in placc without moving it. Pregnant patients deserve the special considerations add ressed in Chapter 19.

CHAPTER 13 Abdominal Trauma _ 209

Dan, Joyce, and Buddy of the Emergency Tran sport System (ETS) have been called to the scene of auto versus tree. As they respond they decide that Joyce will act as team leader and prepare for a patient with chest, abdomen, extremity, and / or spinal inj uries. Upon their arrival, they find the police and a rescue squad already on scene. The scene is safe. There is only one victim. The victim was driving an old truck without shoulder straps or airbags. But he did have his tap belt on when he lost control on a curve and ran off of the road, striking a large tree. There was significant impact, with the truck engine being pushed back almost to the passenger compartment. The ETS team helps the rescue squad extricate the patient from the vehicle. Initial Assessment revea ls an obese young male who is awake but confused with the smell of an alcoholic beverage on his breath. He is talking and has an open airway. His breathing is somewhat labored and he complains of pain with each inspiration. He has strong but rapid radial pulses. He was able to move his hands and feet before and after extrication. They use a short backboard device and they extricate him onto a long backboard, where he is secured. As they are extricating him, they note that there are no obvious injuries to the back. Joyce identifies him as a load ·and-go patient because of the mechan ism along with altered mental sta tus and tachycard ia. She performs a Rapid Trauma Survey while Buddy applies a nonrebreather oxygen mask and has suction ready in case the patient vomits. The airway is clear with no obvious trauma to the head or neck. Breath sounds are present but decreased on the left side. There is no obvious chest trauma. The abdomen has a large bruise from the seat belt and is diffusely tender. There are no obvious extremity injuries. After transferri ng the pa l ient to the ambulance. Joyce performs a brief neurological exam (patient awake but confused, eyes open spontaneously, and he obeys commands =< GCS score 14). She also takes vital signs, while Buddy starts two large-bore IVs. The patient's blood pressure is 140/ 90, pu lse 130, respiration 30, and pulse oxim eter 93 percent on 100 percent oxygen. The patient complai ns of abdominal and chest pain and states he thinks a deer ran in front of his truck and he lost control tryin g to miss it. He has no alle rgies, takes no med ications, has no past history of serious illness. He ate two hamburgers and drank "three" beers just before the collision. Joyce reports to medical direction and is instructed to keep IVs at mi nimum rate unless his blood pressure falls below 90 systolic. The Detailed Exam reveals no other injuries but Joyce th inks she can hear bowel sounds in the left chest. Before arrival (20·minute transport time) , the patient becomes pale and diaphoretic and his blood pressure drops to 70/ 40. IV normal saline is given to raise the blood pressure to 90/ 50. Upon arrival at the trauma center, he is taken directly to surgery where he is found to have a diaphragmatic hernia on the left as well as a ruptured spleen and a contusion of the liver. After a stormy course complicated by delirium tremens, he eventually survives.

210 • CHAPTER 13 Abdominal Trauma

A deceleration motor-veh icle collision can cause injuri es to almost any system, but patients wearing only a lap belt are prone to compreSSion fractures of the lumber spine (clasp-knife effect). The lap belt is prone to cause intra-abdom inal injuries jf it is worn across the abdomen rather than across the pelvis. Sudden compression of the abdomen can cause rupture of the diaphragm and herniation of abdo minal contents into the chest. This usually occurs on the left because the large mass of the liver protects the right side. Anyone with significant abdominal tra uma is subject to develop hemorrhagic shock, so always be prepared.

SUMMARY Effective prehosp ital managemen t of the patient with abdominal trauma entails the following: • Scene Size-up for mechanisms and pertinent histo ry from the patient and/or witnesses • Rapid patient assessment • Rapid transport to the appropriate hospital (optimally, a trauma center) • IV lines and other interventions as needed (usually performed en route) The enemies of the abdominal trauma patient are bleeding and time elapsed from injury until optimal care. If you can minimize on-scene delays, you will help to maximize the patient's chance for survival.

BIBLIOGRAPHY I. Aprahamian, C., B. M. Thompson, J. B. Towne. 1983. The effect o f a paramedic system on mor· tality of major open intra-abdominal vascular trauma. JOllrnal ofTmllma 23: 687-90. 2. Bickell, W. H., M. J. Wail, et al. 1994. Immediate versus delayed fluid resuscitation fo r hypotensive patients with penetrating to rso injuries. New Et1gllll/d Journal of Medicil/e 331 (October): 1105-9. 3. Mattox, K. 1.., P. E. Bickell, et al. 1989. Prospective MAST study in 911 patients. jOllrnlll of Tmrlflw29: 1104-12. 4. Newgard, C. D., et al. 2005. Steering wheel deformity and serious thoracic or abdominal injury among d rivers and passengers involved in motor veh icle crashes. AII/wis of EmergellCY Medicine 45 (January): 43-50. 5. Pepe, P. E., et al. 2002. Prehospital fluid resuscitation of the patient with major trauma. Prehospital Emergel/CY ClIre 6: 81. 6. Pons, P. T., B. Honigman, C. Moore, et al. 1985. Prehospilal advanced trauma life support for critical penetrating wounds to the thorax and abdomen. JourlllIl ofTrarmra 25: 828-32. 7. Scalea, T. ]\'1., et al. 2004 . Trauma of the abdomen. hr Timil/lIlli's emergellCY me(licille, A comprelJensil'e stud)' guide. Sec. 22, chap. 260, 6th cd. New York: McGraw-Hili Companies, Inc. 8. Stone, C. K., L. E. Rodriguiz, et al. 2004 . Immediate management of life-threatening injuries. In Cllrrentemergellcydiagllosis(/Ild treatment. 5th ed. New York: McGraw-Hili Companies, Inc. 9. Todd, S. R. 2004. Critical concepts in abdominal injury. CriticlI/ GlIre Glillics 20 (January): 119-34.

Dan, Joyce, and Buddy of the Emergency Transport System (ETS) have been caUed to the scene of an

(0 Craig J~cwnJ

In che D~rk Ph<>!ogrophy)

auto- pedestrian collision. They are told that the pedestrian is unconscious. What injuries should they expect with a mechanism of this type? Are head and spinal injuries likely? Keep these questions in mind as you read the chapter. Then, at the end of the chapter, find out how the rescuers completed this calL

INTRODUCTION You must never let d istorted o r wounded extremities occupy your attention when then.' may be more life-threatening injuries present. These dramatic injuries arc easy to identify when you first encounter the patient and they may be disabling, but are rarely immediatel}' life-threalening. lt is important to remember that the movement of air through the airway, the mechanics of breathing, the maintenance of circulating blood volume, and the appropriate treatment of shock always come before the splinting of any fracture. Hemorrhagic shock is a potential danger of very few musculoskeletal injuries. Onlydi· rect lacerations of arteries or fra ctures of the pelvis or femur arc coml11only associated with eno ugh bleeding 10 cause shock. Injuries to the nerves or vessels that serve the hands and feet are the most common complications of fract'ures and dislocations. Such injuries cause the loss of function that we lump under the term lIellrowm:II /(i r compromise. Thus, evaluatio n of pulses, moto r fun ction, and sensation (PM S) d istal to fractures is very important.

INJURIES TO EXTREMITIES Fractures

• • • • • PEARLS

Spraitls and Strains Sprain and strain injuries cannot be c:iffeftntialed from fractures in the field. Treat ~ as though they were

""''' . 212

Fractures are generally quite pai nful, and you should consider the lise of analgesic medication if your protocols and the situation allow. Fractures may be open (compound) with the broken end of the bone still pro truding o r having once protruded through the skin (Figure 14- 1a), or they may be closed (simple) with 110 communicatio n to the o utside (Figure 14- 1b). Fractured bone ends are extremely sharp and are quite dangerous to all the tissues that surro und the bone. Since nerves a nd arteries frequently travel nea r the bone, across the fl exor side of joints, o r very nea r the skin (hands and feet), they are frequently injured. Such neurovascular injuries may be due to lacerations fro m bone fra gments or fro m pressure due to swelling or hematoma . Closed fra ctures can be just as dangerous as open fractures because injured soft tissues o ft en bleed profusely. It is important to remember that any break in thc skin near a fractured bone may be considered an o pening for contamina tion.

CHAPTER 14 Extremit y Trauma _ 213

FIGURE 14-1 b Closed forea rm fral;lure. (Photo courtesy of Ruy Also/I, MD)

FIGURE 14.1a Open ankldracture.

A closed fracture of onc femur can cause the loss of up to a liter of blood; thus, two fractured femurs can cause life-threatening hemorrhage (Figure 14-2 ). A fractured pelvis can cause extensive bleeding into the abdomen or the retroperitoneal space. The pelvis usually fractures in several places and may have 500 cc of blood loss for each fracture. Pelvic fractu res may lacerate the bladder or the large pelvic blood vessels. Either of these structu res ca n cause fata l hemorrhage into the abdomen. Remember, multiple fractures can cause life-threatening hemorrhage without any external blood loss. Open fractures add the dangers of contam ination as well as loss of blood o utside th e body. If protruding bone ends are pulled back into the skin when the limb is aligned, bacteria-con taminated debris will be pulled into the wound. Infection from such debris may prevent healing of the bone and may even cause death fro m septic complications.

Dislocations Joint dislocations are extremely painful in juries. They are almost always easy to identify because nonnal anatomy is distorted (Figure 14-3). Major joint dislocations, though not life threatening, are often true emergencies because of the neurovascular compromise that can, if not treated q uickly, lead to amputation. It is impossible to know whether o r not a fracture exists in combinatjo n with a dislocation. It is very important to check fo r PMS distal to major joint dislocations.

214 .

CHAPTER 14 ExtremityTrauma

Estimating blood loss by site and number offrsctures

Pelvls-2 unils 10 loss of complele blood volume The most severe blood loss occurs in fracture of the pelvis

FIGURE 14-2 Internal blood loss fro m fractures.

O rd inarily, injuries should be splinted in the position in which the)' are found. However, there arecerla in exceptions 10 this rule. It is universally true that one can apply oilly gentle traction to any distorted extremity in an effort 10 straighten it. In the few instances that you would use traction to straighten an extremity, usc no more than 10 pounds of force. Most o ften the best treatment for the patient is padding and splint ing the extremity in the most comfortable position and rapidly transporting to a facility that has orthopedic care available.

Amputations Amputations are diS
CHAPTER 14 Extremit y Trauma _ 215

Open Wounds Cover wou nds with a ste rile dressing and bandage ca refu lly. Gross conta mi nation slich as leaves o r gravel should be rem oved fro m the wound, and smaller pieces of contamination can be irriga ted from the wound w ith normal saline in thc sa me manner tha t you would irrigate a c hemically contaminated eye. Bleed ing can almost always be stopped with p ressure dressings o r pneuma tic splints. Tou rniquets sho uld al m ost never be needed 10 sto p bleeding fro m a wound if a m putation is no t present. If necessary, a blood pressure cuff o r pressure o n a la rger artery proxim a l 10 the injury may be app ropriate. However, jf the patient is having exsa nguinating he mo rrhage fro m an extremity injury and )'Oll can not SlOp the bleeding with pressure, you sho uld not hesita te to use a tourniq uet. If you have bleeding that can not be stopped with pressu re or with a to u rniq uet, such as injuries to the axilla or groin , you should use onc of the new hemostatic agents sllch as Q ui kClot ( Figure 14-5) or Celox. These agents sho uld be packed into the wound ( not fo r use in open abdo m inal or chest wounds) and pressure applied. Patients w ith severe hemorrhage should be transpo rted im mediately after the ITLS Pri m ary Survey. Obvious exsangu ina ting hem o rrhage is the o nly time you ca n change YOll r ABC order o f exam to CA B.

Amputated finger

FIGURE 14.04 Amputated parts should be put in a dry bag, sealed, and placed in .....ater that contains a fe ..... icc cubes.

Neurovascular Injuries The nerves a nd m ajor blood vessels generally run beside each o ther. usualJy in the fl exor area of the m ajor joints. They m ay be inj ured together. a nd loss of ci rculatio n and/or sensation can be d ue to disruption. swelling. or com pression by bo ne frag m ents o r hematom as. Foreign bodies o r broken bone ends may well impinge on delicate st ructu res and cause them to malfun ction. Always check fo r PMS befo re a nd after any extremity m anipulation. applicat io n of splin t, or t raction.

FIGURE 14-5 Q uikClot 1st

R~~ pon~

is an ina pcnsivc

hemostatic agent that can be used to stop bleeding from an exsanguinating ext rem ity injury. (PllOlo cOIlrles), of Z-"-'/rdica Corp. )

Impaled Objects Do not remove im paled o bjects. Apply a very bulky type of padding to hold the object in place a nd t ra nsport the pat ient with the object in place. The skin is a pivot poi nt in these

--...

PEARLS

Pulses, Motor FUNctiON, Setrstltiot. AIw¥ record sensation and

cast'S, and ,lfIy m u tiu n u uts idt;> Ihe:- lxxly is Iranslaloo u r magnifie:-J with in tht;> lissut:s, where

circulation initially and after any

the end of the object m ay lacerate o r harm sensi tive structures. Impaled objects in the neck that obstruct the airway or those in the cheek of the face are exceptions to this rule.

",,""',,",

Compartment Syndrome The extremit ies cont ain muscle tissue in closed spaces that a rc su rrounded by to ugh me m branes that will no t stretch. Trau ma (cr ush injuries, closed o r o pen fracture, o r sustained compression) to these areas (fo rearm and lower leg most com mo nly) m ay cause bleeding and swell ing wit hin the closed spaces. As the a rea swell s, p ressure is transm itted to the

"""""'" ..,.,,,,,.

21 6 .

CHAPTER 14 Extremity Trauma

blood vessels and nerves. This pressure may compress the blood vessels in such a manner that circulation is impossible. The nerves may also be compromised. These injuries usu· ally develop over a period of hours. Late symptoms are the five Ps: pain, pallor. pulsd~­ ness. paresthesia. and paralysis. The early symptoms are usually pain and paresthesia. As with shock, you should think of this diagnosis before the later symptoms develop.

ASSESSMENT AND MANAGEMENT

- ----

PEARLS

Priorities Follow the ABU and do not be cistrKted by otMoca txtrI!'!Iity

"""".

• E>ooog~ ~. "" IJICe9tion to the eboYe tfoIow CAB ""'" """ ASCI. ... 1'" IIUt not

for9It to iSIISli6YRf

.. In""",. Be very IIert to the mecNnism of ~ 10 INt )'OU know wl\at bctures to suspect IIId 10 !hit 1"'<M> _ _ COij~t$.

Scene Size-up and History When assessing the patient with extremity trauma, it is especially important to get a history because the mechan ism of injury may not be apparent in your Scene Siu- up. The mechan ism of inju ry and your assessment of the extremity may give you im portant dues to the potential severity of the injury. If th ere are rescuers eno ugh. one rescuer can obtain the history while you are performing the ITLS Primary Survey. If no t, you should not attempt to elicit a detailed verbal history until you have assessed the status of the airway, breathing, and circulation. In the conscio us patient, obtain most of the history at the end of the ITLS Primary Survey. Foot injuries from long jumps (fuJis landing on the feet) often have lumbar spine injuries associated with them. Any injury to the knee when the patient is in the sitting position may ha'·e associated injuries to the hip. In a like manner, hip injuries may refer pain to the knee, so the knee and the hip are intimately connected and must be evaluated together rather than separately. Falls onto the wrist frequently injure the elbow, and so the wrist and elbow must be evaluated together. The sa me is true of the ankle and the proximal fibula of the o utside of the 100...er leg. Any injury that appears to be in the shoulder must becarefullyexamined because it may easil y involve either the neck, chest, o r sho ulder. Fractures of the pelvis are usually associated with very large amounts of blood loss. Whenever a fracture in the pelvis is identified. shock must be suspected and proper treatment begun.

Assessment During the ITLS Primary Su rvey. you are concerned with obvious fractures to the pelvis and large bones of the ext remities. You sho uld also find and cont rol major bleeding fTOm the ext remities. Duri ng the ITLS Secondary Survey, quickl y assess the fulli engih of each extr emity, looking for deformity. contusions, abrasions. penetrations, burns, tenderness, lacerations, and swell ing (DCAP-BTLS). Feel for instab ilit y and crepi tation (see Chapters 2 and 3). Check the joints for pain and movement. Check and record d istal PM S. Pulses may be marked with pen (ballpo int or felt tip) to identify the area in which the pulse is best felt (Figure 14-6). Crepitatio n or grat ing of bone ends is a definite sign of fracture. and once identified. the bone ends should be immediately immobilized to prevent further soft -tissue injury. Checking fo r crepitation should be do ne very gentJy. especially when checking the pelvis. Crepitation meanli hone endli are grating o n one another, and th is means yo u arc causing furt her tissue injury.

Management of Extremity Injuries Proper management of fractures and dislocations will decrease the incidence of pain, disability, and serio us complicatio ns. Treatment in the prehospital setti ng is directed at proper immobilization of the injured part by the use of an appropriate splint. Even with proper immobilization of fractures, the patient may req uire analgesic medica tio n.

CHAPTER 14 Extremity Trauma _ 217

FIGURE 14-6c Palpate the posterior tibial

pulse. (Photo COIlrtesy of Michal Heron )

FIGURE 14-6b Palpate the do rsalis

pedis pulse. ( Photo COllrtesy of Michal FIGURE 14-6a Palpate the radial artery. (Photo courtesy of Midm/ Heron )

HerOl')

Purpose of Splinting: The objective is to prevent mo tion in the broken bone ends. The nerves th at ca use the most pa in in a fract ured ext remity lie in the memb ra ne su rrounding the bonc. The broken bone ends irritate these nerves, causing a very deep and distressing type of pain. Splinting not on ly decreases pa in, but also el iminates further damage to mu scles, nerves, and blood vessels by preven ting fur ther motion of the broken bone ends. When to Splint: There is no simple rule that determines the p recise sequen ce to follow in every trau ma patient. In general, the seriously injured patient will be better off if you splint only the sp ine (long backboard) before transport. The patient who requires a loadand-go approach ca n have extremity fractu res temporarily stabilized by careful packaging on thc long backboard. This docs not mean that you have no responsibility for identifying and p rotecting extremity fractures, but impl ies that it is better 10 do so me splinting in the vehicle en route to the hospital. It is never appropriate to sacrifice time splinting a limb to prevent disability, when that ti me may be needed to save the pa tient 's life. Conversely, if the patient appears to be stable, extrem ity fract ures should be splinted before moving the palient.

PROCEDURE

£iJ

Rules of Splinting

• You must adequately visualize the injured part. Clothes should be cut off, not pulled off. unless there is only an isolated injury that presents no problem to maintaining immobilii'..ation . • Check and record distal sells'ltion and circulation before and after splinting. Check movement distal to thc fractu re if possible (for example, ask the conscious patient to wiggle his fi ngers or observe the motion of the unconscious patient when a painful stimulus is applied). Pulses may be marked with a pen to identify where they were palpated.

• • • • • PEARLS

The Golden Hour Do not waste the Golden Hour. Be cautious but be rapid, and priorim life 0Yef limb.

•

Sp~nt at an appropriate time.

n-.e

axial s.\;eletoo is splinted after the ms Primary Survey. Extremities should be splinted en route if a aitical situatiOfl exist$.

218 •

CHAPTER 14 Extrem it y Trauma

1. Confirm loss of pulse 2. GenUy gmsp extremity above and below break 3. Apply tmction steadily and smoothly 4 . Maintain tmction while splint

is applied 5. Recheck pulse and sensation

FIGURE 14-7 Straightening angulated fract ures to restore pulses.

• If the cxtremity is severely angulated and pulses are absent. apply gentle traction in an attempt to stra ighten it (Figure 14-7). This traction sho uld never exceed 10 pounds of pressure. If resista nce is encounter(.>d. splint the extremity in the angulated position . When you arc attempting to straighten an ex tremity, it is very impo rtant to be honest with you rsel f with regard to resistance. It takes very little force to lacerate the wall of a vessel o r to in terrupt the blood supply to a large nerve. If the trauma center is ncar, always splint in the position found. • Open wounds should be covered with a sterile dressing before you apply the splint. Splints should always be applied on the side of the extremity away from open wounds to prevent pressure necrosis.

• Use the splint that will immobilize one joint above and below the injury. • Pad the splint well. This is particularly true if there is any skin defect or if bony prom inences might press against a hard spUnt. • Do not attempt to push bone ends back under the skin. If you apply traction and the bone end retracts back into the wound, do not increase the amount of traction. You should not usc your hands or any tools to try to pull the bone ends back Ollt, but be sure to notify the receiving physician. Carefully pad bone ends with bandages before

CHAPTER 14 Extre mity Trauma _ 219

apply ing pne um,ltic splints to the lower ext remities. T he healing of bone is improved if the bone ends arc kept moist when transport time is prolonged . • In a li fe-threate ning situatio n, injuries may be splinted while the patient is being transported. When the patient appears stable, splint all injuries befo re mO\'ing him . • If in doubt, splint a possible injury.

Types of Splints Rigid Spli"ts. This type o f spli nt ca n be made from many different ma terials and includes all Gudboard, hard plnstic, metal, or wooden lypes of splints. The type of spli nt that is made rigid by evacuating air fro m a moldable splint (vacuum splin t) is also clnssified as a rigid splin t. Rigid spli nts shou ld be padded well and should always extend one join t above and below the fractu re. Soft Spli"ts. T his type o f splint includes air spl ints, pillows, and sling- and swathe-type splints. Air spl ints arc good fo r fr;l ctures of the lower arm and lower leg. Air splints have the advantage of compression, which hel ps to slow bleeding, but they ha\'e the diSOldva ntage of increasi ng pressure as the tempe rature rises or thc altitude increases. They should not be put o n angula ted fractures since they will automaticall y apply straightening pressure. O ther major dis.1dva ntages of air splints include the fac t thai the extremity pulses can not be monitored wh ile the splint is in place, a nd the splints also o ften stick to the skin and arc painrulto remove. Inflating the splints requi res you to blow the splints up by mouth or by hand or foot pum p (never by co mp ressed air) u ntil they give good su pport and yet can easily be dented with slight pressure from a fingert ip. When using air spli nts, )'ou must constantly check t he pressure to be sure that the splint is not getti ng too tigh t o r too loose (they often leak ). Remember that if aiT splints arc applied in a cold e nvironment and the pat ient is moved into the \"'arm e nvironment of the am bulance, the pressure will increase as the splints warm up. "Vhere ai r ambulances a re available, it must be rememben."!! that the pressu re in air splints increases if they tire applied on the grou nd and then subseq uentl), the patien t is airlifted to the hospi tal. Contin uous monitoring of circulation in the frac tu red extremity is requi red . Also remember that if pressure is released durin g the Aight, the pressure wi ll be too low when the patien t is retu rned to the ground. Pillows make good splints for injuries to the ;mkle or foot. They are also helpful , along with a sling a nd a swa the, to stabili ze a dislocated shou lder. Slings a nd swathes arc excellent for injur ies to the davicle, shoulder, upper arm, elbow, and sometimes the forearm. They utilize the chest wall as a solid foundation and splint the arm agai nst the chest \\'al1. Some shoulder inj uries cannot be brought close to the chest wall witho ut significa nt force being applied. In these insta nces, pillows arc used to bridge the gap bctWl."Cll the chest wall a nd the upper arm. 'f rac'ion Splint. This device is designed for fractu res of the femur. It holds the fra cture immobile by the applica tion of a steady pull on the ankle whi le applying counter traction to the isch ium a nd the gro in. This steady traction overcomes the tendency of the vcry strong thigh muscles to spasm. If t raction is not a pplied, tht· pain worsens because the bone ends tend to impact o r override. Traction also prevents free Illotion of the ends of the femur, which could lacerate the femoral nerve, artery, or vein. T here ,Ire many designs and Iypes of spl ints available to a ppl y tractio n to t he lower extremi ty ( Figure 14-8 ), bu t each m ust be ca refull y padded a nd applied wit h care to prevent excessive pressure on the soft tissues arou nd the pelvis. It is also necessary to usc a great deal of care in a pplying the ankle hitch so as not to interfere with the circulation of t he foot. Man), of t h e~ devices cun be used with a buck's boot as an altern ative to the a nkle hitch.

220 •

CHAPTER 14 Extremity Trauma

FIGURE 14-88 Kendrick traction dc\·ice. (P/IO/O COllrtesy of

FIGURE 14-8b Hare tract ion splint.

Etfrlflrdo ROllh'ro H icks, AU»)

FIGURE 14-8c Sagcr trdctio n splint.

---------

PEARLS

Spit'f! Injuries

In major trftM'l'la. tIlf ami skeleton is .ways sp6nted on along baaboard or appropriate $C:OOI) streicher.

PEARLS

Shock

So """"'" """"""'" when there is'" a peMc or feru"'"

""""

Management of Specific Injuries Spine Injuries: Spine injuries arc cover('d clsewhen.' in the book bu t includ('d h('re to rem ind you thaI if Ih('re is an)' chance of one, proper SM R (spinal motion rcstrictio n) must be done to prevent lifelong para lysis o r even death from a spinal-cord injury. In the most urgent cases, car('ful packaging o f the patient on the long backboard may be adequate splint ing for a number of different extrem ity injuries. Rcm('mber that certain mech:misms of injury, such as a fa ll from a height in which Ihe pat ient lands o n both feel, may cause lumbar sp ine fracture because forces
CHAPTER 14 Extremity Trauma _ 221

FIGURE 14-9a Commercial pelvic sling de\·ice. ( PI,o/iJ rol/rll'S)1 a[S11111 Spli11ls)

FIGURE 14-9b Pelvic sling appli...-c.I. (J'hllll) (()lIrfcSy ofSmll Splil1/$)

Th(' pat ient with a pelvic inj ury sho uld haw SM R. Th e vacu ulll backboard is especially usefu l hne becau se il is nHich more co mfo rt abl e than t he hard b'lCkboa rd. Log-roll ing a pat ient with an unstable pdvic fract ure ca n aggravate the injury. Scoop stretch(' rs or adequa te manpower is needed to move these patients to the backboard. As ment ioned in Cha pter 2, some of the new, more rigid scoop stretchers prov ide SMR equ al to a h'lCkboard ( Fi gure 14- 10). Femur Injuries: T he femur us u.l lly fractures at the midshaCt . although hip fractures 'I re qu ite co mmon. These fractu res may ha\,(' open wounds associated with them a nd , ifso, they must be presllmed 10 be op('n fraclUres. There is a lot o f muscle tissue surrounding the femur. and when sp.lsm d('\'cio ps after a femur fracture, the bone ends tend to ovcrrid(' causing more muscle damage. Because of this. tract io ns splint s arc usua lly used to stahil ize I he fra cture :l nd preven t shortening. Beca usc of the large muscle mass,a great el(';ll o fbkedi ng can occ ur into t he t issue of the thigh. Bilateral femu r fra ctures can be associated with a loss of up to 50 pe rcent of the circulating blood volume.

FIGURE 14-10 This scoop stretcher has m-en round to provide spinal stabilization ('qual to a backboard. ( 1'110/0 COllrll'S), (If Lfim C/lIlrpt.·lI licr. EMT-I': m/(I Ft'rl/o 1\~l$llill~lIm.

IlIc. )

Hip Injuries: Hip fract Urt·., arc most often in Ih e narrow "neck" of the fCnlur. where slrong liga menls may occasionall}' allow this type offractu re to bear weight . The ligamen ts are \'er), st ro ng, and the re is very little mo\'ement o f the bon(' ('nds in Ihe most freq uent type of hip fract ure. You must consider hip fract u res in an)' elderl y person who has fa llen and has pai n in the knee. hip. o r pelvic region. The affected leg will usuall)' (but no t alwa)ls) be externall)' rotated and shortened. This I)' P(' of prt'sellt tltio n and pa in sho uld be consid ered ;l fra clllrc u nti l all x-ray proves ot herwise. In th is age group, pain is frequ ently well tolemted ;md so melimt's evell ignor('d o r denied. In general, th(,tissues in the elderl}' palient arc more delicate. and less fo rce is required to d isrupt a given struct ure. AI\\'ays remember that isolated knee pain may well be com ing from damag(' to the h ip. Do no t lise a IraClion spl int fo r a h ip fra cture. Hip dislocOl tion is tI di fferent story. Most posterior hip d islocatio ns arc a result of Ihe kn('Cs being struck by the dashboard, fo rci ng Ihe relati vely loose. rclaxed hip o ut of the posterior sid(' uf its cup in the pelv is ( Figure 14-11). Thus. any palienl in a severe au to mobile crash with a kn('C injury must have Ihe hip ex.ullint'dic emergency and requi res reduction tiS soon as possible to prevent

222 •

CHAPTER 14 Extremity Trau ma

FIGURE 14-11 Mcchanism of posterior dislocation of the hip, "down and under."

sciat ic nerve injury or necrosis of the femoral head d ue to interrupted blood supply. T his is a very difficult reduction to perform because the amo unt of fo rce required is very great and the movement must be quitt' precise. The posterior d isloca ted hip wi ll usually be fl exed, and the patient will not be able to tolerate having the leg st raightened. The leg will almost invariably be rotated toward the midline. A posterior hip dislocation should be supported in the most comfortable posi tion by the use of pillows and by splinting to the uninju red leg ( Figure 14- 12). The anterio r d islocated hip is rare because o f the com plex mechanism requi red to prod uce t his injury. The patient with an anterior hip d islocation will prese nt with extern al rotat io n of the affected leg much like a fractu red hi p except you may not be able to b ring t hc I~ fo rward in line with t he body. It may be very d ifficult to place this pe rson in the supine posit io n o n a backboard o r o n the st retcher in the ambulance. Wh ile thc posterior h ip d isloca tion pu ts pressure on the scia tic nerve, the an terior hi p d islocat io n puts pressu re on thl.' femora l artery and vei n. If the vein is coll apsed, a clot can form distally prod ucing a large pu lmo nary embolus as soon as th e hip is reduced. Patients with anterio r or posterior h ip d islocations requi re rap id tra nspo rt.

Knee Injuries: Fractu res o r d islocation o f the knee ( Figure 14- 13 ) are qui te serious because the arteries are bound down above and below the knee joint and are often bruised o r lacerated if the joint is in an ab normal position. There is no way to know whether a fracture exists in an abnormally positioned knee and. in either case, the decisio n m ust be based o n the circul ation and neu rological func tion below the knee in the foot. Some authorities state t hat abo ut 50 percent o f knee d islocations have associated inj uries to t he vessels, and many knee injuries later require am putation. It is important to restore the circulation below the knee whenever possible. Prompt reduction of knee disloca tion is very impo rtant. If there is loss of pulse or sensat io n, apply gentle traction by hand o r by way of a traction splint. You Illust be carcful to apply no more than 10 po unds of fo rce. This force Ill ust be a pplied along th e lo ng axis of the leg. If there is resistance to straigh ten ing the knee, spl int it in the most comfo rtable posi t ion and tra nspo rt the patient rapidly. Th is may be considImmobilize in ered a true o rthoped ic emergency. position found Do no t co nfuse t his inju ry wit h a patella dis10catiOIl. The patella will d islocate to the s ide and Mold pillow around knee or bandage to t he affected leg will be held slight ly flexed at the well-padded splint knee. You ca n easily see th at the patella is out of place. Wh ile pai nful , thi s is not a serious injury and should sim ply be spl inted with a pillow under the knee and taken to t he emergency depart ment. Stra ighten ing t he leg usuall y reduces the patella d isloca tio n.

FIGURE 14-12 Splinting posterior dislocation of th{' hip.

Tibia/Fibula Injuries: Fractu res o f the lower leg are often open d ue to th in skin over the front of the tibia and often have significa nt internal andlo r external blood loss. Internal blood loss ca n interrupt the circulation to the foot if a compartment syn-

CHAPTER 14 Extremity Trauma _ 223

••

b.

FIGURE 14-13a Knee dislocation: (a) p ~lItati on of II knee dislocation; (b) x-roy of the dislocation.

drome develops. II is ra rely possible for patients to bear weight on fractures of the tibia, but fra cllI l"l'S of the disl'al fib ula arc frequently m istaken (ur sprains. Fractures of the lower tibia/fibu la may be splinted with a rigid splint , an air splint, o r a pillow (Figure 14- 14), Pneumatic splints will adequately splint upper tibia fractures. H(.' rc again it is important to dress any wound and pad any bone ends tha i may be put under an air splint.

Air ,.pllnt

Apply traction aboYe and below lrac1ure

Distal fract ure Apply splint to limb and inflate

Board splint

Pain SweUing

Pad spaces between leg and splint

I· -

\ 1.1..11 t .

Bandage securely

Apply traction and slide wert-padded splint under leg

FIGURE 14-14 Splinting a lower leg fracture with splint or board splint .

224 .

CHAPTER 14 ExtremityTrauma

Signs and Symptoms • Shoulder bent Iorward • Elbow flexed and Iomarm held across chest • Pain in shoulder area • Swelling or lump

Applying a Sling and Swathe • Fold arm 01 injured side across chesl

• Place arm in sling and secure it to body with swalhe

FIGURE 14-15 "facturcd dav ide.

Clavicle Injuries: The clavicle, the most freq uentl y fractured bone in the body, rarel), causes problems (Figure 14- IS). It is best immobilized wi th ;1 sli ng and swathe. Rilrcl)', there may be injuries to the subclavia n vein and artery or to the nerves of the arm when this ilrca is injured. It is also important th;lIthe ribs and chest be very carefully eVilluatro whenever an injury to the shoulder o r clavicle is di scovered . Shoulder Injuries: Most shoulder injuries are not life th rea tening, but they may be associated with severe injuries of the chest or neck. Ma ny shoulder injuries are di slocations or separations of joi nt spaces and may show up as a defect 31 the upper o uter portion of the shou ld er. The upper humerus is fractured with some degree of frequ ency, however. The radial nerve travels quite close arou nd the humerus and may hi.' injured in humeral fractures. Injury to the radial nerve results in an inability of the patient to lift the hand (wrist drop). Dislocated shoulders are very painful and quite oft en requi re a pillow between the arm and body to hold the upper arm in the most comfortable posit ion. Shoulders that are held in abnormal positions should never Ix' fo rced into a mo re ana tomic alignmen t (Figure 14- 16).

FIGURE 14-16 Dislocated shoulder.

Elbow Injuries: It is o ften difficult to see the difference beh veen a fracture and a dislocatio n. Both can be serious because of the danger of damage to the vessels and nerves that run across the Ilexor surface of the elbow. E.lbow injuries shou ld al-

CHAPTER 14 Extremity Trauma _ 225

Immobilize lirnl;) In position in which it was found

Bent position

Straight position

FIGURE 14-17 Fractures or dislocations of the elbow.

ways be splinted in the most comfort'lble position and the d istal functio n clearly evaluated (Figure 14- 17) . Never attem pt to st raighten or apply traclion to an dbow injury becausc the tissues are q uite de1ic;lIe and the structure is very compl icated. Forearm and Wrist Injuries: Fractures to the fo rea rm and wrist are very COllllllo n (Figure 14- 18 ), lIsually as a result of a fa ll on to the o utstretched arlll . Usually. such a frac ture is best immob iliZ('d with a rigid splint o r an air spl int ( Figure 14- 19). If a rigid splint is used , a roll o f gau ze in the hand will hold th e arm in the Illost comfortable position of

••

b.

FIGURE 14-18a Prescntation of a forearm fra cture: (a) ~I fracture will oft en prescnt with deformit y; (b) an x-ray of the fracture.

226 •

CHAPTER 14 Extremity Trauma

Secure arm in splint

Secure tOl oarm in splint

FIGURE 14-19 Fr:actures of the forearm and wrist.

function. The forearm is also subjcCI to interna l bleedi ng, which ca n interru pt the blood supply to the finge rs ;md the hand (compart ment synd rome).

FIGURE 14-20 Pillow splinting an injured fool.

Hand or Foot Injuries: Ma ny industrial accidents involving the hand or Ihe foot produce multiple open fractures and avulsions. These injuries arc often gruesome in appeara nce but are seldom associated with life- threatening bleeding. A pitlow may be lIsed to support these injuries w ry effect ively (Figure 14-20). An alternative method of dressi ng the hand is to insert a roll of ga U7A' in the p;llm , then arrange the fin gers and thumb in their no rmal position. The en tire hand is then wrapped as though it were a ball inside a very large and bulky dressing. Elevating the isola ted hand o r foot injury above the level of the heart wi lt almost always reduce bleeding dramatica tly during tra nsport.

CHAPTER 14 Extremity Trauma _ 227

Dan , Joyce, and Buddy of the Emergency Transport System (ElS) are on the way to the scene of an auto- pedestrian collision with an unconscious patient, the pedestrian. During travel to the scene. they decide that Buddy is team leader on this call. As they fin ish preparing for a patient with serious multisystem injuries, they arrive on the college campus where the male student stepped out in front of a car and was hit. He was thrown about 1S feet. and has been unconscious since the inj ury. Nothing is known about him, as no bystanders know him. The scene is safe. He is the on ly victim. As they approach , their general impression is bad. The patient is tying on his right side with his right leg at an abnormal angle. He is not moving. He does not respond when Buddy speaks to him. Initial Assessment reveals that his aIrway is open, but his respiration is shallow and slow. He has a weak. rapid pulse at the wrist. The ETS team checks his back (no apparent injuries) as they log·roll him onto a backboard. Joyce begins assisted ventilation with 100 percent oxygen wh ile Buddy performs the Rapid Trauma Survey. which reveals the patient has a hematoma of the right temporal area and only moans when his fingers and toes are pinched. There is no deformity of the neck and the neck veins are flat. The chest has no apparent injuries and breath sounds are presen t and equal. Heart sounds are easily heard. The abdomen is soft and the patient does not seem to have pa in when the abdomen is palpated. The pelvis is stable but seems to be tender, since the patient moans when the pelvis is palpated. There is an obvious deform ity of the right thigh but PMS of all extremities is present (the patient withdraws his fingers and toes to pinching). Buddy immediately gets the team to move the patient to the ambulance and begin transport. A brief neurological exam done en route reveals that the patient opens his eyes 10 pain (pupils 3 mm and react equally to light), moans to pain. and withdraws to pain. His GCS score is calculated to be 8 (severe brain injury). He has no gag reflex. so Joyce intubates him by the oral route with a 7-5 mm endotracheal tube. Vital signs are BP 90/60. pulse 130 , and respiration assisted at 10 per minute. His pulse oximeter saturation is 100 percent and his venti latory rate is ad justed to ma intain his COzlevel at 40 mmHg. White Joyce ventilates the patient, Buddy and Dan start two large-bore IVs and give normal saline to raise the blood pressu re to 120/ 70. They then apply a traction splint to the right leg. Transport time is only 5 minutes, so by the time they contact medical direction they are almost at the hospital. The patient was found to have an epidural hematoma and this was immediately evacuated with good results. The patient also had a fractured pelvis and right femur, but no other injuries. He responded well to treatment and was back in school by the next se mester. He had no residual neurological symptoms.

(C ~ ig I~,ksonl If} ctK I)ar\r; J>hQc ographyJ

228 • CHAPTER 14 Extremity Trauma

This patient had multiple-system trauma, wh ich is the usual case with auto- pedestrian collisions. Because he had a GCS score of 8, it was imperative not to let him rema in hypotensive, so fluid was given to raise his BP to 120 mmHg systolic. His shock was secondary to the fractured femur and pelvis and not to any other internal injuries. The patient's co ma was due to the epidural hematoma , which is one of the few head injuries that usually respond immediately to decompression. The outcome might have been different had he been allowed to remain hypotensive.

SUMMARY Wh ile usually not life threatening, ext remity injuries arc often disabling. These injuries may be mo re o bvious tha n more serious inte rna l injuries, but do not let extremity in· ju ries d istract yo u from fo llowi ng the usual stc ps of the ITLS Primar y Sun'cy. Pch'ic and femur fractures can be associated with life-threatening in ternal bleedi ng, so patients with these injuries a rc in the load-a nd -go category. Proper splinting is important to protect the injured extremity from further injury. Dislocations o f elbows, hips, and knees requi re careful spl int in g and rapid reduction to preve nt severe disability to the affected extrem ity.

BIBLIOGRAPHY I. Abarbanell, N. R. 200 1. Prehospital midth igh trauma and traction splint lI $("": Rccommmdations for treatment protocols. Amerialll JOllmal of Emergency Mellie-ine. 19(2}: 137-40.

2. American College of Surgeons Committl'C on Trauma. 2004 . AlIl'alICell/mll/lIIl life SlIpport. Chicago: American College ofSurgcons, 205--30. 3. Bledsoe, B., D. B..1T11es. 2004 . Traction splint. An EMS relic? JEMS 29(8): 64--69. 4. Cross. D. A., J. Baskerville. 200 1. Comparison of perceived pain with different immobilization techniques. Prell ospitnl Emergmcy ulre 5(3) : 270-74. 5. Dischinger, P. C, K. Read, J. Kerns, et al. 2004. Consequences and costs of lower extremity injuries. Amllwl ProcccdillSs of /lJe Associlllioll fo r /he Arimllccmell/ of AII/OIIIO/il'c Medici"c 48: 339-53. 6. f riese, G., G. LcM
230 •

CHAPTER 15 Extremity Trauma Skills

TRACTION SPLINTS Traction spli nts arc designed to immobilize fractu res of the femur. They are not useful for fra ctures of the hip, knee, or lower leg. Applying firm traction to a fractured or dislocated knee may tear the blood vessels behind the knee. If there appean lo be a pelv ic fracture, yo u can not use a traction splint because it may cause further damage to the pelvis. Fractures below the m idth igh that are not angulated o r are severely shortened may just as well be immobilized by air splints. Traction s plints work by applying a pad ded dev ice to t he back of the pelvis (ischimn) or to the groin. A hitching device is then applied to t he ankle, and coun ter t raction is applied unti l the limb is straight a nd well imm obil ized. Apply the splints to the pel vis and gro in very carefully to preve nt excessive press ure on the gen ita lia. Also usc care when atta chi ng the hitch ing device to the foot and ankle so as not to interfere with circu lati o n. To prevent any unn ecessary movemen t, do not ap ply traction splints until the patie nt is o n a long backboard. If th e sp lint extends beyond the end of the backboard , be ve ry careful when moving the pat ient and when closing t he ambulancc door so that yO li d o not hit the s plint a nd ca use move ment in the fracture sit e. You mu st check the circulation in t he injured leg, so remove the shoe before attaching the hitching device. In every case at least two people arc needed to apply traction. One must hold steady. gentle traction on the foot and leg while the o ther applies the splint. When dealing with load -and-go situations, do not apply the spl int until the patient is in the ambulance ( lIn~ less the ambulance has

n Ol

arrived ).

PROCEOURE 00 Applying a Thomas Traction Splint (Half-Ring Splint) The Thomas sp lint was used exclusively p rior to th e advent of modern traction devices. During World War I, its use decreased the mortality rate fo r battlefield femur fra ct ures fro m 80 percent to 40 percent. At that time it was co nsidered one of the grea test adva ncements in medica l ca re. It is still used in some countries and in the absence of o th er opti o ns. To applY:l Thomas traction splint, follow t hese steps ( Fi gu re 15-1). I. Have your partner support the leg and ma intain gentle traction while you cut awa),

the cloth ing and remove the shoe and sock foot.

(0

check the pulse and sensation at the

2. Position the splint under the injured leg. The rin g goes down and the sho rt side goes to the inside of the [ego Slide the ring snugly up under the hip, where it will be pressed aga inst the ischial tuberosity. 3. Posi tion two support straps above the knee and two below the km>c. 4. Attach the top ring st rap. S. Apply padding to the foot and ankle. 6. Apply the traction hitch around the foo t and ankle (Figure 15-2).

1. Maintain gentle t ract ion by hand. 8. Attach the t raction hitch to the end of the splint. 9. Increase traction by Spanish windlass action using a Slick or to ngue dep ressors. 10. Release manual traction and re:lssess circulation and sensat ion. II. Support the end of the spl int so that th ere is no pressure on the heel.

CHAPTER 15 Extremity Trauma Skills • 1. Apply traction

3. Secure ankle hitch and develop traction

2. Secure splint

4. Secure support cravats an(J elevate splint

FIGURE 1 5· 1 Applying a Thomas traction splint. Paclding

T·slrap

Collins hitch

Spanish windlass

Paclding

FIGURE 15·2 Applying a traction hitch to the ank1e.

PROCEDURE

!:IJ

Applying a Hare Traction Splint

The Hare traction splint is the modern version of the Thomas splint. To apply the Hare Iracljon splint, fo llow these steps (Sca n 15. 1). I. Position th e patient on the backboard or st retcher. 2. Have your partner support th e leg and maintain gentle traction, whi le you cut away the clothing and remove the shoe and sock to check pulse and sensation at the foot.

231

232 •

CHAPTER 15 Extremity Trauma Skills

SCAN 15.

APPLY!NG A HARE TRACTION SPUNT

D

Assess distal pulses and motor and sensory function.

EI

o

Adjust the splint for proper length .

D

o

Attach the ischial strap over the groin and thigh.

o Make sure the ischial strap is snug but not tight enough to reduce distal circulation.

Stabilize the injured leg by applying manual traction.

Position the splint under the injured leg until the ischial pad rests against the bony prominence of the buttocks. Once the splint is in position, raise the heel stand.

C HAPTER 15 Extremity Trauma Skills •

D

With the patient's foot in an upright position, secure the ankle hitch.

D

Fasten the leg support straps.

233

D

Attach the S-hook to the O-ring and apply mechanical traction. Full traction is achieved when the mechanical traction is equal to the manual traction and the pain and muscle spasms are reduced. In an unresponsive patient, tldjust the trtlction until the injured leg is the same length as the uninjured leg.

Em

Reevaluate the ischial strap and ankle hitch to ensure that both are securely fastened.

m Reassess distal pulses and motor and sensory funct ion.

234 • CHAPTER 15 Extremity Trauma Skills

I

3. Using tne uninjured leg as a guide, pull thc splint o ut to thc correct length. 4. Position thc splint under the injured leg. The ring goes down and the short side goes to thc inside of the leg. Slide the ring up sn ugly under thc hip againsllhe ischial tuberosity. S. Attach the ischial strap. 6. Apply the padded traction hitch to thc ankle and foot.

7. Position and attach two support straps above the knee and two below the knee. 8. Attach the traction hitch to thc wind lass by way of the S- hook. 9. Turn the ratchet un til the correct tension is applied. 10. Reassess PMS of leg. 11. Release manllal traction and recheck circulatio n and sensatio n.

12. To release mechan ical traction (when too tight or when removing splint), pull the ratchet knob outward and then slowly turn to loosen.

PROCEDURE 00 Applying a Sager Traction Splint The Sager traction splint is different in several ways. It works by providing counter traction against the pubic ramus and the ischial tuberosity medial to the shaft of the fe mu r; thus it does not go under the leg. The hip does no t have 10 be slightly fl exed, as wi th the Hare. The Sager splint is also lighter and more compact than olher traction splints. You can also splint both legs with o ne spli nt if needed. The current Sager splints are signifi cantly impro\'cd over o lder models and may represent the state of the art in traction splints. To apply a Sager traction splint, fo llow these sleps (Scan 15.2). I. Positio n the patient o n a lo ng backboard o r stretcher.

2. Have your partner support the leg and maintain gentle tractio n while you cut away the clothing and remove the shoe and sock to check the pulse and sensation at the foot. 3. Using the uninjured leg as a guide, pull the splint out to the correct length . 4. Position thc spl int to thc inside of the injured leg with the padded bar fin ed snugly against the pelvis in the gro in. Attach the strap to the thigh. The splint can be used o n the o utside of the leg, using the st rap to maintain tractio n against the pubic ramus. Be very careful not to catch the genitals u nder the bar (or strap). S. While your pa rtner maintai ns gentle manual tractio n, attach the padded hitch to the foot and ankle. 6. Extend the splint until the correct tension is obtained. 7. Apply tilt: elastic SI mps 10 secure: the leg to the: splint. 8. Release manual traction and recheck circulatio n and sensation.

PELVIC STABILIZATION TECHNIQUES Pelvic fra ctures involve either the iliac crest or the pelvic ring. Fractures to the iliac crest indicate serious tra uma; however. they are nOlli fe threatening like fractures of the pelvic rin g wi th resulting blood loss. In either case, the actual techniq ue fo r stabilizing the fracture is the same and may be accomplished by either o f two commo n approaches.

CHAPTER 15 Extremity Trauma Skills •

. . Place the splint along the medial aspect of the injured leg. Adjust it so that it extends about 4 inches beyond the heel.

EI

D

o

Ap ply the ankle hitch and attach it to the splint.

Secure the strap to the thigh.

Apply traction by extending the splint. Adjust the splint to 10 percent of the patient's body weight.

D

App ly the straps to secure leg to splint. Reassess distal pulses lind motor lind sensory function.

235

236 •

CHAPTER 15 Extremity Trauma Skills

PROCEDURE

00

Stabilizing the Pelvis with a Sheet or Blanket

I. Place:1 sheet o r blanket horizo ntall y o n tht" lower half of the backboard prior to mov ing the patien t. 2. Use a scoop stretcher, if a,'ai lable, to 1110" e the paticni o nto the backboard . If a scoop stretcher is not availabk.. tilc pat ient will need to be tog-rolled as gt·nlly and quickl)' as possible. tf YO ll havc OIlC o f the newer more stable scoop stretchers, you can usc it instead of a backboard but )'O U ,.,.it[ have to slide the sheet o r bla nket lip under the pati ent after he is on the stretcher. 3. Tic two diagonal corners of the sheet o r blan ket together with the knot formed at the hip on o ne side. Repea t the lie with the remaining two corners illld the knot formed o n the opposite hip. In each C:lse. gentl y and smooth ly increase th(· tellSion until fi rm support is provided for the pelvis (Figure 15-3).

PROCEDURE

00

Stabilizing the Pelvis with a Commercial Device

I. Open thc dev ice ;md pl an' it horizo ntall y o n the lower half of the backboa rd p rior \0

moving the pa tie nt. 2. US(' a scoop str('(cht'r, if available, to move the pa tient o nto the backboard. If a scoop stn.:ldH.;r is 1101 il vilihL blc, tllt' l-'ill iclit willilecd Iu be lu~- ru llcd ilS gt·ntly and qu ickly as possib le. If you have o ne of the newer more stable scoop stretchers. you ca n usc it instead of a b;Kkboard but yo u will have to slid,' the device lip under the pat ient aft er he is o n the streIch er.

3_ Tightell the device as the manufactu rer recom mends. Gentl }' and smoothl y increase the tension until firm support is provided fo r the pelvis (Figure ' 5-4).

FIGURE 15-3 Manual stllbilizat ion of unstabl(.' pelvic fractu re us ing a sh(.'ct. (Plloto ClJllrusy O/I.I,(}II C}w rpclllil'r, EArr- f»

FIGURE 15-4 Stahilization of an unstable I}(,'h'ic fract ure using a cOllllllericat de\'ic(.'. ( Photo courtesy 1I/5mll ""'I'rii((l/ PrlltJurts)

Dan, Joyce, and Buddy of the Emergency Tran sport System (ETS) have been called to the scene of a wa rehouse fire. Th ey are told that the wat ch man has just been rescued after being trapped in an upstairs bathroom. What injuries should they expect with a

mechanism of this type? Is carbon monoxide poisoning possible? Are there medical problems that can be precipitated or aggravated by this mechanism? Keep these questions in mind as you read the chapter. Then, at the end of the chapter, find out how the rescuers completed this call.

INTRODUCTION According to the America n Burn Association , there arc over I million burn injurics per year in the United States, result ing in more than 4,500 deaths. Thousa nds more arc injured. Many who survive their burns are left sC\'crely disabled a ndlor disfigured. While the num· ber of those kil led or inj ured has decreased in the last 30 years, p'lrt icularly wi th the usc of smoke detectors and the improvements in burn carc, b u rn injury is still a major problem for our society. Appl ying the basic pri nci ples taught here can help decrease death, disabil· ity, and disfigureme nt from burn injuries. As thc rescue of burn p'l tient'S can be extremely da ngerous, fo llowing the rules o f scene sa fely is extremely important. Multiple agents (T:lble 16-\) ca n ca use b urn injuries, b ut in general. pathologic damage to the skin is similar. Specific differences among the ty pes of burns will be discllssed in later sections.

.""",1 " 1. Thermal a. Flame b. Scald c. Steam

2. Electrical 3 . Chemical 4. Radiat ion

ANATOMY AND PATHOPHYSIOLOGY The Skin 238

The largest organ of the body. th e skin , is made up of two laye rs. The outer layer, which we can sec o n the surface, is called th e epidermis. It serves as a barrier between the environment a nd o u r body. Underneath the thin epidermis is a thick layer of collagen connec-

CHAPTER 16 Burns _

239

Capillary netwon': -----I'-------fJ

Dermis Arrector pili

m" ""e -----cf----.J--)l~hl_.

Shaft 01 ha;' ------+--+--~~,..._ Hair foUicle

-------t---i2'"r,::\-y-"

Hair' root { Bulb papilla

Subcutaneous fatty tissue

~- S.,eat gland Deep I.scia ------~I..'---- •• u,"'. fibers FIGURE 16 -1 T he skin.

tive tissue call ed the derm is. This layer co nta ins the importa nt sensory nerves a nd also the support structures such as the hair fo ll icles, sweat glands, a nd o il glands (Figure 16- 1). T he skin has many importan t fun ctions, which include acting as a mechanical a nd protective barrier between the body and the outside world, seali ng fluids inside, and preventing bacteria and other microorga nisms from readily entering the body. The skin is also a vital sensory o rga n thai provides input to the brain o n general and specific envi ronmenta l data and serves a pri ma ry role in temperalure regulation . Damage to the skin renders it unable to carry out these fu nctions and pUiS the bod y at risk for serio us problems. Burn damage to th e skin occu rs whe n heat or cau stic chem icals co me in co ntact with the skin and dama ge its chemical an d cellul ar components. In addition to actual tiss ue inju r y, the bod y's infl ammatory rcspon.<:c to th e ski n cbmage may a lso resll ll in addi tional injuryor increase the seve rity of a burn. The po rtions o f the skin that are necrosed by the thermal insult a rc referred to as th e ZOlle o/Coaglila/ioll and have suffered irreversible injury. Surrounding th is a rea is a ZOlle a[S/asis, bl ood flow is co m promised and tisslles w ill die ifblood fl o w is not restored. T his condition is scc n in the deeper areas of partial -thi ckness burns a nd is helped by good burn care and fl uid resusci tati o n. Surro unding this is the Zo ne o[ Hyperem ia, where th ere i.<: increased bl ood flow to th e tissues as a result of the acti o ns of inflammato ry mediators released by damaged skin .

Classifying Burns by Depth Burns are characte rized, based on th e depth of tissue damage a nd skin response, as superficial (fi rst deg ree), partial thi ckness (seco nd degree), or fu ll thickness (th i rd degree ). Su pcrficial bu rns res ult in III i no r I issue damage to the outer ep iderma l layer on ly. but do

240 • CHAPTER 16 Burns

Cause

Sun or minor fl ash

Hot liquids, flashes, or flame

Chemicals, electricity, flame, hot metals

Skin colo r

Red

Mottled red

Pearly white a nd/or charred, translucent and parchmentlike

Skin surface

Dry with no blisters

Bliste rs with weeping

Dry with thrombosed blood vessels

Sensat ion

Painful

Pai nful

Anesthetic

Healing

3--6 days

2-4 weeks, depending on depth

Requires skin grafting

ca use an in tense and painful infla mmatory response. The most co m mon injury of this type is "sunburn." Although no medical treat ment is usually required , various medicalions can be prescribed that sign ifi cantly speed heal ing and reduce the painful inflammatory response. Partial-th ickness burn s cause damage through t he ep idermis and in to a variable depth o f the dermis. These injuries will heal (usuall y with o ut sca rring) because the cells lining the deeper portions o f the hair follicles and sweat glands willmultipJy and grow new skin for healing. Ant ibiotic creams or various specialized types of dressings arc routinely used to treat these b urns and, therefore, appropriate medical evaluat ion and care should be provided for patients with these injuries. Emergency care of partia l-thickness burns involves cooling the b um and covering wit h a clean dry dressing. Full -thi ckness burns cause damage to all layers of the epidermis and dermis. No more skin cell layers are left , so healing by regrowth of epidermal cells is impossible. All fu ll-th ickness burns leave scars that later may contract and limit motio n of th e extremity (or restrict movement of lhe chest wall). Deeper ful l-th ickness burns usuall y result in skin protei n becomi ng denatured and hard, formi ng a firm,leat herlike covering t hat is referred to as eschar. Characterist ics of these burns arc listed in Table 16-2, and the depth levels and examples arc shown in Figures 16-2, 16-3, and 16-4.

Determining the Severity of Burns

FIG URE 16-2 Superfi cial (firsi-degree) burn.

The body's normal inflammatory response to the burn in~ jury can resu lt in progressive tissue damage for a day or two fo llowi ng bu rn injury, which may well result in an increase in burn depth. Any cond ition that eith er reduces circulation

CHAPTER 16 Burns _ 241

FIGURE 16·3 Partial·thickness (second-degree) burn. (Colirlesyo!Roy Also". MD )

(shock) to this damaged tiSSlle o r by itself causes further tissue damage will lead to burn progression wi th increasing burn dept h. Because of th is process of burn progression, it is not essent ial to determ ine exactly the burn depth in the fi eld. You should, hO\\lever, be able to clearly discern between superficia l and deep burns. Beca use transport to a burn center depends on both depth and extent of the bu rn, you should be able to estimate the amount of body surface involved in the burn . The bu rn size is best estimated in the fi eld usi ng t he rule o f nines (Figure 16-5). The body is d iv ided into areas t hat are ei ther 9 percent or 18 percent of the total body

FIGURE 16-4 Full-thickness (third-dl'grce) burn. (CourlCSYQf Roy Alro", MD )

242 • CHAPTER 16 Burns

Infant 13%

9%

13% 9%

Front 18% Back 18%

FIGURE 16-5 The rule of nines.

surface and by roughly drawing in the burn ed areas, the extcnt can be estim ated. Only pa rtial -thickness and full-thickness burns arc used for this calculat ion. In small children therc arc so mc differences in body size proportions and a Lund and Browder chart is helpful (lilble 16-3). For smaller or irregular burns, the sizc can be estim ated using the palmar surface (including th e fingers) of the patient 's ha nd, which is about I percent of the to ta l body su rface area. Even small burns can be serious if they in volve certain part s of the body that affect fu ncti on or appearance (Figure 16-6). Initial ca re that is directed specifically toward the burn should can· centrate on limiting any progression of the burn depth and extent.

PATIENT ASSESSMENT AND MANAGEMENT FIGURE 16-6 Areas in which small burns are mo re serious: Second- or third-degree burns in these areas (shaded portions) sho uld be treated in the hospital.

Evalu;llion of th e burn patient is often complicated by the dramatic nature of the injuries. You can easil y be overwhelmed by the extent of the injury. You must remember that eve n patients with major burns rarely expire in the inirial postburn period from the burn inju ry. Death in th e immediate postburn period is a consequence of associa ted trauma o r co nditio ns such as airway com promise or smo ke inha latio n. A carefu l, systematic approach to pat ient evalu ation will allow you 10 identify and manage critica l life-threate ning problems and to improve patient outco me.

CHAPTER 16 Burns _ 243

Area

G-1

1-4

5-.

10-1 5

Adults

Head Neck Ant. Trunk Post. Trunk R. Buttock L. Buttock Genitalia R.U. Arm L.U . Arm R.L. Arm L.L. Arm R. Hand L. Hand R. Thigh L. Thigh R. Leg L. Leg R. Foot L. Foot

19 2 13 13

17 2 17 13

13 2 13 13 2M

7 2 13 13 2M

2~

2~

2M 1

2M 1

2~

1

10 2 13 13 2M 2M 1

4 4

4 4

4 4

4 4

4 4

3 3

3 3 2~

3 3 2M

3 3

2~

3 3 2M

2~

2M

2~

2~

2~

5~

6~

8~

8~

9~

2"

3"

Total

2~

1

2~

5~

6~

8~

8~

9~

5 5

5 5

5~ 5~

6 6

7 7

3~

3~

3~

3~

3~

3~

3~

3~

3~

3M Total

Weight Height

Patient Assessment The ITLS Primary and Secondary Surveys sho uld follow the standard fo rmat described in Chapter 2. Scene Size·up: The steps fo r assessing a major burn patient are the same as fo r any other major trauma patient. Begin by performing a Scene Size·up as outlined in Chapter I, with an emphasis o n your own safety. After the size· up is completed, your next priority is to re~ move the patient fro m the source of the burn . This is the first step in treating a bu rn pa ~ tient, and involves both maintain ing your safety and the safety of your patient. There arc specifi c and significant dangers in removing the burn source in aU types of burn injuries. As a structure fire progresses. there is a point at which fl ashover occurs. Flashover is the sudden explosion into flame of everyth ing in the room. with the te m per~ ature rising insta ntaneously to over 2,000 degrees centigrade. There is oft en little warn ing before th is happens; thus removal of patients from burn ing bu ildi ngs takes prio rity over all other trea tment. Remember also that fi re co nsumes oxygen and produces large q u ant i ~ tics of toxic products and smoke. Th us, personnel making ent ry to ca rryollt rescue sho uld wear breath ing apparatus or risk becoming victi ms themselves.

PEARLS

Assessment Treat bum patients as trauma ms I'rimMy S""", oW inle!ventions, and transport decision,

p.ti.""

ms s-m, '""", m ms """'"' Wm

244 •

CHAPTER 16 Burns

--- - -

PEARLS

Safety

• Maintain appropriate wfety when r!I'I'IO'Mg patienti from the source of a bum injury.

• Remembtr that dealing with hwrdous materials requires ptOpef trailing and equipment. Yoo muslll5e appropriate personal protective ~L

••••• PEARLS

Airway Compromise E¥Iy deaths from b..ns iII'e not due to bum injury but to airway compromise. P!rIorm iTequent exams of the ~ and be prepared to sean it.

••••• PEARLS

Inha lation Injury • Arry type 01 w-n can have some degtee of inhalation irlil.BY.

i_INt.""", 01 smoke ~ in a dosed space

is the best predictor 01 srrd:e inhalation or other nay ~

Chemicals are not always easy 10 detect, either on patients or on objects in the e""ironment. Rescuers have suffered severe chem ical bu rns because of the failure to note sources of toxic and caustic chemicals and usc appropriate personal protective equipment. Special training in hazardous ma terials management is recommended for all rescuers. Electricity is exceptionally da ngerous, and handling of high -voltage wi res is extremely ha7..1rdous. Specialized training and knowledge arc required to approprialely deal with these sit uations, and you should not attem pt to remove wires unless specifi cally trained and equipped to do so. Even objects commonly felt 10 be sa fe, such as wooden sticks, manila rope, and firefi ghter's gloves, may not be protect ive and may result in electrocution. If at all possible, the source of electricity should be turned off before any attem pt at rescue is made. Init ial Assessment: People do not actually d ie rapidly from bu rn injuries. Early burn deaths are usually the result of ai rway o r trauma. Death from shock due to nuid loss from the burn will not be seen for many hours (or days) ilnd sepsis takes days to develop. Burn victims may sustain multiple trauma fro m fa lls or other mechan isms. Hemorrhagic shock will develop rapidly compared to burn shock, so that management of the patient's trauma using ITLS guidelines is very important. Even though the burn is highly visible and makes an intense impression at the scene, care o f the burn itself has a lower priority than airway management . You should manage burn patien ts the same as any other trau ma patients and perform an Initial Assessment as soon as thc bu rn victim is in a safe area. Begin by assessing and, if necessary, securing the airway, while simultaneously checking the initial level of consciousness and protecting the cervical spine. Assessment of breathing, circulatio n. and control of major hemorrhage is then carried o ut.

Rapid Tra uma Survey: Based upon the findin gs from the Scene Size-up and the Initial Assessment, a Rapid Trauma Survey is then performed, a baseline sct of vi tal signs is obtained. and if possible, a SAM PLE history obtained. At t his poin t a determination is made on the need for immediate t ransport and critical interventions. Critical problems in the burn patient th at require immediate intervention indudeain vaycomprom isc,altered level of consciousness, or the presence of major inj uries in addition to the burn. Clues from the mechanism of injury that point to critical problems ind ude a history ofbcing confined in a dosed space wi th the fire or smoke, electrical burns, chemical exposure, fa lls from a height, or other majo r blunt fo rce trauma. Supplemental oxygen should be initiated as soon as possible for all major burn patients. The Rapid Trauma Survey of the burn patient is directed toward identification of airway and circula tory compromise. Besides dues from the mechanism of inj ury, other find ings that should alert the responder to potential ai rway problems are the presence of facial and scalp burns, soOly sputu m, and singed nasal hair and eyebrows. Examine the oral cavity and look fo r soot, swelling, or erythema (redness). Ask the pat ien t to speak. A hoarse voice o r persisten t cough suggests involvement of deeper airway st ructures. Auscultate the chest. Wheezing o r rales should alert you to the presence of lower ai rway injury from inhalation. Examine burned areas and check for distal pulses. In your assessment of the burn patient, note and record the type of burn mechan ism and the particula r circumstances such as entrapment, explosion, mechanisms for olher possible injuries, smoke exposure, chemical/electrical deta ils, an d so forth. An appropriate past medical history should also be documented in writing. If the patient is unable to speak, ask other witnesses and/or fire personnel about the circumstances of the injury. ITLS Secondary Survey: Perform a standard Detailed Exam o n stable patients. Th is survey should in<;~ude.an evaluation. of \"he bum, estimating \ne depth based on appear. ance, and al~o estImating the burn sIze. These findings are im portant in determ ining the level of medIcal care that is appropriate fo r the burn victim .

CHAPTER 16 Burns _

245

Patient Management Once the immediate life-threats have been addressed, you should attend to the burn \I'ound itself. Try to limit burn wound progression as much as possible. Rapid coolin g early in the course of a surface burn injury can help limit th is progression. Followi ng remova l from the source of the burn , the skin and clothi ng arc still hot and this heat cont inUl..'s to injure the tissues, ca using an increase in burn dept h and seriousness or the injury. Cooling halts this process and, if done appropria tely, is benefici al. Cooli ng should be do ne with any source of clean water, but this should be undertaken fo r no more than a minute or two. Cooling for longer periods of time G ill induce hypothe rmia and subsequent shock. Following the brief period of cooli ng, manage the burn by coveri ng the patient with clean, d ry sheets and blankets to keep the pa tient warm and to prevent hypothermia. It is not necessary to have sterile sheets. The patient sho uld be covered even when the environmen t is not cold beca use da maged skin loses temperature regulatio n cap'lcity. Pat ients should never be trallsported on wet sheets, wet towels, or wet clothing and icc is absolutely contraindica ted. Icc will worsen the injury as it causes vasoconstriction and thus reduces the blood supply to al ready damaged tissue. Cooling the burn wound improperly can cause hypothermia and additional tissue damage and could be worsc tha n not cooling the burn at all. Initial management of chemica l and elect rical burn injuries will be described later in this chapter in the sections on those injuries. During the evaluation of the ex tent o f the burn injury, you should remove the patient's loose clot hing and jewelry. Cut around burned clothin g that is ad herent, but do not tf)' to pull the clot hing off oftbe skin. IV line insertio n is ra rely needed o n scene du ring initial care unless delay in transport to a hospital is unavoidable. It takes ho urs for bu rn shock to develop; therefore, the only reaso n to initia te IV therapy is if other fac tors indicate a need for fluid volume or medication admi nistration. Attempting to start IV therapy on scene in major bu rn patient s is often difficult and rou tinely delays initial transport and arrival at the hospital. IV ,Iccess may be establ ished during tra nsport. Pain med ication ad m inistratio n in the multiple-trauma patient remains controversial. A risk o f maski ng associated trauma and also both central nervous system and ca rdiovascular depression arc associated with the use of pa in medicat ion. In isola ted burns witho ut coexisting trauma and long transport times, adm inistration of analgesics in appropriate dos..1ges will improve patient comfort. Therefore, prior to admi nistr:ltion of pain medication , consultation with med ical direction is recommended. It is appropriate th at a physician sce burn injuries. There arc now ava ilable spec ialilcd form s of therapy th at offer speci fi c advantages to the treatment of superficial, partial-th ickness, and fu ll-th ickness burns. We have all seen partia l-thickness b urns become infected and progress to full -thickness bu rns beca use of poor ca re. The sooner specialized bu rn ther,lpy ca n be initiated, the more ra pid and s..1tisf'lctory the results will be. Table 16-4 lists co ndition s that would benefit fro m care at a burn center. Based upon available local resources and protocols, it may be appropriate to bypass a local f3cility and transport these patients direct ly to the bu rn center.

Special Problems in Burn Management The follow ing sectio ns review ma nagement of specific types of burns. based upon the injury mechanism. Be aware that mon.' than o ne type of burn cail be present in a patient. For example, a high-voltage electrical bu rn injury may also p roduce flame burns due to ignition of the patient's cloth ing. Flash Burns: Flash burns arc vi rt ually always superficial or partial-thickness burns. A fla sh burn occurs when there is some type of explosion, but no sustain ed fire. The single

• • • • • PEARLS

Cooling Early after the born event, properly

cool the mace thermal ~, but do not cause hypothermia.

••••• PEARLS

Flu;el Resuscitation Initiation of Huid resuscitation 00scene is oot as important as

management 01 other potential &Ie tlnalS. Most bum injunes do not require fllid5 if! the prfllospital

.,..,..

246 • CHAPTER 16 Burns

Partial-thickness bums greater than 10% total body surface area (TBSA) Burns that involve the face. hands. feet . genitalia. perineum. or major joints Third-degree burns in any age group Electrical burns. induding lightning injury Chemical burns Inhalation injury Burn injury in patients with preexisting medical disorders that could complicate management. prolong recovery. or affect mortality • Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases. if the trauma poses the greater immediate risk. the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. • Burned children in hospitals without qualified personnel or equipment for the care of children • Burn injury in patients who will require special sodal. emotional. or long-term rehabilitative intervention • • • • • •

Source: American College of Surgeons. Committee on Trauma. 1999. Guidelines for the operations of bum units (55--62); Resources for optimal care of the injured patient.

heat wave traveling out from these explosions results in such short patient- heat contact that full-thickness burns almost never occur. Only areas directly exposed to the true heat wave will be injured. Typically, fu ce and hands are involved. An exa mple of this type of burn is seen when someone pours gasoline on a charcoal fire in order to get it to heat up faster. In situations of possible flash explosion risk, you sho uld always wear proper protective clothing and avoid entry into explosive enviro nments. Other injuries (fractures, internal injuries, blast chest injuries, and so o n) may occur as a result of explosion. Inhalation Injuries: Inhalation injuries account fo r more than half of the 4,500 plus burn-related deaths in the United States each year. Inhalation injuries are classified as carbon monoxide poisoning, heat-inhalation injuries, or smoke (toxic) inhalation injuries. Most frequently, inhalation injuries occur when a patient is injured in a confined space or is trapped; however, even victims of fires in open spaces may have inhalation injuries. Flash explosions (no fire ) practically never cause inhalation injuries.

Carbon Monoxide Poisoning. Carbon monoxide poisoning and asphyxiation are by far the most common causes of early death associated with burn injury. Carbon monoxide is a by-product of combustion and is one of the numerous chemicals in common smoke. It is present in high concentrations in auto exhaust fumes and fumes from some types of home space healers. Since it is co(orless, odorless, and tasteless, its presence is virtually impossible to detect. Carbon monoxide binds to hemoglobin (257 times stronger than oxygen), resulting in the hemoglobin being unable to transport oxygen. Patients quickly become hypoxic even in the presence of low concentrations of carbon monoxide. An alteration in level of consciousness is the predominant sign of this hypoxia (Table 16-5 ). A cherry-red skin color or cyanosis is rarely present as a result of carbon mo noxide poison-

CHAPTER 16 Burns _ 247

Level

20 30

40-50

60-70

80

Symptoms Headache common, throbbing in nature; shortness of breath on exertion Head ache present; alterad central nervous system function with disturbed judgment; irritability, d izziness; decreased vision Marked central nervous system alterat ion with confusion, collapse; also fainting with exertion Convulsions; unconsciousness; apnea with prolonged exposure Rapidly fata l

ing and. therefore. cannot be used in the assessment of pa50 ~----------------------, tients for carbon monoxide poisoning. Pulse oximetry will remain normal 10 high in the presence of carhon monoxide ~ 40 and cannot be used to assess these patients. Some newer ~ 30 model pulse oximeters can now specificall y measure carboxyhemoglob in levels and. if available. should be used on all persons who have the possibility of exposure 10 carbon 2 4 6 8 10 monoxide. Death usually occurs because of either cerebral Hours or myocardial ischemia or myoca rdial infarction due to FIGURE 16-7 Decay curve for disappearance of progressive cardiac hypoxia. carboxyhemoglobin from 50 pcrcent lethallevel to 20 percent Treat patients suspected of having carbon monoxide acceptable level in air, I aim. O 2 (100 percent oxygen) and poisoning with high-flow oxygen by mask. If such a patient 2.5 atm. 0 1 (hyperbaric oxygen- tOO percent at 2.5 loses consciousness, begin Advanced Life Support with intuatmospheres). bation and ventilation using 100 percent oxygen. If a patient is simply removed from the source of the carbon monoxide and allowed to breathe fresh air, it takes up to 7 hours to reduce the carbon monoxide-hemoglobin complex to a safe level. Having the patient breathe 100 percent oxygen decreases this time to about 90 to 120 minutes, and usc of hyperbaric oxygen (100 percent oxygen at 2.5 atmospheres) will decrease this time to about 30 minutes (Figure 16-7). All suspected cases of carbon monoxide poisoning or toxic inhalation should ~ transported to an appropriate hospital. The decisio n to transport the patient to a hyperbaric chamber should be made by medical direction.

8

Hea t-Inhalation Injuries. Heat- inhalation injuries are confined to the upper airway, because breathing in flame and hot gases does not result in heat transport down to the lung tissue itself. The water vapor in the air in the tracheal-bronchial tree effectively absorbs this heat. Steam inhalation is the exception to this rule. as steam is superheated water vapor. A second exception to this rule is if the patient has inhaled II flammable gas that then ignites and causes thermal injury to the level of the alveoli (example: a painter in II closed space where the paint fum es are ignited by a spark). As a result of the heat injury, t issue swelling occurs just as it does with surface burns. The vocal co rds themselves do not swell because t hey are dense fibrou s bands of connective tissue. However. the loose mucosa in the supraglottic area (the hypopharynx) is where the swelling occurs, and can easily progress to complete airway obstruction and

248 •

CHAPTER 16 Burns

FIGURE 16·8 Hea t inha lation can ca use co mplete airway obst ru ction by swelling of th e h ypo pharynx: left sidellormal :lll:llOmy. ri ghl 5 iu l--~Wt:lIi ll g pro;t(imallO co rU5.

• Burns 01 the lace

• Singed eyebrows or nasal hair • Burns in the mouth • Carbonaceous (sooty) sputum

• History 01 being confined In a dosed space while being burned • exposure

10

steam

FIGURE 16-9 Danger signs of upper airway burns.

• Victims exposed to smoke In an enclosed place • Victims who were unconscious while exposed to smoke or fire • Victims with a cough after being exposed to smoke or fira • Victims short of breath after being exlXlSed 10 smoke or tire • Victims wilh chest pain atlar

death (Figure 1 6~8). There is usually som e ti me between thl' inj ury a nd the development of airway edema, so los.... of airway due to direct thermal injury is rare in the initial prehospital phase. Be aware that once the swel ling begins. the airway can obstruct rapidly. Aggressive fluid resuscitation ca n hasten this swellin g. During seconda ry t ransport to a burn center, thc risk of :I irway swelling can become significant and can ca lise a irway obstruct ion as volume- resusci tation IV fluids a rc being admi nistered. For th is reaso n. if there is a ny potential for airway burns, the patient should be sedated and intubatcd befo re a transfe r. It is much easie r to dectivdy int ubatl.' a p.uicnt in the emergency department than do a c rash intu· bat ion in the back of an ambula nce. Figure 16 ~ 9 lists signs tha t should :llert yo u 10 the danger of your pat ient having up per airway burns. Swollen lips indicate the presence of therm
being exposed 10 s!TlOl<e or lire FIGURE 16-1 0 Pat ien ts in whom rou should suspect smoke illh:llalion .

Smoke- I"'wlatiotl I"juries, Smoke-i nh;llation injuries ( Fig-

ure 1 6~ 10) are the resu lt of inhaled IOx ic chemicals that cause structural damage to lung cells. Smoke may contain hundreds of toxic chemicals that damage the delicate alveolar cells. Smoke from plastic an d synthetic prod ucts is the most damaging. Tissue destruction in the bronchi and alveoli m ay lake hours to days. However, as these toxic products in the smoke are very irritating, they mOl)' precipi tate bronchospasm or coronary ,u lery spasm in susceptible individuals. Treat bronchospasm wi th inh aled beta ago nists (albuterol) a nd oxygen.

• • • • • PEARLS

Chemical Burns Chemical rpifs. in gener.l. require prolonged and copious irrigation.

Chemical Burns: Thousands o f different types of chemicals can cause burn injuries. Chemica ls may not o nl y inju re the skin, but also be absorbed into the body a nd ca use intern,ll organ fai lure (especially liver and kidney damage). Volati le fo rms of chemicals may be inhaled and calise IUllg tissue da mage with subsequent severe li fe~ threa l e n in g respiratory fail ure. The effects of the chemical agen ts on the olherorga n system s, stich as the lung o r liver, may not be immed iately apparent after exposure. Chemical inj uries are frequentl y deceiving in th;lI initial skin changes may be minima l even when a severe inj ury is presen t. This may lead to secondary conta m ination o f resc uers. Minimal burns o n the pa tien t may

C HAPTER 16 Burns _ 249

not be obvious. As a resul t, you can get these chemica ls o n your ow n skin unless a ppropriate prl'caution s arc taken. Factors that lead to tissue damage include cht'mical concentr'ltion. a mo unt , manner and durat ion of skin contact, and the mcchanism of act ion of the chemical agent. T he patho logic proct"S5 causing the tissue damage cont in ues unti l the chemical is e ither co nsumed in the damage process, detoxified by the body, o r is physicall y removed. Atte mpts al inactivat ion with specific neut ralizing chem icals are d'lIlgerolis beca use the process of neutralizatio n may generate o tht'r che mi(;1 1 reactio ns (heat) tha t may worst.'n the injury. T he fefo re, you should aim treat men t at chem ical rellloval by foll owing Ih('se four steps.

PROCEDURE

00

Removing the Source of Chemical Burns

I. Wea r appropriatc protective gloves, c)'cwear, and respiratory prott'ction if needl·d. In

some situations you will nc."('(lto wcar a chemical protecti\'(' suit as well . 2. Remove all the patient's clothing. P1:lCe in plastic bags to limi t further contact. 3. Fl ush chem icals ofT the bod y by irrig;lling copiously with an}' source of available wa ter or other irriga nt. If dry chemicals arc o n the skin. the}' shou ld first be tho roughly brushed off before pc.'rform ing copio us irriga tion. Remember: Tilt' SOIIlI;olllo pol/III;O";Sdillll;o". 4, IklllOvc any retai ned agent adhering to the skin by any a pproprhu e physical l11ea ns such as wiping or gentle scraping. Follow this by further irrig.1 tion ( Figures 16- 11 and 16- 12 ).

Ide:ll ly, all c{)l1 taminatl'd patients should be decontamina ted prior to I'r;msport, so a.s to limit sk in damage a nd prevent contamination of the a.mbulance Of hospita l. Cr itica l interwntions incl uding airway management ca n be initiated prior to and duri ng the decontamina tio n process. If the patient has not been full y decontaminated prio r to transport , no tify ,he receivi ng hospita l as soon as possible, so tha t they can be prepared to manage the patien t. Irr iga tio n of caustic chem ica ls in the ere is exceptionally importan t beca uSC' irre\'ersible damage will occu r in a very short pi'riod of time (k'ss than the transport lime 10 get to the hospit;l l). Irriga tion o f injured eyes may be difficult bl'Causc of the p.1in associated wi th eye opening. However, rOll must begin irrigation to prewnt scvere a nd pennanent damage to the corneas ( Figurc 16- 13a, b). C heck for contact lenses o r foreign bodies

••

b.

FIGURE 16-11 For a chemical burn. (a ) brush away dry I)()..... ders. a nd th en (b) f1 c}O(1 Ihe area wil h walt"r. ( PiJO/'Ii CQIlrIN), "f ,\/i(/lIIll-krml)

250 •

CHAPTER 16 Burns

FIGURE 16-12 Acid burn of the ankle being irrigated. (Colirlesyof Roy AIsoII, MD)

••

b.

FIGURE 16-13 (a) Chemical burns to the eyes; (b ) emergency care of chemical burns to the eye.

CHAPTER 16 Burns _ 251

and, if present , remove them carl}' du ring irriga tion. A nas'll cann ula hooked to an IV bag of normal sali ne and placcd over the bridge of the nose makes an ('xcdl en t bi lateral eye wash system during transport. Electricaf Burns: In cases of electrical burtis, da mage is caused by electricity en tering the body and t raveling throu gh the tissues. Inju ry resu lt s from t he effects of the electricit y o n the fun ction of the body organs and from th e hea t generated by the passage of the current. Extremities art· at risk for more significant tissue damage, versus th e torso, because their small si~e res ult s in higher local curren t densi ty (Figur(' J 6- 14 ). The fa ctors that determine scveri ty of electrical injury include the foll owing: • T}'pe and amount of current (alterl1Hting versus direct c urren t and also the voltag(') • P'l th of the current thro ugh the body • Duration of contact with the current sou rce The I11 0st serious and im mediate injury that resu lts from electrical contact is ca rd i'lc arrhythm ia. Any patient who receives an ck ctric cu rrent injury, rega rdless of how stable he looks, ShOll ld have .1 careful i rmnediate e"aluation of his ca rdiac Sial us and co nt in uo us monitoring of ca rdiac aCli vity. The most common life -threatening arrhythmias are prematu re vent ricular ca nt ractions, vent ricuhlf tachyca rdia, a nd ventricu lar fi brill a tion. Aggressin' Advan((.'(i Life Support managemen t of these arrhy th mias should be um\ertakcn,since these pat ients usu'llly have normal heat thy hearts and th e chances for resuscitation arc excellen t. For a patient in vent ricula r fibrillati o n with o nl }' bask life support available, start cardiop ulmo nary res usc itation (CPR ) and transport immediately to a hospital faci lit y. Most of Ihesc vict i illS do not have preexist ing cardiov'lscular disease, and thei r he'lft Illll Sc1e tissue is u Sll:l II ~' not da maged as a resu lt of the electrici ty. Even under ci rcumsta nces of prolonged C PR, resuscitat io n is often possible. O nce those efforts at managi ng ca rdiac sta tllS arc complete, pf(widc field care as previollsly descrilwd fo r thermal burns. Elect rica! i nju ries '.lUse sk in bu rns at the ent ranc(' and exi t sites because o f high tCI11p('ratllrCS generated by the electric a rc (2,500 degrees ce ntigrade) at the skin surface. Ad ditio nal surface Il ame burn s may result if tIl(' patient's clo thing is igni t(·d. Fractures

FIGURE 16 -14 Elect rical hurn of the lower leg a Ild foot. (Collrlt'sy of Roy A/Stili, MD)

• • • • • PEARLS

Electrical Burns Immediate~ ched:; the cardiac 5talUS of victims 01electricalinjury.

252 •

CHAPTER 16 Burns

and/or d islOC;lt ions mily be present due to the violent m uscle contractio ns that eleWia( injuries cause. O ften vict im s are involved in co nstruction and rna)' sustai n fractures o ther injuries due to fa lls after an declric shock. Internal injuries usually involve damage, nerve damage, and possi ble intravascular blood coagulat ion dm: tu ell,·cI "i",I' current passage. In ternal chest o r abdominal o rga n damage due to electrical c.urrent is exceedi ngly rare. At the scene of an electrica l injury, your first priority is scene safety. Determine jfthe patient is still in contact wi th the electrical cu rrent. If so, yo u must remove the patient from contact without becoming a victim yourself (Figure 16- 15). Handling high-voltage electrical wires is extremely hazardous. Special training and special equipment are needed to deal with downed wires; never attempt to move wires wit h makeshift equipmen t. Tree limbs, pieces of wood, and even manila rope may cond uct high-voltage electricity. Even firefighter gloves and boots do not offer adequate protection in this situation. If possible, lea\'e the handling of downed wires 10 pOlller company personnel or develop a special t rain ing program with your local power company to learn how to use the special equip· ment designed to hand le high-voltage lines. In the field setting, it is impossible to tell the total extent of the damage in electric-II burns. So, all electrical burn pat ients should be transported for hospital e\'3Iuation. Due to the potential for arrhythmia development, routine IV access should be initiated in the ambula nce, along with continuous cardiac mo nitoring. IV fluid resuscitation should be started du ring transport in this situation. Beciluse of extensive tissue destruction, the fluid needs d uring interfacility transport of 3n electrical burn patient are often higher th3n those with thermal burns. Electrical burn pat ients are at risk for developing rhabdomyolysis and rena l fa ilure. Lightning Injury: Lightning kills more persons in Nort h America each YCilr than any other weather-related phenomenon. Injuries from lightning arc very different from other electrical injuries in that lightning produces extremely high voltages (> 10,000,000 volts) and Cll rrents (>2,000 amps), but has a \'ery short duration « 100 mscc) of cOIl!'act.

FtGURE 16-15 Removal of high-voltage electrical wires. Do noltry to remove wires with safety equipll1en t (or sl icks) un less sPf.-'Cially trained. Turn off Ihe e1cctricity !lIthe source o r call the power company 10 rcmO\'c the wires. (Omrtt'S)' of [.cOli Chllrpl'lIticr. EMT-I'}

CHAPTER 16 Burns -

Ligh tni ng prod uces a "fl ashover" phenomenon, in which the current fl ows around the outside of the victim's body. Consequentl y. the internal damage from curren t flow seen with generated elect ricity is not seen in a lightni ng stri ke. Most of the effects from a lightning strike are the result of the lll'lssive DC (di rect current ) shock Ihat is received. Classic light ning strike burns produce a fe rn like or splatter pattern across the skin ( I:igure 16-16). The victim does not need to be struck directly to sustain an injury. Lightning may strike an adjacent object o r nearby ground and st ill produce an injury to a victi m. Often the victim's skin is wei, from either sweal or rai n. This waler, when healed by the lightning cu rrent, is qu ickly vaporized, producing superfi cial and partial-thickness burns, and may IiteTillly explode the clothing off the vict im. As these burns are superficial, aggressive- fluid resuscita tion is not required. Th e most serious effect of a lightni ng strike is ca rdiorespiratory arrest, wi th the massive curren t acting li ke a defibrillator to briefly SlOp the hearl. Cardiac activity often spon taneously resu mes within min utes. However, the respiratory d rive centers of the brain arc also depressed by the current discharge. and these areas take longer to recover and resume the norm:11respiratory d rive. Conseq uently, the victim remai ns in respiratory arrest, which is followed by a second cardi;1( arrest from hypoxia. The essen tial com ponent of the ma nagement of the lightning st rike victim is restoration of ca rdio respirato ry function, while- protecting the cervical spine. Follow standard gu idelines for CPR and Advanced u rdiac Life Suppor t (ACLS). Since lightning stri kes can occur at sporting events and other outdoor gat herings, strikes often become- multipkcasualty evcnts. It must be stressed that in a multiple-casualty ligh tning strike, the conventional triage approach of a pulseless or non breathing patient equal ing a dead patient should not be fo llowed. If a patient is awake or breathing after a lightni ng strike, he will most likely survive without further in terven tion. Resllscitative efforts should concentrate on those victi ms who arc in respirntoryorcardiac arrest, si nce prompt C PR and ACLS represcnt the o nly chance that these victims have for survival. Long- term problems have been seen in lightning strike pa tients, sllch as the development of cataracts, or neu rological and/or psychological difficulties. Pe rforatio n o f the eard ru m is qui te co mmon . and rarel y long bone or scapular fractures, as seen in the-

FIGURE 16-16 Flasho\'er pattern of burns on th.' skin of a victim of a lightni ng strike.

253

CHAPTER 16 Burns

254 •

victim s of generated high -,'oltage electrical injuries, may be seen. These fractures art managed as described in C hapter 14. There are over 200 reported deaths in North America each year due to lightningstrikt. This represents o nly 30 percent of lightning st rike victims; thus it is possible that ),ou wiD have to care for such a victim. These events often involve mUltiple victims. with varying de· gr(!(.'S o f severit)'- Prompt CPR greatly impron.-s the chances of survival. When confronted with a naked (or partially unclothed) unconscious o r confused patient. with perforated eardrums and a fern like o r splatter burn pa ttern on his body, think lightning strike.

Radiation Burns: Ionizing radiation damages cells by brea king male<:ular bonds. Skin burns fro m radiatio n look exactly li ke thermal bu rns and cannot be differentia ted by thdr appearance alo ne. However, rad iation bu rns develop slowly over days and so generally do not present as an emergency. lJccalisc of the damage to the skin cells. radiation burns heal very slowly. They can cause Illiid loss like thermal burns and arc even mo re prone to infec· tion. Patients with radiation burns arc not radio:lctive u nless they are contamina ted with radioactive ma terial. If there is any danger that they might be contam ina ted. you should call for the ha7.ardous materials team to sca n them for radia tion and perform decontami· nation if needed. Noncontaminated radiation -burn patients arc treated the 5.1me as any burn pat ient. Decontam inatio n o f pat ients contaminated by radioact ive material is beyond the scope of this course. Circumf.nmtial Burns: Ci rcumferentia l fu ll-thickness burns may lead to neurovascu· lar compromise. While this is rarely a problem on the {ire scene. this may become signifi. cant during an interfacility transfer. Full-thickness burns that arc ci rcumferential around an extremity ca n act as a tou rniquet as edema progresses. Early o n, the patient may compla in of loss of sensation. tingling and eventuall y devclop ischemic pain with loss o f pu\ses. Circumferential full -th ickness burns on the extremities will requ ire an escharotomy by the physician. especiall y if [o ng transpo rt times arc involved. Circumferential burns of the chest can interfere with chest expansion and thus compromise respirations. Again, e5charolOmy in this sett ing ca n improve ventilato ry status. Be sure to alert the receiving faci lity if you arc transport ing a patient with full-thickness ci rcumferential burns.

••••• PEARLS

Sucmdllry 7r1l"sport • pt., II secondary IJnports 10 bum cent'" tnd tfItctNeIy corttiM.It resuscitation d\Mg sud!

........

• Do not begin a 5«Ondary trJnSpOft of a pitJenl wiItI a

"""'" ""'" "'" """" ... _

boOg ....!.d boI.n

"""""'"

Secondary Transport: Major burns often do no t occur in locations where im med iah.' transport to a burn centef is possible. As a result, transport from a primary hospital to a burn center is commonly necess..1 ry. After the initia l stabilization. prompt transfer to a bu rn center can impro\'e pat ient outcome. Du ring this transport , it is im port ant fo r the ambul:lI1ce crew to continue resuscitation initiated at the referri ng fac ility. Prior to secondary transport , the transferring physicia n should have completed tht following: • Stabilization of respiratory and hemodyna mic function. This may include intubation and IV access fo r fluid admin istration. • Assessment and management of associated injuries • Review of appropriate lab data (specifically, blood gas analysis) • Insertion of nasogastric tube in patients having burns covering more than 20 percent of thc boc..Iy liurfacc an.."a • Placement of a Foley ( urinary) cathetcr to allow measurement o f urine o utput. wh ich can assist in detcrmining the adeq uacy o f o ngoing fluid resuscitation • Assessment of peripheral circulation and :lppropriate wound management • Proper arr:lI1gcments with the recl'iving hosp ital and physician

CHAPTER 16 Burns _ 255

You should specifically discuss the transport with either the referring or the receiving physiciaJl to determine what special fun ctions may need monitoring and to determ ine the approp riate range for fl uid admin istration , since burns often require ext remely large hourly IV rates for appropriate card iovascular suppo rt. Initial resuscitative fluid needs in a burn patient are calculated using the Parkland for mula: 4 cc/kg of Ringer's lactate o r normal sal ine x % burn area X body weight (kg)

= fluid needs in first 24 hours Half of th is fluid is given in the first 8 hours and the remainder over the next 16 hours. It is importa nt for you to mainta in carefu l records indicati ng patient condition and

treatment during transpo rt. You should also make an in-depth report to the receiving faci lity. Pe d iat ric Burns: Ch il dren represent nearly one-half of aU patients who seek treatment fo r burn s. Because of their th inner skin. they are at greater r isk for severe injury fo llow ing a burn. Post burn problems. such as hypothermia, are more likely to occur in children beca use of their larger surface area to body mass ratio. Beca use of differences in anatomy, the rule of nines must be modified, as in smal l children the head rep resents a larger portion of the body surf,lce (sec Figure 16-5). The Lund and Browder chart is better for est imating burn size in ch ildren (see Table 16-2). The palmar surfuce ( ] percent) mle applies to chil dren as well as ad ults. Sadly, burns in children may be the result of intentional abuse and. in fact, 10 percen t of ab use cases in the United States involve burns. You should be alert for signs of abuse. These include burns tha t match shapes of objects such as curling irons. iron s, or ciga rette burns. Also susp icious for abu se are multiple stories of how the inju ry occu rred or sto ries of the burn bei ng ca used by acti vities by the child lh at arc in consistent with the child 's develo pmen t. Burns to th e genita li a, perineum. o r in a stocki ng or glove distribution (Figure 16- 17) should also raise suspi cio n. If there is a suspicion of abuse, this mu st be reported to c hild protective services or 1;IW enforcement. Fire and EM S personnel can help reduce burns in children through community ed ucation. Progra ms to teach parents about limiting the temperature on household water heaters to 120 degrees Fahrenheit and programs to teach children about fire safety can make a signilkant impact on the incidence of pediatric burns in your commun ity. You sho uld also be aware that the elderly may also be victims of abuse by burns (sec Chapler 18).

FIGURE 16-17 Scald burns 011 a child. This is a typical pattern of child ab use burns. ( umrlL'S)' of Roy A/wu, MIJ)

256 •

CHAPTER 16 Burns

Dan, Joyce, and Buddy of the Emergency Transport System (8S) have been called to the scene of a warehouse fire where the watchman has just been rescued from an upstairs bathroom . They prepare to care for a patient with burns and/or inhalation injuries. Duri ng travel to the scene, they decide that Buddy will be team leader on this call. They arrive in the industria l district to find a large warehouse engulfed in flames. The victim has been removed from the area ofthe fire to a local staging area. As they approach, their general impression is bad , as the patient appears to be having difficulty breath ing. He is alert but can only speak in one· and two·word sentences because of dyspnea. His voice is hoarse and there is audible wheezing. Initial assessment reveals that his airway is open but he is having wheezi ng and rapid, stridorous respiration. There are obvious burns of the face. He has a strong but rapid pulse al the wrist. Dan applies an oxygen mask. attached to a demand valve (a flow· restricted oxygen· powered ventilation device, or FROPVD) while Buddy continues a Rapid Trauma Survey. There is erythema and some blistering of the face. The nose hairs are singed. There is soot in the mouth and nose. There is no deformity of the neck and the neck. veins are flat. The chest has no apparent injuries but there are inspiratory and expi ratory wheezes bilaterally. Heart sounds are rapid and faint. The abdomen is soft and the patient denies pain with palpation. The pelviS is stable and nontender. There is some erythema of the hands but no blistering. The re is normal PMS of the extremities. Buddy gets the team to immediately move the patient to the ambulance and they begin transport. Vita l signs are BP 160/ 100, pulse 140, and respiration 40 per min ute. His pulse oximeter saturation is 100 percent, but Buddy realizes that the pulse oximeter is worthless in carbon monoxide inhalation victims so he attaches no sign ificance to the reading. While Dan initiates an albuterol nebulizer treatment with 100 percent oxygen, Buddy starts a large-bore IV at a keep·vein·open rate and gets the SAMPLE history. The patent states he is 45 years old and has a history of asthma. He denies any allergies and his medication is an albuterol inhaler that he uses as needed. He was upstairs making his rounds when he heard a loud explosion. When he opened the door to the stairs, they were engulfed in flames. He went to the back of the building, where he was eventually rescued by the fire department. He complains of burning of his face and hands and also has chest pain and severe dyspnea. He had just fini shed eating his evening meal when the explosion occurred. Bec.ause of the stridor, Oan decides to intubate. Using the rapid seq uen ce intubation protocol , Da n ad ministers a sedative agent followed by a paralytic. He easily passes a 7-mm endotrachea l tube and confirms position. (In the absence of permission for RSI , Dan would attempt to insert a 9-mm endotracheal tube by the nasotracheal route.) Buddy contacts medical direction and is instructed to give a bolus of IV steroids. Given the inj uries found by the crew, medical direction instructs them to transport the patien t to the regional burn center in the next county. When doing the Secondary Survey, Buddy attaches a cardiac monitor and does a 12·lead EKG, which revea ls an acute injury pattern. He immediately notifies medical direction and fills oul the

CHAPTER 16 Burns _ 257

thrombolytic informa tion s heet. The bu m team and the acute card iac ca re team meet them a t the e mergen cy department of the burn cente r. Beca use of the rapid treatment the pat ient eventua Uy makes a complete recovery.

A blast of flame can cause up per airway bu rns , lead in g to loss of the airway from swelling. The patient with facial bums and burn s in the mouth or nose and who has stridor is in danger of immediate loss of the airway. Not on ly does smoke inhalation cause hypoxia and poisoning by multiple toxic gases, it can also precipitate bronchospasm in susceptib le individuals. The hypoxia can precipitate a myocard ia l in fa rction in individua ls who already have borderlin e coro nary a rte ries . The toxic gases can precipitate coronary spasm , leading to myoca rdial in farction or arrhythm ias. Givin g 100 perce nt oxygen is the best pre hospital treatment of ca rbon monoxide poisoning. The pulse oximeter is unable to teU the difference between oxyhemoglobin and carboxyhe moglobin, so will give fa lse results and is not to be trusted in this case .

SUMMARY Burn inj uries arc potentially deadly fo r both you and your patient. You must never forget the rules of scene safety. Half of all burn dea ths are from inhala tion inju ries; do not fo rget the ai rway. Give 100 pe rcellt oxygen if there is any chance of inha latio n injury. Cool the burn to h;lit th e burning process, but do not cause hypoth erm ia. You m ust begi n irrigating chemical burns in the fi eld, o r thc burn damage will contin ue during I.rans(>ort. Th is is one of the few instances in trauma care when extra time spt'nt in the fi eld may be benefi cial to the patient. Elect rical burns are commo nly associated w ith cardiac arrest, but rapid evaluat io n and manageme nt a re usually life-saving. H igh-vo ltage electricity is extre mely dangerous; get t rained personnel to turn it o ff. Do not begin secondary transfer o f a burn patient until the patient has been properly sta bilized and the airway protected.

BIBLIOGRAPHY J. American Burn Associat ion. 2003. Inhalation injury: Diagnosis. Jour/1Il1 of tIle AlIIl'ric(m Col-

lege Of Surgeons 1%(2): 307-12. 2. Committee on Trauma. American College of Surgeons. 2004. Injuries due to burns and cold. A(/wlt/eed TraU/l/a Life Suppor,. Chicago: The College, 23 1--42. J. Cri s..~, E.• and others. 1998. Not just blowing smoke. EmergellCY "'·fediml Sen1ices (March 2003): 27-39. 4. Danks, R. It 2003. Burn management: A comprehensive review of the epidemiology & treatment of burn victims. JEMS 28(5) : 118-4 1. 5. Miller, K. 2003. Acute inahalt ion injury. EmergellCY Mc(liml Clillics of Nor,h America, 2 1, (2): 533--57. 6. Narad7.ay, J. E, R. Alson. 2005. Thermal burns. Emetiicilll': Oll-lille EmcrgellCY Mellialle "lex/. Boston: Boston Medical publishers. 7. Shehan. H., R. Papini. 2004. Initial management of a major burn: Overview. British Melfical Jo/lfIlIll. 328: 1555-57. 8. Singer, A. J. 2000. Thermal burns rapid asscssmellt llnd treatment. EM Practice 2(9). 9. Wald, D. A. 1998. Burn management: Systematic patient evaluation, fl uid resusci tation, and wound 1lI31111gement. Emcrgellc), Medicille Reports. 19: 45-52.

Joyce, Dan, and Buddy have received a call to a home fo r an t8-mo nth-old child w ho fell fro m a couch_ They are told that th e infant appears to be unconscious. As they respond to the sce ne, they decide that Joyce will be team leader. What sort of injuries should

they expect from this mechanism? How does evaluation and treatment of a l -year·old differ from an adult? Keep these questions in mind as you read the ch apter. Th en, at the end of the cha pter, find out how the resc uers completed this caU .

INTRODUCTION Children arc 110t j ust litt le aduhs. Th ey di ffer from adults in that they have differen t pattern s of injuries, frequen ll y have diffe rent responses to those injuri es. requi re spe· cial eq uipmen t for assess ment a nd treatment, are difficult to assess and com mu nica te with , and come with parents and ot her fami ly members. Docto rs as well as EMTs arc uncomfo rt able treating childre n because of these d iffere nces and the fac t th at we trea t them less frequent ly ;;lOd thus do not deve lop <1S m uch ex pertise as we wou ld like. Those of us with child ren of our own are further hampe red by the intense emo tions we feci when treating a seri o usly injured child . For all th ese reasons yOLl sho uld stud), this chapter carefully.

COMMUNICATING WITH THE CHILD AND FAMILY A ch ild is part of a famil y unit. To a child , the one constant facto r in life is fam ily. So fami ly.cen tered care for a n injured child is cr itical. (Remember that the ca regiver of a ch ild will not always be a parent , but fo r simplicity thc generic tefm " parent" is used in this cha pter when referri ng to the guardian of a child .) Following an inju r y 10 a child, par· e nlS should be involved as much as possi ble in emergency care. They should be supported and encouraged to provide lo\'c and concern to their child . Parents who receive careful instruction s and guidance in how they may do so are assets in the fi eld. Ex plain to them wh,1I you arc doin g a nd why you arc doin g it, and then use thei r trust relationship with the child to en hance your history, physical examinat io n, and care orthe patient. Incl usion and respect of the fa mily will improve the performance of all aspects of stabil ization of an injured child. The best way to get pare nt con fid ence is to demonstrate your co mpetence and co m· passion in managi ng the child. Paren ts are more likely to be cooperative if thcy see that you are confident, organized, and using equipment that is designed for children. Show the parents YOli know how important they arc by involvi ng them in the ca re of their chi ld.

259

260 •

CHAPTER 17 Tra uma in Children

Whenever possible, keep pa rents in physical and verbal contact with the child. Thr)' call perfo rm simple tasks such as ho lding a pressure dressing or holding the child's hand. Par ents ca n explain to the child what is going o n or sing their favorite songs. Sho w your concern for the child, but do not freeze. One techn iq ue is to pretend thai the parent is o ne of your examine rs. You ca n thell ta lk your way thro ugh the cxami natio using language tha t is u nderstandable to bot h the child a nd parents. You will also be able to better assess mental status. A child who can be consoled o r distracted by a person ora toy has a normal m ental sta tus (most sensit ive ind icator of adequate perfusion ). On the o ther hand, a chi ld who cannot be consoled o r distracted may have a head inj ur y, may be in shock. or may be experiencing hypoxia o r se\'crc pain. Changes in distrac tibility and abilit y to be consoled are im portan t o bservations about the level of consciousness of child. Record and report the m just as you would report changes in le\'el of consciousn of a n adult. Since they are familiar wit h a child 's baseline mental sta tus, parents art )"our best reso urce for detecting subtle cha nges in the child's level of consciousness. They wi notice when the child is " not acting right" be fo re you will. A child less than 9 mon th s old li kes to hear "cooing" sounds, the jingle and sight 0 keys, and often feels m ore comfortable when swaddled . For the child under 2 years, the flashlig ht is a good distract io n. Usc appropriate language for the devclopmcntallevel 0 the child . C hildren less tha n I yea r of age know many "ah" sounds, like "mama" and "papa." Try to lise IhoSt,. Older children, espec ially 2-year-olds, are typically negative and often difficult to distract or comfort. Expect all q uestions to be answered by " no." There· fore. tell the child and the parents what YOli arc going to do a nd do it. Fo r exa mple, " W~ are going to ho ld your head still. Mom , this is impo rtan t in case he has hurt his neek.Speak simply, slowly, and clearly. Be gentle a nd firm. The toddler a nd young child can ben· e fit from a toy or do ll being wi th them. Ask the parent to get one favo rite belonging, if cas· ily available. for the ride to the hospital. It will make the trip to and through the hospital easier. If ti me a llows and thc patient is stable, you call m ake an airplane o ut of two tongue blades or a do ll o ut of;1 ru b ber glove (if child is over 3 years o ld and will no t cho ke on the rubber). Do nOI get ca ught in the tra p of ;Isking the child if he wants to take a trip in the am· b ulance or to be placed in a cervical collar. The child will an swe r " no" most o f the time. Tell the ch ild what you arc doi ng with a smile o n your fa ce. Show it does not hurt. perhaps by doing il to a pare nt or yoursel f. Size is intim idating. When approaching a child, try to make yourself sm all by getting on the child 's level. In the care of a child , it is appropriate thaI EMTs spend much fiel d time on their kn ees. Frighte ned children, especially around the ages of2 to 4 years, may try to defend them· selves by biting. spi tt ing. o r hitting. They arc act ing out of fear. Stay calm , recogni7.e that the behavior is normal, reassure the child , and use firm , not painful. physical con trol of the patie nt as needed. Paren ts and children do not undersl'and packaging, which m akes them more likel y to resist it. Explain why packaging is Il(.-cessa ry. Most pare lHs will understand if you ex plain that even tho ugh the chances are low tha t there is anyth ing seriously wrong w ith the sp ine, the stakes a re high if there is. Make a gam e of packaging w ith the child. If the parellt refuses to le t you package the ch ild, write it down on your rU Il repo rt ilnd get the pa rent to sign it. W henever possible, allow parents to accom pany their chi ld in the vehicle. It is vcr)' frightening for a child and a fam ily to be separated, especiall y if the injuries arc severe. GiVe the parents specific instructio ns a nd position them to provide com fo rt a nd su pport to their child without interfer ing with the care tha t must be given. Before you leave the scene with the ch ild , be sure to ask the parent about o ther children. Som etimes they a re so concerned about o ne that they fo rget o ther sm all children who may be in a hig h-risk s ituation, such as alone in the house.

CHAPTER 17 Trauma in Children _ 261

PARENTAL CONSENT Many states have consent laws that ex ist to protect ch ildren. Although consen t is necessary fo r child ren who arc stable, and desirable in children who are inju red, any critically injured child sho uld 1I0t have care delayed while attempt ing to obtain consent. EMTs have to make a decision on whether o r not it will take 100 lo ng to find a parent to obtain consent. In a situation in which a child needs emergency care (such as a child in a bicycle/ moto r\'ehicle coll ision and no pa rent present), }'ou must treat that child appropriately. Tra nspo rt before you receive permission, document why you are transporting without permission, and notify medical direction of th is action. If the pa rents or legal guardians do not want YO ll to transport or treat, try to persuade them. If you cannot, document yo ur actio ns 0 11 the written report and try to get them to sign it. If the child has a critical inju ry and the parents refuse transport, no tify law e nforcement and the appropriate social authorities im mediately and try to continue your care of the child until they arrive. If you suspect abuse. notify au tho rities at the appropriate lime. You do not have to confro nt th e possible abuscr.

ASSESSMENT AND CARE Pediatric Equipment Table 17- 1 contains a list of suggested pediat ric eq uipment fo r the prehospital provider. You would no t want to approach a 170-pound man who is having a hea rt attack with a 3.5-mm endotracheal tube. nor sho uld you approach a child wi th adult t"q uipment. Keep pediatric equ ipmen t in a sepa rate trauma box. Eq uipment for each size child could be kept in different Ir3 uma boxcs, so that everything fo r that size child would be at your fingertip s. However, lack of storage space makes multiple boxes im practical for most rescue vehicles and ambulances. In addition, it is impractical to make multiple trips back to the vehicle if the dispatch i.nformation \V3S inaccurate. The solu tion is a length-based tape (Broselow o r Standard Ped iatric Aid to Resuscitatio n Card system [SPARC ]) that, when used to measure the length of a child. gives YO ll the estimated weight of the child, precalculated doses of nuid and medications, and estimated sizes of common equipment needed. You cou ld have equipment and supplies sorted into boxes or bags coded to the colo r pa nels o n the lengthbased tape (compact color-coded bags are commercially available). Using a length-based drug dose chart or tape (such as Ihe Urosclow ta pe or SPA Re system) has becoillc an essential component for determining the appropriate equi pm ent and medicatio n doses fo r a child (F igures 17- 1 and 17-2). These devices all ow you to focus o n the patient instead of remembering the correct equi pment size and drug dose. These tape systems estimate weight better than emergency medicine professionals, and endotrachcal tube size as we ll as anesthesiologists (see Cha pter 9).

Common Mechanisms of Injury Children are m ost commonl y inj ured fro m fa lls, MVCs, auto-pedestrian crashes. burns, airway obstruction from a foreign body, and child abuse. Children who fall usuall y land o n their heads because the head is the largest and heaviest part of a small child's body. Serious head inju ry is unusual in a fall from under 27 inches. The use of motorcycles a nd dirt bikes, especia lly if a helmet is not worn, may result in serious injury. Motor-vehicle collisions, especially if lap belt restraint s arc improperly used, may result in the seat-belt syndrome. and injury may occur to the liver, spleen. intestines, o r lumbar spine. Any situation

• • • • • PEARL<

Abuse You are the O!dy one to see the SCeM 01 tile injury. Be alert to ~ns 01 child abuse.

. -...

PEAlUS

Equipment Children require!opKial equipment Wlthcut this equipment. you caroot provide the pediatric patient with &dequate care.

262 • CHAPTER 17 Trauma in Children

Essential • Oropharyngeal airways: Infant, child, and adult sizes (sizes 00-5) with tongue blades for insertion • Self-inflating resuscitation bag, child and adult sizes • Masks for bag-valve mask device: neonatal. infant, child, and adult sizes • Oxygen masks; infant, child and adult sizes • Nonrebreathing mask: pediatric and adult sizes • Stethoscope • Pediatric femur t raction splint • Pediatric backboard with head immobilizer • Pediatric cervical collars (rigid) • Blood pressure cuff, infant and child • Portable suction unit with a regulator • Suction catheter: tonsil-tip and 6F-14F • Extremity splints: pediatric size • Bulb syringe • Obstetric pack

Desirable

• Infant car stlal

•

•

• •

•

Nasopharyngeal airways: sizes 18F-34F, or 4.58.5mm Glasgow Coma Score refereneQ Small stuffed toy Finger-stick blood glucose device Pulse oximeter

• Thermal bl.:lI1ket

• Water-soluble lubricant AlS Equipment and Supplies ALS units should carry everything on the BLS list, plus the following items. Essential Desira ble • • • • • • • • • • • • • • •

Transport monitor Defibrillator with adult and pediatric paddles Monitoring electrodes: pediatric sizes Endotracheal tubes, uncuffed sizes 2.5-6 mm, cuffed sizes 6--8 mm, Endotracheal tube stylets: pediatric and adult sizes Infant and child laryngoscope straight blades sizes 0-3 and curved blades sizes 2-4 Nasogastric tubes, sizes 8F-16F KID (immobilization device) Magill forceps: pediatric and adult Intraosseous needles, sizes 16, 18, 20 Butterfly cannulae, 23 and 25 gauge Over-the-needle catheters, 1&-24 gauge Pediatric armboards Broselow tape Nebulizer

• Disposable CO 2 detection device • End-tidal CO 2 monitors • Blood glucose analysis system

CHAPTER 17 Trauma in Children _ 263

••

b. FIGURE 17·' Usc of Brosclow ta pc.

FIGURE 11· 2 Standard Pediatric Aid to Resuscitation Card systcm has oolor-coded tape and booklet of prccakulatL-d doses of Ouids, medications. and equiplllent. (1)1I11tll G.mrt,'Sf (If Krct'

Hm,. MlJ)

264 • CHAPTER 17 Trauma in Children

in which the inj ury pattern and mechan ism di ffe r may be child abuse. Suspect abuse iftbt history does nol match the injury, if there is a delay in seeking heahh ca re. or if the SIOIJ' keeps changing.

Assessment of the Airway As you begin the assessment be sure to stabilize the neck in a neutral position with )'Qur hands. Do not take time to 'lpply a cervical collar until you h:n'e fin ished the IT LS Prima1 Su rvey. Recognize the signs o f airway obstruction in child ren: apnea. stridor, o r "gurgliog respirat ion. So that the neck docs nO I have to be moved. the jaw thrust should be the first ai rway maneuver in the unco nscio us ch ild who has susta inoo trauma. In small chilrlre"t the occiput is so big tha t it will fl ex Ihe neck and may occlude the airway when the child i lying fl at. It is often necessary to place a pad underneath the to rso to keep the neck in a neutral position (sec Figure 17-3 and C hapter 11). Hyperextension o f the neck also may causc airway occlusion. Inspecting the airway is easier in the chi ld than in the ad llh ( Figure 17-4). lt is Iruethat the child's tongue is large. the tissue is soft . and the ai rway is easy to obst ruct. but other characteristics make it easier to manage th e child's airway. For example, neonates areobligatory nose breathers. so just opening the mo uth o r clearing the nose with a bulb syringe can be life-sav ing. To use t he bulb syringe. collapse the b ulb end o f the syringe. put the point end in the nose of the ch ild, and release the bulb. Remove the syringe from the nose, squeeze the bulb to empty the mucus. blood, or vomit. and repeat. The b ulb syringe can be used to remove sec retio ns from the posterior pharynx of infants as well. For the unconscious child with no gag refl ex, an o ral airway is very helpful to get the tongue out of the way and keep the airway open (see Chapter 5). If a tooth is loose, be sure to remove it from the mouth so that the child does not choke on it while you are insening the aj rway adj unct. T he oral airway can stim ulate a gag reflex. which is very sensitive in the conscious child. thus limiting the usc of th is airway adju nct to unconscious child ren wilh no gag reflex_ Nasophar yngeal ai rways are too small to work pred ictably in ch ild ren; do nol use Ihem. Give vent ilation instructio ns to your pa rt ner as soon as you complete your evaluation o f breathing. Check the neck fo r signs of inj ury (b ru ises, marks, and lacerations), carotid pulse, and distendoo neck veins. and fee l fo r a deviated trachea. Whal appears to be mino r blunt trauma

FIGURE 17-3 Most children requir ... padding under their back lind shoulders to keep the Cspine in a neutral position. (Coliftl'iY of /Joll f'tlgl', NREMT-P)

C HAPTER 17 Trauma in Children _

i ITLS PRIMARY SURVEY SCENE SIZE·UP

Stondo,d Precoutions, Ho:ords, Number 01 Patients, Need !ex- Additional Help/Equipmet'll, Mecho" ism of Injury

-------- -----------------------! -----------------------------INmAl ASSI:S5MENT Generol ImpreuiOl'i jAge, Sell:, Weighl, General Appeoronce, Position, Activity, Obvious Injuries/Bleeding}

lOC jAVPUI Control Cervicol Spine AIrway

(Snoring, Gurgli"9, Stridor, Silence)

IL I:

Breothing (Preil6nl~ Rate. Depth, EHort)

Rodiol/Corotid Pulses IPrllsenl~

I~

I

~

Rote, Rhythm, Quali ty)

Skin CW, Temperoture, Moisture; Capillory Refill Unconrroll.d Externol Hemorrhage'

-------------------------------}-----------------------------RAPID TRAUMA SURVEY '''Sped Heod and Nec;1r. !Mojor f ociallnjuries, Bruising, Swelling, Penetrotions, SubculClneous Emphysema) (Neck Vein Distentioni Troc;heol Deviotionil 'nsped Chest (Asymmetry, Contusions, Penetrotions, Porodollical Motion, Instobility, Crepitolion)

Breolh Soul'ldl {Present' Equo"l (11 unequal: Perclmion)

Hearl Tones Abdome, (Bruising, Penetrotion/Evisceration, Tenderness, Rigidity, Distention)

Pelvis [TenderneH, Inslobility, Crepitolion) lower/Upper Exlremilies (Swelling, Deformity, Instobility, Motor ond Sen$OfY) PIoce Potienl 01'1 Bockboard Poslerior (Penelrolior'll, Deformity, Presacrol Edemo) 1/ Crilicol Situolion, Tronsfer 10 Ambukmce to Complele Exom. Boseline Vilol Signs Measured Pulse, Respirotions, Blood Pressure Pupil, {Size' Reactive' Equol~1 (II AJre.
Gloscow Como Scole Sc(lfe Eyes, Voice, Motor, OrientotiOl'l, Emotional Slole

FIGURE 1704 Steps in the assessment and management of the trauma patient are the same for both children and adults.

10 Ihc neck can be life threatening. A deviated trachea is difficult to detect in a small child, but has the same significance as in adults. Make a mental note o f the child 's initial level of conscio usness as you begin your survey. Although a preschool child may appea r to be slec p ~ ing rathe r than unconscio us from an injury, remem ber that most children will no t sleep th ro ugh tlu.: arrival o f cll'lc:rgcn cy vchick-s. Al;;k lilt: pilrt:nts tu wake tilt: child so you 1..'1 II gc:l an in itial assessment o f thc airway and level of conscio usness. I:ollowing a IrOlu llla t-ic evenl , a decreased level of consciollsness may suggest hypoxia, shock, hl'ad tra uma, or seizure.

265

266 •

CHAPTER 17 Trauma in Children

Assessment of Breathing Assess the ch ild fo r bre.lI hing difficulty. Coun t the child's respinllory rate. Most children brellthc fas t when they arc havi ng trouble and then, when they can no longer compellS
••

b.

,

•

,. FIGURE 17-5 (a) The mask should fit on the nose and the cleft aoo"e the chin; (b) two-handed face mask seal; (c) o ne-handed face mask seal.

CHAPTER 17 Trauma in Children _ 267

low pressure. less than 20 cm H!O. to keep from inflating the stomach or ca using a pneumothorax. T he rates arc 20 per minute for a child less than a year o f age, 15 per minute for greater than 1 year of age, and 10 per minute for an adolescent. When using a bag-valve mask, it is best to mo nitor your ventilation wi th capnography. Studies have fo und that we tend to hyperventilate even when consciously trying nolto. Most importantly, watch for chest rise when yo u vent ilate. If the chest is rising, air is getting into the lungs. Check air entry o n both sides of the chest with your stethoscope. Gent le cricoid pressure (Sellick maneuver; sec Chapter 4) is useful and recommended in a child. Some sel f-inflatable bag-vakc masks have a pop-off valve ,11 about 40 em H 20 pressure. The pressure generated by Ihese devices is more than adequate most of the lime. However. lu ngs are sometimes stiff from a ncar-drowning, bronchospasm, o r aspiration, and more pressure is needed. Be familiar wi th your equipment. Make su re that your bagvalve mask docs not have a pop-off valve. Endotracheal Intubation: If bag-valve mask ventila tion of the child is effective, then intubation is an elective procedure. It is IISIWUy beNer rIot to i"lIlbaie tile child i" tile field. Int ubation is ext remely difficult to perfo rm even in a dry, well-l ighted emergency department. If you must in tubate in the field, get ready by preoxygena ting (not hyperventilating) the chi ld and preparing your equ ipment. The o ral route shou ld be used on all children. Blind nasotracheal intubat ion is not recommended in the chi ld less than 8 yea rs old beca use the nares arc too small and the larynx is too far anterior. For oral endotracheal intubation, choose an endotracheal tube size suggested by the length -based tape system, or about the same d iameter as the tip of the child's little finger. Another gu ide is as fo llows: 4+

age in years . f 4 "" size a tube (mm )

In smal l children the smallest part of the airway is just below the cords, so you can get a good seal usi ng an uncuffed tube until the tube size is at least 6 mm. There is a signifi cant risk o f neck movement with any tracheal intubation, so have someone stabi lize the n('(k with his hands during int ubation. Using a straight blade, gently move the tongue to the left by entering o n the right side of the mouth; place the blade in the vallecula, and lift. Compared to ad ults, the small child 's larynx is closer to the mouth, and this technique is often effective. If you can not sec the cords, adva nce the laryngoscope blade to the epiglottis and lift again. T he cords should be easily secn. Remember to twld your breath when no one is breathing for the child. As soon as you get an urge to breathe, but after no more than 15 seconds, stop trying to intuba te, bag the child to reoxygenate, and try again in a f(·w minutes. Another effective method fo r reminding you when to ventilate is to have the team member who is stabilizing the neck to count aloud to 15 slowly. Check to see if the tube is in place by following the confirma tion protocol (Chapter 5). Be sure to keep the tube in place. A si mple Oexion of the neck can push the tube into the right mainstem bronchus, an d extension of the neck ca n pull the tube o ut of the trachea. Hold the lube firml y in place with your thumb and forefinger on the lip and gum margin so if the child's head moves, the endotracheal tube will stay in place. Capnography is the best way to monitor the posit ion of the endotracheal tube. Apply benzoin to the cheek and lip, being ca reful nol to let any drop in the eye. Firmly tape (or tie with linen tape) the tube to the corner of the mout h and stabilize the head with a head Illotion-rest riction device. Ideally a commercial cndotracheal tubc holder should be used if available. Supplemental Oxygen: As you package a child, you will often have to improvise. Tape and straps can restrict the ch ild's chest movement, so assess ventilation frequently en route. Any child wi th a significa nt inju ry shou ld receive supplemental oxygen (as close to

• • • • • PEARLS

ENdotracheal IntubatiON The l.IICUffed ~ tOOt ill child may !>Kame dislodged easily, especially dwing movement of the chid. Frequent re.JSSeWnef'lt is very important Constant elq)ired cal IIICII\itoMg (capnograp/1y) is very t.lphA.

268 •

CHAPTER 17 Trauma in Children

100 percent oxygen as possible), even if there seems to be no difficulty breath ing. fear, and crying all increase oxygen demands on tissues. Children with any type of are likely to vomit; be prepared. Remember 10 give ventilation instructions to YOlIf "~ffi' mate before moving to assessment of circulation.

Assessment of Circulation Signs of Shock: Early shock is fur more difficult to diagnose in a child than an adult. sistent tachycardia is the most reliable indicator of shock in a child. Since pulses

PEARLS

Shock

-..,..,""" _01 ___ '" --""...... Because ofsbWIg ~ mechanisms, ~ can Iool

""'"""" good ;, ..., ' aash,"1f you 11M along transp::wt time and the mechanlsm of ~ or the assessment SIJ99'5fS the

.

rtsuscibtion to a chad, give 2Q nt.I\g in each bolus, then reasseu. Mile SID the total amooot of fItid you

rite is reported to the hospital.

difficult to find and assess in a child, practice feeling them on ~:;s~,,~;~~:~~~i~::;:~~;: and nn yOllr own children. In a child, the brachial pulse is usually easy to carotid is not. Feeling a dorsalis pedis pulse causes less anxiety and may be easier to than a femo ral pulse. A weak rapid pulse with a rate over 130 is usually a sign of shock in children of all ages except neonates (Table 17-2). Prolonged capillary refill and cool ex· tremities may indicate decreased tissue perfusion. Capillary refiJI may be used along with other methods to assess the circulation, but do not depend on it alone to diagnose shock. Although currently controversial. capillary refill should still be included as part of the Ini· tiaJ Assessment for shock in a child. To test capiUary refill, compress the nail bed, the entire foot , or the skin over the sternum for 2 seconds and release to see how Quickly the blood returns. Skin color should return to the p recompressed state within 2 seconds. lf it does not, the child has vasoconstriction. which can be a sign o f shock. Individual variances may make some of the signs of shock normal for a particular child. Tachycardia may occur beca use of fear or fever. Mottling may be normal in an infant less than 6 months of age, but it also may be a sign of poor circulation, so note it. Extrem· ities may be cold because of nervousness, cold weather, or poor perfusion. CapiJlary refill rna}' be prolonged in a child who is cold. In general, a child should be carefully eval uated and assumed to have signs of shock if there is persistent tachycardia or signs of poor peripheraJ perfusion (prolonged capillary refill or cool extremities). The child's level of consciousness is also a useful indicator of circulatory status, yet note that circulation can be poor even though the child appears to be awake. As mentioned earlier. if the child is able to focu s o n his parent, or is consolable by the parent or a member of the EM S team, there is enough circulation to allow the child 's brain to be working. Low blood pressure is a sign o f late shock, but measuring blood pressure in a frightened child ca n be time co nsum ing, especially for the inexperienced. To make it easier and more reliable to obtain blood pressure in an emergency. practice taking it at every o pportunity. The rule o f thumb fo r cuff size is to use the largest one that will fit snugly on the patient's upper arm. If there is too much noise, you ca n perform a blood press ure by palpation. Find the radial pulse, pump up the blood pressure cuff until yo u no

Age Newborn 6 mo.-1 yr 2-4yr

5-1!y>' ~1 2yr

>1 2yr

Weight (kg)

(per minute)

(per minute)

l-4 8-10

30-50

120-160 120-140

12-16

20-30 14-2() 12-2() 12-16

18-26 26-50 >50

3().40

100-110

90-100 80-100 80-100

i Pressure (mmHg)

>60 70-80 80-95 90-100 100-110 l00-l2()

CHAPTER 17 Trauma in Children _ 269

longe r feel the pul se, and allow ai r to leak slowly while observing the dial o n t h(· blood press ure cuff. Record the pressure at which you first fee l the pulse and label it "p," for pal pation. This will be a systoli c blood pressure on ly and will be slightl y lower than a b lood pressure th at can be ausc ultated. A systoli c blood pressure less than 80 in children, and less th an 70 in young in fants, is a sign of shock. Shock Illay be secondary to occult blccding in the abdOlllen, chest, or in a femur fraclufl'. AJso, alt hough we leach that patients do not go into shock from intracranial blood loss, in ra re ci rcu mstances, this can happen in the very young infa nt. NOTE: T he ant ishock ga rmen t ( MAST or PASG) is no lo nger recoll1 lllended for treatment of sh ock except in specia l ci rcumstances.

Fluid Resusdtation: If hypo volemic shock is present,

•

FIGURE 17-6 Equipment for giving bolus treatment for shock. (I'hoto CoUrIN)' oj Roy A/sc",. MI) )

the child requires fluid resuscitation. You sho uld establish vascular .1CCCSS and give a fluid bolus. The initial bolus sho uld be 20 m U kg of no rmal s.,line, given as rapidly as possible. See the appro priate eq uipment set up to do this in Figure 17-6. If there is no response, anot her 20 m llkg ca n be given. If the child is in laIc shock and you Gl11not sec o r fee l a vein. o r canllot Slart an IV in two at tempt s or 90 !>econds. yo u Ill:ly need 10 perform intraosscous infu sio n (sec Figure 17-7; and Chapler 9). There is 110 scientific dat a avai lable at this time to suggest that any child in hemorrhagic shock should not be given IV fluids.

Control of Bleeding Obvious bleeding sources must be controlled to ma intain circulation. Remember, the child's blood volume is abollt 80-90 IllUkg,::>o a 10-kg child has less than I liter of blood. T hree or four lacera tions c:ln ca lise ;1 200- m L blood loss, which is about 20 percent of the child 's total volume. Therefo re, pay closer attention to blood loss in a child than you do in an adult. Usc pressure firm eno ugh to control arterial bleeding if necessary. If ),ou ask the parent o r a bystander to help hold pressure, mo nito r them to be sure they are applying enough pressure to sto p the bleeding. Usc a bandage lighll.·llough to control veno us bleedi ng, not one that will just soak up the blood so that YOll do not sec it. Elevating an injured extremi ty .llso can help to control bleeding. Hemostatic 'lgenrs can be used to control c'xsanguin:lting hemo rrhage in children.

FIGURE 17·7 An intraoSS('Ous needle in child's proximal tibia bei ng used for ve nous access. (P/W/I} Courll'syoj /Job Page, NRIiMT. P)

The Critical Trauma Situation If you have found a critical trauma situatio n, the child needs ra pid transport. Log-roll the child o nto a pediatric backboard and leave the scene as q uickly as possible. Remember to usc a pad under the torso to align the neck in a neutral position. Appropriately sized rigid cervical collars arc useful , especially in children over 1 year of age, and Gi n help remind the pat ient and prov iders not to move the head . Do not depend on the cervical collar alone;

270 • CHAPTER 17 Trauma in Children

• • • • • • • • •

Obstructed airway Need for an airway intervention Respiratory distress Shock Altered mental status Dilated p upil Glasgow Coma Scale score <13 Pediatric Trauma Score <8 Mechanism of injury (less reliable indicators) associated with severe injuries: - Fall from a height of 10 feet or more - Motor·...ehicle collision with fatalit ies - Ejection from an automobile in a MVC - In a MYC, significant intrusion into the passenger compartment - Hit by a car as a pedestrian or bicyclist - Fractures in more than one extremity - Significant injury to more than one organ system

...estrict motio n of the head with tape and a head motion-restrictio n device. Children are portable and they can (and should) be transported rapidly. There are very few procedures that should be done in the fie ld. Mi nutes count, especially in children. On·scene times of less than 5 minutes arc desirable. Administer 100 percent oxygen to all crit ical pediatric patients. Bag·val ve mask ventilation of the critical child is preferable to placi ng an endot racheal tube if the transport time to an appropriate emergency department is short. Not all emergency departments have the equipment or personn el to handle pedia tric emergencies. Transfer arrangements fo r more severe problems sho uld be worked out in advance so that when the injury occurs. confusion will be mi n imized and time will be saved. See Table 17·3 for a partial list of mechanisms of injury that are criteria for transport to an emergency department app roved for pediatrics o r a pedi at ric trauma center. These, plus pediat ric burns. neardrowning. and head injuries with loss of co nsciousness should go to fac ilit ies qualified to handle major pediatric trauma. If the child needs a procedure. you must decide whether it is worth the time. You sho uld consider how long it will take to perfo rm, how urgent the procedure is. how difficult it will be at the scene versus at tIle hosp ital. and how much it will delay reaching definitive ca re. If you have a 3- minute procedure (an IV) and a 30-minute transport. the IV probably should be started. If you are awaiting the arrival o f a helicopter, you also may attempt the procedure, but be sure to have the child packaged and ready when transportation arrives. Your li fe -s.win g procedures can be performed in an ambulance while en route to the hospital. Call ahead so that the emergency depa rtment ca n have the nccessa ryequipment and personnel ready. Perform the ITLS Secondary Survey and O ngoing Exams en !"Oute if there is time. If. after completing th e ITLS Prima ry Survey, you find no critical trauma situation, place the child on a backboard and do a methodicall TLS Seconda ry Survey.

CHAPTER 17 Trauma in Children _ 271

Eyes Opening

4 3 2 1

Best Motor Response

6 5 4 3 2 1

Best Verbal Response

5 4

3 2 1

>1 year

<1 year

Spontaneously To verbal command

Spontaneously To shout

To pain No response

To pain No response

>1 year

<1 year

Obeys Localizes pain Flexion-withdrawal Flexion-abnormal (decorticate rigidity) Extension (decerebrate rigidity) No response

Localizes pain Flexion-normal Flexion-abnormal (decorticate rigidity) Extension (decerebrate rigidity) No response

>5 years

2-5 years

0-23 months

Oriented and converses Disoriented and converses Inappropriate words

Appropriate words and phrases Inappropriate words

Smiles, coos, cries app ropriately Cries

Incomprehensible sounds No response

Cries and/ or screams Inappropriate crying and/ or screaming Grunts Grunts No response

No response

ITLS Secondary Survey As in adulls, record accurate vital signs, take a SAM PLE history, and perfor m a complete head- to-toe exam, including a mo re detailed neurological exam. During your neurological exa m make a notatio n of whet her the child is consolable o r distractible. Finish bandaging and splinting, and transport the child while continuously monitoring. Notify medical d irection. Calculate the Glasgow Coma Scale (GCS) score or Pediatric Glasgow Coma Scale score (Table 17-4 ).

POTENTIALLY LlFE·THREATENING INJURIES Head Injury Head injuries arc the most common ca use of death in pediatric patients. The head is the primary foclls of inju ry in the child because the child's head is p roportionately larger than the adult's. The fo rce of im paCi docs some damage to the bra in , but much of the brain damage fro m head injuries comes after im pact, from preventable causes. To avoid this, you must do three things: Head injury increases brain cell metabolic rate and decreases blood fl ow in at least part of the b rain .

I. Give oxygerl.

272 •

CHAPTER 17 Trauma in Children

2. Keep blood pressure lip.

Blood must get to the brain to carry oxygen, so systolic pressure must be at least 80 mmHg in the preschool ch ild and 90 mmHg in oldl'r children. It is therefore critical to rccogni7,c ea rly signs of shock (tachycardia and poor perfusion ) and aggressively correct hypovolemia. E.1r1y hypotension has been shown to be a pred ictor o f poor outcome.

3. Be preparetl to prcvc/lf aspiration. Head-injury pat ients frequent ly vom it. The Sellick manellver sho uld be used d uring bag-valve mask ventilatio n and any inhl bation at tem pts. Suction sho uld be read ily assessable for any child with a head injury. Changing level of cnmcio llsncss i .~ the hest indicato r of head trauma. A child entl'ring the emergency depart ment with a GCS score of I 0 that has co me down from 13 will beapproached very differently fro m the child who has a GCS score of 10 that has come up from 7. Assessments using vague words like "semico nscious" arc not helpfu l. Instead, note specific points such as whether thc chi ld is distractible, consolablc, reachcs for the pa rcnt,or reacts to pain o r voice. Asscssment of pupi ls is as important in the ch ild as in the ad ult. Note also whether the eyes arc moving both left and right o r whether they remain in om.' position. Do not mo\'e the head to determ ine this! Ch ild ren wil h hcad injury o ft en fare much better than adults with the sam e degree of inj ury. Children with head trauma and low GCS scores may do well if they receive aggressive medical ma nagement that foc uses o n m
Chest Injury C hild ren with chest inju ries generall y give visible signs of respi ratory distress, such as tachypnea, gru nting, nasal fl aring, and retractions. Be aware that children's no rmal respiratory rates arc higber than adults' Crable 17-2). A child b rea thing faste r than 40, o r an infa nt fas ter than 60, usually has respi ratory d istress and would benefi t from su pplemental oxygen. A few gru nts arc not sign ifica nt, b ut persistent gru nt ing indic;lIes a nct'd for ventilatory assistance. A child in respirato ry distress ofte n breathes with the nose li ke a rabbit, which is called flarillg. Retractions relate to caving in of the su prasternal, intercostal, or subcostal areas wit h inspiration. Retractions suggest the chi ld is st rai ning to breathe. If any o f these signs are persistent, they should alert you to somethi ng wrong wit h the respirato ry system ( pneu mo/hemothorax, fore ign body, pulmona ry contllsion ). C hild ren wit h blunt chest injury area! risk fo r pneumothorax. Ucc..1Use the chest is small, a difference in breat h sounds frolll side to side Illay be morc subtle than in the adul t. You may not be able to tell a diffl.'rencc, ('ven by listening carefully. It is also difficu lt to diagnose tension pneumothorax in young child ren, who lIsually have short, f"il t necks thai Illask both neck vein distension an d tracheal deviatio n. If a tension pneumothorax develops, the heart and trachea shou ld eventually shift away from the side of the pneumothorax. -'0 hel p detect a shift of a ch ild 's heart, place an "X" over the point of max im ulll im pulse (PM I) of the hea rt. Repe;l\cd ly check the location of the PMI. This will help confi rm the stethoscope fi ndings and guide chest decompression. Needle thoracostomy (sec Chapter 7) can be life-saving. Ch ild ren in the preadolescent age group have higbly elastic chest walls. Rib frac tu res, fla il chest, perica rd ial tampo nade, and aortic rupture are, therefo re. seldom seen in this

CHAPTER 17 Trauma in Children _ 273

group. I-!owever, pulmonary contusio n is common. Jf a child docs have rib fractures o r a nail chest, he has susta ined a significant fo rce to his chest and should be assuml.."
Abdominal Injury The seco nd leading «IUse of traumatic death in most pediatric centers is internal bleeding secondary to rupture of the liver andlor spil'Cn. In children, the liver and spleen both protrude below the ribs, exposing the o rgans to blunt trauma. This poor protectio n and the relatively large size of the liver and spleen in children allow these organs to be easily torn. Abdominal injuries are difficult to diagnose in the field. A child may have a severe abdominal injury with minimal signs of trauma. Any child with seal-belt marks, bicycle handlebar marks, o r bruises to the abdo men should be assumed to have internal injuries. If a child has blunt injury to the chest or abdomen, be prepared to treat for shock. T he capsule of a child 's liver and spleen are thicker than an adult's; therefore, bleeding is often contained within the o rgan. If;1child with blunt trauma is in shock with no obvious source o fbl ecding, your decision should be to load and go. Life-saving interve ntions should be made en route to the hospital. If ),ou have a short (5- 10 minut e) transport tillle to a trauma center, it is not necess..1ry to attempt an JV line. If the child is critical and the transport time is long, )'OU should make no mo re than two attempts at IV lines before going to an intraosseous infusio n. Any child who has been crying o r suffered an abdo minal injury will develop gast ric distentio n and a tendency to vomit; be prepared.

Spinal Injury Altho ugh children havc short necks. big heads. and loose ligamen ts, cervical spine injuries are uncommo n before adolescence. Children less than 9 years of age usually have upper cervical-spine injuries in contrast to older children and adults who usuall y have lower cervica l-spine injuries. There is also a higher incidence o f spin;! l-cord injury without radiographic abno rmalit y (SCIWORA ) than in the adult popUlation. Therefore. yOll should perfo rm approp riate SMR o n all children wi th ,I potential spinal inju f)'. A cervical coll ar is not necessary if the head is properl y restricted in a padded device. Again, try to make a ga me of packaging the child. You can promise you \\'iU give him a ride in t he ambu lance as ,I rewa rd ;Iftcr you get him all wrapped up and read}'. I-!ave a parent or other familiar person assist, if possible. Bc sure your packaging does not restrict chest movement. As mentio ned before, children up to about 8 years o f age will need a pad under the torso to keep the neck in a nellt ral positio n.

CHILD RESTRAINT SEATS A child in a motor-vehicle collision whjle properly restrai ned is much less likely to have a serious injury than an u nrestrained passenger. If in a ca r seat, the ch ild ca n us ually be tra nsported witho ut being removed from the device. Assess the child as you would ot her trauma patients. If no injury is fo und. place padding around the ch ild 's head . ,Ind tape the head directly to the car seat (Sca n 17. 1). This method of transport ation should be used only after a complete assessment that has revealed 110 injury to the child. If the child has ev idence of allY se rious inj uries, then remove the child from the ca r sca t and package. Some cars have b uilt- in infant restrai nt seats. These scats cannot be removed. so th e child who is restrained in o ne of these will have to be extricated and placed o n a ped i;!t ric spinal motion- restriction device.

274 • CHAPTE R 17 Trauma in Children

a

II

D

II

One EMT stabilizes the car seat in an upright position and applies and maintains manual in·line stabilization throughout the SMR processs

The second EMT places a small blanket or towel on the child's lap, then uses straps or wide tape to secure the chest and pelvic areas 10 the seat.

A second EMT applies an appropriately sized cervical collar. If one is not available, improvise using a rolled hand towe1.

The second EMT places towel rolls on both sides of the child's head to fill the voids between the head and seat. The medic tapes the head into place, taping across the forehead and the coilar, but avoiding taping over the chin, which would put pressure on the neck. The patient and seat can be carried to t he ambulance and strapped to the stretcher, with the stretcher head raised.

CHAPTER 17 Trauma in Children _ 275

Joyce, the team leader on this call , Dan , and Buddy receive a cal! to a home for an injured child. They are told that the child had a fall from a couch and is unconscious. When they arrive at an apartment, they see the couch is only 12 incheS high and the child is limp on the couch. A man who identifies himself as the stepfather says, "Donnie fell off the couch and wouldn't move. I picked him up and called 9'1'1." They see an t8-month·old child lying on the couch . The general impression is not good, as the child is neither awake nor moving. He is not clothed and there are obvious old full·thickness bums of his buttocKs and multiple bruises of varying ages on his body. These are not injuries that would have come from a fall off a couch. Donnie does not respond to Joyce when she speaks to him. She immediately checks the airway and finds it open but respiration is slow and shallow. Donnie has a slow but strong pulse at the wrist. Dan immediately places a clean sheet on the backboard and they carefully log-roll Donnie onto it. Buddy stabilizes the neck with his knees and begins ventilation with a bag·valve mask. He makes sure that Joyce sees the right pupil is slightly larger than the left. Joyce performs a Rapid Trauma Survey, which reveals the child has an obvious hematoma of the right temporal area, with bruising of the face. The neck has no obvious deformities; the neck veins are flat and trachea is in the midline. The chest has multiple bruises and abrasions and there is crepitation of the ribs on the left side. Donnie moans in pain when his ribs are palpated and localizes with his hands. Buddy notes that he opens his eyes to pain. Breath sounds are present and equal. The heart can be heard and the rate is about 60 beats per minute. Donnie does not respond when Joyce palpates his abdomen. She notes that the abdomen is not distended but has several bruises in a loop pattern such as an electrical cord would make. The pelvis feels stable. Examination of the extremities reveals normal PMS. but the right thigh is very swollen and the child moans when it is palpated. There are also multiple bruises in linear and loop patterns and some small burns that look like they might have been made with a cigarette. Buddy reports that Donnie has a gag reflex, so he continues bag-valve mask ventilation. Joyce decides to transport immediately due to the critical nature of the child's injuries. As they are going out the front door, they meet a woman with a bruise on her cheek. She appears to be coming home from work. She sees the child and cries, "My God! lester, what have you done to Donnie now?" He glares at her and she begins crying. Neither asks to ride in the ambulance. but she asks where they are taking him and says she will be there soon . Dan drives. Joyce takes vital signs: BP 110/ 70, respiration 8 per minute when Buddy is not ventilating. and pulse 60 per minute. She calculates the GCS score as 9 (eyes. 2; motor, 5; and verbal, 2) and then starts a largebore IV at a keep-vein-open rate. She also attaches the cardiac monitor (sinus bradycardia) and pulse oximeter 05 on tOO percent ox.ygen). She performs an ITlS Secondary Survey, which reveals no new information ex.cept that both eyes react to light. Joyce notifies medical direction that they have an unconscious t8-month-old child with multiple injuries including blunt head trauma, burns, bruises, broken ribs, and

276 • CHAPTER 17 Trauma in Children probably a broken femur. When they arrive. she immediately notifies the doctor and nurse of what they saw and heard at the scene. The police and social services were notified ; the mother and live-i n boyfriend were both arrested. The boyfriend was convicted of child abuse and sent to jail but the mother. because she was also an abuse victim . was placed on probation with loss of child custody. The child required surgery for his subdu ral hematoma and skin grafting for his burns but eventually recovered and went to live with his grandparents. Joyce suffered nightmares. and the whole team went though critical incident stress debriefing.

Child abuse is alarmingly common in our society and is a leading cause of pediatric traumatic death. The common thread among EMS providers is care for others. When con fronted with chi ld abuse. our initial reaction can be rage. We mu st be alert to the signs of child neglect or abuse but never let ou r emotions prevent us from focusing on treatment of the child . (Always transport the child to the hospital if you have suspicions of Clbuse.) The investigCltion is better left to specia lly trained professionClls. Most countries have laws req uiring the reporting of suspected child abuse and providing legal protection for those who do so. It is extremely important that you report suspicions, as you may be the only chance that ch ild has for survival. If you report your suspicions to the emergency physician or nurse and they ignore them, you must make your report directly to the appropriate organization. When making a report, always include local law enforcement. Most socia l service organizations do an excellent job. but many carry heavy workloads and some do not include loca l law en forcement in their investigation. Child abuse is a crime.

SUMMARY To provide good trauma cart:' for ch ildrcn, you must have the proper cquipment, know how to interact wilh frigh tened parents, know the normal vital signs for various ages (or have them posted in your trauma box), and be fam iliar with the inj uries that are mort" common in children. Fortunately, the assessment sequenct:' is the same for children as for adults. If you perform you r assessment well, )'Ou will obta in the information needed 10 make the right decisions in management. Focusing on assessment and management of the ch ild's airway (with cervical-spine control), breathing, and circulat ion will result in the best possible outcome. While assessment and management of the injured child arc life-saving skills, all responders involved in the care of the seriously injured child should be concerned also about prevention (see Appendix H). Car seals, bicycle helmets, seal belts, all-terrain vehicle injuries, water safety. scald burn injuries. firearm safety, and fire drills are within ou r area of concern. We should donate our time to teaching s,1fcty (Figure 17-8), and we should speak out for laws (infant scat restraints. seat belts, drunk d riving) th at save lives.

CHAPTER 17 Trauma in Children _ 277

FIGURE 17-8 It is important to organize or participate in programs that educat~ children abo ut injury prc\'cntion and hcahh care. (0 Cmig jncksoll/ fll tile Onrk PIr
BIBLIOGRAPHY I. Dietrich, A., S. Shaner, J. Campbell. 2002. Pe(/iatric bll5ic trmlllw/i!e support. 2nd ed. Oakbrook T('rl"dce.IL: Basic Trauma Life Support International. 2. DiRusso, S. M. , et al. 2005. Intubahon of pediatric trauma patients in the field: Prediction of negative outcom(' despitc risk stratification . Jouma/ oj 1rmlllw 59 (July): 84-91. J. Causch(' M., R. J. Lewis, et al. 2000. Effect of out-or-hospital pcdialricendotracheal intubation On survival and neu rological outcome: A contro lled clinical trial. lAMA 283(6): 783.

Dan, Joyce, and Buddy are dispatched to the home of an elde rly woman whose ne ighbor called 9-1-1 and said she was hurt. The dispatcher asked th e neighbor to rema in with the pati ent until they arrived. As t hey respond, they decide that Dan will be team leader and they discu ss common home in juries in the elderly. What should you expect if

you answered this call? How does evaluation of the elderly differ from that of younger adult patients? Keep these questions in mind as you read the cha pter. Then, at the end of the cha pter, find out how the rescuers completed this ca lL

INTRODUCTION Citizens over the age of 65 comprise about 12 percent of the U.S. population, but that number is expected to double in the nex t 25 to 30 yem s. The age group 85 and ol der is now th e fastest growin g seg men t o f the U.S. popu lat ion. The geriatri c popu lation already comprises a signifi cant number o f the patients bei ng tran sported by a mbulance. In the United Stat es, over 30 percent o f a ll patien ts transported by ambula nce a rc over the age of 65 . "Elderly" is often understood as bei ng 65 years or older because retirement benefits are usually in itiated at about this poi nt in life. However, chronological age is not the most reliable defi nit ion of "elderly." It is more approp riate to co nsider the biological processes that change with time. such as fewe r number of neu rons, decreased fun ct ioning of the kidneys, and decreased elasticity of the skin and tissues. As a group, geriatric patient's tend to respond to injury less favo rably than the you nger adult popu lation. Geriat ric patient s who are injured are more likely to experience fatal outcomes, even if the injury is of a relatively low severity. According to th e U.S. Nat ional Safety Council, fall s, thermal injury. and MVCs have been identified as co m mon causes of t raumatic death in the geriat ric population. This is an eve n greater concern given that as a whole the ('Iderly popu lation continues to assume more active lifestyles, making them more prone to injury. Falls accoun t for th e majority of injuries in the geri atric population, the most CO lll mon pathology being frac tures of the hip. femur, and wrist. and head injuries. MVCs account for approx imately 25 percent of geriatric death s, although the elderly drive fewe r mi les. The geriatric population has a higher incidence of collision tha n oth er age grou ps, second only to that group under the age of 25. Eight percent of dea ths are attributable to thermal inju ries. These inj uries incl ude inhalat ion, cont'lCt with the heat source resulti ng in sca lding and flame burn s. and elect rical injury. Little has been written on the respo nse of the ge ri atric p.Hient 10 trauma. The ex ist ing lit erature is retrospective in na ture and offers littl e explanatio n fo r the more adverse outco mes expe rienced by the elderly. By ga inin g:1Il und erstanding of the normal

279

280 • CHAPTER 18 Trauma in the Elde rly

physiological changes involved in the aging process, you will be bette r prep.lred to provide optim um care to the geriatric trauma victim. This chapter add resses aging processes, highligh ts illnesses 10 wh ich the geriatric patient is susceptible, and shows how those processes and illnesses make it difficu lt to predict the physiological response to trauma in the geriatric patient.

PATHOPHYSIOLOGY OF AGING Aging is a gradual process whereby chan ges in bodil y funct ions may occur. These changes arc in part responsible fo r the greater risk of injury in the geriat ric population .

The Aging Body Airway: Changes in airway structures of the geriatric patient may include tooth decay, gum disease, and usc of a dental prosthesis. C'ps, bridges, dentures, and fillings all present potential airway obstructions in the geriat ric tmllllla patient . Respiratory System: Chimges in the respiratory system begin to appear in the early adult years and increase marked ly afte r the age of 60. Circulation to the pulmo nary system decreases 30 percent, reducing the amount of carbon dioxide and oxygen exchanged at the alveolar level. There is it decrease in chest wall movement and in the flexibility of the muscles of the chest wall. These changes cause a decreased inhalation time, resulti ng in rapid breathing. There is a decreased vital capacity (o r decrease in the amoun t of air exchanged per breath ) bec;lUse of an increased residua l volume (vol ume of ai r in the lungs after deep exhalation). Ovemll bre.lth ing capacity and maximal work rate may also decrease. If there is a history of cigarette smok in g, or a history of work ing in an area with pollutants, these changes in breathing arc even more significant. Cardiovascular System: Circulation is reduced due to changes in the heart and the blood vessels. C.ordiac ou tput and stroke volume may decrease, and the cond uction system Illay degenerate. The abi lity of the valves of the heart to operate efficiently may deciilU'. These changes may predispose the patient to co ngestive heart failu re and pulmonary edema. Arteriosclerosis occurs with increasing frequency in the coursc oflhe agi ng process, resulting in an increased peripheral vascular resistan ce (and perhaps systolic hypertension). There may be a normally higher blood pressure in the elderly. Thus a significa nt change may occur in a patient when the normal blood pressu re of 160 drops to 120 as a result of trauma. Neurological and Sensory Function: Several changes occur in the brain with age. The brain sh rinks, and the outermost meningeal layer, the dura mater, remains tightly adherent to the sk ull. This creates a space o r an increased d istance between the brain and the skull. Instead of protecting the brain du ring impact, this space allows an increased incidence of subd ural hematoma fo llowing trauma. There is also a hardening, narrowing, and loss of elasticity of some arteries in the brain. A deceleration injury may cause blood vessel rupture and potential bleed ing inside the sku ll There is decreased blood flow to the brain. The patient may experience a slowing of senso ry responses such as pain perception and decre'lses in hearin g, eyesight , or in other senso ry perceptions. Man)' older patients may have a higher pain tolerance from living with conditions such as arthritis, or from being on analgesic medications chronically. This can result in their fa ilu re to identify areas in which they have been injured . O ther signs of decreased cerebral circulation due to the aging process may include confusion, irritability, forge tful ness. altered sleep patterns. and men tal dysfu nctions such as loss of memory and

CHAPTER 18 Trauma in the Elderly _ 281

regressive behavior. There may be a d('cre,lse in the ab ility, o r even an absence of the abi lity, to compen sate for shock.

Thermoregulation: Mechanisms to maintain norma l body temperature may not fu nction properly. Th e geriatric patient may not be able to respo nd to an infectio n with a feve r, or the patient Illay not be able to mainl'lin a normal temperat ure in the face o f injury. The geriatric pa tient wit h a broken hip who has been lying o n the fl oo r in a room where the temperature is 64 degrees Fa hren heit can ex perience hypothermia. Renal System: A decrease in the number o f fun ctioning nephron s in the kidneys of the geriatric patient can result in a decrease in filtration and a reduced ability to exc rete urine and d rugs. Musculoskeletal System: The geriatric patien l may ex hibit signs o f cha nges in posture. There may be a decrease in total height due to the narrowing o f th e vertebral discs, slight nexio n of the knees and hips, and decreased muscle stre ngth. This may resuit in a kyp hot ic deformity of the spi ne, result ing in the "5" curvature of the spine often seen in the stooped elderly. The geriatric patient Illay also have adva nced osteoporosis-a thinning ofthe bone resu lting in a decrease in bone density. This renders the bone more susceptible to frac tures. There is frequently diminished subcuta neous tiss ue that d ecreases protectio n from fa lls and blunt trauma. This lack of subcutaneous tissue ca n also decrease the perso n's abil ity 10 respond to temperature changes. Finally, there may be a weakening in the st ren gth of the muscle and bo ne fro m the decrease in ph)'sical activity; Ihis will also render the geriat ric patient more suscept ible to fracturcs with only a slight 11111. Gastrointestinal System: Saliva productio n, esophageal motility, and gastric secretio n may decrease. This may result in decreased abilit y to absorb nutrients. Constipatio n and fecal impactions are common. The liver may be enlarged because o f d isease processes o r may be fa il ing due to disease o r malnutrition. Th is may result in a d ecreased ability to metabolize mcdica tions. Immune System: As the aging process continues, th e geriatri c patient may be less abl e to fi ght off infeclion. The patient in a poor nutritional state will thus be more suscept ible to infection fro m open wounds, IV access sites, and lung and kidney infections. The geriatric trauma patient who is not otherwise severel y injured Illay die from sepsis from a n impa ired immu ne system . Other Changes: The total body water a nd total nllmber of body cells may be decreascd, and there is an in crease in the propo rtion o f the body weight as fa t. There ma), be a loss in the capacity of the systems to adjust to illness or injury.

Medications Many geriatri c pat-ients take several medicatio ns th.lt ca n interfere with their ability to compensate after sustaining tr aum a. Anticoagulant s may increase bleeding time. Anti hypertensives and peripheral vasodilators can interfere w ith the body's ab ility to co nstrict blood vessels in response to hypovolemia . Beta -blocke rs ca n inhibit the hea rt's ability to increase the rate of contraction even in hypo\'olemic shock. A number of th e aging processes co ntribute to the increased risk o f injury to the geri atric pa tient. The ch.m ges that may incre'lse susceptibi lity to injury include the foll ow ing: • Slower reflexes • Failin g eyesight

282 •

CHAPTER 18 Trauma in the Elderly

• Hearing loss • Arth ritis • Fragi le sk in and blood vessels • Fragile hones Causative facto rs related to the aging p rocess have been linked with speci fi c injuries such as tripping over furn iture and fa lling down stairs. Fu rther invest igation reveals that these fall s are often related as much to a decrease in the func tion of special senses, such as loss in peripheral visio n, as they are to syncope, postura l instability, transient impa irment of cerebrovascular perfusion, alcohol ingest ion, or medication usage. Alterations in perception and delayed response to stresso rs may also co ntribute to injury in the geriatric patient. When treating the geriat ric trauma patient , remember that the priorit ies are the same as for all trauma patients. However, you must give consideration to th ree important issues. • General organ systems may not function as effectively as those in the younger adu!! , especially the cardiovascular, pul monary, and renal systems. • The geriatric patient also may have a chronic illness that may com plicate the effectiveness of trauma care. • Bones may fra cture marc easily with less force. Fractures of major bones such as hips or femurs can be life-th reatening even wil.h proper care.

ASSESSMENT AND MANAGEMENT Geriatric patient assessmen t, as any assessmen t, must take inlo account priorities, interventio ns, and life-threatening co nditio ns. However, you must be acutely aware that geriatric patients ca n die from less severe injuries than younger patients. In addition, it is often difficult to separate the effects o f the aging process or of a ch ronic illness from the consequences of the inju ry. The chief complaint may seem trivial because the patien t may not report tru ly important sym ptoms. You must search fo r importan t signs or symptoms. In the geriat ric patient, it is no t unco mmon for the patient to suffer from more than one illness or injury at the same time. Remember that the elderly patient rna)' not have the sa me response to pain, hypoxia, or hypovolemia as a }'Olmg perso n. Do not underestimate the severity of the patient's condition. You may have difficulty communicating wi th the patient. This could result fro m the patient's d im inished senses, hearing or sight impairment , o r dep ression. The geriatric patient nonet heless sho uld not be approached in a condescendi ng manner. Do not allow others to take over thc repo rt ing of events fro m the patient who is able and willing to communicate reliable informatio n. Unfortu nately, th e patien t ma), minimize or even den)' symptoms o ut of fear ofbcco ming dependen t, bedridden, institutionalized, or even o f losing a sense of self-sufficiency. It is important that you explain any actions, including removing any cloth ing, before initiating the physical assessment. There arc other considerations in assessing th e geriatric trauma patient . Peripheral pulses may be difficult to evaluate. O lder patients often wear ma ny layers of clothing, which can impede physical assessment. You must also distinguish between signs and sym ptoms of a chronic disease and an acute problem, for instance; • The geriatric patient may have no npathologk rales. • The loss of skin elasticity and the presence of mouth b reathi ng may not necessarily represent dehyd rat ion. • Dependent edema may be secondary to venous in sufficiency with varicose vei ns or inactivity rather than congestive heart fail ure.

CHAPTER 18 Trauma in the Elderly _ 283

Pay attention to deviatio n fro m expected ra nges in vit al signs and other physical as: sessmcnt fi ndings in the geriat ric patient. An injury that is isolated and uncomplicated in the yo ung adult may be deb ilitati ng in the olde r ad ult. This may be due to the pa tient's overall co ndit ion,lowered defenses, o r ina bil ity to keep the effec ts of an inj ury local ized . When obtaining thc past medical history, it is important to note wh;lI medications the patient may be taking. Medications may not only account fo r an abnormal pulse, but may also mask normal circulatory responses tha t would indicate deterio ration in the circulatory system. The result can be a rapid decompensation wi thou t warning. Knowledge o f the medications th.Hthe patient is taking can alert you to the fact tha t the patient's condition may be more unstable than that presented by curren t signs and symptoms. Ant ihypertensives, anticoagulan ts, beta -blockers, sedatives, and hypoglycemic agents may profoundly infl uence the response of the geriatric patient to traumat ic injury.

ITLS Primary Survey Scene Size-u p: SiZe up the scene to decide if it is safe, to determine the nu mber of patien ts, and to identify the mechanism of injury. After the ITLS Primary Survey, it may be helpful to obtain further info rmation and to verify the patient's history from reliable fam ily members o r neighbors. This is best do ne in an area where the pat ient is unable to overhear the conversation; otherwise it may suggest that the geriatric patien t is less than a competent adult. Observe the surrounding area for indication s that the patient is able to provide his own care, fo r signs of alco hol abuse o r ingestion of multiple medications. and fer signs of violence, abuse, or neglect. Abuse and neglect of the elde rly arc com mon. When your assessment of the patient and su rrou nd ings is suspicious for abuse 'Or neglect, do not fail to notify the p roper authorities. Be sure to gathe r the patient's medications and bring them to the hospit al. Initial Assessment: As with any trauma patient. YO li must evaluate and provide an adequate airway and maintain motion restrictio n of the cervical spine while assessing the in itiallevel of consciousness. The initial level o f consciousness has more significance with elderly patients than with younger patients, beca use subsequent health-care providers may attribute a decreased level of consc iousness to a preexisting condi tion raLher than to the trauma. Th is is mo re likely to occur if you have not clearly ind icated that the patient was dear,l ucid , and cooperative at the sce ne. If patients respond appropriately to the initial verbal statements, they have an open airway and are conscious. If they do not respond, gentl y open the airway with a modified jaw thrust while maintaining the neck in a neutral posi tio n. Th is position may be difficult t'O determine with certainty because of arthri tis and kyphosis of the spine. It is importan t to recognizc th is and not to forcibl y p];Ke the occiput Oat on the backbo'lrd or grou nd . You should add padding to the backboa rd to maintain the patient's usual spinal position. The airway is likely to be partially obstructed. Clea r the ain."a)'. being alert to possible teeth fragments d ue to decay and gu m disease and dental devices such as caps, b ridges, dentures, and fillin gs. Look, listen, and feel fo r movement of air. Ensure that the rate and volume of air exchange is adeq uate. The geriatric patient with unresolved ainvay d ifficulty or a decreased level of consciousness should be transported immediately. In such a case, frequentl y monitor the respiratory effort and level 'Of consciousness (remember to check blood gl ucose). Consider in-line endotracheal intu bation. Place you r fa ce ove r the patient 's mouth to look at the chest rise, to listen to the qualityof the brea th sounds fro m the mouth. and to feel the pat ient's b reath agai nst you r car. If the breathi ng is so fas t that there is in adequate air exchange (more than 20 breaths per minute), or if it is too slow (fewer than 10 brea th s per minute), or if the volume of air

• • • • • PEARLS

Altered Melllal Stalus Elderly patients with akered mental stalll5 mid always be cheded for hypoglycemii, shock. and head trauma, rriles than assuming tlley

are senile.

284 • CHAPTER 18 Trauma in the Eld erly being exchanged is inadequate, provide ass isted ventilat ion with 100 percent sLLpplt'mental oxygell_ Capnography is the best way to objectively monitor the pa tient's ventii:ltion. Check the rate and quality of the pulse at the wrist (check at the neck if therc is no pulse at th e wrist ). Evalu:lte skin color and condition. Scan the pat ien t fo r bleeding, and co ntrol any bleedin g with press ure.

• • • • • PIWUS Chronic Illnesses Chronic iUnesses such as CHF and coro should be uteo into <JWlUflt as you make judgments about inter\'entions needed to care /or the elderly trauma patient

Rapid Trauma Surveyor Focused Exam: The choice between the Rapid Trauma Survey and the Focuscd Exam depends o n the mecha nism of injury andlor the results of the Init ial Assessment. If there is a dangerolls generalized mechanism of injury (auto crash, fall from a height, for instance) or if the patient is unconscious, you shou ld perform a Rapid Trauma Survey. If there is a dangerous focused mechan ism of injury suggesting an isolated injury (bullet wound of thigh, stab wound to the chest, and so on ), YO ll mOl)' perform tht' Focused Exam that is limited to the area of inju r)'. If there is no sign ifi cant mechanism of injury (d ropped rock on toe) and the In itial Assessmen t was normal (alert with no historr o f loss of consciollsness, b rea thi ng normally, radial pulse less than 120, not complaining of dyspnea or chest, abdominal, or pclvic pa in). you may move directly to the Focused Exam based on the patient's chief complaint. To perform" Rapid Tmu m" Su rve)'. exami ne the hend, neck, chest, abdomen, pelvis, and ext rem ities. That is, brieAy assess the head and neck fo r inj uries and to see if the neck veins are flat o r distended and the trachea is in the mid li ne. You may apply a ri gid extrication collar at this time. Now look. feel, and listen to the chest. Look fo r both asym metriC

Critical Transport Decisions There arc a few proced ures that rna)' be in itiated on scene, b ut do not delay transport. Ex· :lInples of cri tic:ll inten 'erlt'io ns th:1I Illay be ini tiated at the scene are the fo llowing: • Provide airway management. • Assist venti lation. • Begin CPR. • Control major bleeding. • Seal sucking chest wounds. • Stabilize flail chest. • Decompress a tensio n pneumothorax. • Stabilize impaled objects. Co nsider whether or not the time delay in initiati ng these procedu res outweighs the risks of delaying transportation. As me ntioned elsewhere, the chance of survival decreases with a corresponding increase in the length of scene time. The same indications for imme·

CHAPTER 18 Trauma in the Elderly _ 285

diate transport apply for the elderly as for }'Ounger patients (see Chapter 2). but remem ber that you may not have as dramatic a response to inju ry in the clderl)'. so you should have a low threshold fo r early transport. If one of the critical conditions is present , immediately transfer the patient to a long backboard (vacuum b'lCkboard is recommended) with appropriate padding, apply oxygen. load the patient into the ambu lance, and transport rapidly to the nea rest appropriatc trauma facility.

----.....-

PEARLS

SMR • YIrIen perlonning SMA on in

....... _"'00

dot ""

• remai1 on a hitd badboard for exteoded periods

Packaging and Transport Package or prepare the elderly patient for transport as quickly and gen tl y as possible. Take extra ca re when performing SMR on the geriatric trauma patient. This includes padding void areas that may be exagge rated due to th e aging process. The elderly patient with kyphosis will requ ire padding under the shoulders and head to maintain the neck in its usual al ignme nt (Figure \8- 1). Do not force the neck into a neutral position if it is painful to do so, or if the neck is obviously fused in a forward positio n. R('lllember to treat and transpo rt the geriatri c trau ma patient, as you do all trauma patients, gently and quickly.

of time_ You should use SOITl! txtr1 paM'"!}. such as a folded blanket, for the entirt body. The vacut.m hKkboard is far SIlperiof to a liard baO:board for use with the elderly patiem. • Extra J)iCkIing may also be required lI'Ider the head and shooIden in order to maintain the cervical spine VI its IlOI'maI

or"""."

ilLS Secondary Survey and Ongoing Exams Perform an ITLS Seco ndary Survey on scene if the patient is stable. If there is any question as to the patient's condition, you should transport and perform the ITLS Secondary Sur'
Dan , the team leader on this call, Joyce, and Buddy are dispatched to the home of an elderly woman whose neighbor called 9-1'1 and said she was hurt. The dispatcher asked the neighbor to remain with the patient until they arrived. On the way to the scene, they discuss (ammon home injuries in the elderly. When they arrive, the neighbor meets them at the door and takes them to the patient' s room. She is an 86-year·old woman (Mrs. Mary Higginbotham) who

FIGURE 18·1 Elderly pllliellIs with kyphosis require padding under the shoulders and head to maintain t.he spine in its usual alignment.

286 • CHAPTER 18 Trauma in the Elderly has bru ises allover and appears to have been bed-bound for some time. She is confused and babbling. The room and bed linens are filthy. The sheets smell of urine and there are dried feces on the patient's legs. The neighbor states that the woman is usually alert and ambulatory and able to care for herself. Because of Mary's failing eyesight. her grandson ca me to live with her about 6 months ago . The neighbor states that her grandson does not work but lives off her retirement (she's a retired college professor). "He drinks," she said. Mary' s husband died 10 years ago and she has suffered from depression, but seemed to be doing better until her grandson came to live with her. She began having frequent bruises soon after he arrived, but she always explained them by saying, .. , fall a lot." The neighbor (an d long-time friend) said that Mrs. Higginbotham has a history of type II diabetes and mild hypertension, and takes med ication for both. She said that Dexter (the grandson) had discouraged her visiting and lately would not let her talk to Mary on the phone. In response to this sh e had begun waiting until he went out and then com ing over to visit and check on Mary. The neighbor (Mrs. Bixby) said that she had been away for a week and was anxious to see Mary. When she saw Dexter leave this morning. she came over and was appalled to see that Mary cou ld not get out of bed and didn 't even recognize her. Dan began his exam while Buddy and Joyce looked for medicine bottles. Mrs. Bixby was not sure about allergies, but said that she did not know of any. Dan is still not sure if this is a medical or trauma ca ll but decides to do a trauma survey. The airway is open and the respiratory rate is a little fast and shallow. The mucous membranes look dry. The breath sounds are present and equal and the peripheral pulse is weak and rapid. There is a large bruise and abrasion of the right cheek and periorbital area. The pupils are equal and reactive to light bu t there are obvious catMacts in both eyes. The pharynx is edentulous but Dan cannot find the dentures. The neck is non tender but there is marked dorsal kyphosis. There is equal expansion of the chest and no rales or wheezing is noted. The heart rate is fast but he hears no murmurs. The abdomen is thin and scaphoid with no obvious tenderness or masses. The pelvis is stable but she is tender over the left hip and the left leg is shortened and externally rotated. Peripheral pulses are present in both legs. There is very poor skin turgor. She moves all extremities but cries out when the left leg is moved. By the time Dan is finished, Joyce has taken the vital signs and tells him that the blood pressure is 170/ 110, pulse 110, and respiration is 26 per minute. Pulse oximeter reading is 96 percent on room air. Buddy has found a half-empty bottle of Diabeta (oral diabetes med ication) open by the bedside table and a full, unopened bottle ofTenormin (beta-blocker antihypertensive medication) in the kitchen on the counter. Both bottles were filled a week ago. They carefully move Mrs. Higginbotham to a vacuum backboard and mold it to her to support her neck and hip. They then move her to the ambulance, where Dan applies nasal oxygen at 3 liters per minute. Buddy drives and Joyce does a finger-stick glucose, while Dan starts an IV with normal saline at a keep-vein·open rate. The glucose is 40. Dan gives 25 g IV glucose by protocol and soon Mrs. Higginbotham is alert and oriented. She complains of pain in her left hip. When asked how she hurt it, she lowers her eyes and says, "I fall a lat." She does not remember about her medicine but says that sometimes Dexter gives it to her and sometimes she takes it on her own. She has been unable to walk for 5 days. "Dexter has to be out a lot so I haven't been able to keep the place cleaned up. He is really a good boy but he is forgetful an d he has to be gone on business a lat." (Mrs. Bixby had told them that his " business" is drinking at the local pub_) Mrs. Higginbotham denies allergies and cannot remember when she last ate. The Ins Secondary Survey revealed no new find ings.

CHAPTER 18 Trauma in the Elderly _ 287

At the hospital Mrs. Higginbotham is found to be dehydrated and malnourished

with a fracture of her left hip and multiple bruises and abrasions. Dan reports their suspicion of abuse and neglect. An investigation later confirmed those suspicions. her hip repair and upon recovery moved into an assisted living facility.

Mrs. Higginbotham survived

Dealing with the very elderly can be challenging, especially if you are not already familiar with the patient. (Many are tran sported so regularly that responders are on a first·name basis.) If the patient has an altered mental status, it is always helpful if there are family members or friends who can give you pertinent history. In this case. the neighbor said that the patient was usually alert and ambulatory. She voiced accusations against the grandson that mayor may not have been true. but the Scene Size-up suggested that the patient was at best being neglected. and at worst being physi cally abused. It became obvious that she had taken too much of her diabetes med ication (hypoglycem ic. with half of her tablets gone a week after the bottle was filled) and none of her blood pressure medication. (Tenormin is a beta-blocker that causes decrease in heart rate and blood pressure; she was hypertensive and tachycardic_) The team was misled by the evidence of trauma and mistakenly assumed that the altered level of consciousness was caused by age and head trauma. They correctly pi cked up the hypoglycem ia when they started the tV and checked the blood glucose. No matterwhat the age. if the patient is not abusing alcohol or drugs. the most com mon cause of altered mental status is hypoglycemia. Just as for suspected abuse of children , you have a moral obligation to report suspicion of elderly abuse. You may be their last hope.

SUMMARY You will be ca ll ed upon to trea t and transport an increasing number of geriat ric trauma

patien ts. Although the mechanis ms of injury Illay be different from those of yO llnger ad ults, the prioritized evaluation and treatment is the same. As a gene ral rule, elderly pa -

tients have more serious injuries and more compl icatio ns than you nger patients. T he physiologic processes of agi ng and freq uent concurrent ill nesses make evaluation and treatment Illore d iffi cult. You must be aware of these d ifferences to provide optim.11 ca re to the pa tient.

BIBLIOGRAPHY l. Bergeron. E., et al. 2004. Elderl y trauma patients with rib fract ures are at grea ter risk of death

and pneumonia. Tile /Oitr/W/ ofTrarHlm 54(3): 478-85. 2. Diku. M .. K. Newton. 1998. Geriatric trauma. Emergelll)'Metlicinc Cli/licsofNorth America 16( I). 3. j:lcobs, D. G. 2003. Special considerations in geriatric inju ry. ClIrrcllf Opi/lions in Critical Cllre 9(6 ): 535-39. 4. Pute!, V. I.. H. Thadepalli. P. P:ltcl, A. MandaI. 2004. Thoraco.1 bdominal injuries in the elderly: 25 years of experience. lournal of the Nationul Medical Assochllion 96(12): \ 553- 57. 5. Pudelck, It 2002. Geriatric trauma: Spcrial needs for a special population. AACN CIi,limllsslIes 13( t ) : 61 - 72. 6. Stevenson. J. 2004. When the traullla palient is elderly. / Perilmesllll!sitl Nllrsing 19(6); 392--400.

CHAPTER

Joyce, Dan, and Buddy are dispatched to a sin gle-auto cra sh. As they approach the scene , they decide that Buddy will be team leade r. Upon arrival th ey find that the scene is sa fe. A local rescue sq uad has arrived and extricated the driver onto a long backboard. She is the only person involved. Her auto has run off the road and i nto a power pole. There are no downed wires. Since she is already packaged, Joyce, Dan, and Buddy move her into the ambulance and begin the exam. The young woman states she was talking on her cell pho ne and took her eyes off of the road. She was not restrained ("I heard tha t seat belts might kill the baby") , and the ca r was not equip ped with airbags. She says that she is 25 years old and is 6 months pregnant. She denies any loss of consciousness. She complains of head, back, and lower abdominal pain. What is different about caring for this potient? What

sort of injuries should Buddy suspect? Keep these questions in mind as you read the chapter. Then , at the end of the chapter, find out how the rescuers completed this call.

INTRODUCTION When the crossroads of pregnancy and trauma meet, there arc un ique challenges. The vul nerability of the pregnant trauma patien t and potent ial injuri es to the unborn child serve as reminders of the dual roles of providing care to both mot her and fetus. In addition, the pregnallt patient is often at risk for a highe r in cidence of acc idental trauma. The increase in f;linti ng spells, hyperventilat ion, and excess fatigue th at are common ly associated with ('arly pregnancy. as well as the physiological changes th at affect balance and coordination, add to risks. Trauma is a leading cause of mo rbidity and mortality in pregnancy. Approximately 6 to 7 perce nt of all pregnant women ex perie nce some degree of trauma. Sign ificant trauma occurs in ~Ip proximatel y 1 in 12 pat ients who arc inju red. Injuries requiring l eU admissio n occur in 3 to 4 pregnancies per 100 deli veries. Motor-vehicle col lisions account for 65 to 70 percen t of trau ma in pregnan t patients. Falls. abuse and domestic violence, penetrating injuries. and burns follow. Becausc minor injuries rarely prese nt problems fo r EMS providers, the fo llowin g discussion focuses on the more severe tra umatic injuries to the pregnant patien t.

289

290 •

CHAPTER 19 Trauma in Pregnancy

PREGNANCY Fetal Development The fet us is formed during the first 3 mont hs of pregnancy. Aft er the third month of ges· tation, the fully fo rmed fetus and uterus grow rapidly, reaching the umbilicus by the fifth mo nth and the epigast rium by the seventh mon th (Figure 19- 1 and litble 19-1 ). The f(,tus is considered viable at 24 weeks.

Physiological Changes During Pregnancy During pregnancy, dramatic physiological changes occur. The changes that are unique to the pregnant state affect and sometimes alter the physiological response by both the mother and fe tus. Changes include blood volume (increases ), cardiac output (increases), and blood pressu re (decreases) (Figu re 19-2). Th e respiratory system also has significant changes du e to an enlargin g uterlls that will elevate the diaphragm and decrease the overall volume of the thoracic cavity. This leads to a relative alkalosis and predisposes the patient to hyperventilation. There is, in addition, an increase in both red blood cells and plasma. With the increase of plasma greater than red blood cells, the patient will appear to be anemic (physiological anem ia of pregnancy). However, many pregnant patients have poo r nutritional in take during pregnancy and develop an absolute anemia. Gastric motili ty is also decreased; thus, always aSsume the sto mach of a pregnant pa tient is full. Always guard again st vomiting and aspi ration . Table 19-2 illustrates changes during pregnancy.

3 Months

8 Months

""'....

Umbilcal

"''''

L +

_

Vagina

- + ---' I

Pubic bone

Bladd."

Cervix

FIGURE 19-1 Anatomy of pregnancy: ute rus at 3 months and al 8 months gestatio n.

CHAPTER 19 Trauma in Pregnancy _ 291

;

.

"",

...-

First Trimester (1-12 weeks)

Second Trimester (13-24 weeks)

Third Trimester (25-40 weeks)

Viability

Fetus not viable

Potential viability

Fetus viable

Vaginal bleeding

Potential for miscarriage

Potential miscarriage

Potential preterm birth

Fetal he art tones

Not obtainable

120-170 beats per minute

120-160 beats per minute

Height of fundus above symphysis pubis

Difficult to measure

Halfway to umbilicus equals 16 weeks; to the umbilicus equals 20 weeks

1 em equals 1 week until 37 weeks. then uterus height decreases as the baby settles into the pelvis

PEARlS

HypovolemiQ

Responses to Hypovolemia

• Do not!Mtab ~

Acute blood loss result s in a decrease in circulatin g blood \'o lume. The ca rd iac o utput decreases as the ve no us ret urn falls. This hypovolemi a causes the arterial blood pressure to fa ll. result ing in a n inhibit io n of vagal to ne and the release of catccho la mines. The effec t of this respo nse is to produce vasoco nstrictio n and tachycardia. This vasoconstriction profoundl y 'Iffects the ut erus. Uteri ne vasoconstrictio n lea ds to red uct io n in ulerin e blood fl ow by 20 to 30 perce nt. The pregnant patient may lose up to 1.500 cc of blood before any detectable ch.mge is no ted in the blood pressure of the mo ther. The fetus reacts to this hypope rfusio n by a d rop ill the arterial blood pressure and a dec rease in heart rate. The fetus now begins to suffe r fro m reduced oxygen concentratio n in the matern al circulation. Therefo re. it is impo rt ant to give 100 perce nt oxyge n to the mother in o rder to provide sufficient o xyge n to the fetus. wh o suffe rs fro m both oxyge n starvatio n and inadequate blood suppl y. A shock stale in th e mo ther is associated with an 80 percent fetal mortalit y rale.

vital.

in pte!,WII pitients 15 sig's of shod. The Jft9'IIf'd patient 1m J namalleS1ilg FUse !hat is 1010 ISbeaa faster !h.! lIuhncl the blood ~ is 10 to IS rmflg lower !han UR.Iai.IiowMr, ~ is also ~ to rea6ze tNt a blood loss of l) 10 35 pera!f1I ~ oco.r in these patiems before there is a

....... m.".;,~

"....... _ . bo ..,.a.ly aIM to all signs ohhodt. and mcritof the with

Wil .

rns """"" "'.... • """'" c.<»c arrest in the ~ patient is treated the Ymt as for other W:tims. Defib!&tion

....... ood ..., """" .. "" same. For hypoYoIemic Irrest, the vokme of requi'ed fluid iIcrease5 Met 4 ~ of I'IOImII Wne shcMd be giv!!"s fast 15

,.,...mm,_

Monitored 4000 mL

70

110nO Hematocritlhemoglobin PCO,

4-5 liters per minute 13/40 38 Normal

Increased 40%-50% Increased 10%-15% Decreased 5-15 mmHg Increased 20%-30% Decreased Decreased Decreased

292 •

CHAPTER 19 Trauma in Preg nancy

Blood volume usually Increases by about 45%. Dilution resulting from the dispfOpOr· tionale increase 01 plasma volume over lhe red cell mi!lss "anemia 01 pregnancy;

cardiac output increased by '.0 to 1.Slhers per minute during the 1st trimester. reaches 6 to 7 liters per minute by the late 2nd trimester. and Is maintained essentially at this level until delivery.

The stroke volume progressively declines to term following a rise eariy in pregnancy. Heart rate. however. Increases by an average of 10 to 15 beats per minute.

FIGURE 19·2 Ph ysiological changes duri ng p r egnancy. ( continued nex t page)

ASSESSMENT AND MANAGEMENT Special Considerations Major goals in ca ring for the pregnant trauma patient arc evaluatio n and stabil i7. •1.tion. The ITLS Pri mary Survey is th e sa me fo r th e pregna nt patient as fo r other pat ients (see Chapter 2). All prehospital int('rven lions arc directed toward optimizin g bot h feta l a nd maternal outcome. If th e patient is pregna nt . there arc two patien ts being treated. Optimal care for the fetus is appropriate treatmen t of the mother. Oxygen adm inistration ( 100 percent by nonreh reather mask or by endotracheal intubation) should be rapid. Promptly obt ain venous access a nd begi n admi nist ration of JV flu id. Mo nito ring of this pa tient

CHAPTER 19 Trauma in Pregnancy _ 293

The mean level 01 blood pressure Is characteristically 10 to 15 mmHG lower during pregnancy, the decline usually apparent by the end 01 the 1st trimester. Widened pulse pressure results 'rom a proportionately great8l'" recluction In the diastolic component

Peristalsis is slowed; thus, the stomach may still COIltain food hours after e meal.

Be alert to the danger 01 vomiting and aspiration.

PEARLS

Tuatment You are trNtiIg two patients. - . tho """"" 01 tho I!tus is rebted to the treatment ,...;dod "tho _ . Tho "'" of prehospitaI irrteMntion is 10 maxinize the chInces of mattmaI tho ... "" tho I..",... r"

.....,. """'oil.,... .....,.

Injury to the uterus 01" pelvis may cause

massive hemormage.

•

~ the rTIOItM!r - . rontiIue CPR Jnd notify the hospital to be p!fplr&Cllor irrme
"""""" """,,",t r" FIGURE 19-2 Con tinued.

should be immediate and constant because the anatomic and physiological changes of pregnancy make the tra uma assessment more difficult. Acute hypotension in the pregnant patient due to decreased venous return requiresspecial mention. This "supine hypotension syndrome" usually occurs when the patient is in a supine position wit h a 20-week (uterus up to umbilicus) or larger uterus (Figure 19-3). This can lead to maternal hypotension, syncope, and fetal bradycardia. Therefore, the transport of all p regnant trauma patients, if no contraindication exists, should be by o ne of the following methods to alleviate vena cava compression.

• Tilt or rotate the backboard 20 to 30 degrees to the patient's left. • Elevate the right hip 4 to 6 inches with a towel and manually displace the uterus to the left.

iI!vne6ate evaluation of the feNS.

• ~ 01 tho 1m ""y 9" IJYIOticed in the ~ pregIaI1t PI!ient Trutment shWd idxIe

.".1Iow_

PEAIlLS

""""' --Transport

TrillSpOll. must include ~

.....

sp/"1Ilt5, Jnd prMntion of 'o'ef\j em

294 • CHAPTER 19 Trauma in Pregnancy

FIGURE 19-3 Venous return to the maternal heart may be decreased up to 30 percent beuuse of vena ca\'a compression by the fet us. Transport the patient on her left side or tilt the backboard to the left.

You must be very carefu l when strapping a thi rd-trimester pregnant patient onlo 3 long backboard and then tilt in g the backboa rd 15 to 30 degrees to Ihe left. Mllny palients (n nd backboards) will roll right over on lo the ambulance floor if the backboard is not secured to the streicher. The vacuum backboa rd (J:igurc 19-4) is more comfortable and makes it easier to main tain SM R of the pregnant patient. Table 19-3 illustrates eval uation of uterine size and its effect on managemen t of the pregnant patient.

Types of Trauma

FIGURE 19-4 The pregnant patient is beUer stabilized and more comfortable in a vacuum backboard than a h-ard backboard.

Motor-Vehicle Collisions: Though relatively minor abdominal t r,llIma can cause fetal dea th , the most CO Ill· mon cause of fe lal death in trauma is maternal death. Motor-\'ehicle collisions account for 65 to 75 percent of pregnancy-rela ted trauma. Fetal dist ress. fetal deat h, placental abruption, uterine rupture (Figure 19-5), and preterm labor arc o ften seen in pregnan t patients who have been in MVCs. A review of the literature indicates that less than I percent of pregnant patients will sustain injury when there is mi nor damage to the veh icle. Head in jury is thc most common cause of dca th in pregnant patient s involved in MVCs. This is closel)' fo l· lowed by un co ntrolled hem orrhage. Pregnan t victi ms of MVCs have associated injuries, such as pelvic fra ctures. that oft en result in concealed hemorrhage wi thin the retroperitoneal space. The ret roperito neal area, because o f its low-pressure venous system, can accommodate the loss of 4 or more liters o f blood into that area wi th few cli nical signs. Scat-belt use with both a sho ulder rest mint and lap belt can Significa ntly decrease patient mortality and has not shown any inc rease in uterine injuries.

CHAPTER 19 Trauma in Pregnancy _ 295

Uterine Size <20 Weeks

Uterine Size >20 Weeks

Utgrus Not to Umbilicus

Utgrus to Umbilicus or Higher

J. Pregnancy Management Unchanged

J. lateral Displacement of Uterus

J. Maternal Stabilization

J. Brief Confirmation of Fetal Heart Activity (if possible) Maternal Stabilization Secondary Fetal Stabilization

• • • • • PEARLS

Abdominal Trauma

Penetrating Injuries: Gunshot wounds and stabbings are the most com mon injuries encountered. If the path of entry is below the fundus, the uterus will oft en offer protection to the mother, absorbing the force of the bullet o r knife. Upper abdominal wounds will of· len injure the bowel due to its compression in a smaller than normal space by the uterus. Stud ies have shown that gunshot wounds to the pregnant abdomen carry a high mor· tality rate for the fe tus (40-70 percent). They are lower for the mother (4-10 percent) be· cause the large uterus usually protects vital organs. Stab wounds follow much the same pattern of o utcome, with feta l mortality rates of about 40 percent. Definitive ca re will depend on several facto rs. involving degree of shock, associated organ injury, and rime of gestation.

Trauma to the abdominal compartment can cause occult bleeding in either the intraLlterine 0/ retroperitoneal area. KHp in rMd that gradual mtching of the abdominal waU during pregnancy, along with honnooaI changes within the body, make the peritoneal surface less sensitive to irri~bIe stimuli. Therefore, bleeding can occur intraperitoneal~, and the signs of reboood, guarding, and rigidity may not be present

Domestic Violence: A large percentage of pregnant women experience domestic violence. The freq uency appears to worsen as pregnancy progresses. Through the second and third trimesters, it is estimated that I in iO pregnant women experiences abuse du ring pregnancy. Physical abuse is mOTe likely to be manifest with proximal and midline injuries than the distal injuries of accidental trauma. The face and neck are most commo n. Domestic abuse has also been associated with low birth weight. The pregnant patient who is under grea t stress produces hormones (high circulating adrenaline levels. and so on) that are not good for her pregnancy. The "old wives' tale" that pregnant patients sho uld be shielded from frightening or disturbing si tuations is probably true. Spouses and boyfriends are the perpetrators of the violence in 70 to 85 pefct'nt o f cast's. Falls: The incidence of falls increases with the progression of pregnancy. This is in part due to an alteration in the pa· tient's center of gravity. The incidence of significant injury is proportionate to the force of impact and the specific body part that sustains the impact. Pelvic injuries may result in placental separation and fetal fractu res. Emergency depa rt · ment evaluatio n and monitoring is recommcnded for cven mino r abdominal trauma du ring pregnancy.

FIGURE 19·5 Blunt trauma to the uterus may cause separation of the placenta or rupture of the uterus. Massive bleeding may occur, but there may not be visible vaginal bleeding earl y.

296 •

CHAPTER 19 Trauma in Pregnancy

Burns: Of the 2.2 million paticn ts that suffer burn injuries in the United States annuall)" less than 4 percent arc pregnant. The ovenl\l mortality and morbidity resulting from ther· mal injuries to the pregna nt I>at ient is not markedly different from the nonpregnant pa· tient. However. it is important to remembe r that the fluid requirement for the pregnant patient is greater than lh:u of In(' nonprcgn.1II1 fC llliIlc. Fewllllort"lity increases when tnc maternal surface burn exceeds 20 percellt.

TRAUMA PREVENTION IN PREGNANCY Upon reviewing major C:luses of t raum
Joyce. Oan, and Buddy are dispatched to a single-auto crash. (Buddy is the team leader on this call.) Upon arrival they find that the stene is safe. A local rescue sq uad has arrived and extricated the driver onto a long backboa rd. She is the only person involved. Her auto has run off the road and into a power pole. There are no downed wires. Buddy notes that the windshield is sta rred and the stee ring wheel is bent. Since she is already pa ckaged, they move the pa tient into the ambulance and begin the exam. Dan is told to transport to the hospital as soon as Buddy fi nishes the ITlS Primary Survey. The patient sta tes she was talking on her cell phone and took her eyes off the road. She was not restrained and the car was not equipped with airbags. She says that she is 25 years old and is 6 months pregnant. She denies any loss of consciousness. She complains of head, back. and lower abdominal pain. Buddy asks Joyce to tilt the backboard about 20 degrees to the left and strap it down well so it does not flip over onto the floor of the ambulance. The patient has an open airway and seems to be breathing normally. She has bruising and a laceration of the forehead where she struck the windshield. The cervical collar is opened to examine the neck. There is tenderness and spasm but no deformity noted. Neck veins are flat and the trachea is in the mid line. The cervical collar is replaced. The chest has no obvious d eform ities but is tender over the stern um . Breath sounds are present and equal. heart sounds are easily heard, and she has a strong rapid peripheral pulse. The uteru s is felt halfway between the umbil icus and the xyphoid. and it is hard and very tender. Buddy cannot hear fetal heart tones with his stethoscope and does not have a Doppler. The

CHAPTER 19 Trauma in Pregnancy _ 297

pelvis is stable and nontender. She has good PMS of the extrem ities. Joyce reports that the vita l signs are BP 100/ 60, pulse 120, respiration 24, and the pulse oximeter reading is 95 percent on ambient air. Joyce applies a nonrebreather oxygen mask while Buddy starts two large IVs. The patient says she feels as if she has wet herself but when Joyce checks there is a large bloodstain on her pants. Joyce notifies medical direction and asks her to have the emergency department send for a sonogram machine to assess the fetus on arrivaL She also asks for the trauma team and the obstetrician on-call to be present on arriva L She then applies the card iac monitor (sinus tachycardia) while Buddy does the ITlS Secondary Survey The patient denies any medical problems or allergies and is taking only prenatal vitamins. She has not eaten today because she was a little nauseated. The Detail Exam reveals that the neurological status is normal but the abdomen is tender with obvious constant spasm of the uterus. The BP has dropped to 90/ 50 and the pulse is up to 130. Buddy gives a liter of normal saline as a bolus but the BP and pulse do not im prove . He repeats the bolus, with the BP rising to 100/ 60 and the pulse dropping to 120. When they arrive at the emergency department a sonogram reveals that the fe tus is still alive but the abdomen is full of fluid. The patient is taken to surgery where a ruptured uterus is found. About 2,000 cc of blood is suctioned from the abdomen. The patient has to have a hysterectomy to stop the bleeding. The baby requires a month in the neonata ll CU, but both mother and child survive.

Because of the ra pid treatmen t and tra nsport, th is patient survived what would have been a fatal inju ry. She was transported with the backboard ti lted to the left to prevent compression of the inferior vena cava by the gravid uterus. Her shock was aggressively treated by oxygen and flu id resuscitation in the ambulance and by rapid evaluation and surgery at the hospita l. If she had worn her seat belt, she would probably have had only minor inj uries.

SUMMARY Management of the pregnant trauma patient requires knowledge of the physiological changes thai occur d uri ng pregn:lIlcy. Pregnant patients require rapid evaluation and also rapid interventions for stabilizatio n, induding 'lggressive oxygen administration and fluid resuscitation. They req uire special techniques in packaging and transport to preven t the vena cava compressio n syndrome. Because of the difficulty in early diagnosis, you should have a low threshold fo r load ·and·go if there is .my danger of the development of hemor· rnagic shock. Pregnant patien ts wi th serious injuries should be directly transported to a facility (Irauma center) cap.lble of managing these complex patients. Optional felal care is dependent o n care of the mot her.

298 •

CHAPTER 19 Trauma in Pregnancy

BIBLIOGRAPHY I. Chang, J.• C. Berg. L Saltzman . J. Herndon. 2005. Homicide: A lead ing cause of injury deaths among pregnant and po~tpartum women in the United Statc~. AmericcHI 10llnlCli of Pub!~ Health 95 (3): 47 1-77. 2. Coker. A., M. Sanderson, B. Dong. 2004. Partner violence during pregnancy and ri ~k of adverse pregnancy outcomes. Paediatric and Perinatal Epidemiology 18 (4): 260-69. 3. EI Kady, D., W. Gilbert. J. Anderson, et al. 2004. Trauma during pregnancy: An analysis of ma· ternal and fetal ou tcomes in a large population. Americall Jourllal of Obstetrics "lid GYllecolog) 190 (6): 1661-68. 4. Esposito, T. J. 1994. Trauma during pregnancy. Emergency Medicine C/illics of North America I ' 167-99. 5. Fildes J., L. Reed, N. Jones. et al. 1992. Trauma: The lead ing cause of maternal death. The lour lIal 0fTrcwma 32: 643. 6. Hill, D. A.,J. J. Lense. 1996. Abdominal trauma in the pregnant patient. Alller;cml Fnlllily Phy cian 53: 1269-74. 7. Maghsoudi, H., R. Samnia, et al. 2006. Hums in pregnancy. Hllms 32 (2): 246--50. 8. Pons, P. T. 1994. Preho~p ital con~iderati on~ in the pregnant patient. Emergency Medical Clinia of North America 12: 1-7. 9. Vaizey, C. J., M. J. Jacobson, F. W. Cro~s. 1994. Trauma in pregnancy. British jOllrnal ofSurgerJ 81: 1406--1 5. 10. Weiss, H., T. Songer, A. Fabio. 2001. Fetal death~ related to maternal injury. lAMA 286 (15 1863--68.

CHAPTER

Joyce, Buddy. and Dan have been dispatched to a run·down section of town after the police called to report a man being stabbed. They have been to this area many times before to pick up patients after altercations over alcohol or drugs, They are to ld that the patient is covered in blood but is not cooperative. What injuries would you expect in this

situation? What strategies would you use to get the patient to cooperate with treatment? Keep these questions in mind as you read the chapter. Then, at the end of the chapter. find out how the rescuers comp leted th is call.

INTRODUCTION

• •••• PEARLS

Under the Infl"ence It is eweme~ d"lfficuk to differentiate between patients under the influence and those eKperiencing

a medical and/or trauma emergency. Yoo may 11m to aher your VSUil management techniques. Many pa!iefJts wiM initially refuse trea~t Yoo may have to consult local protocol, medical Mction, and appropriate law enforcement peoomeI for HSistance.

The relationship between alcohol and trauma is well documented. For instance. it is reo ported that car crashes involving alcohol result in injuries to about 500,000 people a year. Studies of individuals who are substance abusers note that these persons are at grealer risk to suffer an injury than the general population and that these individuals are mo re likely to have repeated injuries. Substance abuse includes individuals who have abused alcohol, drugs. or both. It has been associated with a number of traumatic events, often resulting from accidents. car crashes, suicides, homicides, and other violent crimes. Further. a study reported in the jOl/ mal oflheAmericall College 0fSllrgeolls fou nd a high rate of alcohol and ill icit drug use in patients who die from trauma. Therefore, it would not be surprisi ng to find that a number of seriously injured trauma patients arc under the influence of alcohol or some other substa nce. This group of trauma patients often presents with un ique chal· lenges that can require some special patient management techniques along with good ITLS care. A high index of suspicion combined with the results of the physical exam, the history obtained from the patient or bystanders, and evidence at the scene can cl ue you into whether your patient is under thc influence of alcohol or drugs. Table 20- 1 includes CO Ill' monly abused drugs. along with signs and sympto ms of their use.

ASSESSMENT AND MANAGEMENT

300

While your ITLS Primary and Secondary Surveys should foll ow the ITLS guidelines thai have been described in this book (see Chapler 2). there arc some particular aspects to be aware of when conducting the exam when you suspect the patient has abused substances. Pay particu lar attention to mental status, pupi ls. speec.h, and respiration, and note any needle marks you may discover. An altered mental status can be seen in every form of substance abuse. However, remember that an altered level of consciousness is always due to a head injury, shock. o r hypoglycemia until proven otherwise. Pupils are often constricted

CHAPTER 20 Patients Under the Influence of Alcohol or Drugs _ 3 01

Co mmon Names Alcohol

Amphetamines/ Methamphetamine

Cocaine Hallucinogens

Marijuana Narcotics/Opiates

Sedatives

Beer, whiskey, wine

Altered mental function , confusion, polyuria, slurred speech, coma, hypertension, hyperthermia, tachycardia Bennies, ice, speed, Excitement, hyperactivity, dilated uppers, dexies, pupils, hypertension, tachycardia, Ecstasy, MDMA tremors, seizures, fever, paranoia, psychosis Coke, crack, blow, rock Same as amphetamines plus chest pain; lethal dysrhythmias Hallucinations, dizziness, dilated Acid, LSD, PCP pupils, nausea, rambling speech, psychosis, anxiety, panic Euphoria, sleepiness, dilated pupils, Grass, hash, pot, tea, weed dry mouth, increased appetite Heroin, horse, big H, Altered mental status, constricted Darvon, codeine, pupils, bradycardia, hypotension, respiratory depression, stuff, morphine, hypothermia smack Altered mental status, dilated Thorazine; GHB; pupils, bradycardia , hypotension, barbiturates; benzodiazepines respiratory depression, hypothermia (e.g., Ubrium, Valium, Xanax, Ativan, Rohypnol)

in patients who have abused o piates. Dilated p upils arc common in patients exposed to am phetamines, cocaine, h;lllucinogens, and marij uana. Patients who use barbiturates will have pupils that arc constricted ca rlyo n. However, if high doses have been consumed, the pupils can eventually become fixed and dilated. Speech can be slu rred when pat ients usc alcohol or sedatives, and patient s who are under the influence of hallucinogens may seem to ramble when they talk. Respiration can be significan tly depressed with opiates and sedatives. The history supplied by the pa tient o r bystanders can also help to establish whether substance abuse is involved. Try to find o ut what was used , when it was taken, and how much was taken. However, be aware that patients often deny that they have used o r abused any substance. If possible, inspect the patient 's surroundings for clues that drugs or alcohol may have been used. Note any alcoholic beverage bottles, pill containers, inject io n equipmen t, smoking paraphernalia, or unusual odors. Tra uma patients under the influence of alcohol o r d rugs can challenge the provider not only by their traumatic inj uries but by their attitudes. The way in which you interact with patients who have abused substances can determine if the palient will be cooperative or uncoo perat ive. How you speak to these patients can be as important as what you arc doing for thelll. Your interaction style, if offensiv{', can make patients uncooperative and force you both to lose precious min utes o f the Golden Ho ur. If your interactive style is positive

••••• PEARLS

Attitude The standMd InS a~ to patiel1l Qlre wi! wtrt wei, ~ with patients ooder the influence. YOI.I" attitude C¥I help determile if )'01.1" patient aPJ:tOKh wi be accepted or

not"_"~"'.

302 •

CHAPTER 20 Pat ients Under t he Influence of Alcohol or Drugs

and nonjudgm ental, th e patient is more likely to be cooperative and to allow all the appr()priate Illedical intervent ions, thus decreasing on-scene time. As noted before, all the substances that are abused can cause an altered mental state. When interacting wi th patients yo u must be prepared to deal with euphoria, psychosis, paranoia, or confusion and disorientation. Some strategies to help you gain your patient's cooperation follow: • Ide ntify yourself to pat ient s and orien t them to their surroundings. Tell the m your name and you r title, for example, " EMT, Paramedic." Ask them their name and how they would like to be addressed. Avoid using generic nameS like " Bub" or " Honey." With this patient popu lation it may be necess.'u y to orient them to place. date, and what is go ing on. These patients may need to be reoriented frequentl y.

• Treat the patient in a respectful manner and avoid bein g judgmental. O ft en a lack of respect can be heard in the tone of your voice or how you s.'ly things, not just in what you say. Never forget that you arc there to save li ves; this includes all patients. You art not a police officer (do not gather evidence) and you arc not there to pass judgment on the patient's worth to society. Also take care not to destroy evidence. • Acknowledge the pat ient's con cerns and f('("li ngs. The patient who is scared or confused may be more com fortable wi th what is taking place if you recognize and 'ldd ress these feelings. Be ge ntle but fi rm. Explain all treatment interventio ns before they arc performed. Be honest. Backboards and extrication collars are uncomfortable, and IV lines hurt. • Let your pat ients know what will be requ ir<.>d of them . Fo r instance, they may be co nfused and not real ize thai they need to hold still while you arc trying to Slabilii'-c them on a backboard. • Ask closed-ended quest ions when getting your history from the patient. These are qut'stions that can be answered with a yes or no. These patients may only be able to concentrate fo r short periods of lime, and they may ramble when asked open-ended questions that req uire a fu ll answer. Consider gelling as much of the history as you ca n from relatives, friends, or bystanders. Th is may help improve the reliabili ty of what you discover. Get as much relevant histo ry as you can , but do not delay transport.

THE UNCOOPERATIVE PATIENT A slllall percentage of your patients may be uncooperative. You mllst be finn wi th these patients. Set limits to their behavior, and let them know when their behavior is inappropriate. Co nsider physical restraint o nly if YO lL are not able to secure eno ugh cooper'llion to provide adequate ca re for your patient. O ft ('n a show of fo rce may be enough to convince an un cooperative patient to allow medical ca re to be provided. First, chLock with your loe.1i jurisdictio n to determine what protocol yO LI mllst usc when restraining patients aga inst their will. Most municipalities allow police officers to place people in custody if they are a threat to themselves or others. Severel y injured trauma patients who refu se o r wiJl not cooperate with ca re can be considered a threa t to themselves. Once the decision has been made to restrain the patient , it must be carried out with care. Securel y strapping a patient to a backboard with usc of a cervical collar and head motion-restriction device wi ll serve to restrain most patients. C'lution must be taken not to worsen an}' current injuries or to innict any new ones. There is often no good sohltion to th is predicament. Rest rained patients mlly struggle so hard that spinal mot ion restriction is rendered ineffective. The Reeves sleeve is o ne of the few pieces of equipment thai is very effective in provid ing both restra in t and motion restrictio n ( Figure 20-1).

CHAPTER 20 Patients Under the Influence of Akohol o r Drugs _ 303

Crews sho uld plan and practice procL-xiures fo r rcstr:lin ing patients. The trau ma scene is not the plaec to learn I1 CW skills. Reassess restrained patients oflcn . Yo u don't want to be th e o ne providing care fo r a drug- impaired pat ient who dies by asphyxiatio n d uri ng prehospital restraint. The standard ITLS approach to patient care will work wcli, cvcn wi th patients under thc infl uence of alcohol o r d rugs. Ensure that the scene iss.1fe, detcrminc the number o f inju red, and d isco\'er the mech an ism of injury. Usc standard precautions. This patient population incl udes people who arc at high risk fo r infection with hepatit is 13, hepat itis C, and HI V. Follow the ITLS Primary ilnd Secondaq Su rveys as recordcd in Chapter 2. Remember to note any mental status changes that m ight be associated with substance abuse. When perform ing the ITLS Secondary Survey, be su re to incl ude the specifi c areas that ca n provide clues to substance abuse. As with all trauma patients, treatm ent includes the consideration o f oxygen,an IV line, cardiac mo nitoring, and O 2 s.1 turation o r exp ired COl monitoring. Table 20-2 lists d rug categories and associated specific treat ments or areas to pay close attentio n to when substancc abuse is suspected .

FIGURE 20-1 Rec\·csslecve.

~"" Drug CatQgory

SpQcific TreatmQnts and ArQoiIS to ASSQSS

Akohol

Administer IV thiamine and glucose; use D50W if ind icated; watch for hypothermia. Monitor for seizures and dysrhythmias; treat seizures with diazepam or lorazepam Monitor for seizures and d ysrhythmias; treat rhythm disorders Provide rellssurance. Provid e reassurance. Try naloxone', watch for hypothermia, hypotension, and respiratory de pression (C0 2 monitor). Try naloxone' and consider flumazenil", watch for hypothermia, hypotension, and respiratory depression (C02 monitor).

Amphetaminesl Methamphetamine Cocaine Hlillucinogens Marijuana Nacotics/ Opiates Sedatives

' Naloxone should be titrated to the patient's respi rations. Repeated doses may be indicated as the narcotic may last longer than the effects of the naloxone. ~Flumazenil use is controversial; it can precipitate seizures in patients dependent on benzodiazepines. Further, flumazenil use may cause seizures in those who have been using benzodiazepines to prevent seizures and in those patients who have overdosed on tricyclic antidepressants. Flumazenil should only be given on direct order of medical direction.

••••• PEARLS

Managemetrt • Ched Iing«-stick glucose and provide Et:G mtlfIitoring on eYf!f'J patient with ahered mental status. In this population. hypothermia, hypotensioo, ind ~ot)' dep~ are C~ and P'I'IJSI be ueated aggressively.

304 • CHAPTER 20 Patients Under the Influence of Alcohol or Drugs

(Photo , ,,urt('Sy of RoyAJiOtl . MIl)

Joyce, Buddy, and Dan have been dispatched to the scene of a stabbing. They have been to this area many times before to pick up patients after altercations ovel alcohol or drugs. They are told that the patient is covered in blood but is not cooperative. As they respond , they decide to have Joyce act as team leader since she is good at interacting with uncooperative patients. They ca refully don perso nal protective equipment since the police described a lot of blood, and hepatitis and HIV were known to be present among the regulars they treat in th is area. When they arrive they see that the police have the scene under control and are putting a cursing, struggling, handcuffed man into a patro l car. There is a very unkempt man lying on a pallet on the sidewalk. He is actively bleeding from lacerations of the chest and abdomen. There is an impressive amount of blood on the front of his sh irt and trousers. There are several empty wine bottles strewn about. Joyce introduces herself and asks him, "What happened?" "We were drinking together and he hogged all of his wine down and then reached for my boftle. I fold him fa get his own wine and the SOB cut me!"/oyce asks him his name (Cuthbert Mulford), and assures him that he is not in any trouble and the police are only there to arrest the SOB who cut him. She explains that the paramedics are there to help him and take care of his wounds. She asks for permission to examine him and he grudgingly agrees. Since the patient denies any injury other than being cut. they do not apply spinal motion-restriction preca utions. He obviously has an open airway and seems to be in no respiratory difficulty (the odor of stale wine on his breath makes Joyce dyspneic), so she proceeds with the Rapid Trauma Survey. There are no appa rent injuries of the head or face. His neck is nontender. the neck veins flat, and the trachea in the midline. There is equal expansion of the chest, with breath sounds present and equal. There are two 8 - 10 em lacerat ions across his left anterior chest but they do not appear to go into the chest cavity. Heart sou nds are heard and the rate is rapid . with a weak peri pheral pulse. There is a deep laceration across the left upper quadrant of the abdomen with protrud ing intestines. As Joyce lifts his shirt, Cuthbert sees it and says, "He gutted me, did n't he?" Joyce has Buddy apply a sa li ne-moistened dressing and then an occlusive dressing. She conti nues her assessment. She finds no other injuries and 50 she explains to Cuthbert that they wilt have to take him to the hospital to fix his intestines. He seems markedly more sober after looking at his intestines and readily agrees. They carefully move him to the stretcher and tra nsport immedi ately. During transport Joyce bandages his lacerations and starts a precautionary IV line while Buddy takes vilalsigns: BP 110/70, pul se 110, respiration 24, and oxygen saturation 96 percent. Cuthbert states his only medical history is seizu res (a lcohol wi thdrawal?) for which he takes no presc ription medications, has no allergies, and has not eaten in the last 24 hours. " I get my nourishment from cigarettes and a bottle of Sly Fox." The ITLS Secondary Survey reveals no new find ings . Cuthbert's recovery is comp licated by delirium tremens and a wound infection, but he lives to ride with Joyce on many more occasions.

CHAPTER 20 Patients Unde r the Influe nce of Alcohol or Drugs _ 305

Because people who abuse alcohol and drugs freq uently are the victims of trauma (and often the cause of trauma to people who do not abuse alcohol and drugs), you will treat them on almost a daily basis. A patient, caring attitude will save you much grief, but we all know that some people who are intoxicated are sociopathic and no matter what you do they will not cooperate. Many confrontations will not go as well as the case study above. The Reeves sleeve is invaluable for the patient that must be restrained for his own safety. It does not require placing the patient prone and it allows you to manage the airway and give medication and IV fluids. It can be ca rried rolled up in storage unti t you need it; slide a backboard into it, and you have a total body restraint system . Whether or not the patient is sober enough to refuse treatment may be the ha rdest decision to make. Sometimes you, the police, and medical direction have to make the best decision based on the situation. As men tioned above, sometimes there is no good answer.

SUMMARY Knowing the signs and symptoms of alcohol and drug abuse will allow you to recogni7.e the patient who may be impaired from their use. Assessing the pat ient for signs and symp· toms outlined in this sect ion can help you confirm your suspicions. Determini ng that your patien t has abused some s ubstance will allow you to pay attention to speci fi c areas for crit· fcal changes as well as provide life· s.1ving interventions that may be indicated for individ· ual substances. The five interact ion strategies for improving patient cooperatio n are very important whe n dealing with the patient unde r the innuence o f alcohol or drugs, but these strategies shouJd also be used wi th ;1]1 patients. Reme mber that the patient's safety is a pri· ma ry concern. If you must restrain a patient for his o r her safety, do so in a preplan ned manner that is most sensitive to your patien t's needs.

BIBLIOGRAPHY I. Bledsoe. B., It Porter, R. Cherry. 2005. Paramedic care: principles and practice. 2nd cd. vol. 3. Uppe r Saddle River, NI; Prelllice Hall, pp. 414-57. 2. Demel riadcs D., G. Gkiok;ls, G. C. Vdmahos, el al. 2004. Alcohol a nd illici.t d rugs in tra umalic deat hs: Prevelance and association with type and severity of injuries. }OIlnltll o[ ti,e America" College o[Surgeol/s 199(5); 687- 92. J. Miller, T. R., D. C. Lcstina, G. S. Smith. 2001. Injury risk among medical ly identified alcohol and d rug abusers. Ako/lo/ism, Clinical 1111(1 ExperimelJ/(I/ Rese(lrcl" 25( I): 54- 59. 4. Sanders, M. 2001. lo.'losb(s paramedic tc.'I(lbook. 2nd cd., 5.lint Louis, MQ; Mosby, Inc., 1011 - 36.

Joyce, Dan. and Buddy have been dispatched to an ice skating rink whe re a man has been injured in a fight. It' s a cold. wet day. As they re spond , they ponder what sort of injuries

( I'holo cour lC~r of F.duiltrdo l{oll1('ro Ilkks, ~'ID )

they will find, They decide t o have Dan act as team leader. When they arrive they find a large group of teenagers gathered outside the rink, Police are on scene an d have th e crowd under control. Two boys have been in a fight and the injured one was wi nning until they fell down and he injured his wrist. The other got up and ran away when the poli ce arrived. The patient is an 18·year·old who compla ins of a broken wrist and some bru ises on his face. He denies any other injuries. He is not very cooperative and is angry and belligerent. He admits t o drinking "two beers." Dan's general impression is good, since the patient is ambulatory and talking loudly. Joyce coaxes the patient into the ambulance and he sits on the stretcher. He refu ses to remove his coat ("I am too damn cold and my arm hurts!") but does let them strap him into the stretcher in a si tting position. Dan doe s a focused exam of the right wrist an d sees a deformed di stal forea rm fracture with good pulse and sensa tion. He applies a spli nt to the wrist. When he is doing this, the patient begins to hyperventilate and then comp lains of dyspnea and tingling in his hands. He becomes very agitated. Dan is trying to attach a pulse oxim eter and get him to accept a no nrebreather oxygen mask when he co llapses. What is going on here? Keep that question in mind as you read the chapter. Then, at the end of the chapt er, find out how the rescuers completed this call.

INTRODUCTION You will encounter trauma patil'n ts who are found pu lseless or apneic on scenc or who ",r;lsh" ;lnd develop those signs wh ile lInder yOllr care. v"hile it is rare to save sllch a patient, it is possiblt· in certain cases. The chance to s;l" e someone like this is why wc chose th is profession .

THE UNSALVAGEABLE PATIENT Attempting to resuscitate the patien t in tralllll;ltic ca rdiac arrest can put YOll and thc public in d'1I1ger (rapid transport and possible exposure to bloodborne pathogens). Do

307

30 8 •

CHAPTER 21 The Trauma Cardiopulmonary Arrest

1. Resuscitation should be withheld in cases of: a. Blunt trauma with no breathing, pulse, or organized rhythm on EKG on EMS arrival at the scene. b. Penetrating trauma with no breathing, pulse, pupillary reflexes, spontaneous movement, or organized EKG activity. c. Any trauma with injuries obviously incompatible with life (e.g., decapitation). d. Any trauma with evidence of significant time lapse since pulselessness, including dependent lividity, rigor mortis, etc. 2. Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with the clinical condition, suggesting a nontraumatic cause of the arrest, should have standard resuscitation initiated. 3. Termination of resuscitation efforts should be considered (consult medical direction): a. With EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation. b. When transport time to the ED is more than 15 minutes. 4. Special consideration should be given to victims of drowning, lightning strike, and hypothermia. *Joint Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma

not attempt resuscitation unless t here is some chance of the patien t's survival. One review o f 195 trauma patients who presented unconscious, without palpable pulse or spontaneous respira tion, fou nd that patients with sinus rhythm and nondiJal ed «4 Illlll ) reactive pupils had a good chance of su rvival; but of those with asystole, agonal rhythm, ventricular fibrillation , or ventricular tachycardia, there were no survivors (see Bibliograp hy 2). Th ~ Nill iu uai Assu ci;lIiuli ur EMS Physici;ms a11(11h~ A m~ricilll

••••• PEARLS

CArdille Arrest Cardiac arrest followir.g trauma is

U$Ua!ly r.ot due to cardIac disease.

Cullcg~

ufS u rgt:om

Committee on Trau ma have jointl y developed gu idelines for withholding o r terminating resuscitatio n in prehospital traumatic cardiopulmon ary arrest Crable 21- 1). Advanced cardiopu lmonary resuscitation has always been directed toward dealing with a cardi;lC cause for the pulseless pat ient. In the trauma situation ca rdiopulmonary arrest is usually not due to primary cardiac disease such as coronary art ery disease with acute myocardial in farct ion. You must direct treatment by identifying the underlying cause of the arrest, or yOll will almost never be Sllccessful in resuscitation. Use the JTLS Primar), Survey to ident ify the ca use of the arrest and those patients for whom you sho uld attempt resuscitation.

HYPOXEMIA Hypoxemia is the most commo n ca use of traumatic cardiopulmonary arrest. Acute airway obst ruction or ineffect ive breathing will be clinically manifested as hypoxemia. Carbon dioxide accumula tion from inadequate b reathing will playa role in your being unable to resusci tate the patient. Airway p roblems such as those listed in Table 21 -2 lead to hypoxemia by preventing th e Aow of oxygen to the lun gs. Drugs andlor alcohol, o ft en

CHAPTER 21 The Trauma Cardiopulmonary Arrest •

1. Airway Problems a. Foreign body b. Tongue prolapse c. Swelling 2. Breathing Problems a. Tension pneumothorax b. Sucking chest wound c. Flail chest d. High spinal·cord injury e. Carbon monoxide inhalation f. Smoke inhalation g. Aspiration h. Near-drowning i. Central nervous system depression from drugs/alcohol j. Apnea secondary to electric shock or lightning strike 3. Circulatory Problems a. Hemorrhagic shock (empty heart syndrome) b. Tension pneumothorax c. Pericardial tamponade d . Myocardial contusion e. Acute myocardial infarction f. Cardiac arrest secondary to electric shock in conjunction with m inor head t rauma, can result in airway obstruction by the to ngue as weU as by respirato ry depressio n . Careful mo nitoring of the intox icated patient may p revent an arrest situation. The sa me is true o f the patient who is unconscious fro m a head injury. The lax muscles in the pharynx allow the tongue to hIli back and o bstruct the airway. O btain ing and maintai ning an open airway by jaw thrust alo ng with an o ral o r nasopharyngeal airway is paramo unt for p:tticnts witho ut a gag refl ex. Yo u m ay need to use a blind insertio n airway device (Comb itube, LMA. and so o n) but insertion of an endotracheal tube is even better, since it will also decrease the chance of aspiratio n if the patient vomits. Patients with cardiores· pirato ry arrest caused by airway obst ructio n will respond to Advanced Life Support if the anoxic period was not prolo nged . Patients with hypoxia secondary to a breathing problem have an adequate airway, but are unable to oxygenate their blood because they can not get oxygen and blood together at the alveolar capillary membrane of the lungs. This could be fro Tll the fo llowing: • Inability to ventilate, as in a tensio n pneumotho rax, sucking chest wound, fl ail chest, o r high spinal-cord (C-3 o r above) injury. • Lung tissue filled with fluid , as in the patient with aspiratio n of blood o r vo m itus o r adult respiratory distress syndrome (ARDS). Ncar-drown ing patients have hypoxemia early from lack of oxygen, but later their lungs are full of water ( like pulmonary edema o r ARDS). • Lungs fill ed with gas (smoke inhalatio n) th at does not contain the appropriate amo unt of oxygen but instead contains harmful gases such as carbo n mo noxide o r

309

310 •

CHAPTER 21 The Trauma Cardiopulmonary A rrest

cyanide. In addition , the hot vapor can result in pulmonary edema, furth er preventin g oxygenation by increasing the d istance (by alveo lar capillary membrane swel ling) between the red b lood cells and oxygen . • Hypoventilation caused by head injury, ligh tn ing strike, and/or drugs and alcohol. Patients with breathing problems should have aggress ive airway management ana ventilation with high-fl ow oxygen. Ma ny of th ese patients will respond quickJy if th have not been anox ic for too lo ng. A significant number ( 19 percent, in o ne study) ci nea r-drowni ng patients who appear lifeless in the fi eld will eventuaUy have a complete recovery.

CIRCULATORY PROBLEMS

. ---.

PEARLS

A.CLS Protocols Do not rely on Aa5 protocols alone. Protocols should be modified to provide adequate volume replacement and chest decompression when indicated.

Patients with tissue hypox ia because of inadequate blood fl ow will have one o f the causd listed in "Ia ble 2 1-2 . Hemorrhag ic shock (hypovolemic o r empty hea rt syndrome) is tht most commo n ci rculatory cause of the t rauma cardi opulmonary arrest. T he patient with cardiac arrest secondary to perica rdial tamponade will present as p ulscless patient who mayo r m ay not have an electrical complex o n the card iac monitor pli isciess electrical activity ( PEA). The p:lt ient with perica rdi al tamponade may rapid\y deterio rate from shock to PEA to, fin all y, asystole. In pericardial tamponade the ca rdiac output may be so low tha t you canno t feel a pulse. Th e hea rt is squee,..ed by the blood in the perica rdial sac and cannot fill with bl ood befo re each beat because th e p ressure inside the sac (and thus in the heart chambers) is higher than the pressure in the venous system returning the blood to th e heart. T hus there is;1 rap id , weak pulse that will continue to diminish as the tam ponade worsens. The radial pulse may disappear wit h insp imtion (pulsus paradoxus) as th e cond ition worse ns. Early ill the perica rd ial tamp0 Tl:lde syndrome a tiny am ount of blood fl ows fro m the heart with each beat. The main clinical features in isolated tamponade arc p rofo und shock with distended neck veins and normal bilateral breath sounds. In the mo re typical multiple-t ra uma situation, the parient will have associ.ltcd blood Joss and th!! nec k ve in s wil! no t be d istendl.>d . Pati ~ nl S without d ish:l1d cd lll"Ck veins may appea r to be in PEA but will not respo nd to Advanced Cardiac Life Support (AC LS) protocols. Acute myoca rdial infarction and myoca rdial contllsion can produce inadequate blood Ilow (circulation ) by either one or a combinatio n of th ree m echanisms. T hese mecha nisms are dys rhythmias, acute pump f.lilure, o r pericardial tamponade. The patient with a myoca rdial contusio n has usually been in a d eceleration accident. There may be a chest wall or sternal con tusion . A full arrest fro m an electric shock usually presents as ventricular fibrillati o n. It responds readily to AC LS protocols if you arrive in time. The ca rdiac arrest is frequentl y due to the prolonged ap nea that Illay follow electrocution or lightning strike. The victim o f an electrical shock has sulTered severe muscle spasm and may well have been thrown down or fallen a great distance. Thus the sa me systematic approach to th e patient is required ( 0 identify all as" sociated injuries and to give the patient the best chance for a good outcome. Be sure the patient is no longer in contact with the electricity source. Do not become a victim yourself! Patien ts with card io pulmonary arrest related to inadequate circu latio n have either of the foll owing: • In adequate retum of blood to the heart because o f • Increased pressure in the chest ca usin g increased resistance to the venous return to the heart , as in tension pneumo thorax o r pericardialta mponade • Hemo rrhagic shock wi th inadequate blood vo lume to be retu rned to the heart

CHA PTER 21 The Trauma Cardiopu lmonary Arrest _ 311

• Inadequate pumping of the heart because of • Rhyth m d istu rba nces as in myocardial co ntusion, acute myocardial infarction, or elect rical shock • Acute heart fa ilure with pulmonary edema, as in large myoca rd ial co ntusion or acute myocardial infarction

APPROACH TO TRAUMA PATIENTS IN CARDIAC ARREST Trauma patients in cMdiac arrest arc a special group. Most are young and do not have prcexisting cardiac condirions or coronary disease. Ensuring a complete Scene Size-up is impo rtan t as some involve crim inal activity (stabbings. shootings), so carefully rL--cord (after the ru n) your observations of the scene. Some of these patients lllay be resuscitated if YOll arrive soon eno ugh and you pay attention to the di ffe rences from the usual med ical ca rdiac arrest. The ex t remely poor resuscitation rille for tramllil patient s in card iac arrest is probably due to t he fact that many of t hem have been hypoxic for a prolonged period of time before thc arrest occu rred. Pro lo nged hypoxia ca uses such scvere acidosis that the patient wi ll not respond to attem pted resusci tation. Patien ts who suffer cardioresp iratory arrest from isolated head injury usually do not survive. b ut these pat ients should be :lggressivei y resuscitated because the extent of injury (annO( always be determined in the field and, therefore, yOll can no t predin the Ollicome for the indi vidual patien t. (They arc also potential orga n donors.) Patients who arc fOllnd in asystole after massive blunt t rau ma arc dead; they may be pronou nced dead in the field. Children are a special case. \<\Ihile some reports show the sa me dismal results for resuscitation o f child ren in ca rdiac arrest in the fi eld as for adults, one review of over 700 cases of children who received CPR in the fi e ld fo und that 25 percent survived to d ischarge. Th is may be in part because sometimes the pulse is difficu lt to find in a child . bu t is still present. In a ny case, you should be especiall y aggressive in attempt ing to resusci tate children with no palpable pulse.

GENERAL PLAN OF ACTION Afterdetermining unrespo nsiveness, restrict the motion of the cervkill spine and secure the patient's airway. Open the airway with the mod ified jaw th rust. If there arc no respirations. give two fu lJ breaths. If the ai rway is obstructed, repeal the jaw thrust and t ry ventila tion agai n. If the airway is still obstructed by a foreign body, attempt to clear the ain... ay with rour fingers o r a laryngoscope and suction. You will need assistance to maintain cervical motion restrict ion. If th is is unsuccessful, do abdominal th rusts (the patient must be o n a firm surfa ce). There is a chance of injuring the spine if there is an associated vertebral injury. but this is of less co ncern if the patient is d ying of an airway obstruction. (Desperate situations often require desperate measu res.) If still unsuccessful, yOll may attempt cricothyroidotomy or translaryngeal jet vent ilation (if you arc tra ined and p ro tocols allow). If the airway is not o bstructed. give two ful l breaths and t hen check the pulse. If no pulse is palpable, YOLI must begi n cardiopulmonary resuscitation and prepare for immcdi ~ ate transport. Allow two of you r teamma tes to do the card io pulmonary resuscitation wh ile rou get the mon itor and check t he cardiac rhythm. If ventricular fib rillation is present, go ahead and defi brillate at 360 watts/sec (or lise the manufacturer's recommended setting o n biphasic defi brillator). Immediatel y resume CPR. If asystole o r PEA is present or if the ventricular fibri llat ion persists, you should evaluate the patient for the cause of the arrest. If the patient is a victim of blun t trauma, consider

• • • • • PEARLS

Pregnant Patients Cardiac arrest in the pregnant patient is treated the same as in other patienl$. Defibrillation settings and drug dosages are exactly the

same. The volume of fluid needed increases and 4 liters of normal sallne should be given as fast as possible dUMg transport

-. . . .

PEARLS

Proper Response Iv> adequate number of rescuers are

required to handle this situation well: one to drive the ambulance, one to ventilate, one to do chest compressions, and one 10 diagnose and treat the cause of the arrest.

312 • C HAPTER 2 1 The Trauma Cardiopulmonary Arrest

• • • • • PEARLS

Asy$tole Patients found in asystole aher massive blunt trauma are dead. There is no reasonable expectation of resuscitation.

• • • • • PEARLS ITLS Primary Survey The pu!seless Ir.Juma patient requires atttfltion to the IllS Primary Swvey to identift treatable problems in the """,priority-

termination of reSliscitation. If the patie nt has penetrating trauma, check the pupils. 1ft pupils are dilated and nonreactive yO lI should consider termination of resliscitatio n. Resusl citation efforts for patients with injuries incompatible with life or those who have evidenc of prolonged time si nce the a rrest Crable 2 1- 1) should not be in itiated or should have ler mination of resuscitation efforts as directed by your local m edical direction. For pat ients with an organized rhythm on EKG, you must quickly evaluate and treat fo r Ihe ca lise of the arrest. This should be done in the am bu lance during transport, if pos-sible. Follow the ITLS Primary Survey that you follow for every trauma patient.

PROCEDURE

E:!J Initial Assessment and Critical Actions 1. Establ ish a nd control the airway (with a n e ndotracheal tube if possible) and ven tilate with 100 percent oxygen. Wh ile the othe r two rescuers arc ventilating and performing chest compressions, you must systematically look for the correctable cause(s) of the arrest.

2. Look for breathing problems as a cause of the arrest. Answering the following quest io ns will allow you to identify a ny breathing proble ms that may be the cause or a co ntributing factor. a. Look a t the neck: ( 1) Arc the neck veins flat or distended? (2) Is the trachea midline? (3 ) Is the re evidence of soft-tissue t rauma to the neck? b. Look at tbe chest: ( I) Docs the chest move symmetrically each time you vent ilate? (2) Are there chest injuries (penetrat io ns, bruising, flai l segm ent)? (3) If there is spontaneo us respira tion, is there any paradoxical motion noted? c. Feel the chest: ( I ) Is there any instability? (2) Is there any crepitation? (3) Is there any subcutaneous emphysema? d. Listen to the chest: ( J) Are breath sounds present on both sides?

(2) Are the breath sou nds equal? Ifbreath sounds arc no t equal, percuss thccncst.ls Ihe side with the a bsent or decreased breath sounds hyperresonant or dull? If in tubated, is the endotracheal tube inserted too f'lf? If there are distended neck veins, decreased breath so unds on one s ide of the chest, with th c t rachea deviated away from the s ide of the injury, and hype rreso nance to percussion of the c hest on the affected side, then the patient probably has a tension pneumothorax . An imprope rl y posit ioned endotrac hea l tube can cause un equal b reath sou nds and w ill be harmful to t he patie nt . since on ly one lung ca n be venti lated. You should always recheck the position of the endotrachea l tube before you make a diagnosis of tension pneumothorax. It is much more com mon to have a poorly positioned e ndo tracheal t ube than to have a tension pneumothorax. A tension pn eumo th orax requi res need le decompression ( if you ar e trained, and protocols allow). If required, call medical direct ion immediately for permission to decompress. Continue ventila tion with 100 percent oxygen.

CHAPTER 21 The Trauma Cardiopulmonary Arrest _ 313

Do not discontinue chcst comprcssio ns until there is a palpable pulse. Even though you have found a cause, there may be other cau ses for the patient's arrest. O ther breat hing problems (suckin g chest wound, nail chcst, simple p neumothorax ) will be adequatel y treated by endotracheal intubatio n and vcntilation with high- now oxygen. Once you have intubated the patien t, yo u no longer have to sea l suckin g chest wounds or apply ex ternal stabilization to flail s. Remember that positive pressure ven tilation ca n convert a simple pneumothorax to a tensio n pneumothorax. Now that the patient has both an adequate airway and is being ventilated, you may concen trate o n the ci rculatory system . As soon as IV access is o btained, rapidly give 2 liters of normal 5.1 Iine. Once again, do no t delay at the scene. An treatment past establishing the airway should be done during transport. Hemo rrhagic shock is the most common circulatory ca lise of traumatic card iopul monaq' arrest. If th ere is no ex tern al bleeding, the patien t must be ca refully examined for evidence of internal bleeding. Reexamine the neck vei ns. Flat neck veins with sinus tachyGlrdia favor the presence of hypovolemic shock (empty hea rt synd rome). Attempt to sta rt two large- bore IV lin es while en route. If during the chest exam there ,Ire decreased breath sollnds on o ne side with percussion dullness on the same side, this confirms a hemothorax o f such degree that shock will be pT<.'Senl. Obvious bleeding, distended abdomen, multiple fractures, or an unstable pelvis also confirm inadequate volume. If any of these situatio ns exist, assume the arrest is seconda ry to hemorrhagic shock. Transport rapidly with rapid infusion of2 to 4 liters of normal saline. If the neck veins arc distended bu t the trachea is midli ne and breath sounds are equal, rou must suspect pericardial tamponade. Pcnetrating wounds of the chcst or upper abdomen, or contllsions of the anterio r chest, are associated with pericardial and/or Illyocardial contusio n. Attempt to start two la rge-bore IV lines while proceedi ng with all possible haste to the emergenc}' department. Elect rical shock creates a sp<.-cial situation. It usuall y presents as ventricular fibri llation. Cardio resp iratory arrest secondary to electric shock responds readily to ACLS protocols if you arrive before the acidosis is too sc\'ere. Sc\'Cre acidosis can develop rapidly, making resllscitat ion mo re difficult. Do not forget to restrict the motion of the spine. A victim of high-voltage electrical shock will often have fallen from a power line o r have been thrown several fee t by the violent muscle spasm associa ted with the shock. Be s ure the patienl is no longer in contact with the el ectrical source. Do not become a victim!

Joyce. Dan. and Buddy have been transporting an 18year·old boy who seemed to be drunk and have a focused injury to the right wrist until he began hyperventilating and then collapsed during transport to the hospital. As soon as the patient becomes unresponsive, Dan begin s an Initial Assessment. while loyce cuts off his clothes. His airway is open but he is not breath ing. There is no peripheral or carotid pulse an d the neck veins are very distended. The trachea appears to be in the mid line. Joyce (Buddy is driving) immediately begins bag-valve mask ventilation. Dan hears breath sound s only on the right side, and he now sees a stab wound in the left posterio r chest. It is not a

• • • • • PF.ARLS

TratlSport Rapid transport to a Sl.l9ica1 fdty is necessary. Periorm procedures in the ambulance dI.Iing transpOrt. Do not waste va!~ time.

(Pholorou rlayo( l:..:Iu~rdo

Romero I lieU. 11.11»

314 • CHAPTER 21 The Trauma Cardiopulmonary Arrest sucking wound and there is almost no bleeding. The chest is hyperresonant to percussion on the left side. Dan tells Buddy to ca ll medical direction and tell her that they have a you ng male who has been stabbed in the chest and has a trauma arrest from a tension pneumothorax. While Buddy is talking to medical direct ion, Dan is getti ng a large-bore over·the·needle catheter and an Asherman chest seal. With medi direction's permission he inserts the catheter over the th ird rib in the midclavicular line; anteriorly and there is an immediate rush of air. He applies the Asherman chest seal over the need le to act as a one-way valve. The patient now develops a rapid pulse and his blood pressure is 110/70. Dan now has ti me to apply monitor leads, and the patient is seen to have a sinus tachycardia. The pulse oximeter reading is 98 percent. Dan quickly inserts a ta rge-bore IV in the left arm. The patient begins to breathe on his own and make some purposeful movement by the tim e they get to the hospita l.

Th is case is loosely based on a real case in wh ich a young man died of a tension pneumothorax after having been allowed to go to jail from the scene of a fight. It was wi nter and the paramedics did not remove his coat, since he did not compla in ofa ches injury. The young man did not realize he had been stabbed at the time. When he collapsed in jail it was too late to save him. This is a good example of how an intoxicated patient ca n throw you off of your usual exam. Luckily for Dan, he observed the colla pse and rapid ly repeated the Initial Assessment. He Quickly found the cause of the arrest and performed the correct life· saving treatment. Doing a disorganized survey at this time would have been a fatal error.

SUMMARY The trauma patient in cardiopu lmonary a rrest is usually suffering from a breathing or cir· culatory problem. If you arc to save this patien t, yo u must identify t he cau se of the arrest with Ih e ITLS Primary Sur ve),. and Ihen r:lpidl)' tra nspo rt the patient while performing those p rocedu res that specifically address the ca use of the arrest. While it is very rare t sllccessfully resuscita te a patien t suffering from il trauma arrest secondary to h emorrhagi shock, attention to deta il w ill allow you the best chance to " bring one back from the dead, w h ich is the g reatest challenge and g reatest satisfaction in EMS.

BIBLIOGRAPHY l. American Heart As.<;ociation. 2005. International Consensus on Cardiopulmonary RI.:SIISCiI3-

tion (CPR) and Emergency CarJ iO\'ascualar Ca re ( ECC ) Science with Treatment Recommendatio ns. Circli/(llioll 1 12 ( 22): 111 - 1 to 111- 136. 2. Cera. 5., G. Mostafa, It Sing, el al. 2003. Physio logic I'rcdiclors of survival in post-traumalic arrest. The Americtlll Surgcon 69: 140-44. 3. J-Iopson. L, E. Hirsh, J. Delgado. et ,II. 2003. Guidelines for withholding or terminalion ofresuscitation in prehospital traumatic card iopu lmOll;lT), ,urest: loint position statement of tile National Association of EMS Physicians and the American ColIl'ge ofSurg~'Ons Com miltl'f on Trauma. /mmwl of fhe American Col/eKe 0fSIITjiCOIIS 196: 106-12. 4. Perron, A. D., R. Sing, el a!. 1997. Research forum abSlracts. Predicting survival in pediatric trauma patients receivi ng CPR in the prehospital setting. Ann(//sofE,III'rgcIICJ' Medi6m' 30: 381.

CHAPTER

Joyce. Buddy. and Dan have been dispatched to a bar where a man has been injured in a fight. As they respond , they decide that Buddy will be team leader. and they don personal protective equipment, since they expect the patient to be bloody. When they arrive they find that the police are already there and have the scene under control. Sitting in a chair is a young man who has been beaten and "stomped" by motorcycle gang members. As they approach, Buddy's initial impression is not good. The patient is bloody and is struggling to breathe. The patient answers them appropriately when they introduce themselves. They ask him not to move until they finish examining him. Joyce stabilizes his neck with her hands and asks Dan to apply a nonrebreather oxygen mask. The airway is open but there is poor movement of air. There is a rapid, weak peripheral pulse and an obvious large flail segment on the left side of the chest. Buddy instructs Dan to get the backboard and the Kendrick extrication device (KED) to use to splint the flail chest. He begins the Rapid Trauma Survey. The face has bruises and ab rasions all over and there is dried blood in the nose, but the active bleed ing has stopped. He appears to have facial fractures but the airway is not compromised. The neck is bruised and tender but with no obvious deformities. Neck veins are flat and the trachea is midline. The breath sounds are decreased on the left side but heart sounds are normal. The abdomen is tender to palpation but not distended, and there are no masses felt. The pelvis is stable and nontender. The extremities are bruised but there is good PMS. The patient has good sensation and movement in his fingers and toes. The KED is applied to stab ilize the flail chest. The patient says the pain is much improved. The team then moves the patient onto the long backboard and transports immediately. Joyce drives. Vital signs taken en route are BP 90/ 50. pulse 140. respiration 36. and pulse oximete r reading 95 percent on 100 percent oxygen. The cardiac monitor shows sinus tachyca rd ia. Buddy starts an IV with a large-bore catheter. Before the safety device is set. the patient becomes combative. causing Buddy to stick his hand with the bloody needle. What should he do naw? What tests

will need to be done? What sort of information should be recorded? What is the

worst that can happen? Keep these questions in mind as you read the chapter. Then, at the end of the chapter, find out how the rescuers completed this call.

316

CHAPTER 22 Standard Precautions in the Preho spital Setting _ 317

INTRODUCTION EMS perso nnel have always faced risks when ca rrying o ut their jobs. These risks have mostly involved highway hllZards, fi res, downed electrical wires, tox ic substances, a nd scene security problems. The prov ision o f pati ent care Illay p resent th e possibility of ex posure to blood bo rne and ot her d iseases. Fo rtunately, there are p recautions that ma}' be taken to ma rkedly reduce these risks. Add itiona lly, if perso n.11 protective eq ui pmen t could not be used o r fa il ed. trea tm ent is 'lVailable to reduce the risk o f acqu iring these di seases following an exposure cvcn t. Expos ure docs not mea n intection; ex posu re can be

treated. The spectrum of d iseases to which you arc potentially exposed is beyond the scope of this book. However, the three m ost com mon ty pes of viral infect ions are appropria te to discuss in conju nct io n wi th tra uma management , since their modes of spread arc p rimarily by co ntam inated blood and other potentiall}' in fectious materials (OP IM). They arc hepatitis B (HBV), hepat itis C (H llC), and HIV infection. Bod y fluids th at d o not pose a risk fo r H8V, H8C, and HJV are tears, sweat, saliva, urin e, stool, vomitus, nasal secretions, and sputum unless they contain visibl e blood contamination .

HEPATITIS B The term viralllcpnlilis is used to dt'scribe a group of vi ral infectio ns involving the liver. At least five types of vi Tllses have been described: hepatitis A, B, C, D, and E. Hepa tit is A and E are spreople in the Un ited 5t,lIes are infected each year. In 1995, OS HA reported that about 800 health-ca re workers acquired the d isease thro ugh occupatio nal exposure. Because of the un ive rsal vaccinatio n program, these nu mbers have decreascd by almost 90 percent si nce 1992. Followin g acute infect io n, 5 to 10 perc('nt of these p~\ t ie nts cont inue to be chron ic carriers of the viru s. These carriers arc potentia lly infec tious. HBV is sp read b)' con tact with conta minated blood o r O PI M (o ther po tenti ally infectious material ), sex ual transm ission, and d irect contact with a contami nated item and nonilltaci skin. Infect io n usuall y occurs fro m cont am inated need le sticks o r th rough sexual contact. There is an estimated 6 to 30 percen t chance that health-ca re workers who arc exposed to a nccdlestick by HBV-co nt ami nated blood \vi ll develop hepatitis B infect io n if the}' have no t received their vacc ine or have not develo ped an appropriate imm une response to the vacci ne. Passage o f the Needlestick Safety and Prevention Act of 2000 by the U.S. Co ngress requires the use of needle-safe o r needleless devices. This legislat io n has cut the nu mber o f sharps injuries by mo re th.1Il half since 2003. Infectio n ca n also occu r by contacting infectious bloody secretio ns with open skin lesions o r mucosal surf.lees. Routine testing of donor blood for H BV makes transm ission from blood transfusion very rare. Although H BV infec tion is uncommon in th e general po pu lat ion. members o f certain groups arc considered much more likely to ha rbo r the virus. High-risk groups arc im mi grant s from areas where HBV is prevalent (Asia , Pacific Islands), incarcerated individuals, institutio nal ized patients. intravenous d rug lIsers. male homosexuals, hemophiliacs, household contacts of HBV patients, and hemod ialysis pa tients.

- - . --

PEARLS

An EMS Standard

AJ patieflts Me potential carriers of infectious disease. That is why standard p-ecautions ¥e the EMS standard /Of practice.

-----

PEARLS

I mmu 1I;zat;oll$

Be prepared! Stil)"Up to date on .a of )'011" immunizations.

318 •

CHAPTER 22 Standard Precautions in the Prehospital Setting

-. --.

PEARLS

OPIM The itbbre'o'iation 'OPIM" rm to other (than blood) pot~ infectious materials. Those materials ~,

• "'~ I\id (CSf) Synovial fluid

• Amniotic fluid • Pericard"W IIuid

Pleural fluid • Any fluid with gross .,;sible blood

In the United States. the Occupational Safety and Health Administ ration (OSHA) mandated in 1991 that all employers of health-care workers are required to offer HBY vaccine to any health-care worker who is at risk of occupational exposure to blood and OPI M. This must occur with in 10 days of being hired. This vaccine offers lifelong protection. Vaccines ava ilable today are recombinant; they contain no human components. A titer (blood test) is performed I to 2 months after completion of the vaccine series to document response to the vaccine. If positive, no further titer testing is needed or recommended. The vaccine is safe and produces immunity in over 90 percent of people vaccinated. Th e seco nd form of protection is hepatitis B imm unoglobulin (HBl G). This preparation contains antibod ies to HBV and prov ides temporary, passive pro tection against HBV. HBIG is only 70 percent effective and when effect ive, provides protection for only 6 months. HBI G is used o nly when th ere has been a significa nt exposure to HBY in an unimmunized person but is given in conj unction with vaccine to offer full coverage postexposure.

HEPATITIS C The hepatitis C virus (HCV) was identified in 1988-1989. This virus is thought to be respo nsible for the majo rity of what had been identified as non -A, non-B hepatitis infections. The incubation period is 6 to 7 weeks. Antibodies to the HCV have been used 10 identify pat ients with previous Hev infection. Those exposed to Hev are tesl-positive 5 to 6 weeks after exposure. Prior to 1992, HCV was the leading cause of hepatitis resulting from blood transfusions. In addition to being spread by blood transfusion, the virus also appears to be spread by sharing of intravenous needles. sexual contact. tattooing, and body piercing. much like HBY. Health -care workers can acquire infection through hollow-bore necd lesticks with contaminated needles. The likelihood of becoming infected wilh HCV after a single highrisk needlcstick is estimated at 1.8 percent. This risk is furth er reduced by the use of nccdJesafe devices. HCV infection tends to be less severe than HBV during the init ial infection. However, there appea rs to be a greater likelihood of becom ing a chronic ca rrier of Hey following infectio n. Liver failure and cirrhosis occu r in 10 to 20 percent of chronic HeV earners. There is cu rrently no vacci ne available to prolect against HeV infection. Evidencc suggests that there is no protective effect pro\' ided by administering immune globulin following exposure to HeV. Now, rapid HCV testing can be performed on the sou rce patient and if positive, the exposed provider can be offered a follow-up test (HCY-RNA) in 4 to 6 weeks post exposure. This latter test detects the virus itself. This reduces the concern about having acq uired the disease to 4 to 6 weeks instead of 6 illonths of follow-up. Treatment is available for people who acquire the disease. Current treat ment is with Pegasys, a combination of lo ng-acting interferon and another antiviral agent , ribavirin. Together, this treatment has resu lted in 56 percent of persons clearing their in fec tion.

HUMAN IMMUNODEFICIENCY VIRUS INFECTION HIV infect ion is caused by the human immunodeficiency virus (HI V). Patients with HIV infect ion develop a defect in their immune system. This predisposes the HIV-infected patient to a variety of unusual infections not genera lly seen in healthy patients of similar age. Patients infected with HI V ca n present w ith a wide spectrum of clinical man ifesla-

CHAPTER 22 Standard Precautions in the Prehospit al Setting lions. Many pat ients with H1 V infectio n arc asymptoma tic. However, any patient \vho carries HI V, wheth er he manifests sympto ms of AIDS or nOI , can transmit the virus. HI V patients being treated with curren! drugs may be virus neg:ltive and as such, pose a min ute risk. HIV appears to be transmitted in a manner similar to HBV. Although the virus has been cultured from a variety of body fl uids, o nly blood has been implicated in the transmission of the vi rus in the workplace. This is because o ther body fl uids do not ca rry enough virus particles to t ransmit the disease. Semen and vagi nal secretions have been shown to transm it the virus during sexual act ivity. but this sho uld be of no concern in the workplace. Th ere is no evidence to suggest that the HI V is transmitted by casual contact. Transmissio n 10 hea lth -care workers has been documented only after accidental pa renteral exposure (needlestick) or exposure of mucous membranes and opcn wounds to large amounl s of infected blood. Measurable risk dat'a for occupatio nal exposu re is 0.3 perce nt for needlcstick injuries and 0.09 percent for IllU CO US membrane exposure. There is o ne documented case of transmission fro m infected blood on nonintac! skin. Th is case was reported in 2002 and involved a health -care worker wilh extensive dermatitis who did not always use gloves approp ri ate when caring fo r a patient coi nfected with HI V and HCV. 1-1 IV appears to be different from the hepatit is B virus in two ways . • HIV does not survive outside the body. No special clean ing agents are requi red . • HI V is transmitted far less efficiently than HBV. Several groups have been iden tified as having a high risk of HI V in fec tion. These include male ho mosexuals or bisexuals, intravenous drug abusers. pati ent's who have received blood transfu sio ns o r pooled-plasma products (such as hemophiliacs). and heterosexual co ntacts of J-II V-positive people. However. because of the difficulty in identifying HI V-in fected patients. all contacts with blood and OPIM should be considered a potential HIV exposu re. Th is concept (all patients are potentially infective) is why standard preca uti ons are "universally" applied. There is currently no available vaccine to protect aga inst HIV in fection. Antiretrovi ral drug regimens, though not a cure, have been shown to prolong the li fe of 1-1 IV/AIDS patients. So me studies have suggested that antiretroviral agents may reduce the risk of HI V transmission in health -care workers if ad mini stered immedi ately fo llowi ng a significant exposure to HIV-i nfec ted blood and OP IM. The decisio n to administer such agents should be based o n the nature of the exposure, the likelihood that the patient is infected with HIV, and the du ration of time follow ing exposure (Figu re 22- 1). In general , hollow-needle exposures are more significant than solid instruments (such as a scalpel). If the exposure meets the CDC cri teria for offerin g drugs postexposu re to the healthcare worker, they can be admi nistered with in " hou rs but not days." Employees nccd to be counseled about the side effects and the unknown issues involving the usc of these d rugs befo re they arc started. Baseline lab work also needs to be drawn. This can all be avoided by performing rapid HIV testing on the source patient. This is the standard of care and prevents a health-ca re provider fro m being placed on these d rugs awaiting blood work o n the source. Remember, aU postex posure medical fo llow-up begins with tesli ng the sou rce, not the exposed employee.

TUBERCULOSIS From 1985 to 1993, the incidence of active tuberculosis increased significantly to over 25,000 cases in the United States. This was the result of an increase in cases among people infected with HIV and an increase in immigra tion of people from areas where tuberculosis in fection is endemic (Asia, L.1tin America. the Caribbean. Africa). Beca use of better

319

320 • CHAPTER 22 Standard Precautions in the Prehospital Setting

Highest Risk Recommend Antj-HIV therapy

End-stage HIV infection AND Deep injection with hollow needle

Increased Risk End·stage HIV infedion AND Superficial wound with hollow needle OR Solid needlestick OR Contaminated IV line OR Other sharp instrument or puncture OR Open skin or mucous membrane

Off., Anti· HIV therapy: possible benefit

Deep injection with hollow needle AND Known HIV carrier OR High-risk source (prisoner, IV drug user, homosexual or bisexual, hepatitis)

Low Risk

Superficial wound with hollow needle OR Solid needlestick OR Contaminated IV line OR Other sharp instrument or puncture OR Open skin or mucous membrane AND Known HIV carrier OR High-risk source (prisoner, IV drug user, homosexual or bisexual, hepatitis) OR Unknown source

1----l~~1

Offer Antj·HIV therapy; benefit unlikely

End-stage HIV infection AND Intact skin

No Risk Known HIV carrier or unknown source AND Intocl skin OR Urine OR Saliva

/-- - -;,..

No anti·HIV therapy

FIGURE 22· 1 Risk assessment for anti· lilV therapy following blood and body fluid exposure_

CHAPTER 22 Standard Precautions in the Prehospital Setting _ 321 public health measures, tuberculosis has been declining in the last several years. Cases decreased by 58.8 percent from 1997 to 2004 . In fact, the number of cases in 2004 was the lowest ever reported in the United States. Risk fa ctors for tuberculosis include homeless patients, certain immigra nt populations, patients at risk for HIV infectio n, and people who live in congregate settings (correction facilities, nursi ng ho mes, homeless shelters). On a global perspective, tuberculosis is still the deadliest infectious disease with 8 million new in fectio ns ann ually and 3 million deaths. Tuberculosis is caused by a bacteri um, Mycobacterillm fIIbercll/osis, which is spread fro m .111 in fected person to susceptible people through the air, especially by coughing or sneezing. This is 110/ a highly communicable disease. Con tract ing tuberculosis requires prolo nged direct contact, as in a family living situation. Only persons with active infection of the lung o r throat spread tuberculosis. II is esti mated that up to 5 percent of health-care workers wilJ test positive for tuberculosis when worki ng in high-prevalence envi ro nments. Cli nical manifes tations o f the disease become apparent only when the pa tient's immune system fa ils to keep t he bacteria in check. The bacteria then begins to infect the lungs and may spre
PRECAUTIONS FOR PREVENTION OF TRANSMISSION OF INFECTIOUS AGENTS "Standard precautions" refer to t reating everyone (incl uding you) as if they arc infectious. Your goal is 10 prevem the spread of infl'Ction from you to th c pal ient and fro m the pa tient to YOll . In loday's environment, yOll mllst use preca utions fo r each and every patient. Equipment uscd is task based Crable 22-1 ).

PROCEDURE

00

General Considerations

I. Be knowledgeable abou t infection fro m hepatitis B, hepatitis C, and HI V. Understand

their etiologies, signs and symptoms, routes of transmission, and epidemiology

• • • • • PEARLS

TB If your patient has a pef5islenl cough plus other symptoms wggestiore of TB, place a mask on the patitnt, flOt

on yoooeIf. You should weara mask il lIle patient requires oxygen and annoI wear a mask.

322 •

CHAPTER 22 Standard Precautions in the Prehospital Setting

Task or Activity

Gloves

Gown

Mask

Eyewear

Bleeding control with spurting blood

Ves

Ves

Ves

Ves

Bleeding control with minimal bleeding Emergency childbirth Blood drawing Starting IV line ET intubation or use of BIAD

Ves

No

No

No

Ves

V.s

Vo,

Yos

Ves Ves Ves

No No No

No No

No No

Oral/nasal suctioning, manually cleaning airway Handling and cleaning instruments with microbial contamination Measuring blood pressure Measuring temperature Giving an injection

Ves

No

No, unless splashing is likely No, unless splashing is likely

No, unless splashing is likely No, unless splashing is likely

Ves

No, unless soiling is likely

No

No

No

No

No

No

No

No

No

No

No

No

No

No

"From U.s. OSHA Guidelines

(relationships of the various facto rs determining the frequ ency and distribution of a disease). 2. If you have open or weeping lesions, take special precautions to prevent exposure of these areas to blood or OPIM. Lesions should be covered with a bandage. If these lesions cannot be adequately protected, avoid invasive procedures, other direct patient care activities, o r handling of equipment used for patient care. You are placed on work restriction. 3. Perform ro utine handwashing before and after all patient contact. Wash hands as soon as possible following exposure to blood o r OPIM. A1cohol· based foam or gel is best for in -field use. No artificial nails or extensions for patient care providers (see reference 2 at the end of this chapter). 4. Become immun ized against the hepatitis B virus. 5. Report any exposure event to your designated infection control officer.

CHAPTER 22 Standard Precautions in the Prehospital Setting _ 323

PROCEDURE

00

Personal Protection During Patient Exposures

l. Wear gloves if exposure to blood o r O PI M is anticipated. This precautio n should be

taken when performing an invasive procedure o r hand ling any item soiled with blood or body fluid s. Almost .111 trauma patients arc risks for exposure to blood or body fluid s. 2. Disposable gowns, masks, and eye coverings are IlL'Cessary on ly when extensive contact with blood or body Auids is anticipated. These prec.m tio ns arc advised when spraying, or airborne spread of blood or body fluids is likely (such as with endotracheal intubation, blind insertion airway devie(', vagina l deliveri(·s. and major trauma).

-. . . .

PEARLS

3. When treating an y pat ient with respiratory complain ts. mask the pat ient wit h a surgical mask or nonn'breather oxygen mask. It is al so im po rtant to get a travel hi story.

Artificial Vetltilntiotl Be prepared! Have appropriate barrier deo.kes with 'fOJ 50 YQ'J are not required to do ~to-mooth breathing. HoY.rewr, you have an

4. Di rect mouth -to-mouth ventilation of pati ents during CPR is d iscouraged. Use disposable mouthpieces when artificial vent ila tion is indicated. However. if not avai lable or not working, mouth-to- mo uth is to be performed. Do not let the patient die because you were not prepared.

obligation to perform ITJClIJtiI.tomouth resuscitation if your pat:ent needs it and yw forgot your equipment

PROCEDURE

00

Handling and Cleaning of Items Exposed to Blood or OPIM

I. Prevent sharps injuri es by using need le-sa fe or need le-less devices. It is the hlw and

in your best interest. 2. Any dispos,1ble eq uipmen t such as masks. gowns, gloves, mou thpieces, and airw.lYs thai have been contami nated by blood or O PIM should be collected in an impervious plastic bag. These plastic bags should then be disposed of accord ing to stat(' defini tions of med ical wasle, in proper waste contai ners available in hospital emergency departments or other health -care locations. No ndisposablc gowns can be laundered using simple laundry procedures. Yo ur hospital should have linen bags o r linen containers designated fo r contami nated gow ns. etc. 3. With a low-sudsin g detergent wit h a n('ut ral pH . wash any surface spil ls on nondisposable equipment that docs not usually come in contact with skin or mucous membranes. T he eq uipment should then be wet down o r soaked fo r 10 minutes in a 1;100 dil ut ion of ho usehold bleach (o r 70 percent isoprop)'1 alcohol). In this concentration , bleach will not cause corrosion or metal objects ( U.S. Center for Disease Con trol and Prevcntion , 1989). 4. Using a low-sudsing detergent with a neutral pH , wash no ndisposable medical devices that will frequently contact skin or mucous membranes. Then soak them fo r 30 to 40 minutes or more in 2 percell t alkaline gluta raldehyde (e.g., Cidex) or simi lar sol utio n in a well -venti lated arca , rin se in sterile water, and package u ntil reusc. PROCEDURE

00

Reporting Accidental Exposure to Blood or OPIM

I. Thoroughly w,lsh o r irrigate the exposed area immedia tely following an exposure to

blood or cont aminated body fluid s. In the United States, you must contact your designated offi,,'r (mandated by fcdemllaw. March 1994 ). All employers of health -care

324 • CHAPTER 22 Standard Pre cautions in the Prehospital Setting

REPORT OF EXPOSURE TO BLOOD OR OPIM NAME OF EMS PERSONNEL ________________________________________ NAME OF EMS SERVICE _________________________________________ 551 _________________________________________________ (WORK) ADDRESSOFEMSSE~~V~'C~E~==================~~~~~~~~===== TIME OF EXPOSURE ______

PHONE NUMBER (HOME) DATE OF EXPOSURE

NAME OF PATIENT _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ __

NUMB"E;R~==============:;;:~========

HOSPITAL 10 PATIENT ADDRES~7.

PHONE NUMBER (WORK) _ _ _ _ _ _ _ _ _ _ _ _ (HOME) ____________

ROUTEOFEXPOSURE: __~~------~----~----------------------­ ( ) Parenteral exposure (needleStlCk or sharp Instrument) ( ) Mucous membrane ( ) Open skin ( ) Intact skin ( )OIh6< _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ TYPE OF FLUID: ( ) saliva ( ) blood ( ) emesis ( ) othe,"'________________________________ ( ) stool ( ) urine SOURCE OF EXPOSURE: H1V: ( ) Yes ( ) No ( ) Unknown ( ) Unknown ( ) Acute ( ) Chronic Carrier Hepatitis B: ( ) No ( ) Unknown Hepatitis C: ( ) No ( ) Chronic Carrier ( 1Acute ( ) Yes Tuberculosis: ( ) No RISK FACTORS: ( ) IV Drug Abuser ( ) Homosexual ( ) Hemophllia ( ) Dialysis Patient ( ) Sexual Contact of the Above ( )OIhe'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ HIV Test:

( ) Pos.

( ) Neg.

( ) Unknown

Date of HIV Test: -:-:~--------,_:_c_------__:__:__-----------------------HBsAg: ( ) Pos. ( ) Neg. ( ) Unknown DruemHBsAgTest _____--:________~----__--__--__----~------~---DeSCription of Circumstances Surrounding the Exposure, Including Measures Taken After Exposure:

INSTITUTION NOTIFIED:

==c,--____________= =-:= = = -:-:= ,-_______

PHYSICIAN OR RESPONSIBLE PERSON: ________ DATE OF NOTIFICATION: TIME OF NOTIFICATION: ______ NAME OF EXPOSED PERSONNEL DATE __________________ SIGNATURE _________________________________________________

FIGURE 22-2 Sample report (orm.

CHAPTER 22 Standard Precautions in the Prehospital Setting •

workers must have a designated officer ( DO). The des ignated officer will deal with the incident and the medical facility from this point. 2. The DO will make the fi rst determination rega rd ing whether or not an exposure occurred. The DO will notify the receiving facility of the possible exposure at the time of the incident. The DO will ask the fucility to cooperate in determining the serologic status of the source. In some areas, informed consen t need not be obtil ined to determ ine serologic st,ltus of the source. Know your local laws. 3. Write a report of the incident as soon as possible. The min imum information that should be recorded on the report is included in Figure 22-2. The writ1en ambulance report Illily be used to supplement. but not replace, the incident report. [n the United States, you will fill olll a confiden tial exposure report form. On ly the exposed employee, the DO, and the treating physician arc allowed to see the for lll. An exposed employee has become a patient and has a right to privacy. 4. Blood tests (if any) to be done onlhe exposed employee depend on reports of testing of the sou rce patient. If the results of rapid H IV testing arc negative, then no fu rt her testing of the employee is needed. If the source patient is posit ive for HIV, then the exposed employee shou ld undergo HIV serology determi nation at the time of the incident. Repeat testing should be done at I month, 3 months, and 6 months. If the source patient is HeV positive, the exposed employee can be tested for HeV in 4 to 6 weeks. If the source patient is HBV positive and the exposed care provider has 1I0t already been immunized, hepatit is B vaccine should be administered. The adm inistration of HBI G shou ld be determ ined by the serologic testi ng of bot h the source (where possible) and fhe exposed health-care provider, as well as by the assessment of the risk of the exposure.

Joyce, Dan, and Buddy a re transporting a male patient who was beaten severely and has a flail chest. As he is starting the IV, Buddy accidentally sticks himself wit h the catheter need le. He finishes connecting the IV fluids and tapes the IV in place and immediately washes his hand thoroughly. He continues his care of the patient. The SAMPLE history reveals that the patient was beaten by a gang of men but did not lose consciousness. He complains of pain "aU over." He has a history of HIV infection but has never been told that he has AIDS. He also had "hepatitis," but does not know which kind. He takes several medications for his HIV but does not know their names and does not have them wi th him. He last ate an hou r ago. He has no known allergies. An IlLS Secondary Survey reveals that the a bdomen is becoming distended and more tender. The blood pressure has dropped to 70/40. Buddy reports all of th is to medical direction, who instructs him to give enough IV fluids to maintain a blood pressure of 80- 90 systolic. The patient does not improve with 2 liters normal saline en route and is taken directly to surgery when they arrive at

325

• • • • • PEARlS

Reporting nil Exposure Irr,me&te~ report to your

designated officer (know who 1M; isl ¥ry possible exposure to blood or OPIM Of an airborne tr~

disease.

326 _ C HAPTER 22 Standard Precautions in the Prehospital Setting

the hospital. The patient has a fractured liver and a hemothorax as well as the flail chest. He requires 10 units of blood and survives surgery but later dies of pneumon ia. His blood is positive for HIV and for hepa titis B. Bud dy has already been immunized for hepatitis B. He is offered an ti-H IV therapy but he declines and signs a declination form. He is counseled by the med ical director of infectious disease and is followed by him for a year. Buddy has HIV tests done immediately and at 1. 3. and 6 months afterwards. He remains seronegative.

All health-care workers should be immunized against hepatitis B since the im munization is very effective and without it there is one chance in fou r of contracting hepatitis B if exposed . In contrast. there is no immunization for HtV but there are only three chances in 1,000 of contracting the disease if exposed to a large hollow-needle stick. with visible blood . and the source has a high titer oflJirus in the blood. This patient was a low ri sk for transm ission because he was taking his anti-H IV medications and thus should not have had a viral load in his blood. Buddy's refusal of anti· HIV medication was based on his consideration of the toxicity of the antivira l drugs being offered and a lso the low risk of infection in this situation_

SUMMARY Li ke most health -care workers. you are at ris.k of exposure to many contagious diseases. Because of the presence of blood and contaminated secretio ns in many t ra uma victims, you must take extra precautions to avoid exposure to the viruses that ca use hepatitis n, hepatitis C, and H IV and to the bacteria that ca lise tuberculosis. Knowledge of the modes of exposure, as well as adherence to barrier precau tio ns,or postexposure medical follow-up will reduce your risk of contracting any of these infections. In the United States, the recent standards rdeased by OSHA make adheren ce to t hese precautio ns m ~1Il dator y for healthcare workers at risk for exposure to contami nated blood o r OPIM wit h the exception of not delaying care if pe rso nal protective equipment is not read il y av'lilablc.

BIBLIOGRAPHY I. NIOSI-I Alert. 1997, June. l atex allergy. 2. U.S. C{""nt el"$ (o r Disc-usc Control und Pren-nlion. 2002, October 25. 1·land Il)'!;ienc guideline$. 3. U.S. Centers for D iS('a.se Control and Prevention. 2001. Updated U.S. Public Health Servia'

guiddines (or the m
4. U.S. Center for Disease Control and Pre\·ention. 1989. Guidelines for Publk Safety. 5. U.S. Congress. 2000. NeedJestick Safety and Prevention Act. 6. U.S. Department of Labor. 200 I, NO\'cmber 27. Compliatlce rlin'ctil't' for occllplltiomr/ exposllrr to i1foodlJom e plltlrogm5 (CPL 2-2.69). 7. U.S. Publk Health Service. 2005, December 30. Guidelines for the prcvention of transmission of M ycolmcwrillm tIIi1CrCU/05is in health-care senings.

Optional Skills Donna Hastings. EMT-P (Optional Skills 1-8) Roy L. Alson. PhD. MD. FACEP (Optional Skill 9)

OPTIONAL SKILL 1: Digital Intubation Objectives Upon completion of this Skill Station. you should be able to: I.

Recite the indications for performing digital intubation.

z. Perform digital intubation. The original method of endotracheal intubation, quite widely known in the 18th centu ry, was the "'tactilen or «digital" technique. The intubator merely felt the epiglott is with the fin ~ gers and sUpped the endotracheal tube distally through the glottic opening. Recently, the technique has been refined and demonstrated to be of usc for a wide variety of patients.

INDICATIONS Digital orotracheal intubation is particularly useful for deeply comatose or cardiac arrest patients who: • Are difficult to position properly. • Are somewhat inaccessible to the full view of the rescuer. • May be at risk for cervical-spine injury. • Have facial injuries that distort anatomy. • Have copious oropharyngeal bleeding or secretions that render visualization difficuh. You may prefer to perform digital intubation when you are confident of your ability with this technique or when a laryngoscope fails or is not immediately available. The technique is most val uable in those patients in difficult positjons such as extrications and in those who have copious secretions despite adequate attempts at suctioning.

EQUIPMENT This method of intubation requires the following: • Endotracheal tube, 7.0-, 7.5-, or S.O-mm internal diameter • Malleable stylet ( Note: Some prefer to perform the procedure without a stylct. )

327

328 •

APPEND IX A Optional Skills

• Water-sol uble lubrican t • 12-cc syringe • Dental prod, mOllth gag, and so on for placing between the teeth • Rubber gloves

TECHNIQUE I.

Perform routine prepara tion proced ures as taught in Chapter 5.

2. Prepa re the tube b}' inserti ng the lu b ricated stylet and bending the lUbe into an "open J" configu ration. The stylet should not protrude beyo nd the tip of the tube, but il should co me 10 at least the side hole. 3. Apply a water-solu bl e lubricant lib<"raJly to the tip and cuff of the tube. 4. Wear gloves fo r protect ion. s. Kneel at the patien t's left shou lder facing the patient, and pl'lce a dental p rod or mouth gag between the patient 's molars (Figure A-I ). 6. "\V'Ilk" the index and midd le fin gers of your left hand down the midline of the tongue, all the whik pulling forward on the ton gue and jaw. 'Illis is a most import.lIlt maneuver and serves to lift the epiglottis up with in reach of the probing finge rs. 7. Palpate the epiglott is wi th your middle fi nger; il f<.'els much like the tragu s of the car. B. Press forwa rd on the ('piglottis and slip the tube into the mou th at the left corner of the mouth (Figure A-2 ), Usc the index fin ger to keep the tube tip aga in st the side of the middle finger (that is still palpating the epiglottis). Th is guides the tip to the epiglott is. You ca n also use the side hole o f the tube as a landmark to ensure that you are always aware of the positio n of the tip o f the endotracheal tube. This is a crucial principle of thi s technique.

FIGURE A·1

Digital intu bation. Pre paring patient with usc of mouth (den tal) prod to protl'Ctt.he intubalor aga inst ocing billen.

APPENDIX A Optional Skills •

L

b.

FIGURE A·2 (a) Insert your index and middle finger into the patient's mouth. Elevate the epiglottis with your middle fin ger. (b) Guide the tube forward and into the gloltic ope:ning with yo ur index and middle fin gers.

9. Gu ide the wbe lip to lie agai nsl the epiglottis using Ihe middle and index fingers. The epiglollis is in front and the fin gers behind. Advance the IUOC distally thro ugh the cords using the right hand . Press fonvard with the index and middle fin gers of the left hand 10 prc,rent the tube from slippin g posteriorly into the esophagus. 'ole: AI this point the lube-stylet combination may encounter resistance, especially if the distal curve of the tube is sharp. This usually means that the tube tip is pressing on the anterior wall of the thyroid cartilage. Pulling back sligh tly on the stylet will allow the tube 10 conform to the anatomy, and the tube should slip into the trachea. 10. Confirm placement by the confirmation protocol taught ill Chapter 5.

,

329

33 0 • APPENDIX A Optio na l Skills

OPTIONAL SKILL 2: Transillumination (Lighted Stylet) Objectives Upon completion of th is Skill Station, yo u should be able to! I. Describe the advantages of this technique. 2. Perform endotracheal intubatio n by th e tr.lI1 siUumination method. The tran sillumi nat ion or ligh ted stylct method of endotracheal intubat io n is based on the fac t that a bright light inserted inside the upper airway can be seen through the soft tissues o f the neck when inside th(' larynx o r trachea. This permi ts you to guide the lube tip through the glott ic opening wit hou t di rectly visuali zing the cords. It has bcrll called the " indirect visua l" method and has been shown in several stud ies to be reli:lble, quick, and atra uma tic. It is partic ularly attractive in trauma patients beca use it appc'lrs to 1110ve the head and neck less tha n convent ioml l orotrachealmethods.

EQUIPMENT • Stylct. The lighted stylet (Figure A-3) is a malleable wire co nn ect in g .1 proximal ballery housing to a d istallighlbulb, co\'Cred with a tough plastic coa ling Ihat prevents the light from being separated from the wire. An on/off switch is 10" lIed 3\ the proximal end of the battery housing.

• El/rlotmrheaJ lubes. All tubes should have an in ternal diameter of 7.5 to 8.5 mm. • Olher equipll/w l w ill be stand ard to a ny intubation procedure: suction , oxygen, glovcs. lubricant . .. nd so on.

FIGURE A-3

Thl' lightl'd styll't.

APPENDIX A Optional Skills •

TECHNIQUE The success of this intubation mcthod depends upon several factors. • l.evei oftllellmbictlt ligllt. The light should be cut down to aboull O percent of norma], o r the patient's neck should be shielded from direct sun o r bright daylight. While the Iran silluminated light can be seen in thin patients even in daylight, succcss will bc mo rc likely in darker surroundings. • Pulling forward on tile tOtlgll~r tongue and jaw-lifts the epiglottis up out of the way. This is essential to this method (Figure A44). • Bend of tile tubc stylet. Bend the tube stylet combination just proximal to the cuff. A bend that is too far proximal will cause thc tube to strike against the posterior pharyngeal waUand prevent the tube advancing anteriorly through the glottic opening (Figure A 4). Slip the lubricated stylet into the tube and hold firml y against the battery housing while bending the tube stylet. Bend the tu be ~styl e t more sharply if the patient is not in the sni ffing position. 4

4

4

4

To perform the transilluminatio n or lighted stylet method of endotracheal intubation , follow these steps. 1. Perform routine preparation procedures taught in Chapter 5.

2. Stand or kneel on either side facing the patient 's head. Wear gloves for the

procedure. Switch on the light. 3. Grasp the patient 's tonguc--or more easil y, the tongue and jaw-and lift gently

forward wh ile slipping the liberally lubricated tubc stylet combination down the tongue. 4

Pulling forward on the tongue and jaw lifts the epiglottis and allows for intubation with the stylet. The bend in the stylet must not be too far proximal so that it will not strike against the posterior pharyngeal wall. Note gloves are worn.

FIGURE A-4

331

33 2 •

APPENDIX A Opt ional Skills

FIGURE A-5 Correcl pl!lcelllC'nl of tube. Bright circum scribed glow seen when Ihe lip of the stylct is at or ber ond the cords.

4. Using a "so up l
in Chapter 5.

or

A~ Incorrect placement lub('. Clearly ~ n light Irllllsilluminatl'
FIGURE

APPENDIX A Optional Skills •

333

OPTIONAL SKILL 3: Translaryngeal Jet Ventilation Objectives Upon completion of this SkiJ! Station , YO ll should be able 10: I. Discuss the indications for this procedure. 2. Perform translaryngeal jet ventilation (TLJ V). When the airway cannot be maintained because of obstructio n or partial obstruction above the cords. access below the level of the cords is needed. Translaryngeal jet ventilation (TLJV) provides a quick, reliable. and relatively safe method of adequate oxygenation and ventilation, especially in the trauma patient. Ma ny misco nceptions and erroneous impressions persist about this technique, and the medical literature is in a state of confusion on the subject. Clinical experience and studies done using appropriate equipment in both an imals and patients d ea rly indicate the followin g: • Patients can be both oxygenated and ventilated with th is technique. which delivers 100 percent oxygen in volumes exceed ing I L per second. • Venti lation can proceed in definitely, providing the correct size cannula is used with the proper driving pressure. • Cannula of 14 gauge or larger with side holes must be used. • Driving pressures of at least 50 psi (30 psi in a small child ) must be used to deliver sufficient volumes to ensure adequate ventilation. You cannot ventilate patients using small-bore cannulae with continuous flow oxygen attached. The forego ing principles must be adhered to if you are to safely and effect ively use this technique.

EQUIPMENT The tools needed fo r TLJV sho uld be prepared well in adva nce and sto red in a small bag or kit. • No. 14 or I3-gauge canl/lIla, with side ho les (Figure A-7). These sizes are the

minimum necessary for adeq uate ventilation. Side holes are especiall y important. since they prevent the cann ula from remaining against the tracheal wall and subjecting it to sudden pressures that could rupture it. • Manllal jet vetltilator de vice. These are commercially

ava ilable and are merely valves th at allow high-pressure oxygen to flow through them when a butto n is pushed. They should have high-pressure tubi ng attached solidl y with special fasteners and tape. • WrenciJ. A small wrench should be attached to the jet

ventilator tubing SO that you lose no time looking for a way to tap into the oxygen tank o r turn it on.

TECHNIQUE Identificatio n of the cricothyroid membrane is essential to this technique, although placement between the tracheal nn gs probably would not result in major complications.

FIGURE A-7 A specially designed 13-gaugc cannula for translaryngcal jct ventilation. This is hooked into a SO-psi oxygen source for adequate ventilation and oxygenation.

334 • APPENDIX A Optional Skills

FIGURE A..8 Puncture of cricothyroid membrane with jet ventilator cann ula. Note syringe in place fi lled with saline. Bubbles on as pirat ion indicate corrcct intrat racheal placement.

I. \'Vhilc continuing attempts at ve ntilat io n a nd oxygenation , puncture the cricothyroid membrane wi th the c
APPENDIX A Optional Skills

FIGURE A-9

Cannula is distal ly slid off the n«dle when membranl' is punctured.

FIGURE A-10 Patien t is ventilated indefi nitely with 1- to 5-second bursts of oxygen from 50-psi source at a ra te or20/min.

II

335

336 • APPENDIX A Optional Skills

OPTIONAL SKILL 4: Pharyngotracheal Lumen Airway Objectives Upon completion o f this Skill Station, you should be able to: I.

Explain the five essential po ints about use of this airway.

2. Correctly insert the pharyngotracheallumen ain vay (PtL).

Introduced in the early 1970s, blind insertion airway devices (BIADs) were designed for use by EMS person nel who were not trained to intubate the trachea. ALI of these devices (PtL, Combitube, Rusch Easy Tube, and KING LT- D airway) are designed to be inserted into the pha rynx without the need for a laryngoscope to visualize where the tube is goi ng. All of these devices have a tube with an inflatable cuff that is designed to seal the esophagus, thus preventing vomiting an d aspiration of stom ach contents as well as preven ting gastric d istention during bag-valve mask or demand -valve m ask ventilation. It was also tho ught that by sealing the esophagus, more air would enter the lungs and ventilation would be im proved. These devices have their own dangers and require carefu l evaluation to be sure that they are in the correct position. None of the BIADs are equal to the endotracheal tube, which has become the invasive airway o f choice for advanced EMS providers. T he pharyngotracheallumen (PtL) airway is an ainvay developed for EMS p roviders who are not trained to perform endotracheal intubation. The PtL consists of a smallerdiameter lo ng tube inside of a short large-diameter tube (Figure A- II ). The longer tube goes either into the trachea or the esophagus, while the sho rter tube opens into the lower pharynx. Each tube has a cuff; the lo nger tube's cuff seals the esophagus o r trachea, and the sho rter tube's cuff seals the oropharynx so th at there is no air leak when you ventilate the patient. You insert the PtL blindly into tbe pharynx, and then you must carefully determine whether the lo nger tube is in the esophagus o r the trachea. If the lo ng tube is in the tra· chea, you ventilate through it. If the tube is in the esophagus, you ventilate through the larger tube in the pharynx. The PtL has advantages over the obsolete EOA and EGTA in

Slide domp- ollowt large InRotion line to cuff to be deRated a nd smoll ~ moll cuff (distal) cuff to remoin inHaled when intvboling around Ptl ~
InRotion line to large cuff (proximol)

_~~~"'~i~~~w2:::.::::1

deRa"" both ",ff, Pilot bolloon-con~rms cuffs a re inRoted

""--

Small (distal) cuff seals either esophagus or trachea FIGURE A-11

Neck strop

Lorge (proximal) cuffseals oral nosal pharynx

I

Distal end of shorl green tvbe

Parts of the PtL airway.

APPENDIX A Optional Skills • that you don't require extra hands to keep a seal with a face mask; also, the cuffin the pha rynx prevents blood and mucus from entering the airway from above.

ESSENTIAL POINTS You must remember five essential points abo ut the PIt. • Usc the PtL only in patients who are unresponsive and wi thout protective refl exes. • Do not use it in any patient with injury to the esophagus (e.g., caustic ingestions) or in children W llO are below the age of 15 and of average height and weight. • Pay careful attention to proper placement. Unrecognized intratracheal placement of the long tube is a lethal complication that produces com plete airway obstruction. Such an occurrence is not always easy to detect, and the results are catastroph ic. One of the great disadvantages of this airway is that you can determ ine correct placement on ly by auscultation and observation of ches t movement and both may be qui te unreliable in the prehospital setting. Usc of capnogrnphy to confirm airway placement and mon itor position of the airway is recom mended. • You must insert gently and witho ut force. • If the patient regains consciousness, you must remove the PtL, as it will cause retch ing and vomiting.

TECHNIQUE The ainvay is relatively easily inserted and mllst never be fo rced. In the supine patient the following procedure is used. I. Ventilate with mouth-to- mask or bag-valve mask and suct ion the pharynx befo re insertion of the airway. 2. Prepare the ainvay by checking to be sure that both cuffs are full y defla ted, that the long no. 3 tube (Figure A- 12) has a bend in the middle, and that the wh ite cap is securely in place over the deflat ion port located under the no. I inflation valve. 3. Aft er liberal lubrication , slide the airway into the oropharynx while the tongue and jaw are pulled forward. 4. Holding th e PtL in your free hand so th at it curves in the sa me direction as the natural curva tu re of the pharynx, advance the ain vay behi nd the tongue until the teeth strap contacts the lips and teeth. On very small patients you Illay have to withdraw th e airway so that the teeth strap is up an inch from the teeth. Co nversely, on very large patients YOll may have to insert the teeth strap into the mouth. past the teeth. s. Immediately inllate both cuffs. Make sllre that the while cap is in place over the deflation port located under the inflation valve. Deliver a sustained ventilation into the inflation valve. You can detect failure of the cuffs to inflate properly by failure of the external pilot balloon to i.nflate or by hearing or fee lin g a ir escape from the patient's mouth and nose. This usually means that one of the cuffs is torn and that the ainvay must be removed and replaced. When you determine that the cuffs are inflating, continue inflation until you get a good seal. 6. Immediately determine whether the long no. 3 tube is in the esophagus or the trachea. First ventilate through the short no. 2 tube. If you see the chest rise, hea r breath sou nds, feel good compliance, and hear no breath sounds over the epigastrium, the long no. 3 tube is in the esophagus, and yOll should conti nue vent ilating through the no. 2 tube.

337

338 •

APPENDIX A Optional Skills

A

The Ptl airway inserted in the esophogu~. Air ond/or oxygen delivered into the short no. 2 tube pones into the lungs. An inHated cuff at the end of the IonQ no. 3 tube seals the esophagus, while another inRotedcuff seals the oropharynx and prevents air loss from the mouth and nose. FIGURE A-1 2

The Ptl ail"'HO)' inserted in the trochea. Air and/or oxygen is delivered into the long no. 3 tube after the stylet is i-efnoved. The inHaled cuff 01 the end of the long tube keeps air from leaking from the trachea into the esoPhagus. The large cuff thai is sealing the oropharynx !.e!"Ves as a se<:ondary seal.

The PtL in place in (a) the esophagus or (b) the trac hea.

7. If you do not sec the chest rise, hea r breath sounds, and feci good compliancc when the no. 2 tube is ventilated, the no. 3 tube is probably in the trachea. In this case, remove thc stylet from the no. 3 tube and vent ilate through the no. 3 tube. If you see the chest rise, hear breath sounds, feel good compliance, and hear no breath sounds ovt!r the t:pigastrium, the no. 3 tube is in the tracht:a , and you should continuc ventilating through the no. 3 tube. 8. When you arc sure that the patient is being adequatcly vcntilated , carry the neck strap over the patent's head and tighten it in place. Continually monitor the appearance of the pilot balloo n durin g vcnt ilation. Loss of pressure in the balloon signals a loss of pressure in the cuffs. If YO ll suspect a cuff is leaking, increase pressure by blowing into the no. I inflation valve or replace thc airway. If the patient becomcs conscious. you must remove the Pti... Remove thc whitc cap from the deflation port to simultaneously deflate both ctlffs. Extubatio n is likely to cause vomiting, so be prepared to suction the pharynx and turn the backboard .

APPENDIX A Optional Skills •

339

Optional Skill S: Esophageal Tracheal Combitube Objectives Upon completio n of this Skill Station, you should be able to: l.

Explain the fi ve essential points about use of this airNay.

2. Correctly insert the Combitubc. Introduced in the early 19705, blind insertion airway devices (BiADs) were designed for use by EMS personnel who were not trained to intubate the trachea. All of these devices ( PIL, Combilube, Rusch E..1SY Tube, and KING LT- O air-vay) were

designed to be inserted into the pharynx wi thout the need for a laryngoscope to visualize where the tube is going. All of these devices have a tube with an inflatable cuff thaI is des igned to sealtheesophagus, thus preventing vomilinga nd aspiratio n of stomach contents, as well as preventing gastric distention during bag-valve mask or demand -valve mask ventilation . It was also thought that by sealing the esophagus, more air would enter the lungs and ventilation would be improved. These dev ices have their own dangers and requi re careful evaluation to be sure that they arc in the correct position. None of the BLADs arc equal to the endotracheal tube, which has become the invasive airway of choice for advanced EM S providers. The Co mbitube is like the PtL airway in that it has a double lumen. However, in the Combit ube the two lumens are separated by a partition rather than one being inside of the other (sec Figu.re A- I3). One tube is sealed at the distal end , and there arc perfo rations in the area o f the tube that wou ld be in the pharynx. When the long tube is in the esophagus. the pat ient is ventilated through th is short tube. The long tube is open at the distal end, and it has a cuff thai is blown up to seal the esophagus or the trachea, depending on which it has entered. \'\Then in serted, if the long tube goes into the esophagus, the cuff is inflated and the patient is ventilated through the short tube. If the long tube goes into the trachea, the cuff is inflated and the patient is ventilated th rough the long tube. Like the Pt!. airway, this device has a pharyngeal balloon that seals the pharynx and prevents blood and mucus from entering the a.irway from above. T he Co mbitube is somewhat quicker and easier to insert than the PIL airway bu t, as with the other BI ADs. you must be sure that you are ventilating the lungs and not the stomach.

FIGURE A-13 Esophageal p laccment of thc Combitubt." ventilate through lube 1.

ESSENTIAL POINTS You must remember fi ve essential poin ts abou t the Combitube. • Usc the Combitube on ly in patients who arc unresponsive and without protective refle-xes. • Do not usc it in any patient with injury to the esophagus (e.g., caustic ingestions) or in children who arc below the age of 15 and o f average height and weight. • Pay careful attentio n to propcr placcment. Unrecognized intratracheal placement of the long tube is a lethal complication that produces complete airway obstructio n. Such an o ccu rrence is not always easy to detect, and the results arc ca tastrophic. Like the PtL, one of the great disadvantages of th is airway is the fict that you can determ ine correct placement only by auscultati on and observation of chest movement and both may be quite unrcli'lblc in the prehospita l setting. Use of capnography 10 confirm airway placement and monitor position of the airway is recommended.

3 40 • APPENDIX A Optional Skills

• You m ust insert gently and without force . • If the patient regains consciousness. YOln nust remove the Co mbitubc, as it wilJ cause retching and vomiting.

TECHNIQUE I. Insert the tube blindly, watch ing for the two black rings o n the Combitube that are used for measu ring the depth of insertion. These rings should be positioned between the teeth and the lips (Figure A-13 ). 2. Use the large syringe to in flate the pharyngeal cuff with 100 cc of air. When in fl ated. the Combitube will seat itself in the posterior pharynx beh ind the hard palate. 3. Use the small syringe to fill the distal cuff with 10 to 15 cc of air. 4. The long tube will usually go in to the esophagus. Ventilate th rough t he esophageal connector. It is the external t ube that is the longer of the nvo and is marked no. 1. As wit h th e PtL airway, you must see the chest rise, hear b reath sou nds, feel good compliance. and hear no b rea th sou nds over the epigastrium to be sure that the long tube is in the esophagus. s. If you do not see the chest rise, hear breath soun ds. feel good compliance, and you hear b reath sounds over the epigastrium , the tube has been placed in the trachea (see Figure A- 14). 1n this case, change the ventilator to the shorter tracheal connector, which is marked no. 2. Again you must check to see the chest rise, hear breath sou nds, feel good compliance, and hear no brea th sounds over the epigastrium in o rder to be sure that you are ventilating the lun gs. Like the other BlADs. if the patient becomes conscious, you m ust remove the Comb itube. Extubatio n is likely to cause vomiting, SO be prepa red to suction the pharynx and turn the backboard.

FIGURE A-14 Tracheal placement of the Combitubc-ventilate through tube 2.

•

APPENDIX A Optional Skills •

OPTIONAL SKILL 6: KING LT-O Airway Objectives Upon completion of this Skill Station, you should be able to: 1. Explain the six essential points about use of this airway.

2. Correctly insert the KING LT-D ainvay. Introduced in the early 1970s, blind insertion airway devices (B LADs) were designed fo r use by EMS personnel who were not trained to intubate the trachea . All of these devices (PtL, Co mbitube, Rusch Easy Tube, and KING LT-O airway) were designed to be inserted into the pharynx without the need for a laryngoscope to visualize where the tube is going. All of these devices have a t ube with an infla table cuff that is designed to seal the esophagus, thus helping to prevent vomiting and aspiration of stomach contents, as well as preventing gast ric d istentio n du ring bagvalve mask o r demand-valve mask ventilation . It was also thought that by scaling the esophagus, more air would enter the lungs and ventilation would be improved. These devices have their own dangers and require careful evaJuation to be sure that they arc in the correct position. None of the BlADs are equal to the endotracheal tu be, which has become the invasive ainvayof choice for advanced EMS providers. The KING LT-D ain vay d iffers from the Co mbitube and the PtL airways in that it has a single lu men (Figu re A- IS). O nce the tube is inserted into the esophagus, both the esophageal and pharyngeal cuffs are inflated and the patient is venti lated thro ugh the single tube. With the airway in place you may insert a bougie o r a fiberoptic bronchoscope th rough the ven tilating tube and swap the airway for an endotracheal tube. There is also an LTS-D airway that has a port through which you can insert a gastric tube to decompress the stomach. it js inserted exactly the same as th e LT- O airway. The KING LT-O a irway is q lLicker and easier to insert than eit her the PtL ainvay or the Combitube but, as with the o ther BlADs, you must be su re that you are ven tilating the lungs and not the sto mach.

FIGURE A·15 airway.

ESSENTIAL POINTS You must remember six essential poi nts about the KING LT-O airway. • Use the KING LT-O ainvay o nly in patie.nts who arc unresponsive and wi thout protective refl exes. • Do not use it in any patient with injury to the esophagus (e.g., caustic ingestions) or in children who are below the age of 15 and of average height and weigbt. • Do not usc in patients who are less than 4 fee t tall. • Pay careful attention to proper placement. Unrecognized intratracheal placement of the tube is a lethal com plication that produces complete ainvay obstructio n. Such an occurrence is not always easy to detect, a.nd the results arc catastrophic. Capnogra phy is recom mended fo r co nfirmation of tube placement. • You mllst insert gently and wi tho ut fo rce. • If the patient regains conscio llsness, you mllst remove the airway, as it will cause retching and vomiti ng.

KING LT·D

341

342 • APPENDI X A Optional Skills TECHNIQUE I.

Select the correct size KIN G LT4D airway. • Size 3 (yellow con nector color) is fo r adults 4 to 5 feet in height. • Size 4 (red connector color) is for 'ldults 5 to 6 fee t in height. • Size 5 (purple con nector color) is for ad ults greater than 6 feet in height.

2. Test cuff in fl atio n system for air leak. 3. Apply water-soluble lubricant to the distal tip. 4. Hold the airway at the connector with your dominant hand. With your

nondominant hand. hold the mouth open and apply a chin lift. Using a lateral app roach. introduce the lip into the mouth (Figure A-16). S. Advance the tip behind the base of the lo ngue while rotating the tube back to the midline so that the blue orientation line faces the chin of the patient (Figure A- 17). 6. Withou t exerting excessive fo rce. advance tube until base of connector is aligned with teeth or gu ms (Figure A-18 ). 7. Hold the KLT 900 Cuff Pressure Ga uge in nondominant hand, infla te Ihe cuffs of the KING LT-D wi th air to a pressure of 60 cm H 20 (Figure A- 19). If a cuff pressure gauge is not available and a syringe is being used to inflate the KING LT-D. in flat e cuffs with the minim um volume necessary to seal the ai rway at the peak ventilatory pressure employed (just seal volume). Typical inflation volumes are as fo llows: • Size 3 (yellow) = 45-60 m L • Size 4 (red ) = 60-80 mL • Size 5 (purple) = 70-90 m L

FIGURE A-16 Hold the KU-O with dom ina nt hand. With nondominant hand, open mouth and ap ply chin lift. Using a lateral app roach. introduce tip into mouth.

APPENDI X A Optional Skills •

343

FIGURE A·17 Advance Ihe li p behind Ihc base of the tongue while rotating Ihe tube back to the midline so Ihat the blue orientation line fa ces the chin of the patient.

8. Attach the resllscitator bag to the airwa),. \"' hile bagging the patient , gent ly withdraw the tube unti l vent ilation becomes easy and free flowin g (Figure A-20). Adjust culT inflatio n if necessa ry to obta in a seal of th .., airway ilt the peak ventil atory pressu re employed. You must see the chest rise, hear breath sounds, feci good co mpliance. and hear no breath sounds over the epigast ri um to be sure thai the KING LT-D ai rway is correctl y placed. However, this method is unrel iable and thus capnography is recommended for con firming and mo nitoring the positio n of the tube. Like the other I3I ADs. ifthe patient becomes (.onsciolls, you IllllSI remove the airway. Ext ubatio n is likely to cause vomiti ng, so be prepa red 10 suction the pha rynx and turn t he backboard. FIGURE A-18 Gently advance the tube unt il the base of conrlt'ctor is alig ned wilh teeth or gums.

344 • A PPEN DIX A Optional Skills

FIGURE A-20 Attach the nVM 10 the ai r....-ay. While bagging the patil.' nt, gently wi thdraw thl.' t ube un til ventilat ion bl'Collles easy. Adj ust cuff in flation if necessary to obtain a seal of the airway. FIGURE A-19 Holding the KL:r 900 Cuff Pressure Gnugl.' in nondomina nt hand, inflatl.' the cuffs ofthl.' KI NG L:r-D wi th air to a pressure of 6O COl H20. If a cufT prl.'ssure ga uge is not avaiJabll.' and a syringl.' is bdng used to in flatl.' the KI NG IT-D, inflatl.' cuffs wi th thl.' minimu III \'olume necessary to SC".lllhe airway at the peak ventilatory pressure employed (just seal m lume). Typical inflat ion voluml"S are as fo llows: - Sizl.' 3 (yellow) = 45-60 ml - Size4 (red) = 60-80 ml - Sizl.' 5 (purple) = 70-90 mL

,

APPENDIX A Optiona l Skills •

OPTIONAL SKILL 7: Laryngeal Mask Airway Objectives Upon complet ion of th is Skill Statio n, you sho uld be able to: I.

Explain the five essential po in ts about use of the airway.

2. Correctly insert the laryngeal mask airway (LMA). The la ryngeal mask ai rway (LMA) was developed fo r lise as an alternative to the face mask for achieving and maintain ing control of the airway du ring ro utine anesthetic procedu res in the operati ng room. Since il docs not protect the ai rway against vomiti ng and aspi ration, it was mC'lIlt to be used in pat ients who had been fasting and thus had an empty stomach. It was later fo und to be useful in the emergency sit uation when intubation is nol possible and you ca nnot ventilate with a bag-valve mask. It may prevent having to do a surgical procedure to open the airway. The LMA is anot her BIAD but differs fro m the others in that it was never designed to seal the esophagus a nd was not originally meant fo r emergency usc. It is 110 t equal to the endotracheal tube, and should o nly be used when efforts to intubate the trachea have been unsuccessful and ventilatio n is compromised.

WARNINGS • Use the LMA o nly in patients who are unrespo nsive and without protective renexes. If the patient st ill has a gag rencx, the LMA Illay cause laryngospasm or vomiting. • Do not usc it in any patien t with injury to the esophagus (e.g., caustic ingest io ns) o r in children who arc less than 30 kg. • Lubricate o nly the posterior surface of the LMA to avoid blockage of the aperture or aspi ration of the lubrican t. • Patients should be adequately monitored (constant visual monitoring, cardiac monitor, and if possible. pulse oximeter) at all ti mes during LMA usc. • To avoid trau ma to the ai" ...ay, fo rce sho uld never be used du ring LMA insertio n. • Never O\'erinflatc the cuff after insertion. Overinflatio n may cause malposition, loss of seal, or tra uma. Cuff pressu re should be checked periodically, especially if nit ro us oxide is lIsed. • If airway problems persist or ventilatio n is inadequate, the LMA should be removed and reinserted or an airway established by other mea ns. • The LMA docs 110t prevent asp iration if the patient vomits. The presence of a Ililsogastric tube docs not rule o ut the possibility of regu rgitatio n and may even make regurgitatio n more likely because the tube makes the esophageal sphincter incompetent. • If the pat ien t regai ns consciousness, YO ll must remove the LMA, as it wi ll cause retching and vomi ting.

,

345

346 •

APPENDIX A Optional Skills

LMA Size

3 4 5

Pat ient Size

Maximum Cuff Volumes (A ir Only)

Children >30 kg and small adults Normal and large adults

20ml 30 ml

large adults

40mL

TECHNIQUE l. Ventilate with mouth-ta-mask or bag-valve mask and suction the pharynx before

insertion of the air.vay. 2. Remove the valve lab and check the integrity of the LMA cuff by inflating with the maximum volume of air (Table A- I). 3. The cuff of the LMA should be tightly deflated using the enclosed syringe so that it form s a flat oval disk with the rim faci ng away from the aperture. This can be accomplished by pressing the mask with its hollow side down on a sterile flat surface ( Figure A-2 Ia). Use the finge rs to gu ide the cuff into an oval shape and attempt to eliminate any wrinkles on the d istal edge of the cuff. A completely fl at and smooth leading edge faci litates iJlSertion , avoids contact with the epiglottis, and is impo rtant to ensure success when positio ning the device (Figure A-2 I b). 4. Lubricate the posterior surface of the LMA with a water-soluble lubricant just before insertion. 5. Preoxygenate (do not hyperventilate) the patient. 6. If there is no danger of spinal injury, posit io n the patient with the neck fl exed and th e head extended. If the mechanism of injury suggests the potential for spinal injury. the head and neck must be maintained in a neutral position. 7. Hold the LMA like a pen, with the index fmger placed at the junction of the cuff and the tube (Figu re A-2 Ic). Under direct vision. press the tip of the cuff upward against the hard palate and fl atten the cuff agaiJlSt it (Figure A-2 1d). The black line on the airway tube should be oriented anteriorly toward the upper lip. 8. Use the index finger to guide the LMA, pressing upward and backward toward the ears in one smooth movement (Figure A-2 Ie). Advance the LMA in to the hypopharynx until defi nite resistance is felt (Figure A-21 f). 9. Before removing the index finger, gently press down on the tube with the other hand to p revent the LMA from being pulled out of place ( Figure A-2 1g). 10. W ithout holding the tube, inflate the cu ff with just enough air to obtain a seal. T he maxim um volumes are shown in Table A-I. 11. Co nnect the LMA to the bag-valve mask and employ manual ventilat io n of less than 20 em H 20 (this precludes use of a FROPVD unless you use one that aUows you to set the pressu re). As with the BIADs, you must see the chest rise. hear breath sounds, feel good compliance, and hear no breath sounds over the epigastr iu m to be sure that the LMA is correctly placed. However, this method is unreliable. so use of capnography to confirm and monitor tube position is recommended. 12. Insert a bite block (not an oropharyngeal air.vay) and secure the LMA with tape ( Figure A-2 Ih). Remember thai the LMA does not protect the airway from aspiration. If the patient becomes conscious. the LMA must be removed. Extubation is likely to cause vomiting; be prepared to suction the pharynx and turn the backboard.

APPENDIX A Optional Skills •

FIGURE A·21A

FIGURE A·21B

~----

FIGURE A·21C

FIGURE A·21 0

~----

FIGURE A-21E

FIGURE A·21 F

FIGURE A·21G

FIGURE A·21 H

FIGURE A·21

Inserlion of Ihe lary ngl'al mask ai rway.

347

348 • APPENDIX A Opt ional Skills

OPTIONAL SKILL 8: Adult Intraosseous Infusion

1

Objective s Upon com pletion of this Skill Station, you should be able to: l.

Explain the indications fo r the use of adult intraosseous in fusion.

2. Perform an adult intraosseous in fusion .

Standard vascular access in the adult patient involves the peripheral venous system. Under conditions common in trauma, the peripheral veins often collapse. In the past, adult in4 traosseous in fusion was used in some cases to give medications, but the flow rate was too slow to be uscd fo r flui d resuscitati on of adult trauma patients. Now devices arc available that allow adult intraosscous infusio n to be used fo r fluid resuscitation and fo r adm inis4 tration of medications. The first of these devices (F.A.S.T. I) makes usc of the stern um but now there are two other devices that use the proximal tibia. They are not included here but can be reviewed by going to their respective websites: the EZ 410 (battery·powered d rill ) at \vww.vitaid.com/usa/ez4ioli ndex/htm and BIG (Bone Injection Gun ) at W'ovw.waismcd. com. All of these devices may fail to reach the marrow cavity in very obese persons. The F.A.S.T. I uses the sternum for the intT
• It is usually exposed, or easy to expose, in a trauma patient. • The recommended infusion site on the midJinc of the manubrium, 15 mm below the sternal notch, is easy to locate and lan dmark. • There is no appreciable time lag between central venous infusion and in traosscous infusion of most substances. For adult trauma patients who need flui d resuscitation or medications and ror whom YO li are unable to quickly obtain a peripheral IV line, this device may be the vascular access of choice. It is fast (60--90 seconds), simple (failure rate <5 percent ), safe (the dev ice positions the infusion tube at a controlled depth), and has adequate flow rates (30 mUmin by gravity, 125 mU min by pressure cuffed IV bag, and 250 mUmin by syringe).

INDICATIONS • The adult patient who is in cardiac arrest and in whom you cannot quickly obtain peripheral venOllS access • Hypovolemic adult patients who have a prolo nged transport and in whom you arc unable to quickly (two sticks o r 90 seconds) o btain peripheral venous access

CONTRAINDICATIONS • Fractured sternulll • Recent sternotomy (may have compromised the integrity of the manubrium o r its vasculariz...11ion) • Severe osteopo rosis o r bonc4softening cond itions

APPENDIX A Optional Skills •

ESSENTIAL POINTS ON ADULT INTRAOSSEOUS INFUSION • As with aUadvanced procedures, this technique must be accepted local protocol, and you must obtain medical direction o rally or by protocol before perfo rming. • If infi ltration occurs (rare), YOll must abort the procedure. This is thc only bone in which this device is used. • Potential complications are subperiostial infusion due to improper placement, osteomyelitis, sepsis, fat embolism, and marrow damage. Studies have shown these complications to be ra re. However, good aseptic technique is important, just as with IV therapy.

TECHNIQUE 1. Place the target patch at the sitc. The single recommended site of insertion is the adult manubrium, on the midline and 1.5 cm (5/80) below the sternal notch. The site is prepped with aseptic technique, and the index finger is used to align the target patch with the patient's sternal notch (Figure A-22a) . 2. With the patch securely attached to the patient's skin, the introducer is placed in the target rone, perpendicular to the skin. A firm push on the introducer releases the infusion tube into the correct site and to the right penetration depth . The introducer is pulled straight back, exposing the infusion tube and a two-part support sleeve that falls away (Figure A-22b).

8. Placing the target patch at the site

c. Connecting the Huid source

FIGURE A-22

b. InsertillQ the infusion tube

d. Applying the protector dome

Insertion of the EA.S.T. 1 adult intraosseous infusion device. (Courtesyo!Pyng Medical Corporation)

349

350 • APPENDIX A Optional Skills

3. Correct placement is verified by observation of marrow entering the infusion tube. The infusion tube is joined 10 tubing on the patch, which is con nected to a purged source of flu id. Fluid can now flow to the patient (Figure A-22c). 4. The protector dome is pressed down firml y over the target patch to engage the Velcro fastening. The site is clearly visible through the dome, the in fusion tube and connection tubing move easily with any strain o n the skin, and the site requ ires no further sta bilizatio n while the patient is transpo rted (Figure A-22d).

APPENDIX A Optional Skills •

OPTIONAL SKILL 9: Rapid Sequence Intubation Objectives Upon completion of this Skill Station, you should be able to: I. Discllss the situations where rapid sequence intubation (RSI ) can be of benefit to the patient. 2. Discuss the situations were RS I can be detrimental 10 the patient. 3. Correctly perform RSI. The import ance in appropriately managing the airway of the trauma patient cannot be overemphasized. Loss of airway remains the leading cause of early preventable trauma deaths, and hypoxia has been shown to worsen outcomes for trauma patients, especially those with closed head injury. The indicat ions fo r active airway management and the options managing the airway are well covered in Chapter 4 and the skills for managing lhe ainvay are detailed in Chapter 5 of the text. All responders should be familiar with the materials in these two chapters and be able to apply this care. When EMS first obtajned ability to perform endotracheal intubation, it was essentially performed on "dead" patients: unresponsive and apneic. Not all patients fit this situation and ai rway management of patients who were agitated, combative, or had airway trauma had to wait until they deteriorated and became unresponsive. It is important to remember that all ainvays managed in tJle field meet the American Society of Anesthesiology's definition of a "difficult ainV'dY." Thus the responder must have many "tools" in the toolbox, available to manage the ainvayofthe trauma patient. PopuJar in EMS circles, one tool in the toolbox for airway management (one that addresses the problem above) is rapid seq uence intubation (actually rapid sequeflce indllction). The term raphl sequence ill1l1batiotl is a misnomer because this procedure is certainly not rapid (Figure A-23). Because of this, it can adverseJy affect patient o utcome by prolonging scene time. Unless there is a critical need. this proced ure should be performed during transport. In the urban setting where there are sho rt transport times there are almost no indications for this procedure. A variant of the practice of rapid sequence ind uction used by anesthesiologists when co nfronted with a no n fasting patient, the technique allows the intubator to achieve conditions that improve the li kelihood of intubating the patient. while minimizing the risks of aspiration, by rapidly administering a sedative and paralytic to improve intubating conditions. Numerous studies have shown that EMS personnel can be effectively taught to use th is technique and apply it in the field setting. Other studies have shown the real danger in the patient having prolonged hypoxia du ring this procedure, so constant recording of pulse oximetry reading should be done and there should be a strict Qual ity Improvement program that monitors intubation time, oxygenation of the patient, and scene time. The actual technique of RS I is quhe sim ple. The difficult part for EMS persollnel is to recognize the patient who should not undergo RSI. The worst thins you can do in ain\lay management is take a spontaneously breathing patient and place her into a "can't intubate and can't ventilate" situation. All personnel who utilize RSI should be fami liar with and able to use one of the many blind insertion airway devices (BIAD) and also should be able to perform a cricothyrotomy if unable to ventilate o r intubate the patient. Lastly (but most important of all ), all EMS personnel should be able to manage an airway using a BVM. Remember BLS comes before ALS. Lastly, many EMS providers erro neously see use ofRSI and even intubation as a measure of "prestige." It is simply one of many tools available to us to manage an ain\lay. The real trick is to choose the right one for your patient and correctly apply it.

351

352 •

APPENDIX A Optional Skills

Rapid Sequence Intubatian ABC,

Indications for RSI:

100% oxygen Assist ventilation Evaluote need for RSI Monitor and e nd-tidal C02

• Inability 10 maintain Sp02>90% in unconscious patient with closed head injury and clenched teeth • Severe flai l chest with respiratory failure and inabi lity to intubate d ue to gog reflex • Other conditi ons as determined by medi cal direction

Preparation : IV access, assess airway

for difficulty, assemble equipment Pre-oxygenate 3 min. with 100% oxygen

Atropine 0.01 mg/kg IV

0.3 0.1

IV or IV)

Apply cricoid pressure Attempt intubation

If unable 10 intubate

Confirm tube position with plus ETC02 assessment and

Continued paralysis; Vecuronium 0. 1 mg/kg IV

Continued sedation: Midazolan 0.1 IV

Monitor

Keep patient warm Paralyzed palient can't maintain FIGURE A·23 Steps in rapid sequence intubation.

Succinylcholine

1.0-1.5 mg/kg IV

Unsuccessful

1 . Attempt placement of BIAD 2. If unsuccessful perform

APPENDI X A Optional Skills •

At the time of public.1tio n. several studies have called into question the utility of this skill in the field setting. The decision to implement the useofRSI by an EMS system should be carefully reviewed, especially with respect to issues of skill retention, tra nsport times. and the availability of alternative airway methods. Any system using Rs l must have in place a strong educational and quality improvement program.

TECHNIQUE The ideal app roach uscs the six Ps: Preparatio n, Preoxygenation, Premedicate, Paral yze, Pass the tube, confirm Position.

t. Prep"mlioll. First. evaluate the difficulty you may experience when you try to in tubate. Do th is by using the Mallarnpati score (see Cha pter 4). If the patient appears to be particularly difficult to intubate. you would be better served using a DI AD o r BVM than st ruggling with a paralyzed, apneic, hypox.ic patient. If you decide to perform Rs l, you should have a plan fo r an escape airway sho uld inl'ubation be unsuccessful. All necessary equipment, including suction , should be readily ava ilable and checked. Proper positioning is an im portant part of preparation. Whi le the EMS environ ment often precludes placing the patient at a good height, on a stretcher, in the sniffing position, any steps we can take to better position ourselves so that we have the best view are helpful. Given that many of our patients arc in spinal motion restriction, o ne "positioning step" we can take, just prior to intubation, is to remove or looscn the cervical collar and apply in-line stabiliz.1tion. Th is will allow you to move the jaw forward and improve visuali7.ation of the cords. 2. Preoxygellarioll. Since the patient will be rendered apneic. hypoxia will rapidly follow. To extend the time for intubat ion, nitrogen in the lungs is "washed out" by having the patient breathe 100 percent oxygen for 2-3 mi nutes. Washout of the nitrogen allows the patien t to tolerate up to 5 minu tes of apnea (o nly 2- 3 minutes in children) during intu batio n without becom ing hypoxic. In patients with airway compromise o r other problems. ventilat ions can be assisted, though care should be made not to vent ilate wi th too much fo rce, thus reducing the risk of insumating air into the stomach and th us regurgitation of stomach contents leading to aspi rat io n. Applica tio n of cricoid pressure (Sellick's maneuver) will help red uce th is, as well as red uce risk of aspiration as the lower esophageal sphincter relaxes ;Ifter adm inist ration of paralytic. All patients sho uld be placed on a cardiac monilor, a pulse oximeter, and a cap no meter at th is time, if not previously done. 3. Premedicate. Both the act of intubatio n and some paralytics can raise in tracranial pressure. Though advocated in the past. use of IV lidoca ine prior to intubation has been fo und to be of no benefit in the field setting. Pediatric patients given succi nylcho line may develop bradyca rdia. Most experts feel that pediat ric pat ients and those adults receiving a repeat dose of succinylchol ine should receive 0. 1 mglkg of atropine. Remember also in the pL-diatric patient that the usc of a length-based system, such as the I3roselow tape o r similar, can decrease dosing errors. Depolarizi ng paralytic agents like succinylcholine can ca use fasiculations, which can cause a rise in bot h intracranial pressure and intraocular pressu re as well as be uncomfortable for the patient. A nondepolarizi ng blocki ng agent such as vccuronium at 0.01 mglkg can be given at 3 minutes prior to admi nistering the pa ralytic agent. Because it adds time to the process in what is often a time-critical situation, many fi eld providers om it th is step. The last premedication is the sedat ive. This ensu res that the patient is not awake while para lyzed. Benzodiazepines such as versed at 0. 1 mglkg can be used, tho ugh

353

354 • APPENDIX A O ptional Skills

• • • • • •

Histo ry of Malignant Hyperthe rmia Burns ove r 24 hours o ld Crush Injury over 48 hours o ld Stro ke. Co rd Injury> 7 days < 6 mo nths Sepsis ove r 7 days Myo pathies. De ne rvating Diseases

etomidate (0.3 mg/kg) is a more common sedative agent and has the advantages in that it has minimal effects on hemodynamics. Some trauma surgeons do not support use of etomidate due to reported ad renal suppression . with even a single dose.

4. Paralyze. Two types of paralytics are available. A depolarizing agent , such as succinylcholine is the preferred agent d ue to rapid o nset of action and rapid degradatio n. At a dose of I to 1.5 mg/kg (2 mg/kg in children), intubating conditions are achieved within 90 seconds of administration and is clea red within 5 minutes. Contraindications to use of depolariz.ing agents are listed in Table A-2 . Nondepolarizing agents have a longer onset and paralysis lasts longer. The fastest acting agent is rocu ro ni um (0.5 mglkg adult; 0.75 mglkg in children). Vecuronium 0. 1 mg/kg can be used to maintain paralysis after intubation is successfu l. 5. Pass the Tube. Once intubating conditions are achieved. pass the tube. Aids in the process include the use of a stylet. the gum clastic bougie, and external laryngeal manipulation . 6. Confirm Position. Use techniques described in Chapter 5. Use of capnography is mandatory so that inadvertent tube dislodgement can be detected. See ideal timeline for RSI in Table A-3.

- 7 minute s -5 minutes -3 minutes

o 3/4 to 1.5 minute s ' .5 to 2 minutes > 2 minute s

Identify need fo r intubat ion Brief history if possible to rule out co ntraindications Prepare equipment and patient Preoxygenate Pretre at and sedate Paralyze Pass the t ube Co nfirm positio n Post intubatio n care

APPENDIX A Optional Skills •

BIBLIOGRAPHY 1. Davis, D. P., D. Hoyt, M. Cehs, et al. 2003. The effect of paramedic rapid sequence intubation

o n o utcome in patients with s~vere traumatic brain injury. Journal o/Trauma 54 (3): 444-53. 2. Nowicki, T., S. London. 2005. Manag~m~nt of the diffiwlt airway. EM

3.

4.

5. 6.

7. 8. 9.

Reports.

Am~rican

Health Consultants 26: 208-22. Robinson, N., M. Clancy. 200 1. In patients with head injury undergoing rapid sequence intubatio n. does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. EmergellCY Medicille JournaI I8(6): 453-57. Sivestri, 5., G. Ralls, B. Krauss, et al. 2005. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monito ring on the rate of unrecognized misplaced intubatio n within a regional emergency medical services system. Anl/als 0/ EmergerlCY Medicine 45(5): 497-503. Stewart, C. 2002. Advanced airway mallagement. Upper Saddle River, NJ: Brady-Pearson Education. Walls, R., et al. 2004. Marlllal 0/ emergency airway management, 2nd cd. Philadelph ia: Lippincott Williams and Wilkins. Wang, H., et al. 2005. Procedural experience with out-of-hospital endotracheal intubation. Critical Care Medicine 33(8): 1718-2 1. Wang, H. E., p. Davis, R. O'Connor, R. Domeier. 2006. Drug assisted intubation in the prehospital setling. PreilOspital Emergel/CY Ctlre, 10(2): 261-71. Wang H. E., I. Li, B. Dannenberg. 2006. Managing the airway of the pediatric trauma patient: Meeting the challenge. Trauma Reports, American Health Consultants 7(2).

355

Communications with the Receiving Hospital Corey M. Siovis, MD, FACP, FACEP

Objectives Upon completion of this appendix. you sho uld be able to: 1. Discuss the four-phase commu nicatio ns poticy. 2. Discuss the 12 sleps that make lip those phases.

3. Provide accurate itnd succinct p
convey the urgency of the situation in a professional ma nner. The radio microphone shou ld be held a few inches from your mouth to allow accurate voice transmission bu t not so far (m ore than 6 inches) as to allow interference from other noises at the scenc. The fo llowing fo rmat for communications is designed to maximize the efficient transfer of informa tion (see Tables B- 1 and B-2 ). It may also be used for calls not involving trauma.

FOUR·PHASE COMMUNICATIONS POLICY The ITLS communica tions policy is divided into fou r parts, having a total of 12 steps. The first of these phases is devoted to the EMS unit confirming radio contact with a specific hospital or base station.

3S6

APPENDIX B Communications with the Receiving Hospital _ 357

Phase I: Establishing Contact 1. Initiation of call EMS service Level of function (basic, paramedic, etc.) Unit number Medical direction facility being contacted 2. Receiving facility response Name of facility Name and title of radio operator Renaming of calling EMS service Phase II: In-the-Field Report 3. Reidentification EMS service Level of function (basic, paramedic, etc.) Unit number 4. Chief complaint/on-scene report One brief sentence Indudes age, sex, complaint, and/ or mechanism of injury 5. L.jf..saving resuscitation Patient's response to life-saving maneuvers 6. Vital signs/primary survey abnormalities Vrtal signs in stable patient 0'

Primary Survey in unstable patient

7. ETA State ETA S. Request for orders State what is desired 0'

State "no orders requested" Phase III: Base Station (Hospital) Directed Activity 9. Physician response Agree or deny or state desired orders Request for additional history andlor information 10. Rescuer response Clarification or response to requested maneuver or therapy Phase IV: Sign-Off 11 . EMS unit sign-off 12. Base station sign-off

358 • APPENDIX B Communications with the Receiving Hospital

Do's • Think about your report before making radio contact. • Be brief and concise. • Talk calmly and clearly. • Relate only the key points of the history-don't give every single fact you've learned about the patient . • State the patient's primary problem and what you are re questing early in the call. • Ask questions if you are unsure of the base station's reply. • Ask for clarification on therapies you think are wrong or dangerous. • Call your supervisor for "unresolvable" problems. Don'ts • Don 't make a speech . • Don 't ramble. • Don 't use jargon, codes, or abbreviations. • Don't significantly alter how you normally talk. • Don 't assume anything. • Never give a therapy you think is dangerous BEFORE further clarification. • Don't make unprofessional comments that will embarrass you when the tape is replayed . • Don't argue over the radio.

Phase I: Contact Phase

Step I-Identification In attempting to establish radio contact, state what EMS service is cailing, the unit's level of fun ction (e.g., basic, param edic), and the unit's identification number. For exam ple: "This is county paramedic unit 501 calling county hospital."

It is importan t fo r you to identify your level offunctio n so the physician knows which procedures and medicatio ns to consider. The EMS service sho uld be identified, because different services operating in the same area may function with d ifferent protocols. The EMS unit's own iden tifi cation number needs to be included for potential recontacting and for audit purposes. As different hospitals may have the same radio frequency, the specific facili ty being called should be stated by the caller each time cont act is initiated.

Step 2- Facility RespotlSe The base statio n o r receiving hospital should now respond by identifyi ng their fac ility. the perso n speaking o n the radio (including their professio nal title). and then the call sign of the EMS unit they are addressin g. An example might be: "This is Dr. Tho mas Smith at county hospital. Go ahead county paramed ic unit 50 1." By restating the EMS unit's service and number. confusion will be minimized when multiple units are communicating with a single receiving fac ility. It is recommended that hospital-based radio operators identi fy themselves. This is impo rtant beca use the initial

APPENDIX B Communications with the Receiving Hospital •

response to an EMS radio call is often nOI by a physician . It is also important that physicians identify themselves so that you may document who is giving you o rders. Phase II: In-the-Field Report The second phase of commun icat io ns is the most impo rtant. Here you should give the allimportant Primary Survey information and request appropriate o rders. If a physician is not on the radio and yo u will be requiring one for o rders o r advice, then specifically request th.1I a physician come to the rad io console. This phase of communiC:lI ion is divided into the six steps that fo llow.

Step 3-Reidelltificatiotl O nce co ntact has been confirmed, the in-the- field repo rt begins by you reidentify ing the EMS service. its level of function. and unit number: "This is coun ty paramed ic unit 50 1 calling county hospital." This in fo rmation may not yet have been recorded or even heard by a physician, if she has just arrived at the radio console.

Step 4-C/lief Complaillt/Oll-Scetle Report After you have iden tified your level of fu nction and unit number, thc next sentence should provide the receiving facility wi th the most com plete picture of the pat ient possible. This sentence should include the patien t's approxi mate age, sex, complaint. and/or mechan ism of injuf)'. Havi ng information such as the vict im's approximate age and sex allows the physician and/or other listeners to form a menta l picture of the patient. Similarly, by knowing the chief co mplaint and/or type of injury. the physician has an idea of the type of emcrgency she will be handling. Exam ples of th is part of commun icatio n might be: "We are on the scene with a 23-year-old femal e restrained driver involved in a deceleration motor-vehicle collision. She is complaining of chest pain." "We are o n the scene with a 23-year-old fema le who has a gunsho t wound to the chest .n The patient's med ications. additional com plaints, o r more complete description of inj uries should not be given at this time.

Step 5-Life-Saving ReSllscitati01l lf any emergency maneuvers or li fe-saving therapy has been perfo rmed du ring the Primary Survey, then it should be reported next. Thus, if an airway maneuver has been performed or CPR sta rted, it should be reported at this poin t. Examples of th is incl ude: "The patient's sucking chest wound has been sealed." "We have begun CPR and defibrillated the patielll.'" The result of a finger-stick gl ucose, if already perform ed on a comatose patient , should be reported du ring th is phase.

Step 6-Vital SigtlSl Primary SlIrvey Ab'lormalities In the next sentence, give vital signs and/or Primary Su rvey abnormalities. In stable patien ts with a normal Primary Su rvey, a complete set of vital signs are blood pressu re, pu lse, respira tory rate, skin temperatu re (if pert inent ), and oxyge n S<1turatio n by pu lse oximetry (if available; see Chapter 5). A typi cal communicat ion might be: 4

"The patient has a no rma l Primary Survey with vital signs of blood pressu re 130/90, pu lse 90, respi rat io n 16, and oxygen satu rat ion of 98 percent on room air." If, howeve r, there is an abnormal Prima ry Survey, as many of the specified vital signs as could be obtai ned should be repo rted. In th is type of unstable pati ent, problems with

359

360 •

APPENDIX B Communications with the Receiving Hospital

airway, breathing, cardiovascular stabil ity, and neuro logic disab ility would be reported to the p hysician. In this so-call ed load -a nd -go type o f call, un im portant physical fi ndings, histo rical fuc ts, or med ication usage do no t need to be repo rted at th is t ime. Two examples o f typ ical commu n icatio n wo uld he: "Primary Survey as follows: no palpable pulses present, respiration is 40, chest exam reveals a slicking chest wound ; patient is confu sed and combative, no Oz satu ration ca n be obtained." " Blood pressure is 70 by palpat ion, pulse is 130 and weak, aJld patient is very ho t and dry. We fo und him in a warm, enclosed room . Finger-stick blood glucose is 100."

Step 7- Esti",a,cd Tim e of Arrival You sho uld now state how much tim e it will take tq get to the hospital from the present locatio n . If you are en route, this should be reported. If, however, Significant additional time is required to extricate or load the patient into the EMS vehicle, this sho uld be specificall y s tated . Exam ples of the estimated time of arrival (ETA) phase of communicatio n include: "We are en ro ute to your locatio n; our ETA is less than 4 minutes." "We are still on -scene and will req uire 10 to 15 m inutes before we begin transport to the hospital."

Step 8--Reqllest for Orders Before relinquishing radio/telephone control to the base statio n, state what o rders are desired, or lhat no o rders are desired , or that the base station physician's help is needed to determine what to do fo r the patient. Exa mples of these respective si tuations include: "Requesting two large-bore IVs o f normal 5<1line to maintain blood pressure." "No o rders requested." " Base station . how do you advise?"

Phase 111: Base Station (Hospital) Directed Activity In this phase of com municatio n you are no longer in charge of d irecting the conversation. You should now respond to the physician's approval or denial o f orders. In other cases there may be talk back and fo rth between you and the physician .

Step 9-Phys;c;all's Response It is now up to the physician to determ ine how to proceed with management o f lhe patient . The physician may merely agree with your req uest by stating: "Go ahead with your requested therapy of 0.5 mgs o f atropine." O r the physician may d isagree completely: "O rders denied. Tra nspo rt the patient as soon as possible." Ph ysicians sho uld always Iry to repeat the s pecifics of the order to min imize any chance of confusion . W ith complicated patients, the physician may need mo re in fo rmation than you have transm itted. T his is not a criticism of the rescuer's radio ab ilities, b ut merely a need for the physician to obtain additio nal info rmation. Exam ples: "Are the patient 's neck veins flat o r distended?" "Does the patient seem to i}l1prove in the Trendelenburg positio n?" You should be prepared to answer routine questions read ily and to perform requested maneuvers.

Step lQ- Yollr Respollse YOll should confirm any given o rders by repeating them. If the base station has given orders that are incomplete or with which you disagree, it is now appropriate to give additional history or request an o rder. Examples of these problem s include:

_.

•

APPENDIX B Communications with the Receiving Hospital •

"Be advised that the patient has 3 long history of cardiac p roblems an d is on multiple m edicatio ns." "Base Station. did you copy that tbe patient is hypotensive and that we are requesting an IV of normal saline wide o pen?" If you can not answer a question asked by the base station, then tell the physician . Examples o f this type of exchange would be: "We do no t have any available in fo rmation all downtime.... "We are un able to attem pt th is. The patient is still trapped inside the vehicle,"

Phase IV: Sign-off The fin al phase o f EMS-base station comm unicatio ns is the sign-off. You should make it very dear that the unit is leaving the med ical freq uency and returning lodispalch freq uency.

Step II - EMS Unit Sign-off You shouJd now advise the base station thai you are ending communications. Altho ugh everyone seems to favor a different ending ph rase, each EMS service should agree o n a common sign-off phrase. The use of a time signal at the end of a comment is recommended but optional. Acceptable closings include: "Paramedic unit 50 1 is dear." "Unit 50 1 is out at 13:59 hours." Avoid using code numbers, as many physicians do not understand them o r may use sim ilar codes for different purposes; thus "Unit SOl is 10-8 you r locatio n code 3" is not recom mended , nor is"501 , 10-8, 1359."

Step 12- Base Statiml Closi"g The base station physician sho uld similarly end commu nication with the sam e agreed-upo n ph rase, for example: "County hospital clear." Yo u should try to concentrate o n transm itt ing the most informat io n with the least amount o f words.

BIBLIOGRAPHY I. Browner, B., A. Pollak, C. Gupto n (editors). 2002. Emerge"cy clIre and IrallSporlalion of the sick and injllred. 8th cd. Basion: Jones and Ba rtlett, 280-303. 2. Limmer, D., M. O'Keefe. et al. 2oot. Emergency care. 9th cd . Up per Saddle River, NJ: Prentice Halt, 279-89.

,

361

,

Documentation: The Patient Care Record Arlo F. Weltge, MD, MPH, FACEP Objectives Upo n completion of this appendix, YOll should be able to: Create a patient ca re record that ch ronicles the medical care given, commun icates medical information, and prov ides a permanent record that ca n be used as ev idence that the standard of ca re W;IS delivered. 2. Discuss when to use an addendu m to the record. I.

3. Discuss wh;lI to do if there is a complicatio n or bad result and you d id not record pertinent information on the run r('po rt.

INTRODUCTION Wi th the recognition of the important and increasing role of the prehospital care provider has co me deserved respect. Howewr, with th is recogn itio n comes the expectation of a st andard of care ;md resultantl iabil ilY when the care does not meet that standard. Th is appendix shows how to create a record that chronicles the medical care given, commu nicates medical informat io n, and provides a permanent record that ca n be used as evidence that the standard of care was del ivered. This record also can become thc basis for third -pa rty billing ,Hld quality improvement effort s.

THE NARRATIVE REPORT

362

The EMS system namllive report ca n vilry drarnillicall y fro m being primarily a billing fo rm to an excellent narrative medical record. In most EMS systems the narrative report usually prov ides enough space fo r medical documentation to be adequate for the majority of transports. since most runs do not require much mo re tlmn bas ic ski lls and a sim ple transport. This report can be effective whether based upon paper records or electron ic templa tes, but it docs require knowledge and practice. It is important to usc the system narrative repo rt effectively. There should be enough space fo r a chief compla int. si mple history and assessment, and other comments. All narrative fepo rts sho uld be filled o ut completely fo r the level of service. Eve n though the tra nsport may have been "si mpl e," fai lure to document vital signs, to com plete checkoff boxes for the history and physical, and to enter times, events, and ot her sim ple information may rd lect poorly on the care delivered if the report is ever reviewed. If the system report does not provide adeq uate space fo r a reasonable histo ry and assessment, or if the case is more difficult. for ex:un plc, requiring interventio n o r long t rans-

APPENDIX C Documentation: The Patient Care Record _ 363

port times, or involving potential patient complications, then it may be necessary to incl ude an addendum. The addendum can be a simple form. It requires basic information, including the patient's name, date. identification of the EMS system, and the run identification number. The report should be written at or near the tim e of the run, and the original must be signed and kept as a regular part of the system's medjcal records and attached to the regular written report. An example of a simple addendum is shown in Figure C- I. An addendum can be used fo r almost any situa60n or problem. The narrative report, using an addendum, requires more effort , however, since there is not a host of fill -in-theblank or checkoff boxes to use when creating the report. To document a complex case adequately using the continuation sheet, one needs to be familiar with the general form or sequence of a narrative report. The form is dictated by convention (or otherwise known in

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364 •

APPENDIX C Documentation : The Patient Care Record

the medical community as a generally agreed~ upon habit or standard ). Effective documentation requires using this convention as well as skill and practice. It is also recogn i7..ed that a patient care record cannot be comprehensive fo r all aspects of the patient encounter. so it can be helpful at times to re<:ord events or items that m ight help one recall specific events. The narrative report shouJd be b rief, yet, like the verbal report. relevant and focused. T here are times when the clin ical problem is confusing and the report must be lengthier, but length does not necessarily reflect accu racy o r relevancy. T he record sho uld document relevant events and discrepancies and should be created so another reader can reconstruct the events. T he report should also justify the action, even if o ne's impression at the time was wrong. A "mistake" may have been enti rely justi fi ed given the circumstances at the time. but it oft en can be justified o nly if the circumstances are clearly and honestly documented as part of the record . The repo rt contains the following information, but rarely will include all the information. In fact. it is more important to effe<:tively treat the patient and document that treatment than it is to get all the in fo rmation while the patient suffe rs because of lack of treatment or delay in transport. It is reasonable to take brief notes and to fill out the patient care record at the hospital before returnin g to service. Care o f the patient is the provider's fmt goal.

Contents of the Narrative Report Conten ts o f a narrative report include: descriptio n of the ru n call, scene description, patient's chief complaint, history of the p resent illness/injury o r symptom s. patient's medical history. findi ngs from the physical exam , any procedures performed, findings from the O ngoing Exams, impression, and prio rities (Table C- I).

Run Call Note how the caU was dispatched, particularly if there is d iscrepancy between the d ispatch description and the actual find ings. It is helpful, for example. to explain de-lays in t ranspo rt if a call came in as a rout ine sick party when actually it was a motorveh icle coiJision with multiple victims. Document time whenever possible. The dispatch time is important because, realistically. it may be the last reliable docu mented time until arrival at the hospital.

Same Descriptio,. Document any scene hazards that delay or affect patient t reatment or t ransport. It is easy to forget scene hazards, b ut d elays may affect patient outcomes an d the mention o f scene hazards may help jog the memory of the run when reading the report at a later time.

1. Run call 2. 3. 4. 5. 6. 7. 8. 9.

Scene description Chief complaint History of the present i11nessllnjury or symptoms Past medical history Physical exam Procedures Ongoing Exam Impression , O. Documenting the priorities

APPENDIX C Documentation: The Pat ient Care Record _ 365

The mechan isms should be noted as well. Often th is is most effectively done by stick figures (Figure C-2). The EMS personnel arc often the only sou rce of the mechanism of in jury for subsequent treatment providers. Clear, simple d rawings of mechanisms are quick and ('asy, useful for commun icating mechanism and suspicion of occult inj uries, and can help jog the memo ry of the event at a later time.

CI,iefComplai"t Record age. sex, mechanism. chief complaint or injury, and the o nsct o r time of occurrence. These identifiers focus the thought process. If previously mentioned, mechan ism does not have to be documented here. History of tile Presetlt 11111ess/Iujllry or Symptoms Record relevant positives and negatives. Document any relevant history that you obtain from the pat ient. If the history does not come from the patient but from another witness, note the source and the specific informa tion fro m that person, especiall y when it conflicts wi th other history. Additional useful information incl udes the patient's recollection of the events immediately prio r to the incident (such as did the patient faint first and then fa ll?), prio r injuries 10 the same location (fractured the same leg last year, fo r example). and any trea tment given befo re your arrival (such as pa tient pulled from car by bystanders). Past MedicalRistory Record previo us illness, medications, recent surgery, allergies. and when the patient last ale a meaL You are usually not responsible fo r getti ng a complete medical history. However, in acutely sick and injured victims. you may be the last person able to get th is information before the patien t loses consciousness. Again. treating the patient is the 1110st important prio rity. bUI gaining useful information may save a number of complications. Other information thai can be useful may include relevant family histo ry (any diseases that run in the fam ily) and social history (use of alcohol. tobacco. o r o ther drugs). This should be documented as the SAM PLE history.

Symplollls Allergies Me(iicntiolls Past medical history (other illnesses) Lasl meal Eyents preceding incidellt

S A M -

PL E

Physical Exam Record appeara nce, vital signs, level of consciousness. Prima ry Survey, and Secondary Survey. A general statement of the appearance helps focus the reader on urgencies (e.g., the patient appeared alert and in 110 dist ress or appeared in extreme pain and was ashen and sho rt of breath). The level of consciousness should be docu mented with the vital signs. This is best done using stimulus and response (responds to voice/pain with moan.

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Example diagrams for mechanisms of inj uries.

366 • APPENDIX C Docume ntation: The Patie nt Care Record

decerebrate posturing). The shorthand method is to note the stimulus that provokes a response using the AVPU scale:

A V -

Alert RespolJds to verbal stimuli

P -

Rcspollds to pail/

U-

Umespollsive

Document that a co mplete exam was done. Simply stating the body part (back, abdomen. upper extremity) with a zero or slash afterward can indicate that the part was examined and that there were no significant findin gs. One of the easiest and best ways to document the exam in a seriously injured patient is to seq uen tially note the findings and procedures as one does the Primary and Secondary Surveys. It can be helpful to write "Primary Survey." note findings, describe the resuscitation , and then start the rest of the exam with "Seconda ry Survey." By doing this, anyone reviewing the record can immediately recognize that you are oriented to trauma assessment, and by assu mption , have performed an organ ized Primary Survey. One pictu re is worth a thousand words and may aid the memory at a later date. Diagrams of inju ries fo r locations or for severity (l ike cu ts) shou ld be simple yet contain eno ugh detail to locate site of injury; that is, identify if it is right or left, volar (palmar) or dorsal. part of an extremity, or front o r back trunk (Figure C-3).

Procedures (Jndica tio", Procedllre. Result) Document th e need, describe the procedure. and note the time and patien t response when performing an invasive procedure Cfable C-2 ). Any proced ure potentiall y can have a harmful effect, sometimes delayed. All proced ures should be documented (for example, stating an IV was started in the right fo rea rm o n the seco nd sti ck protects yO ll from charges of improper tech nique when the patient later develops a thrombophlebitis from an IV in the left arm). It may not be possible to docume nt every IVauem pl. However, when perfo rmin g invasive treat ment procedures such as needle decomp ressions and need le cricothyro idotomies, yO ll should document th e need, the confi rmin g evidence. the procedure, and the effect. even if the effect is a negative result. O"going Exam (Recheck, Changes, Conditio" on Arrival) Documenti ng the initial findings establishes a basel ine. but Ongoing Exams during lo ng transports, changes while the patient is still in your ca re, and conditio n on o r just prior to arrival should be recorded as neceS5.1ry to establish that decompensatio n did or did not occur while in your care. It is important to remember that as soon as the patient arrives, other people will perform an exam

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Example diagrams of injuries.

RIGHT PALM

APPENDIX C Documentation: The Patient Care Record _ 367

Patient was pale, short of breath, lost the radial pulse (hypotensive), and had decreased breath sounds on right side (the suspicion). The right chest was tympanic and the trachea was deviated to the left, but neck veins were not distended (confirming findings present or absent). A 14-gauge needle was inserted over the top of the third rib in the middavicular line with a rush of air. The patient's radial pulse returned and color improved, but respirations were still labored.

and record their findings. Any discrepancies o r fin dings documented in their report wiU be presumed to have occurred while in your care unless documented by you as not having existed prior to your arrival. Discrepancies place the burden fo r documentation on you to show that complications did not occur while in transport but at the scene prior to your arrival. T his is not to suggest that patients will not decompensate while in your care, but you should notice ~u ch decompensatio n and document that you respo nded to it.

Impression Your impression may be included to summarize the significant findings. However, care must be taken not to overdiagnosc. A tender forearm does not necessarily mean fract ure any more than shortness of breath must m ean a tension p neumothorax. lmpresn sions sho uld be as "generic as possible, noting the actual find ing, such as pain or br uising ( not the diagnosis, such as fracture or pulmo nary contusion ), and should include relevant info rmatio n such as distal pulse. Suspicio ns sho uld be noted (fo r example, sho rtn ess of b reath, decreased breath sounds o n right, and tender right chest; o r tender right fOTearm , possible fractu re, sensatio n/ pulse intact). Docume"ti"K ti,e Priorities The detailed descriptio n is designed fo r the occasio n when events allow time for gathering of the in fo rmation and completion of the Seconda["y Survey (Tab le C-3). T here are times when urgent prior ities limit the evaluatio n to t reating the immediate complications and the exam never gets past the Prima ry Survey. Care o f the

Call: Single MVC. Scene: One victim in roadway, car head-on into pole, patient through windshield supine in roadway. Diagram: See diagram attached. Primary Survey: Mid-twenties, unresponsive male, ashen, grunting respiration with contusions to face, neck, and anterior chest. Absent radial pulse, rapid, thready carotid pulse, sucking wound right chest. Abdomen distended and tender, pelvis stable, extremities appeared to have no major injuries. Cervical spine controlled manually, no change in respiration with jaw thrust, chest wound covered with an Asherman Chest Seal. Patient log-rolled onto long board. No obvious back injuries. loaded and transported. Ongoing Exam: Patient's right pupil fixed and dilated, left midposition . Respiration remained rapid and shallow. Patient given oxygen and ventilated by BVM. One 14gauge IV RL right anticubital started, arrived at city hospital in 3 minutes, patient still with rapid thready carotid pulse.

368 •

APPENDIX C Documentation : The Patient Care Record

patient is the first priority. Often the best way to document this is to describe the sequence as it occurs, using the Primary Survey and Secondary Survey and/or O ngo ing Exams.

IMPROVING DOCUMENTATION SKILLS Documentation refl ects o n the quality of clin ical practice. Like clinical care. one can improve skills by practice as well as by observi ng the better quali ties of others. Following are suggestions to help improve the quality of documen tation.

• Practice dOCIIlllellwtio// witll critique. Have somebody else try to reconstruct the events based on yo ur narrative and evaluate what co mments were useful and what comments were left out. Sometimes the most obvious events are the easiest to forget to documen t.

• I~ead otllers' //armtive reports and try to reconstruct the events. • Practice allticip(ltiflg problellls (l1/(1 criticisms. A fractu red bone needs to have distal pulse and sensation checked and docu mented. Invasive procedures, com plications, unusual events, or an ticipated patient complaints can be noted and justifiC
• Write

fO remind yourself If there are specific even ts uniq ue to this run or which will help you distingui sh th is run from o ther similar runs, note it in the record.

• Be professiOlwl. People's lives depend o n yo ur care. Yo ur records sho uld reflect that you take your respo nsibility seriously. The medical record is not a place fo r humo ro us or derogatory comments. Usc caution when describing the patient. Do not use words that could indicate your care was prejudiced by the patient's prese ntat io n. Words such as "the patient was hysterical" would be better written as "the patient was very excited and upset."

• Be cot/cise. Longer is not necessar ily better. If it is of in terest, write it down. but get to the poi nt and write what is important.

• Review yOllr OWII records. Cml you reconst ruct the events and were complica tions antici pated? Would this record be a friend in court?

• Practice quality care. including caring for the patient. A patient is a potential adversa ry o r advocate. The exciteme nt of the minute often results in a brusque attitude. Ask yourself if you would have been happy with the way you were treated if yo u had been th e patient.

IMPORTANT POINTS ABOUT THE WRITTEN REPORT The narrative report should be kept as a regular part of the patient's record and should be considered a legal document (Figu re C-4 ). There arc some basic rules to follow.

• Keep the report legible if handwritten and attem pt to be thorough if using an electronic tem plate. • fill ill tile blallks as much as possible. Empty boxes im ply that the q uestion was not asked. Open spaces impl y that info rmation might be added after the fact. However, releva nt boxes should be completed o nly if based upon your assessment. Do not document act io ns as having been done, if they were not done.

• Nel'er alter (j medical record. If there is an error o n the record, note the erro r or in a paper record draw a single line th rough the error and make a note that it was an error and why.

APPENDIX C Documentation: The Patient Care Record _ 369

CALL: INJURED PARTY 10:15 A.M. DIAGRAM: SCENE: AUTO· PEDESTRIAN SINGLE PATIENT KNOCKED DOWN (NOT THROWN ANY DISTANCE) AND PULLED FROM THE STREET PRIOR TO ARRIVAL BY BYSTANDERS. PATIENT LYING ON SIDEWALK ON ARRIVAL CC: MID-TEEN MALE COMPLAINING OF PAIN IN THE HEAD AND NECK.

"

HISTORY: PATIENT: DENIES LOSS OF CONSCIOUSNESS. COMPLAINS OF HEAD AND NECK AND LEFT HIP, BUT NO OTHER INJURIES. DENIES PAIN IN ARMS, LEGS, OR BACK. MOTHER: BRIGHT RED HAIR AND LIPSTICK - VERY EXCITED - STATES PATIENT IS "ALLERGIC TO EVERYTHING: DID NOT SEe ACCIDENT. DRIVER: STATES PATIENT STEPPED OUT AND KNOCKED DOWN - NOT THROWN AND NOT KNOCKED OUT. PMH: PATIENT: NO MEDICAL PROBLEMS, NO MEDICATIONS OR SURGERY, AND NEVER BEEN HOSPITALIZED. THINKS HE IS ALLERGIC TO PENICILLIN AND CODEINE. EXAM: ALERT MALE, SCARED BUT NOT CONFUSED. BP 110170 P 98 HEAD - HEMATOMA RIGHT OCCIPUT, FACE NONTENDER PUPILS EaUAL REACTIVE NECK - TENDER RIGHT SIDE C-COLLAR AND PLACED ON BACKBOARD CHEST - NONTENDER BREATH SOUNDS EQUAL ABO - NONTENDER SOFT BACK - O UP/lOW EXT-QO + DISTAL PULSE AND MOVEMENT PATIENT TRANSPORTED CODE I TO CITY GENERAL WITH C-COLLAR AND BACKBOARD. 10:25 EN AOUTE 10:30 ARRIVED -

ALERT REPT VS: BP 118n0 P 70 PATIENT ALERT, VS UNCHANGED, MOVING ALL EXTREMITIES

IMPRESSION: AUTO·PEDESTRIAN WITH INJURIES HEAD AND LEFT HIP. AND PAIN IN NECK. NO LOSS OF CONSCIOUSNESS.

FIGURE C-4

Example of a completed narrative repo rt.

• Document the call ill a timely mmmer. Events fade and memory can be challenged. Write the chart as soon as possible after the event. If there is some delay, note the reason.

• Always be honest Ott the chart. Never record observations not made. Never try to cover up actions. (We cannot always be right, but we must always be honest. ) The record, your primary source of support , may be discredited if any of your observations are shown not to be accurate.

• Always clea rly distinguish. time. and date any changes or additions to the record. Changes after the fact may be used against you if the appearance is that you were trying to alter the record in your favor. Such alterations give the appearance of lying.

370 • APPENDIX C Documentation: The Patient Care Record \"'hal du you do if tlu:rt: is a complicatio n or bad result illld yo u did 1101 record perij·

nent information o n the run repo rt? The best method is to sit down immediately and doc· ument, as accurately as possible, the sequence of events using whatever records are avai lable and to the best of your memory. This is not as useful as a document transcribed at the time, but an accurate record even after the fact can be useful al a later date in recon · structing the events.

BIBLIOGRAPHY 1. Browner, B.,A. Pollak, C. Gupton (editors). 2002. Emergency cnremld transportation o/the sick and injured. 8th cd. Boston: Jones and Bartlett, 297- 30 1. 2. Limmer, D., M. O' Keefe, et al. 200 1. Emergency care. 91h ed. Upper Saddle Ri ver, NI: Prentice Hall,290-305.

Trauma Care in the Cold Jere F. Baldwin, MD, FACEP, FAAFP

Objectives Upon co mpletion of this appcndi.'(, you should be able 10: 1. Modify the principles of trauma care to the cold environment. 2. Discuss general principles of the management of hypothermia.

INTRODUCTION One evening during the winter of 1998 it was reported that 24 of the U.S. and all of the Canadian provinces had temperatures below freez.ing. In a multihospi tal st udy done in the United States, of 400 reported cases of frostbite, 69 ca me from the sunny slate of Florida. Thus, for many if no t mos l prchospital EMS providers, tho ught needs to be given to the application of JTLS principles to trauma ca re in the cold enviro nment. Th is appendix addresses the basics of managing a h),polhcrmic trau m3 pat ient (core temperature less than 95 degrees Fahrenheit or 35 degrees Celsius) and describes how a cold environment changes the assessment and treatment of trauma patients. Managing trauma patients in the cold is both challenging and rewarding. You need a thorough un· derstanding of the princi ples of ITLS and knowledge of the conditions and limitations imposed by the cold environment. You also must always be aware that your patient may be hypothermic. The signs and symptoms of hypothermia arc listed in T;lble D- I.

COLD WEATHER TRAUMA CARE Six Stages of an Ambulance Can T here are six stages o f an ambu lance call (Figure D-I). The predispatch stage is the most important in the successful application of the principles of ITLS in the cold env iro nment. Effective cold weather response is heavily dependent o n adequate prepa ratio n before the emergency. EMS providers living in cold environments have already learned the importance of proper clothing, including hand - and footwear. likewise, EMS systems operat ing in cold environ ments have already learned the im portance of mai ntain ing the rescue vehide, which indudes special ti res and the use of engine warming blocks. EMS systems also must develop a system to keep their equipment at an appropria te temperat ure for immed iate use. Medications ca n be kept in a portable box and carried to the vehicle for each ru n, but this is no t practical for other equipln ent. Plastic endotracheal tubes and IV tubing must be kept warm eno ugh so that they are malleable enough to use. Bags of IV fiuid afe of special concern because they could cause harm to the palient if cold IV fiuid s were rapidly infused into a patient. There are several methods to mai ntain the lemperntllre o f IV fluid s. These include nny type of eleclric \'Iu rmcr fro m electric blankets

371 j

372 • APPENDIX D Trauma Care in the Cold

Neuromuscular System Amnesia, dysarthria, poor judgment (34 degrees Celsius) Loss of coordination, appearing -drunk" (33 degrees Celsius) Shivering ceases (32 degrees Celsius) Progressive decrease in level of consciousness (29 degrees Celsius) Pupils dilated (29 degrees Celsius) Loss of deep tendon reflexes (27 degrees Celsius) Gastrointestinal System Ileus Respiratory System Initial hyperventilation « 34 degrees Celsius) Progressive decrease in rate and depth of respiration Noncardiac pulmonary edema (25 degrees Celsius) Cardiovascular System Sinus bradycardia Atrial fibrillation (30 degrees Celsius) Progressive decrease in blood pressure (29 degrees Celsius) Progressive decrease in pulse (29 degrees Celsius) Vent,;",I., irritability (28 degrees Celsius) Hypote nsion (24 degrees Celsius) Kidneys, Blood, Electrolytes Cold diuresis leading to hypovolemia and hemoconcentration Lactic acidosis and hyperglycemia

T
",the

Hospital

AI the Hospital

T
",the

Scene FIGURE D·1

Six stages of an ambulance call.

APPENDIX D Trauma Care in the Cold •

to sm all dog warmers on the rig. Obviously, the best solution is to keep the rescue vehicle in a heated garage. Traveling to the scene, stage 3, often takes on additional meaning in the winter. The shortest route, because of t ravel condit ions, may not be the quickest or the safest. Several EMS systems have recogn ized that more than one mode of travel is needed. Th is may in* dude any combination of helicopter, ambulance, snowmobile, or even dogsled. Traveling to the hospital, stage 5, may be long and ardUOliS du ring win ter rescue. The distances nlay be greater, the travel may be slower, and the \'ehide more likely to break down or become stuck. Some EMS systems in North America have developed relay and backup systems fo r the patient. These relay systems facilita te the transfer of the patient to the nearest appropriate facility by the most appropriate mode of travel. The backup sys* terns include a buddy system to ensure that there is someone aware of the location of the ambulance who can intervene in the event of a breakdown or a loss of communication.

Patient Assessment ScelleSize~up On· scene trauma assessment in the cold environment starts with the Scene Sizc·up. The hazards may not be apparent. The frozen, slippery walk or road under the snow or even -the falle n power line under rhe snow may await the hasty rescuer. The total number of victims may not be apparent; you must look for clues to more victims. A pa· tient left in the cold is a fatal error. It is easy to miss an unco nscious, ejected patient at night or in poor visibility. The essential equipmen t may need to be slightly different-hydraulic equ ipm ent does not work efficiently, batteries last 25 percent as long, and flares last half as tong. The phenomena of icy fog and the suspended vehide exhaust from the rescue vehicles themselves cause decreased visibility. You must constantly reevaluate the safety of the scene, and you need the ability and backup equipment to react appropriately. Determine the mechanism of injury. Look for dues to hypothermia. Even in a rela· tively warm 50 degree ( 10 degree Celsius) environment, the patient could have hypother· mia. Consider this possibility in the aged patjent, the stroke victim , or the septic patient who has been lyi ng on the bathroom floor for hours. Consider it with the intoxicated pa· tient who has been lying at the foot of the basement stairs for hou rs. In the outside envi· ronment, wet clothing and wind chill ca n cause rapid hypothermia in the trauma patient.

Primary Trallma Slirvey The ITLS Primary Survey is even more critical in the cold envi· ronment. Evaluation of the airway, cervical-spine control, and documentation of ini tial level of consciousness is th e same. However, you must consider that the decreased level of consciousness could be a result of hypothermia in additio n to any trauma or shock. The evaluation of breathing is the same; however, a decreased rate and depth of res pi rat' ion may be d ue to hypothermia in addition to head injury or intoxication from alcohol or d rugs. The trcat nwnt of an inadequate respiratory effort is the same: adequate ventilation with 100 percent oxygen. Jf the patient has isolated hypothermia, ventilate with warm humidi· tied oxygen. Do not hyperventilate. The evaluat ion of the circu lation has the same im portance that was described in Chap· ter 2; however, the cold environ ment may make it more difficult to eval uate. Note the rate and quality of the radial pulse. Check a carotid pulse if you cannot feel a radial pulse. 'Illis may take longer than lIsual because of the vasoconstriction caused by the exposure or because the pulse is slowed by the hypothermiC state. It is important not to stjlrt chest compressions on the hypothermic patient who simply has a slow wc.,k pulse; the compressions could induce ven· tricular fibrillation. The examination of the skin color and condition may be nonproductive. Because o f the peripheral vasoconstriction, the skin may be pale and cool even when the pa· rient is not hypothermic. All cold patients (except those with spinal·cord injuries) will have pale, cold extremities and delayed capillary refill. InitiaUy, the best way to get an idea of the

37 3

374 • APPENDIX D Trauma Care in the Cold

patient's temperature is to put your hand down the back of the neck and feci the skin of the back. This is quicker and easier to do than trying to feel down the front of the chest. The paticnt in a cold environment, especially the patient who is thought to be hypothermic, cannot be exposed for a complete examination of the chest, abdomen, pelvis, and extrem ities. Assess the head and the neck. Application of the cervical motio n-restriction device may be difficuh at this time because of tile patient's clothing. Palpate tile patient's back with your bare hand (covered onl y with a latex glove) under all the layers of clothing. Palpate for tenderness, instabili ty, and crepi tation (TI C). Feel for adequate and symmetric chest waU rise. Your hand should also note the patient's temperature. If the back (or anterior chest) underneath the clothing feels in any way cool, then the patient may be hypothermic. You may at this point decide that the patient is sufferi ng from hypothermia in addition to the o ther injuries you Illay have found. The converse is that patients who have obviollsly froze n handsor feet may stil l be warm to touch under their clothes. (Frostbite is more common than significa nt core hypothermia. ) Handle the h)'pothermic patient very gently to prevent a lethal ca rdi,lC arrhy th mia. Even if the patient is hypothermic, you must co mplete the Primary Su rvey. Auscultate the lungs, ,lIld examine the neck, abdomen, pelvis, and extremities as best as you can. You should try to spend no more than 2 minutes doing this ell tirl' evaluation in the cold environment. in part to conserve body heat and to prevent further hea t loss. At this point, the patient can be log-rolkd and put on:l backboard.

Criticallrltervetltions mid Tra nsport Decision \¥hen the Primary Su rvey is complete, you have enough informat ion to decide if the patient is critical or stable. If yo u find that the patient falls in to the 10ad-and-go ca tegory outlined in Chapter 2, perform critica l in terventions and package the patient on a wooden or plastic backboard (not metal) and im mediately load into an ambu lance for transport. If the patient appears stable but is in a cold environment, or if it is cool but the victim is :llso wet, consider this a load-and-go situation. Gently transfer thc pat ient to the warm ambulance for the Secondary Survey, additional critical carc, and the Ongo ing Exams. Close the ambulance door quickly to preven t any further heat loss from the vehicle so you can remove the patient'S wet clothes (if necessary). At this point, the baseline vital signs and further patient history can be obtai ned. Secondary Survey When the weather is cold, you should perform the Secondary Survey in the ambulance. Remove wet and cold clo thin g and cover the patient wit h warm blankets. The piltient with hypothermia IIIl1st have wet, cold clothes removed in order to be (('warmed. Down clothing probably should not be cut off in the usua l fa shio n since the heater in the ambulance will blow the feathers into the paticnt's wounds and the EMS equipment. Begin to rewarm the patient by both passive external rewarming with dry blankets in the warm ambulance and by core rewa rming with warm ( 100 degrees Fahrenheit) humidified oxygen. This is usually an adequate method of rewarming for the patient with mild hypothermia (core temperature of 90 degrees Fahrenheit or greater ). Do not massage o r put hot co mpresses on the cold extremities. This may block the shivering refl ex and may calise an "afterdrop" in co re temperature. Rapid warming of the skin abolishes the vasoconst riction , allowin g the cold blood in the extremities to return to the core causing a further lowering (afterdrop) of temperature. Pat ients who arc stiIJ shivering have on ly mild hypothermia and will do fine with passivc rewarming with just warm blankets. Perform the Secondary Survey as described in Chapter 2. Critical Care mid O'lgO;lIg Exam Critical care is usually performed in the ambulance during transfer. Not only is this advantageous for the patient, but also your warm hands are belter able to provide the ca re. Advanced airway management is easier in the ambulance than in the bitter cold o utside. The endotracheal tube is more malleable and is less likely to stick to the warm mucous membranes, and your glasses do not fog up in the cold. Tube placement confirmatio n with the colorimetric end-tidal carbon d ioxide detection device

APPEND IX D Trauma Care in the Cold •

may prove unreliable in the cold env iro nment. Provide the patient with warm humidified oxygen in the ambulance; the plastic humidifier bottle can be fi lled wit h saline warmed to about 45 to 55 degrees Celsius (80-- 100 degrees Fahrenheit ). Heated saline or water in a thermos will provide some help. Any other warming unit must be carefull y checked fo r safety to ensure that the patient is not harmed. Perform frequent O ngoing Exams d uring transport. Especially wa tch the pulse, blood pressure, and card iac rhythm . The mild ly hypothermic pat ient will often have m uscle arti fact (sometimes from the shivering); there may be sinus bradycard ia, J or Osborne wave immediately after the QRS complex. or atrial fib rillation. These dysrhythmias require no treatment o ther than warm ing the patient. At 82.4 degrees Fahrenheit (28 degrees Celsius) core body temperature, there may be ven tricular fibrillation that is u nresponsive to defibrillatio n, and below 69.8 degrees (21 degrees Celsi us) there may be asystole. Currently t here is no medication thaI has proven effective for treat ing ventricular fibr illation in the severely hypotherm ic patient. The abdomen needs to be examined freq uently. Your initial assessment may miss an abdominal catastrophe in the hypotherm ic patient. You should also freque ntly check and record the neurological exam. You should decide about IV fluids du ring transport. If fluid s are ind icated, they should be at least the ambient temperature of the warm ambulance. Warmed fluid s arc preferable to room tempera ture Iluids in the hypothermic patient but have very little effect in ra ising the core tem perahlre. Flu id resuscitation may be necessa ry for hypovolemic shock o r fo r hypot hermia. Prolonged cold ex posure ca uses prolonged peripheral vasoconstriction, resulting in more blood perfusing the kid ney. This causes a "cold diuresis,n an inappropriate d iuresis of fl uid induced by the cold . The patient will become hypovolemic. Pat ients with frostbite also benefi t from warm Iluids, which help the poor circulation in the vasoco nst ricted extremities. T here is currently so me exciting research going on about some new devices t hat may be used to wa rm the hypothermic patient in the field.

COlltacti"K Medica l Directio" If you r patient is hypothermic, it is ext remely importa nt to contact medical directio n early. Even though it may take considerable t ime to arrive at the nearest appropriate medical facili ty, the faci li ty needs time to assemble the proper trauma team or to arrange for more exped itious transfer to another facility. Medical di rectio n needs to know how lo ng the p,ltient was exposed to the cold and the patient 's core body temperature. Remember t hat axillary and skin temperatures are not closely correlated with core body tempera ture in the cold environment. The oral temperat ure is inaccurate at tempera tu res below 96 degrees. A tym panic membrane thermometer is the most practical m ethod to take an accurate core temperature in the ambulance. Multiple temperature assessmen ts must be perfo rmed. Medical direction may order the usc of some IV medications, but th is wiil depend on ind ividual circumstances.

NOTES FOR WILDERNESS RESCUERS If you are required to be in the cold for long periods of time ( hiking or skiing in to rescue someone in a wilderness area ), then remember the fo llowing:

• Blood is heat. Good circulat ion is necessar y 10 prevent frostb ite. Drink plenty of fluid s and keep your canteen under your clothing so it is warm. You 0.1J1 force more blood (heat) to your cold. vasoconstricted hands by "wipdmilling" your arms (sling your arm in a circle. forcing blood into the hands) .

• Never go i1l/0 the wildemcss wit/lOllt a partllcr. You need someone to help watch yOll fo r signs of frosth ite or hypothermia and who will aHow yO Il to warm your cold hands or feet in their axilla or groin under their clothing o r snuggle with you in a sleeping bag (wilderness friend s are close friend s indeed ).

375

376 • APPENDIX D Trauma Care in the Cold

• Good clo/hillg aud eql/ipmem are essellti,,! so that you maintain your tem peratu re and don't become hypothermic or develop frostbi te (don't become a victim ). If you have skin areas (face, scalp, hands. elc. ) exposed to the cold. not only will they vasoco nstrict but they will also calise generalized surface vasoconstriction. Thus the saying, " If your feet are cold. put on a hat." • YOllr perceptiofl of cold is related to yOllr sllrface temperatllre. not you r core temperature. Beware the heated hand warmer thai makes yOll fee l warm wh ile your core temperature is dropping.

BIBLIOGRAPHY L Auerback, P. S., E. C. Geehr. 1989. Mnnllgemelll of wilciemess lind ellvirOl/melllal emergencies. 2nd 00. St. Louis: C. V. Mosby. 2. Gregory, J. S., J. M. Bergstein, et al. 1991. Comparison of three methods o f rcw'lrming from hy· pothermia: Advan tages of ext racorporeal blood warming. Jounwl ofTrmmw 3 1: 1247-52. 3. H{'ctor, M. G. 1992. Treatment of acci
Role of the Medical Helicopter Russell B. Bieniek, MD, FACEP

Pam Gersch, RN , CLNC

Objectives Upon completion of this append ix, you should be able to: 1. Discllss tbe various roles of the medical helicopter.

2. Discuss the advantages a medical helicopter may offer over ground transport.

MEDICAL HELICOPTER SERVICES Air mC'dical hel icopters were lIsed extensively to tra nsport injured servicemen during the U.S. military conflicts of Korea and Vietnam. On October 12, 1972, Flight for Life, the first u.s. hospital-b'lscd civ ilian air medical helicopter serv ice, went inlo operation at 51. Antho ny Hospital in Denver, Co lo rado. In the ye.lrS that followed, similar programs were established at multiple hospitals and va riollS other orga nizations across the United States and th roughout the world . Acco rdi ng to the Association of Air Medical Services (AAMS). in 2005 there were approximately 750 helicopters dedicated to EMS usc in the United States, transportin g 375,000 patien ts per year. The st ructure and role of these air med ical programs va ry trcmendollsly. as does their in tegration with t he local EMS system and in· volvement in tra uma ca re. The spon soring agency a nd o rganizational structure of a medical helicopter service encom pass a wide range of models. They ma y be mili tary or o ther government servicefederal, state/province/territory, or local. They may be independent or work in coopera· tion with local med ical care providers to provide rescue and/or transportation of injured patients. The crews may be on call and/or th e helicopter may need to be reconfigured or additional equipmen t may need to be brought on board. The far end of the spectrum, and most common , is the ful ly dedicated medical helicopter that flies only critically inju red or ill patients and whose interior is specificlilly designed and co nfigured , always medically staffed and consistentl y available fo r a medical mission. T he role established for a specific program may be one of primary interfacility trans· ports (hospital to hospita]), scene t ransports (fiel d to hospital) o r, as is most frequ ently the case, a combination of the two with va ryi ng percentages of each type. T he involvement that a medical helicopter service may have in the local EMS co mmunity may depend o n its percentage o f scene involvemen t. The type of patient that a service t ransports is usually a mixture of cl in ical classes, in· eluding neonatal, pediatric, card iac, maternal, medical, and trauma. The service mny tra nsport all classes of patients, may limit services to specific types o f patients, or may have specific teams that accompany each clinical class of patients. The medical crew on board

377

r 378 • APPENDIX E Role of the Medical Helicopter

also varies with the specific p rogram. The AAMS membershi p database in 2005 revealed that the majority of med ical helicopter programs utilize two medical attendan ts. The crc-

dentials of the medical crew vary widely. ranging from an EMT·P to a physician. The most common configuration consists of a nurse and a paramedic, com prising 75 percent of the two-attendan t crew design. The makeup of the crew also may vary by the type of specialty medical m issio n to wh ich the helicopter is dedicated . If a medical helicopter service is available in your regio n, it is impo rtant that you become acquainted with them and know in advance the type of cases for wh ich YOll will utilize them. You also will need to know how to access them and how to involve them in your system to help improve pat ient care. Multiple fac tors in fl uence the availability of a medical helicopter. These incl ude sched· uled maintenance, mechanical factors, weather, and being committed o n a previolls mission. This resource can be very beneficial to the EMS service and the patient, but there should not be dependence on it. They may not be able to respo nd o r have to cancel en routc. Contingcncy plans must always be in place. Rcgarding safety, there needs to be prio r education and train ing with th e medical helicopter service. This ed ucatio n would entai l learn ing proper commun ications between ground and air, picking and dcscribing a safe landing zo ne, and coordi.n ating unloading and loading of the aircraft. In the uncommon, but possible, event o f an airc raft accident, correct knowledge of the hel icopter's equipment an d access could be vital to crew and grou nd personnel. Safety m ust always be the first concern, as in your ITLS trai ning: " Is the scene safe?"

THE MEDICAL HELICOPTER AND THE TRAUMA PATIENT Caring for the trauma patient can be extremely challenging. However, it is quite rewllrd· ing to you and the patient if all the components arc in place and th ings arc do ne p roperl)'. As an established component and resource to an EMS service, the med ical helicopter can improve patient outcome by providing assistance in two areas. The first is speed of transportation; the second is the introductio n of a h igher Icvel of cljnical expertise, equipment, or procedures at the scene o r cn route to the hospital. Helicopters obviously are able to transport patients qu icker than ground un its over long distances. Th is in volves their abil ity to travel at high speeds and in a straight line. They also do not havc to fight road conditions, eithcr cnvironmental o r traffic. Th is dccrcases the exposu re of thc general p ublic or the caregivers themselves to the potential dangers of an ambulancc rushin g th rough busy streets with other traffic and pedestrians. In many areas of the United States the only care available at a trauma scene is BLS. A medical helicopter would then be able to provideALS assessment and care at the scene and en route to the hospital. Often, even in areas where ALS is available, the medical helicop· ter crew may be able to provide additio nal critical ca re expertise, skills, and/or equ ipment. Some of these may incl ude, but are not be limited to, needle o r su rgical cricothyroidotomy, needle o r tube thoracostomy, intraosseous needle insertion, pericardiocentesis, and vari· ous medications fo r such things as sedation and chem ical paralysis of the head -injured patient fo r control of the airway and to assist in controlling increased intracran ial pressure. Additional equ ipment might include pulse oximetry, end·tidal CO 2 monitors, positive pressu re ventilators, and Doppler·assisted blood pressure monito ring devices, to mention a few. Many services also carry pacKed red blood cells to use in the field. T he medical helicopter service perso nnel also usually handle a higher volume of critically injured trauma patients than the average individual provider in a rural ground system, so they may exhib it greatcr fam iliarity and comfort in working with these patients. For intcrfacility tra nsports, the patient is evaluated by the nursing and physician staffs at the referring hosp ital, wh ich determ ine whether the patient requ ires addjtio nal evalua·

'" APPENDIX E Role of the Medical Helicopter _ 379

tio n ancUor treatment al a fa cility with mo rt' resources available to handle the serio us trauma patient. The medical helicopter provides the vehicle, crew, and speed necessary to provide a continuum of the critical care enviro nment en route during transport .

ITLS AND THE MEDICAL HELICOPTER ITLS provides a commo n language that can be used through the continuum of care for the seriously injured trauma patient. This requires coordinated educatio n and training in a region and possibly could be an educatio nal program offered by the medical service itself. Trauma patients wo uld then be assessed rapidly. accurately, and completely in the field by the pre hospital providers, and the decision scheme that is developed fo r the region o n utilizing the medical helicopter service could be partly based o n the results o f this assessment, o ther specific trauma scores, types of injuries, and mechanism of injury. The medical helicopter service wou ld then easi ly understand the assessment and initial treat· men! that was do ne prior to their arrival. and the repo rt could be acco mplished qui ckly, as they are all "speaking the same language." The hel ico pter medica l crew Can then rapidly d o their ITLS assessment and begin transpo rt with further treatments if necessary at the scene o r en ro ute. Yo u must constantly evaluate your skills at doing a rapid assessment of the trauma patient. When you turn your patient over to another service, such as a medical helicopter ser· vice fo r transport, you will not get immediate feedback o n the o utcome o f the patient, as YOll do when yOll d eliver the patient to the hospital yourself. The medical helicopter service may serve as a link between you and the hospital to help obtain this im portant information. When cases are reviewed, the ITLS assessment and initial management can be used as a stand ard to compare with the actual care given. Medical helicopter services are o ne of many special tools available to you and the hos· pital. As with all tools. there needs to be initial and continued education and training to ensure proper and safe usage. This will improve the utili7.ation of resources in your service area and help achieve everyone's common goal o f maximizing patient o utcome.

BIBLIOGRAPHY I. Association of Ai r Medical Services (AAM5) Mem bership Database. 2005. Contact at 526 King St., Stc. 4 15, Alexandria, VA 223 14-3 143. 2. At las & Database of Air Medical Services (ADAMS). 2005. http://www.adamsa irmcd.org/

,

Trauma Scoring in the Prehospital Care Setting Leah J. Heimbach, JD, RN , EMT-P

Objectives Upon complet ion of this appendix, you should be able to: l. Discllss the adult and pediatric Glasgow Coma Scale score.

2. Discuss the Revised Trauma score and the Pediatric Trauma score.

TRAUMA SCORING SYSTEMS Trauma scoring systems consist of assigning a numerical rating or score to various clinical signs, such as vital signs or respo nse to pain. They are used to assess the sevt'rity of injury and are especiall y valuable in assessment of the trauma patien t with multiple injuries. Tra uma scoring systems have importan t llseS in trauma systems at alllevcls, including the hosp ital setting and th e prehospital setting and in overa ll health -care system analysis. There are several methods of scoring severity of injury in trau ma patients, including the Glasgow Coma Scale sco re and the Revised Trauma score (Tables F-I and F-2 ).

USES FOR TRAUMA SCORING In the hospital sel'ting. trau ma sco ring systems have many uses, includi ng the followin g: • Standardizing triage between heal th -care facili ties (deciding when it is appropriate to transfer a patient to a tra uma cen ter) • Allocating medical resources • Evaluatin g the health-ca re fu cility's overall effectiveness in providing patient care • Conducting audi ts (making sure that pat ien ts who are predicted to survh'e their traumatic even t actually do survive) • Predicting morbidity and mortality of patients based on a particular trauma sco re Although prehospital care providers should never delay transport 10 complete a trauma sco re, trauma sco ring systems can provide an objective and standardized way to triag(' patients ilppropriately (includ ing whether a patient should go to a trauma center) and to communicate injury severity. using a common language, to Olhcr members of the health-care leam. Trauma sco res recorded in the field arc also usefu l in the analysis and research of EMS systems. Th is analysis can thcn be used to develop protocols for prchospi lal care to meet the necds of a specifi c EMS region .

380

APPENDIX F Trauma Scoring in the Pre hospital Care Setting _ 381

Always report scores of the three components as well as the t ot al. Verbal Response

Eye Opening Points Spontaneous To voice To pain None

4 3

2 1

Motor Response Points

Oriented Confused Inappropriate words Incomprehensible sounds Silent

Points

5 4 3

Obeys commands Localizes pain Withdraws

2 1

Abnormal flexion Abnormal extension No movement

*Decorticate posturing to pain **Decerebrate posturing to pain

Contribution to Revised Trauma

Score

Score

Total Glasgow Coma Scale score (See Table F-1)

13-15 9-12 6-8 4-5

4 3

3

0 4 3

Systolic blood pressure (mmHg)

>89 76-89 50-75 1-49 None

Respiration (per minute)

10-29 >29 1>-9 1-5 None

2 1

2 1 0 4 3

2 1 0

Note: If total score is 11 or less, the patient should be taken to a trauma center.

The ITLS patient assessment includes a neurological assessment, using the AVPU scale (alert, responds to verbal stimulus, respo nds to painful sti'fnulus. and unresponsive), and identifies param eters to determine whether the patient is a load-and-go case, Communicating this info rmatio n alo ng with a list of the patient's injuries to the receiving hospital will allow the hospital perso nnel to gather the necessary resources to o ptimize care.

6

5 4

3'

2" 1

38 2 • APPENDIX F Trauma Scoring in the Prehospital Care Setting The use of traum a scores in the prehospital setting can be confu sing at a time when patient assessment, injury management, and communication to the receiving hospital need to be concise. It is recommended rh at you repo rt the following information to the receiving facility. I. Age, sex, and chief complaint 2. Mechan ism of inju ry 3. Level of consciousness 4. What parameters led to the load - a nd ~go decision 5. List of the patient's injuries 6. What treatment was rendered 7. Patient's response to treatment Many EMS regions will req ui re the use of some type of trauma score system in the prehospital setting to faci litate patient care andlor to promote prehospital research. An exam~ pie of the Revised Trauma score is shown in Table P-2. An example of the Pediatric Glasgow Coma sco re and Pediatric Trauma score is shown in Tables F-3 and F·4. When you record and report the Glasgow Coma Scale score, always give the individual scores of the compo nents of the scale (eye opening, verbal response. motor respo nse) as well as the total score. Recent literature (see references 2 and 3 in the Bibliography) q uestions the reliability of the Glasgow Coma Scale score (GCS) and the Pediatric Glasgow Coma Scale score (PGCS). Por adults, some researchers believe that the motor component of the GCS sho uld

year Eyes Ope ning

Best Motor Response

Spontaneously To verbal command To pain No response

Spontaneously To shout To pain No re sponse

>1 year

<1 ye ar

Obeys Localizes pain Flexion-withdrewal Flexion-abnormal (decorticate rigidity) Extension (decerebrate rigidity) No response

Localizes pain Flexion-normal Flexion-abnormal (decorticate rigidity) Extension (decerebrate rigidity) No response

>S years

2- 5 years

0-23 Mo nt hs

5

Oriented and converses

4 3

Disoriented and converses Inappropriate words

Appropriate words and phrase s Inappropriate words Cries and/or screams

,

Incomprehensible sounds No response

Grunts No response

Smiles, coos, cries appropriately Cries Inappropriate crying and/ or screaming Grunts No response

4 3 2

, 6

5 4 3

2

, Best Ve rba l Response

2

APPENDIX F Trauma Scoring in the Prehospital Care Setting _ 383

>44lb (>20 kg) Normal

22-44lb (10-20 kg) Oral or nasal a irway

Blood pressure

Pulse at wrist >90mmHg

Level of consciousness

Completely awake

Open wound Fractures

None None

Carotid or fe moral pulse palpable SO-90mmHg Obtunded or any loss of consciousness Minor Closed fracture

Weight Airway

< 221b (<10 kg) Intubated Tracheostomy Invasive airway No palpable pulse <SOmmHg Comatose Major or pe netrating Open or multiple fractures

replace the GCS in outcome pred iction. In children, concerns have been raised regarding the fact that cu rrent scoring systems in pediatric trauma have significant limitations because they are not age specific. it is likely that both adu lt and pediatric trauma scorin g systems will undergo revision in the near fut ure to more accurately predict mortality associated with traumatic injuries.

BIBLIOGRAPHY 1. Champion, H., W. Sacco, W. Copes, et al. 1989. A revision of the trauma score. ]ollmal of

Trallma 29: 623-29. 2. Healy, c., T. M. Osler, F. B. Rogers, M. A. Healy, L. G. Glance, P. D. Kilgo, S. R. Shackford, J. w. Meredith. 2003. Improving the Glasgow coma scale score: Motor score alone is a better predictor. }oumal afTrauma 54(4): 671-78; d iscussion 678-80. 3. Potoka, D. A., L. C. Schall, H. R. Ford. 2001. Development of a novel age-specific pediatric trauma score. ]ollmal of Pediatric Sllrgery 36( I); 106- 12. 4. Rimel, R. w., J. A. Jane, R. F. Edlich. 1979. An injury severity scale for comprehensive management of central nervous system trauma. Amfllis of Emergency Medicine (December); 64-67. 5. Teasdale G., B. Jennett. 1974. Assessment of coma and impaired consciousness: A practical scale. Lal/cet 1: 81--83.

,

383

Drowning, Barotrauma, and Decompression Injury James H. Creel Jr., MD, FACEP John E. Campbell, MD, FACEP

Objectives Upon completion of th is append ix,

YO ll

should be able to:

I. Discuss the general management of near-drowning pat ients.

2. Discliss which body organs arc 1110St affected by baro trauma. 3. Discuss barotrauma of descent. 4. Discuss ba rotrauma of ascent. 5. Discuss decompressio n sickness ( DCS). 6. Explain why skin divers and snorkclers do not get DCS.

DROWNING Approximately 7,000 people drown an nually, makin g drowning the third-lead ing cause of accidental death in the Un ited States. Freshw:lter drownin gs a re mo re commo n than saltwater drowni ngs, and there are mo re immersion accidents in pools than in lakes, ponds, and rivers. The pea k incidence occurs in the wa rm mo nths and most commonly involves teenagers and children under the age of 4. Drowning is death from suffocation afte r sub mersion in the water. There arc two basic m echan isms: • Breath holding. which leads to asp iration of water and wet lungs • Laryngospasm wit h glottic closure and dry lungs Both these mechanisms can lead to profound hypox ia and death. Most adults who have d rowned have about 150 cc of flu id in their lungs. T he amount (2 .2 cc per ki logram ) is eno ugh to prod uce profound hypoxia. It is thought to take about JO times th is amoun t to get electrolyte changes, and this is rarely seen. In the prch ospital phase, hypox.ia is the prim ary concern. Surviva l of the victim depends o n your rapid evaluation and management of the Alles. • Initiate management as soon as possible. Be aware of surfingfdiving mechanisms that ind icate potential occult cervical-spine inj ury. Protect the cel"vical spine during fescue of the patienl.ln water, CPR is generall y ineffective. Remove the patient to a stable s u rface as soo n as possi ble; then in itiate C PR and the approp riate protocol. In cases in which

384

APPENDIX G Drowning , Barotrauma, and Decompression Injury _ 385

hypothe rmia is responsible for the near-drowning, it appears to provide the brain, heart, and lu ngs some degree of protection (diving reAex) by slowing the metabolism. Therefore. no o ne is dead until warm and dead; do not stop CPR.

BAROTRAUMA Barotrauma refers to injuries due to the mechanical effects of pressure on the body. We all live "under pressure" since the weight of the air in which we live exerts force on our bodies. At sea level, the weight of air pressing on the body equals 14.7 pounds per square inch (psi). Since solids and liquids arc not compressible, they are not usually affected by pressure changes. The study of barotrauma is the study of the effect of pressure on gas-filled organs of the body. Gas-fiUed organs are ea rs, sinuses, upper and lower airways, stomach, and intestines. : ro understand the effects of pressure changes, yo u must know some properties of gases. Boyle's law states Ihat the volume of a gas is inversely proportionai lo the pressure applied to it. This simply means that if you double the pressure o n a gas, Ihe volume of the gas will decrease by one-half. If you halve the pressure on a gas, the volume will double. The pressure at sea level is called one atmosphere absolute (AlA ). If you go up in an airplane (or cl imb a moun lain ), you have less atmosphere above you; thus the pressure decreases and the gas inside the body expands. Most commercial airliners fl y al about 35,000 feet elevation (o ne-fifth ATA or gas volume 5 times normal) but are pressurized to a cabi n pressure equal to 5,000 to 8.000 feet elevation (two-th irds to three-fourths ATA ), so that gas expands to on ly about 1.2 to 1.4 times its original volume. Ai rl ine passengers notice no change except fo r "poppin g" of the ears as the expandi ng gas in the mid d le ea rs ven ls off through the eustachian tubes in to the pharynx. Waler is much heavier than air. When one descends in lo saltw"ater, there is a change of one atmosphere for every 33 fee t of depth (34 feet fo r freshwater). This means that at 33 feet of depth the body is subjected to 2 ATA. and gas in the body has been compressed to one-half of its original volume. Because of the pressures involved, d ivers are exposed to certain poten tial injuries during both descent and ascent. Trauma of Descent: HMlddle Ear Squeeze" Since there is a large pressure change during the first few fee t of a d ive, skin divers and snorkelers as well as scuba divers arc subject to trauma of descent. Let's 5.1y that a skin diver takes a breath and rapidly descends to a depth of 33 feet. All the g.1S in his body will decrease in volume by one-half. This includes gas in the lungs, intestines, stomach, sinuses. and middle ears. The clastic lu ngs, intestines, and stomach will simply decrease in size to match the volume of gas. Problems develop with the middle ea rs and sinuses if the pressure cannot be equalized. The sinuses (air pockets in the bones of the face and skull) each have an opening through which air from the pharynx can enter to equalize the pressure. If the o penings are blocked. the skin diver will experience pain in the sinuses and may even develop bleeding and inflammation (barosinusitis). Other than the discomfort, this causes no serious problem. Each middle ear has an open ing, the eustach ian tube, through which air fro m the pharynx can enter to equalize pressure. If the eustachian tube is blocked (mucosal co ngestion from allergy, infection, etc.). the pressure will push in on the eardrum and cause intense pain. Th is begins to be noti cea ble at a depth of 4 to 5 feet. If the d iver cannot equalize the middle car pressure and ret con l'inues to descend, the pressure will eventually rupture the eardrum and flood the middle ea r with cold water (even the warm waters of the Caribbean arc 20 degrees below body tempera tu re). Cold waler in the middle ear causes dizziness, nausea. vomit ing, and disorien tation (" twi rly bends"). The result can be pa nic

386 • APPENDIX G Drowning, Barotrauma, and Decompression Injury and drowning or near.d rowning. The diver using a self·conta ined underwater breathing apparatus (scuba diver) who surfaces rap idly can develop air embolism or neurological de· compression sickness. Vomiti ng under water can cause aspiratio n and drowning. Barotitis media (middle ear squeeze) requires no prehospital treatment . The pressure is relieved when the diver returns 10 the surface. If there is hearing loss o r continued ear pain, the diver should see a physici;m for treat ment of ruptured eardrum or bleeding into the middle ear. The conditions that you are more likely to have to manage are the near· drowning cases caused by the disorientation fro m water in the middle ears. Trauma of Ascent Injuries from expanding gas can occu r as divers ascend. These injuries arc much more common in scuba divers, since such injuries lIsually either require some time to develop (longer than a ski n diver can hold his brea th) o r requi re the breathing of compressed air.

Reverse Middle Ear Squeeze If a eustachian tube beco mes blocked during a dive, the gas in the middle ear will expand and ca use pain during ascent. If there is enough expansion, the eard rum can rupture, with all the symptoms and dangers mentioned previously. Gastroi"testillal Barotralltlla If the diver swa1lows air while breathing compressed air o r if the diver has previously eaten gas· forming foods (e.g., beans), he may accumu late a siS· nificant amo unt of stomach or intest inal gas duri ng a dive. If the diver was at a depth of 66 fee t, the gas will expand to three times its origina1 vol ume d uring ascent. If he is unable to expel th is gas, he will develop abdom inal pain and occasionally even collapse, and de· velop a shocklike state. Pulmotlary Overpressurizatiotl Syndromes (Burst LlmgJ These occur only in divers who have been brea th ing comp ressed air. During a dive the lungs arc completely filled with air, which is at a pressure equal to the depth at wh ich the diver is swimming. If a diver panics and surfaces without exhaling, the rap idly expanding gas will overinflate the lungs and calise one of the th ree overprcssuri1.ation synd romes listed below. Remember, the total volume of the lungs is about 6 L. An ascent from 33 feet would cause expa nsion to 12 L; 66 fee t, 18 L; and 100 feet, 24 L. It is easy to see how delicate alveoli can be ruptured by this expa nsion. The expandi ng air will dissect into the interstitial space, pleural space, pul· monar)' venulcs, or a combination of the three. Air in the Interstitial Space. This is the most common form of pul monary overpressuri· za tio n syndrome. As millio ns of tiny air bubbles escape into the interstitial tissue, they may dissect into the med iastin um and up into the subcuta neo us tissue of the neck. Symptoms may develop immedia tely upon surfaci ng or may not develop for several hours. The diver may have increasing hoarseness, chest pain, subcutaneous emphysema in the neck, and difficulty bre'lthi ng and swallowing. Any diver with these sympto ms should gct oxygen (no positive pressure ventilatio ns unless the diver is apneic) and transpo rt to the hospital. While inlerstitia l air does not require treatment with a recompression chamber (hyper. baric chamber), these patients often devd op ai r embolism or deco mpression sickness. They should be observed in a fa cility that is capable of providing recompression treatment if necessary. Air in the Pleural Space. If the alveoli rupture into the pleural space, a pneumotho rax and possibly a hemothorax will develop. The amou nt of pneumothorax will depend o n how much air escaped into the pleural space and how far the diver surfaced aft er the air entered the pleural space. A 10 percen t pneumothorax at 33 fee t wi ll be a 20 percent pneumothorax

•

APPENDIX G Drowning, Barotrauma, and Decompression Injury _ 387

at the surface. A 20 to 30 percent pneumothorax at 33 feet may be a tensio n pneumo tho rax at the surface. The symptoms will be the same as for interstitial air except the diver will now h.we decreased b reath sounds and hyperresonance to percussio n o n the affected side ( may be on both sides). A tension pneumothorax will also have distended 11(.'Ck veins and shock (and possibly tracheal deviatio n-a rare sign). These patients may require a needle decompressio n if they have a tension pneumotho rax. O thenvise. gl\re 100 percent oxygen and transport immediately.

Air EmboHsm. T he most serio us syndrome of overpressurization is pulmo nary air embolism . If the overdistended alveoli rupture into the pulmo nary venules, the millio ns of tiny air bubbles can return to the left side of the heart and then up the caro tid arteries to th e small arterioles of the br:lin. These bubbles, composed moslly o f nitrogen, obstruct the arterioles and produce symptoms similar to a stroke. T he symptoms produced depend on which vessels arc obstructed . There wi ll usually be sudden loss of consciousness and focal neurological signs. Th e symptoms almost .llways occur immediately wilen the diver surfaces. This is a very important point in differentiating air embolism from decomp ression sickness (which usually takes hours to develop). The patient should be placed in supine position , ghlcn 100 pcrcent oxygen, Bnl V (normal saline), and transported to a facility that can provide reco mprcssio n treatment . This is o ne instance in which you should not hyperventilate o r give positive p ressure ventilatio ns. Hyperventilatio n causes v'lsoconstriction , which will trap the bubbles. Posit ive pressure ventilatio n may fo rce mo re air into the veins, worsening the injury (if the patient is not b reathing. you must give posi tive pressure ventilatio n). This paticntillusl have immediate recompressio n in a recompression chamber no matter how much time has passed since the injury and no mailer how far away the recompressio n cham ber may be. In a reco mpf('SSion chamber, the p ressure is ra ised to 6 ATA (multiple placechambcr), which win decreasc the si1.e o f the bubbles to o ne-sixth of theif p revio us volume. If o nly a mo noplace chamber is available, recompression will be at 2.8 ATA. This mOlY allow them to pass through the capill aries back to the lungs to be expelled . Air embo lism may rarel y affect the coronary arteries, causing myocardial infarction , d ys rhythmias, or cardiac arrest.

DECOMPRESSION SICKNESS Decompression sickness ( DeS) is caused by another property of gases. Henry's law stales that the amo unt o f gas dissolved in a liquid is directly proportio nal to Ihe pressure applied. This means that twice as mu ch gas wo uld be dissolved in a liquid al a d epth of 33 feet as 'It sea level. It also means that gas dissolved in a liquid at 33 fect will C0111e out o f solutio n as th at liquid ascends. This is analogous to a sealed bo ttle o f carbonated beverage that has no bubbles as long as it is sealed but bubbles the instant that the cap is rcmoved and the pressure is released. Ni trogen, which accounts for about 80 percen t of the volume of inspired air, is an inert gas that d issolves in blood and fat. When a diver is under water, nitrogen d issolves in the blood and fat tissllc. This nitrogen is released as he surfaces, so he must surface slowly eno ugh to allow this nit rogen to be expelled through h is lungs. The U.S. avy has developed a set of tables o f no-decompression limits that give general guidelines about how lo ng o ne can stay at a certain depth without going through stage decomp fl'Ssion during ascent. There arc also standard air d ecompression tables for those dives that cxcC"cd the nodecomprcssio n limit. Theoretically, if one fol lows the recommendations of thc tables, nitrogen bubbles will not fo rm in the blood during ascent. This may no t always be true, because the tables were developed from a study of u.s. Navy divers, who arc unifo rmly young. healthy, well-conditioned men who were diving in saltwa ter.

r 388 • APPENDIX G Drowning, Barotrauma. and Decompression Injury Today, there are 3 million recreational scuba divers and 300,000 new divers certi fied each year. Sport divers a re nol uniformly young. h ealthy, or conditioned. They a rc often

older, poorly cond itioned. and not always healthy. A spccial problem is obesity. Fat absorbs about 5 times as much nitrogen as blood o r o ther t issue, so obese divers require longer de-

compression times or shorter dives. Sport divers should he very conservative when using diving tables, especially whe n diving in freshwater or in lakes above sea level. The greatest danger occurs when a diver who h as been submerged for a significant period of time has a d ivi ng accident, panics, and surfaces rapidly. Nitrogen bubbles will fo rm in the blood and tissue just as ca rbon dioxide bubbles form in c hampagne. This is a differen t injury from barotrauma or pulmonary overp ressu ri7A1tion synd rome, and may exist along with any of the barotrauma syndromes. It is frequently seen in divers in neardrow ning situations. The symptoms a re almost always delayed for m in utes to hou rs after a dive. As a general rule, symptoms that develop within 10 minutes of surfacing are caused by air embolism until proved otherwise. Sym ptoms developing after 10 minutes arc decompression sickness until p roved otherwise. Fifty percent will be sympto matic in 30 min utes, 90 percent will be symptomatic in 3 hours. 99 percent w iJI be symptomatic in 12 ho urs. and 100 percent will b e sym ptoma tic in 36 hours. A special case is the vacationing diver who is asymptomatic aft er a deep dive and then catches a plane home the sa m e day. This diver may develop symptoms during fli gh t, since the cabin pressure is only Iwoth irds or three-fourths ATA. These sym ptoms may not appear u ntil the d iver has returned home fa r inland from the site o f the dive. All emergency providers should have some knowledge o f diving injuries.

Type I Decompression Sickness

CutalleO l1S ("Skill Bends") Millio ns of tiny nitrogen bubbles may form in the micrQvasc ulatu re o f the skin. This causes a generalized itch ing rash that may be red and inflamed or mottled with a cent ral purple discolo ration. It is called "marbleized skin" (cutis marmorata). Th is condition requires no treatment but may be an early sign of mo re serious decompression sickness, so the patient must be observed. G ive the patient 100 percent oxygen, and transport to a facility capable of recompression the rapy. Muscu loskeletal ("Bends" or "Pa ill-O"ly Bemis" ) T hi s is the most com mon presentation of decompressio n sickness. Over 85 percent of divers wi th decompressio n s ickn ess will present with pain in the join ts. The shoulders or knees arc affected m ost com mo n ly, but any joint may be affected. The pain is usually deep an d aching, and there may be vague numbness around the affected joint. Characte ristically. there arc no physical find ings a nd the pain may be eased by p ressu re sllch as inflating a blood pressure c u ff. These patients requ ire recom press ion therapy no matter how lon g it has bee n since th e symptoms sta rted a nd no matter how fa r the nea rest recompressio n cha mbe r may be locat ed. Symptoms usua ll y occur within 36 hours and m ost cases a re obvious with in 24 hours. Type II Decompression Sickness These syndro mes are more serious and may be life threatening. This incl udes severe card iopulmonary and neurological syn1ptoms. They arc emergencies that requ ire rapid diagnosis and treatmen t.

Plllmonary Emergencies ("Chokes" 2 Percent of DCS Cases) Nitrogen bubbles formi ng in the vasculature of the lungs cause symptoms similar to the interstitial pulmonar yove rp ressurizat ion synd rome. The patient will develop cough, chest pa in, difficulty b reathing, and sometimes hemoptysis. These symptoms usually develop within an hour of

A PPENDIX G Drowning, Barotrauma, and Decompression Injury _ 389

surfaci ng (50 percent ) but may be delayed for up to 6 hours and even rarely fo r 24 to 48 hours. Pulmonary overprcssu riz.1tion syndrome usually appears within a few minutes o f surfaci ng. In ei ther case, the patient requ ires oxygen and recompressio n therapy. Here again , be careful of positive pressure ventilation , as it may cause gas bubble emboli to the brain.

Neurological Em ergencies Of DCS cases, 60 to 70 percent are now neurological. Nitrogen bubbles in the nervolls system may present with any symptom from personality changcs to specific localized neurological changes. By far the most commo n symptoms involve the lower spinal cord and often produce weakness or paralysis of the legs and urinary bladder. Bladder problems arc so commo n that historically, urinary catheters were considered essential equipment fo r d ivers. These patients must have recompressio n therapy o r irreversible paralysis will occur.

MANAGEMENT OF DIVING INJURIES Patient History • "f)'pe of divi/lg mltl elluipmclll used. This is very im po rt an t. Remember that skin

divers and snorkelers cannot get ovcrpressuriza tion syndrome or decompressio n sickness, but all divers ca n drown. The treatment for ncar-drownin g is very different fro m that fo r decom pressio n sickness or air embolism .

• History of the dive. You need to know where the dive occurrl'
• Past mediCllI }'isloTJ~ Pulmonary problems that pred ispose to air trapp ing (asthma or obstructive lung disease) arc frequently associated with overpressuri7...1tion syndrome.

• Exactly

wl/j!/j

tile symptoms first OCCllrred. This may be hclpnl l in differentiating air

embo lis m ~ nd decompressio n sickness.

• Complicatiolls of tile dive. Did rhe diver run out of air? Was there an attack by marine animals? Did a diving accident occur?

• Travel after tllC dive. Travel in g at higher altitudes may preci pit ate decompression sickness.

Initial Management • Follow standard patient assessment protocol: Primary Survey, critical interventions and transpo rt decision, Secondary Survey, and Ongoing Exam. • If there is any chance o f ovcrpressurization syndrome o r decompression sickness, do not hyperventilate o r give positive p ressure ventilation. Positive pressure ventilation is indicated onl)' for apneic pat ients. • C heck for hypothermia (see Appendix D) in all diving-accident victims. • Patients with air embolism or neurological decompression sickness sho uld be placcd in supine position. • All diving accident patients should get 100 percent oxygen . • Shock and ot her injuries are t reated by rou tine protocols. • If a rccompression facility is needed and you need info rmatio n about the onc Ile.lrest to your faci lity, you may obtain assistance 24 ho urs a day th rough the Nat io nal Diving Alcrt Network at Duke Un i\'crsity: (9 19) 684-811 !.

390 •

APPENDIX G Drowning. Barotrauma, and Decompression Injury

No matter how far you may live from a large body of water. you may be called upon to manage a patien t with near·drowning or diving injuries. \¥hen treating the near·drowning patient, the performance oftheABCs is most important in the prehospilal phase. but do not forget the possibility of hypothermia. \o\'hen treating barotrauma. you should not only fol· low the basic principles of ITLS, but also remember the importance of the history, patient positioning, the possibility of hypothermia, and the dangers of positive pressure ven tilation.

BIBLIOGRAPHY 1. Clinchy, R. A.,G. Egstrom, L. Fcad. 1992. Jeppesou's open watCf sport diving mauual. 5th 00. En· glewood, CO: Jeppeson Sanderson, 25-49. 2. Kizer, K. W. 2003. Dysbarism. In J. E. Tintinalli (cd.), Emergency medicine. 6th ed. New York: McGraw· Hill.

,

Injury Prevention and the Role of the EMS Provider Janet M. Williams, MD Jonathan M. Rubin, MD

Objectives Upon completion of this appendix, you should be able to: I. Discuss the three components of the epidemiology triangle. 2. Discuss the three phases of an injury event as it relates to Haddon's matrix. 3. Discuss the difference between active and pass ive preventive interventions. 4. Discuss four ways EMS providers can help prevent injuries.

THE INJURY EPIDEMIC Every day prehospital health-care providers serve the public by delivering quality emefgency ca re. The ITLS curriculum has been developed to convey thc principles of acute prehospital care of the injured patient. Well-trained prehospital care providers with ITLS skiJIs save many lives of inju red patients each year. Unfortunately, over 50 percent of trauma deaths occur immed iately after the injury event. As a result, you often arrive at the scene only to find a patient who has died or is dying and for whom no life*S3yjng measures can be taken. These cases illustrate the importance of recogn izing injury as a preventable disease. Your role extends fa r beyond the acute care of the inju red patient. The entire EMS community must become active in preventing injury from occurring in the firs t place. Though underrecognized, injury is a major public health problem worldwide. In the United States, injury is the single greatest kilJer between the ages of 1 and 44 and is respon* sible for more years of potential life lost than cancer and heart disease combined. In the United States alone, the cost of injury is estimated to be over $210 billion annually. Injury has been misconceived by the public as being a result of an unavoidable "act of God," an "accident ," due to "bad luck," or a result of a behav ioral problem on the part of the injured individ ual. In reality, injuries are health problems that behave like classic in * (eclious d iseases. Inj uries may be characterized by demographic distributions, seasonal variat ions, epidemic episodes, and risk factors. In addition, they are predictable and preventable. An analogy has been made be" vcen the ca use of an injury and the ca lise of a disease such as mal aria. Table H- I illustrates how disease causation can be appl ied 10 both of these entities. Traditionally, medical education programs have emphasized the treatment of acute ill jury and have neglected the concept of injury prevenlion and control. It is interesting that

391

392 • APPENDIX H Injury Pre vention and the Role of the EM S Provider

Malaria Injury (i.e .. head injury)

Host

Agent

VectorlVehicie

Exposure Event

Human Human

P. v;vax Kinetic e nergy

Mosquito Motor vehicle

Mosquito bite Crash

patients presentiJlg with cardiac symptoms are nearly always asked if they have risk fac tors such as history of smoking, diabetes, hypertension, hypercholesterolemia, and family history of heart disease. In add ition, these patients are counseled as to how to reduce their risk for hea rt disease. As health -care providers, we have a responsibility to do the g.,me for injured patients. Besides playing a vital role in the acute care of injured patients. prehospital ca re providers have a unique opportunity to assess risk fadors for injury, to examine patients ill the injury setting, to provide valuable injury in formation to other med ical care providers, and to educate the public on injury prevention. In add ition, prehospital care providers often sec the "ncar-m iss" patient who survives what could have been a fatal injury event. Such circumstances are an opportune time for prehospital care providers to give injury prevention advice.

THE INJURY PROCESS What Is an Injury? Injury may be defined as any damage to the human body that results from acute exposure of physical energy o r from an absence of vita l entitles such as heat an d oxygen. There arc five basic fo rms of injurious energy: thermal, mechanical, elect rical, radiating, and chelllical. Roughly three-fourths of all inju ries are caused by exposure to mechanical or kinetic energy d uring incidents such as motor-veh icle crashes, fa lls, and firearm discharges, Examples of injury resulting fro m a lackOofh eat or oxygen are fros tbite and drowning. An in dividual's tolerance for injury depends on factors such as physical size, age, and presence of underlying disease. Injury has also been defined as a disease that results from the interaction oflhree com ponents of the epidem iology triangle: 1I0S1, agel/t, and elll'irol/ment (Figure H-I ). The host refers to the human being or victim, the agent is the form of energy involved, and the environmen t provides the opportunity for the agent (energy) to be transmi tted to the host. The environment may be either protect ive and prevent injury or hostile and encourage injury (Figure H- 2). The mechanism by which the agent o r energy is transferred to the host is referred to as the vector. For example, du ring a motorvehicle crash, the automobile is the vector that may transmit physical (kiThe Injury Epidemiology Triangle netic) energy to the host if the environment is permissive. Injury may be classified as intentional or unintentional. Intentional Host {victim} injuries include those such as suicide, assault, and hom icide. Unintentional injuries include those that are not deliberate or pla nned, such as faUs, motor-veh icle crashes, and b u rns. In so me cases, it may be difficult to distinguish in tentional from uninten tional injury. Inju ry also may be categorized by the actual type of inju ry (such as fracture o r head injury), Injuring agent Environment by the mechanism or cause of injury (such as motor-vehicle crash or faU), o r by the populat io n at risk (s uch as pediatric, young males, or the FIGURE H-1 The injur)' epidemiology triangle. elderly).

APPENDIX H Injury Prevention and the Role of the EMS Provider _ 393

Environment

Environment

Injuring agent

Hostile environment In jury may occur a t overlap

Host

Protective environment Injury prevented

FIGURE H·2 The relationship of the environment, injuring agent, and host.

Why Do Injuries Occur? Injury results when the victim is exposed to energy in amoun ts that exceed the threshold of human tolerance. In most cases, energy is transmitted as the victim is attempti ng to perfo rm a speci fi c task or action. The performance of a task refers to how well the individual executes an action, and the task demand is the amount of skill that is required to successfull y perform the task. Any time that an individual's performance is below the task demand fo r the action, there is potential for release of injuriolls energy ( Figure H-3) . For example,

?ERFORMANCE TASK DEMAND EVENT:

Evenl l Task demand is increased in this case as on otherwise healthy man attempts to walk over an ice patch but Falls.

I",~ ~ II",,, :t:c

Event 2 Performance by this drunk driver is below the tosk demand, resulting in the crash.

Event 3 This elderly woman with poor eyesight and difficulty walking with subnormal performance is unable to tolerate only a slight increase in tosk demand such as walking over on area rug. She trips and Falls.

FIGURE H·3 The relat ionship of perfo rmance and task demand in the injury process.

394 • APPENDIX H Injury Prevention and the Role of the EMS Provider

PERMISSIVE ENVIRONMENT

PROTECTED ENVIRONMENT

FIGURE H4

HOST

HOST

The role of injury control and prevention in providing a protective environment.

a drunk driver may lack the skills necessary to drive an automobile and ultimately crash. The crash results in the release of kinetic energy (motion ), which may be transmitted to the driver, causing injury. In an unprotective environment , the energy is transmitted to the individ ual and results in an injury. The environment may also protect the victim from injury in cases in which the road conditions are favorab le, guardrails are present to prevent driving over an emban kment . or the victim is restrain ed ( Figure H·4 ).

Analyzing Injury Events An injury event can be analyzed by separating it into three phases: the preinjury phase, lhe injury event. and the postin;ury phase. Within each phase, host, vehicle. and environ men· tal factors may contribute to the injury process. Prei njury factors either contribute to or inhibit the potential release of energy prio r to the injury event. The injury phase has fac · tors that may enhance or inhibit transmission of energy to the host du ring the injury event. Postinjury facto rs lend to contribute to or diminish the severity of the injury once it has occurred. Prehospital care p roviders playa major role in the postinjury phase by provid· ing rapid and high·quality care to injured victims in the field. The analysis of the three phases of an injury event with respect to host. vehicle. and environmen tal factors is referred to as Haddon's matrix. Table H·2 provides an exa mple of an analysis of a motor·vehicle crash using Haddon's matrix. This tool is very useful for identifying factors co ntributing to the outcome of an injury event, broadening the discus·

APPENDIX H Injury Prevention and the Role of the EMS Provider -

Phases

Host

Pre-event

Impaired capacity due Defective parts to alcohol , age, poor (brakes, tires), poor vision, fatigue , maintenance, dirty windshield/windows, inexperience, poor judgment improper brake lights, ease of control, speed of travel

Event

Tolerance of body to e nergy, injury threshold due to aging , chronic disease (osteoporosis), etc., safety belt use Extent of injury sustained, knowledge of fi rst aid, physical condition, and age

Postevent

Results

Physical and mental impairment

Vehicle

395

Physical Environment

Sociocuttural Environme nt

Narrow road shoulder, poor lighting, road curvature and gradient, road surface type, weather conditions, divided highway, visibility of hazards, signalization Recovery areas, guardraits, fi xed objects (trees, telephone poles). median barriers, embankments

Attitudes about alcohol, drunk driving laws, speed limits, injury preve ntion programs

Placement hardness and sharpness of contact surfaces (dash, steering wheel), automatic restraints, vehicle size Fuel system integrity Access to EMS, quality of EMS care, (bursting gas tank), entrapment of victim availabitityof extrication equipment, rehabilitation programs Cost of vehicle repair Damage to environment

sio n fo r developing prevention strategies, and revealing that most injuries are the product of a large number of causal factors and are not just ra ndom happenings.

INJURY PREVENTION AND CONTROL Perhaps the most im po rtant principle of inj ury prevention and cont rol is that injury is a d isease subject to prevention by modifying transmission of energy to the individ ual. The goal of prima ry iI/jury prevention is to prevent injury fro m occurring in the fi rst place. Examples include wearing a scat belt, helmet use by motorcyclists and bicyclists, and the installalion of smoke detectors. Strategies that attem pt to minimi ze further injury or death after the initial trauma or injury event has occurred are called secondary injury prevent;OII. Prehospital care providers practice secondary injury prevention, or acute care, by ensuring adequate airway. brea thing, and circulation as well as ce rvi c~-s pin e stabilization and rapid transportation to the closest appropriate medical facil ity.

Injury Surveillance Injury surveillance data fo rms the fo undation of inju ry control. Accurate and detailed data are needed to determine the incidence of specific injury events, the demographic distributions, the cause of an injury event, and inj ury risk factors, as well as other factors

Attitudes about seatbelt use, enforcement of child safety seat laws

Training of EMS personnel. trauma system programs

Legal costs, costs to society (loss of lives and income)

396 •

APPENDIX H Injury Prevention and the Role of the EMS Provider

involved in injury. .Prebospital data such as location of the inj ury site. mechanism of injury. host factors. agent factors, and environmental factors are required. PrehospitaJ care providers are in a crucial positio n to docu ment the mechanism of injury in great detail, incl uding information such as the extent of damage to a motor vehicle (starred windshield or deformed steering wheel). Description of the location and conditions of the inj ury site also may be useful in identifying a dangerous section of road where motor vehicle crashes occur time and again o r a hazardous area such as an unsafe playground where injuries occur frequently.

Risk Factors Injuries are not random events. Some special populatio ns, such as males, alcoholics. and certain age groups. arc at higher risk for injury than others. A risk/actor is a variable that makes an individual more Likely to be injured. We ca n prevent injuries by reducing or eliminating risk factors. An example of a host risk factor that may predispose an individuru to injury is the usc of drugs o r rucohol while driving a motor vehicle. A high-risk group is defined as a subset of the population that has a higher incidence of injury. This group may be exposed to hazards more frequently, may be unable to avoid a hazard, or may have a lower injury threshold. Young males are one well-known group that is at higher risk for being involved in a motor-vehicle crash than the general population.

Preventive Interventions Haddon's matrix can be used to iden ti fy the fa ctors affecting the extent of injury during specific inju ry events. Some of the factors may be amenable to prevention strategies o r interventions designed to reduce the incidence or severity of injury. The three types of interventions are educational. en forcement, and engineering. lnterventions may also be classified as either active or passive. An active intervention requires a change in behavior by the individual in need of protection. Educational programs such as those that encourage seat-belt use or installation of home smoke detectors are examples of active in terventions that attempt to persuade individuals to alter their behavior for increased self-protectio n. These programs may increase public awareness but are often ignored by those who are at highest risk for injury such as the economically and ed ucatio nally deprived. Laws against drunk driving and mandatory helmet use by motorcyclists are other examples of active interventions that are aimed at changing an individual's behavior. However. the introduction of a legal intervention does not necessarily imply that it will be enforced by the authorities o r adhered to by the public. Unfo rtunately, alcohol continues to playa part in half of all fatal motor-vehicle crashes despite laws against driving under the influence of alcohol. Active education and enforcement interventions are more effective when used together. Passive interventions provide automatic protection and are generally more effective than active interventions, since they do not rely on human behavior change. Modifications in the engineering and design of vehicles and the environment have been very effective in reducing the incidence and severity of injuries. The incorporation of airbags and softer dashboards into automobiles has significantly reduced the incidence and severity of motor-vehicle-related injuries. Engineering improvements in road design also have heeD found to be effective countermeasures in preventing motor-vehicle crashes.

Designing Interventions

,

When developing injury prevention programs, it is cri tical to recognize potential pitfalls for failure as well as ingredients fo r success. Many intervention programs are difficult to initiate. expensive to maintain, and require the use of limited community resources. The following suggestions will be helpful in selecting injury prevention activities.

APPENDIX H Injury Preve ntion and the Role of the EMS Provider _ 397

Drowning

2·year-old to S-year-old males

Install fencing around pools at least 1 meter high with self-locking door; water motion alarm; swimming lessons; prominent "no diving " notices near shallow water; easy access to

EMS Bicycle

S-year-old to 12-year-old males

Poisoning

1-year--old to S-year-old children

Falls

Elderly with poor vision and/or unstable gait

Encourage helmet use; use of safety reflectors; bicycle traffic lanes; rider education programs Package medicines in childproof conta iners; install safety latches on storage cabinets Remove throw rugs; use nightlights; handrails on stairs; access to activate

EMS

• Target effo rts toward a problem that occurs frequently or results in severe inju ry in your community. In some regio ns, this may be ho use fi res and, fo r others, moto rvehicle crashes. • Address the problem injuries that have specific countermeasures that are known to be effective. Focus o n limited, concrete solutions to specific injury events and avoid diffuse, general approaches. Examples of directed specific solutio ns include fire-safe cigarettes, smo ke detectors for ho use fire prevention, and helmets fo r bicycle-related head injury prevention. • Make the interventio n as sim ple as possible to increase public acceptance and minimize the chance of misuse. • Develop a critical mass of community awareness through broad -based grass-roots support, legislatio n, enfo rcement, and professional actio n. Prehospital care providers should take advantage of their connectio ns with local and regional community leaders to build coalitions for effective prevention programs. • Promote institutio nalization of programs that will last beyond the initial volunteer effort or temporary grant fund ing. Injury prevention programs sho uld be designed to become a permanent component of prehospital ca re. Table H-3 provides examples of injury-specifi c interventions that have been develo ped and found to be successful.

Role of the EMS Provider Prehosp ital care providers are a vital link in the chain of the natio nal injury control effo rt. Their interactio n with the public is an opportunity t9 practice both primary and secondary injury preventio n. As part of the medical community, EMS personnel provide information to emergency physicians and nurses, which is important in the acute ca re of injured victims as welJ as in injury control research. The inju ry epidemic can be addressed o nly th rough a concerted effort by the medical, co mmunity, and legislative o rga nizatio ns.

398 •

APPEN DIX H Injury Prevention and the Role of the EMS Provider

Following are t he fo ur areas in which prehospital personnel can make an impact and preven t injuries in their own communi ties.

Acute Care/Seconda ry IlIjflry Prevention of tile Inj ured Patient: Medically t rained perso nnel, such as ITLS providers, are the init ial and vital li nk in the t rauma care system . l3y p roviding promp t .md appropria te care, many lives arc saved each year. Com"uw ity Ed flca tioIJIPri",ary Injury Prevelltioll: As respected and cred ible members of the com m unity, prehospital care providers have a u nique opportun ity to p ractice primary injury p reventio n, since they interact d irectly with inju red patients and their fam ilies. Less severely injured patients and their fa m ilies and friends ca n be counseled about how the present and any futu re inju ry could be prevented. Exam ples include advising th e publ ic to wea r helmets when riding bicycles, motorcycles, and all -terra in veh icles, as well as wearing seat belts and usi ng child car seats in automobiles. By assessing the scene of the inju ry, prehospital person nel may iden tify specific injury p revention st rategies for a given family, such as how to "childproof" a ho me o r ways to make the ho me of an elderly persOIl less risky fo r falls. As commu nity spokespersons, p rehospital can: prov iders uften interact wi th gruups s uch as tlu: lucalp,m:nt-tcacher association and the rotary club. In doing so, community leaders will become more aware of the important concepts of injury prevention and work toward developing a safer community.

Public Policy : Seat-belt and fire-safe cigarette legislation are two examples o f regulations that have been instituted with the suppo rt of EMS personnel. $eat-belt iegis[
Research/ Inj ury Surveillallce: Accura te documentation of the circumstances surrounding injuries such as demographics. locat ion, mecha nism of injury. and associated risk factors is im po rtant in ident ifying problem injuries :lIld design ing and im plementing prevention strategies. Provid ing reliable in fo rmation to local community leaders, legislators, and physicians-such as the location of the "da ngerous intersection ," the poorly supervised quarry, and the "unsafe" playground----<:an lead to the develop ment o f effective injury prevention strategies and a safer community.

APPEND IX H Injury Prevention and the Role of t he EMS Provider _ 399

BIBLIOGRAPHY 1. American College of Emergency Physicians. 1992, September 16. Guidelines fo r trauma care

systems. Dallas: The College. 2. Baker,S.• B. O'Neill, M. J. Ginsburg, G. Li. 1992. The injury fact book. New York: Oxford Uni· versity Press. 3. Centers for Disease Conlrol and Prevention. 1992. Setting the lIational agenda for injury colllrol ;n the 19905: Positioll papers from the third national inj!lryconrro/ conferelfce.Atlanta: The Centers. 4. Cen ters for Disease Control and Prevention. 1993. II/jury control ill the 19905: A national plall for actio". Atlanta: The Centers. 5. Christoffel, T., S. P. Ten"l. 1993. Protecting the public, legal issues in injllry prevcmioll. New York: Oxford University Press. 6. Committee o n Trauma Research, Commission on l ife Sciences, Natjonal Research Council. and the Lnstitute of Medici ne. 1985. Injury in America: A continuing public health problem . •Washi ngton, DC: National Academy Press. 7. K.1albfleisch, I., F. Rivera. 1989. Principles in injury control: lessons to be learned from child safety seats. Pediatric Emergency (Are, 131-34. 8. Martinez, R. 1990. Injury control: A primer for physicians. Allnals of Emergency Medicine 19: 72- 77.

9. The National Committee fo r lnjury Prevention and Control. 1989. Injury prevention: Meeting tile chaUellge. New York: Oxford University Press. 10. Wilson, M. H., et al. 1991 . Savillg children, a guide to injury prevention. New York: Oxford Uni-

versity Press.

-

Multicasualty Incidents and Triage David Maatman, NREMT-P/IC Roy Alson, PhD, MD, FACEP Jere F. Baldwin, MD, FACEp, FAAFP John T. Stevens, NREMT-P

Objectives Upon completion of th is appendix, you sho uld be able to:

I. Com pare and contrast the defi n l\ion5 of the terms disaster and il/cidelll.

I1Il1ltiCl/S//a{ty

1. Define the term spall of cOllfrol.

3. List the responsibilities of the medical director, triage su pervisor. transport supervisor, treatment supervisor, and staging su pervisor. •. Describe the Initial Assessment. 5. Identify Priority \,2,3, and 4 patients.

DISASTERS AND MULTI CASUALTY INCIDENTS Definitions • Disaster {lIwjor}. Any natu ral catast rophe that causes damage of sufficient severit y and magn itude to warr,mt major d isaster assistance. • Incidellt Command System (lCS). The combinat io n o f facilit ies, equipment, personnel. proced ures, and cOlllmunications o perating with in a co mmon organiZ<1tio nal structure, designed to aid in the management of reso urces d uring emergency incidents. It is used fo r all kinds of emergencies and is applicable to small as well as large and co mplex incidents.

• Multicasualty Incident (Mel). An incident involving a large number of perso ns injured in which the EMS system is u nable to manage the situation utilizing day- today proced ures. An MCI may be classi fi ed as a di saster, b ut not all disasters are MCis.

• Paper P/tm Syndrome. Having a written MClld isilster plan withou l lraining the individuals who would most likely activate and work it.

• Span ofColllrol. The number of individuals a superviso r is responsible fo r, usually expressed as the rat io of supervisors to ind ividuals. (Under the NIMS, an appropriate span of control is between 1:3 and 1:7.)

• Triage. To p rioritize o r sort injuries or the inj ured, usually into four categories: 400

Priority 0, 1,2, and 3 ( Black, Red, Yellow, and Green ).

APPENDIX I Multicasualty Incidents and Triage _ 401

The Role of EMS It is not uncommon for EMS to have more than one paticnt at a trauma scene. !-Iowever, most day- to-day ope rational procedures are designed for the single-patient inci dent. Safety, orga nization, and co mmunication are pa ramo un t in all EMS acti vit ies. When fa ced with mult iple pat ienTs, this need is even greater. It is essential that these components be effective and that all entities of the emergen cy system work from the sa me plan. An effective and efficient way to o btain this unity is to have Emergency Medical Services operate as a branch of the Incident Command System (lCS). Primary functional components of the medical branch include the medical director, triage, treatment, transport, and stagi ng. (Even with a singl e-p
Incident Command System In the early 1970s the ICS was developed in southern California under FIRESCOPE (Flrefighting RESou rces of California O rga nized for Potential Emergencies). Though originally developed to assist in the respo nse to wildland fires, it was quickly recognized as a system that could help public safety responders provide effective and coordinated incident management for a wide range of situations. Mult iple variations of the FI RESCO PE ICS ha\'e been developed to include Fi re Ground Command System (FGC) and Natio nal Fire Protection Association (NFPA) 1561, which was then called Standard on Fire Department Inciden t Management System. FIRESCO PE ICS and its variations served as the basis for the National Incident Management System Incident Command System (NIMS ICS). The NIM S ICS was developed, under the Department of Homeland Secu rity (DH S) Federal Emergency Management Agency (FEMA). Addi tional information about NIMS can be found online at www. fema.gov/NIMS The typical oil-scene components of the Operations Scct ion of an ICS are Command, Fire Suppression, Rescue/Extrication, Law Enforcement . and Med ica l (Figure I-I). The struct ured fl exibility of an ICS enables it to be adapted to all types of emergency incidents: fire, rescue, law enfo rcement , and multic<\sualty inciden ts. Because of its modular design, the st ructu re of the ICS CilO be expanded or compressed, depending on the changing conditions of an incident. It must be staffed and operated by qualified personnel fro m an emergency service agency. If an on-scene incident command system is not immediately established, other rescuers will take independent actions, which will freque ntly be in conflict with each other. These independent actions (freel ancing) may be dangerous and disruptive in an env ironment that req uires organi7..1tio n and accountability. Withou To rga niza tion and accountability, chaos will occur and too many people will attempt to command the incident. If you do not co ntrol the situation , the sit uation will cont rol YO ll . Medical (Emergency Services) Branch One branch of the o perations sector of an on-scene ICS is the medical branch, which is broken down into manageable compo nents (subfunctions o r groups). ihe fi ve primary

402 • APPENDIX I Multicasualty Incident s and Triage

Iincielen. Command I

FIGURE 1-1

I

I

I

Fire Suppression Branch

Rescue/Extrication Branch

I

I

law Enforcement Branch

Medical Bronch

On-scene incident command structure.

pOSitio ns of the medical branch are the medical dircctor, triage group, treatment group, transpo rt group, and staging group (Figure 1-2). It may not be necessary to have one person in each position, but it is necessary to ensure the function of each position is executed. At a scene with multiple patients, it may bc necessary to have morc than one person take on the function of these components. When considering the need to expand or condense the medical branch of the lCS, the best indicator is current or anticipated span of control. The general rule is to have one person oversee five subordinates. Some latitude may be given due to the complexity of the situation. A highly complex or difficult situation may require a span of control of 3: I, or a simple situation may allow up to 7: I. All participants of an ICS need to know their responsib ilities. Following are ideas and suggestio ns used in determining the responsibilities of the medical branch of an ICS.

• Medical Director • • • • • • •

Establishes liaisons with on-scene Incident Command Establishes a working branch with a ppropriate groups Ensures that proper rescue/extrication services are activated Ensures law enforcement involvement as necessary Ensures that helicopter landing zone operations are coordinated Determines the amount and types of additional medical resources and supplies Ensures that area hospitals and medical control authorities (MCAs) are aware of the situation so they can prepare for casualties

I Incident Command I

I

I fire Suppression Branch

Medical Branch

I

I

low Enforcement Branch

Rescue/Extrication Branch

Medical Director

I Triage Group FIGURE 1· 2

I Treatment Group

Medical branch of the ICS.

1

I

Transport Group

Staging Group

APPEND IX I Multicasualty Incidents and Triage _ 403

• Designates assistance officers and their location • Ma intains an appropriate spa n of control • Works as a conduit of comm unications betl'.'"een subo rdinates and the Incident Commander

• EMS Staging Supervisor • Maintains a log of available units and medical supplies • Coordinates physical locatio n of incoming resources (i.e., ambulances and helicopters) • Coo rdinates inco ming perso nnel who wish to aid at the scene • Prov ides updates to the medical director as necessary

• Triage Supervisor • Ensures proper utili7..,.1tion of the Initial Assessment triage system or o ther local protocol • Ensu res that triage tags or other visual ident ificat ion technique is properly completed and secured to the patien t • Makes req uests fo r additional resources through the medical director • Provides updates to the medical director as necessary

• Treatmetlt Supervisor • • • •

Establishes suitable treatmen t areas Communicates resource needs to the medical director Assigns. supervises, and coord inates treatment of patients Provides updates to the medical director as necessary

• TUHlsporl Supervisor • Ensures the organized transport of patien ts ofT-scene • Ensu res an appropriate distribution of patients to aU local hospitals to prevent hospital overloading • Completes a transpo rtation log • Con tacts receiving hospitals to advise them of the number of patients and cond it ion (may be delegated to a communicat ions leader) • Provides updates to the medical director as necessary

TRIAGE As a triage person, yo u should spend less tha n I minute doi ng the In it ial Assessment to determine the priority of a patient. It cannot be overemphasized that th e person doing the triage does not render any treatm ent to a patient. Treatme nt is to be done by the treatme nt group of the medical branch of the ICS. A triage person begi ns treat ment of victim s is no longer doing triage, and the functio n of triage must be reassigned. O nce the medical priority of a patien t has been determined, usi ng the ITLS Triage Decision Tree (Figure 1-3), the triage person should affix an appropriately co mpleted triage lag (Figure 1-4) o r other visual identificat ion technique 10 th e vict im and move o n to the next victim to be assessed.

Patient Assessment In triage, patients typically are prioritized in to fou r categories.

• Priority O.

Black tagged; dead or alive, bu t nonsalvageable (Some EMS systems will group the "alive but unsalvageable" patients in the Priorit y 1 category and work on them as lo ng as resources are available and it does not take away from the needed resources for a salvageable patient.)

404 •

-

APPENDIX I Multicasualty Incidents and Triage

SCENE SIZE-UP Standard Precautions Scene Hazards

Number of Patients Need for More Help or Equipment Mechanism of Iniury

Can Victim

Wolle-

Abnormal

I Potential load.cnd-Go

r- Yes

Ye,

I No

PriariIy 2

Seriou.

'----- No,- -

Priority 0 Deceased / Expectant

°ln lorge-scole incidents with a great number of patients, have those who ore able walk to a designated area to be assessed . FIGURE 1-3 ITLS Triage Decision Tree. This decision tree reflects the steps of initial triage. Subsequent and more detailed assessments should occur throughout patient care.

• Priority /.

Red tagged; critical condition , unstable but salvageable (load and go)

• Priority 2.

Yellow tagged; serious condition, potentially unstable

• Priority 3.

Green tagged; stable condition, minor injuries, "walking wounded"

Although th ere is a tend ency to over triage. o ne must refrain from this because of its impact on the resources available to the EMS system. We need to be as accurate in o ur triage assessment as possible. Three basic human systems need to be quickly evaluated to determine the patient's medical priority: neurological system (LOC), respiratory system, and circulatory system . By utilizi ng the ITLS Initial Assessmen t durin g the triage phase and the Rapid Trauma Surveyor the Focused Exam in the treat ment phase, we will be accurate

APPENDIX I Multicasualty Incide nts and Triage _ 405

F 348807

tA- - - "'.-:--- - - - ,aI. ____

O"'~

-.-. -..._-. --•.. --

FIGURE 1-4 Triage tag. (a) fron l and (b ) back.

in our assessment and make the best use of resources by providing the grea test amount o f good to t he greatest number of pat ients. The general steps arc as follows: • General impression (patient overview) • Victim's approximate age? • What posit ion is the victim in? • What is the victim's activity (aware of surrou ndings, anxious, in distress)? • Does the victim have adequa te perfusion (skin color)? • Arc there any majo r inj uries or bleedi ng? • Level of consciousness • Airway • Is it open and self-mainta ined? • Is it compromised? • Breath ing • Is the vict im breath ing? • What is the approximate rate (fas t, slow, normal), quality and effo rt? • Circulation • Is there a pulse? • Wha t is t he approximate rate (fast, slow, normal), quality, and regularity? Once the Initial Assessmen t has been completed and you have fi gu red in a "survivabil ity factor," you have a good idea how to prioritize the patient. An example of applying the survivability fac to r would be if you were presented with a geriatric patient and a pediatric

406 • APPENDIX I Multicasualty Incidents and Triage patient with similar critical injuries and you o nly have eno ugh resources fo r o ne. Which one do you choose, and why? The decision should be based o n objective evaluations rather than emotio ns.

Special Considerations lnjured Rescuers Many ICSs provide a separate medical component at the scene of the incident for the care and treatment of the rescuers. Structurally, this branch is part of the logistics sectio n of a large ICS structure. In the event of illness or injury to one of Ollr colleagues, we need to be assured that they will not fall into the triage system of thc victims of the incident. We are obligated to take care of o ur own. This will enable Ollr fallen colleague to return to duty quicker and help the overall operation by providing the remaining rescuers the peace of mind of knowing that their fellow rescuer has not been forgotten. Stm.dard of Care When reviewing the care of a patient of an MCI, we have to consider the adverse circumstanccs EMS was o perating under at the time of the incident. During normal day-fa-day operations. standard protocols treat aU patients for the worst-case scenario and thus many patients are overtreated. Wh en manpower and resources arc available, it is prudent to provide such carc. However, when working in an MCl or disaster environment. the ineffici ent use of manpower and resources may be catastrophic. The guiding principle in triage and treatment of victims of an MC] is to_do the greatest good for the greatest number of patients with the least depletion of available resources. Critique and Debriefitlg The management of all MCls and disasters should be formally critiqued. Primary focus should be on what wo rked and what did no t. An MC I/Disaster Plan is a dynamic document. modified when there is a problem. In additio n to taking time to critique the incident, time must also be taken to provide Cri tical Incident Stress Debriefing (CISD) fo r the participants of an incident. The mental health of EMS professionals is as important as their physical health.

Other Triage Schemes The term triage is used in many different ways. Although the definitio n of the term is essentially the same (to sort), the mechanisms to sort and the application varies. The START (Simple Triage and Rapid Transport) system developed by the Newport Beach Fire and Marine Department and Hoag Hospital in Newport Beach, California, and Jum pSTART developed by Dr. Lo u Ro mig fro m Miami Children's Hospital in Miam i, both utilize algorithms that require a quantitative assessment (actual count) of respiratio ns. This provides a "hard point" fo r determinatio n of p rio rity or continued assessment. However, the algorithms do not provide for a qualitative assessment , the use of a general impressio n, or opportunity to determine if the victim is salvageable. Sacco Triage Method (STM ) developed by Dr. Bill Sacco utilizes mathematical computations to determine a physiological score that predicts survival. Patients are triaged on an ticipated o utcome in conjunction with transport and treatment resources. The use of precise mathematical formulas in the initial phase of an incident may be considered overwhelming and not aid in the oil-scene resource ma nagement. This scheme claims to be evidence based and shows promise for develo pment of regional impact plans. The American College of Surgeons Committee on Trauma (ACS COT) developed "field triage criteria" that is specific to tra uma patients and aids in the determination of transpo rt destinatio ns to trauma centers. This algorithm assesses vital signs and level of consciousness. anatomy of inj ury, mechanism of injury. and como rbid factors. Based on these fi ndings. it recommends a transport destination. This triage scheme is detailed and may no t be applicable for the initial phases of on-scene triage to determine which patients should be treated and transpo rted first.

APPENDIX I Multicasualty Incidents and Triage _ 407

ITLS RECOMMENDATIONS The priorities of any incident, no matter how small or large. should be safety.organi7.ation, and then patient care. To provide the most effective and efficienl patient care. one must ap· proach il in a safe and organized fashion. To have an effective medical branch of the ICS requires its use in day·to·day opera· lions, including the routine. small emergencies. The rehearsal of the standardized slruc· ture of an ICS on smaller situations will develop proficiency and allow fo r a smoolh transition into the larger, more complex incidents. Activating the ICS only when an inci· dent reaches a high level can result in a lack of famiJiarity with its usc. Routine activation of the system develops confidence in its use for all levels of command and agencies involved. To avoid the paper plan syndrome, the regular im plementation and review of an Me l/d isaster plan is paramount to having successful operatio ns. An ICS is no t :I magic wand t hat will save lives by itself, no r will it replace the cOlllmon sensc and good judgmen t required of experienced EMS professio nals. There is no Hol y Grai l for effectivc triage in all situations. It is nCCeS5.1 ry to have a plan, co mmunicate, and execute it. It may be necessary to blend multiple triage schemes to capitalize on the best ou tcome. Successful management of a situation still requires properly trained people who know what to do and how to do it. ICS properly utilized can increase the overall effective· ness o f the partici pants by p roviding a proactive approach to managemcnt. If you do no t manage the situation, the situation manages you. The key to effective performance in a leadership role is not necessarily rank, but the understanding of the duties of that position and the ability to properl y function at that level. For large-scale incidents an operation may last for days or even weeks and will require additional resources. As part of the disaster plan, 3.n ICS provides the structure for the nee· essa ry administrative, planning, financial , and logistical support.

BIBLIOGRAPHY I. 2. 3. 4. 5. 6.

http://www.jumpstarttriage.com (created 2006; revised December 30, 2006) http://www.sta rHriagc.com/(accessed January 31, 2007) http://www.sharpthinkers.com (accessedJanuary31.2007 ) http://www.fucs.org (revised January 10, 2007; accessed Jlllluary 31, 2007) http://www.fcma.govtnims lCS·loo: Introduction to ICS, September 2005 Maatman, D. v..S. A. Huisman. 2005. T·4, Triage ITetllmem &- IrallSport lrailling. Grand Rapids. MI: D&D Publications.

•

Agricultural Rescue Course Overview Davis Hill, EMT-P S. Robert Seitz, MEd, RN, NREMT-P

Objectives Upon completion of this appendix, ),ou should: I. Be aware of the need fo r EMTs and rescue personnel in rural agricultural areas to

have coo rdinated training in rescue and t rcaLmenl of victims o f fu rm injuries. 2. Know how to obtain access fo r Ihjs type of training.

RESCUE ON THE FARM The term resclle is defined as actions to set free frOIll danger. Rescue is needed when someone or something is in danger, and action is taken to either SlOp or remove a person or thing from that danger. (I is the desire and expectation that after the rescue intervention, the person or thing will be removed from the danger with the minimal amount of additional injury. Consider the fo llowing scenario.

A northeastern daif)l farmer was found pin ned under his tractor late one October afternoon , just at dusk. The temperature was in the low 50S. He was alert and oriented and in co nsiderable pain, but could not feel his lower extremities. He was pinned under the rear wheel at his pelvis and both legs. He remembers overturning the tractor and believes it happened in the earty afte rnoon, although he really could not recall the timing clearly. He was found by his wife and son who promptly called for emergency services by contacting 911. This rural community was served by a local volunteer fire service and BLS ambulance. By the time emergency responders arrived on·scene, several family members and neighbors were present an d obviou sly very anxious. The fi re chief called for a med ical helicopter and a ground ALS unit was dispatched earlier. As soon as the tractor was secured from further moven1ent, EMTs on·scene began a patient evaluation. The patient's vitals were surprisingly stable for his condition and they determined that initially his most serious cond ition appeared to be crush ing injuries to the lower extrem ities and pelvis. They urged the fire service members and the fire chief who was incident commander (tC) not to extri cate until ALS units arrived on· scene for further evaluation. This request was backed up by both incoming units, as their arrival time was estimated to be between 10 and 15 minutes. However, due to the family's demands and the fact that the outSide temperature was dropping, the Ie ordered the extrication to take place and stated that the patient could be treated by AlS in the ambulance. As the tra ctor

408

APPENDIX J Agricultural Rescue Course Overview _ 409

was lifted from the patient, his cond ition deteriorated rapidly. When AlS provid ers arrived on-scene, the patient had arrested and could not be resuscitated.

RURAL RESCUE Rescue is a relatively new term in rural communities. To truly be proficient in rescue techniques, individuals need to be knowledgeable and competent with mechanical skills as well as advanced patient care techniques. While such skills training may be more readily available to career personnel, obtaining it can be very difficult or ncar impossible for volunteers. This type of training may be hard to justify in areas that have very few true "'rescue" calls. Requiring every fire/ rescue member to be a paramedic or experienced EMT and trained in multiple aspects of agricultu ral rescue is unrealistic with the exist ing constraints of personnel, finances, train ing. and competency requ irements. Thus, performing rescue in rural communities requ.ires teamwork between the people doing the mechanical work (normally firefighters) and the people doing the patient care work (EMS providers) . The time to realize th is is not at a scene as described above, bu t du ri ng a train ing exercise that involves both parties.

FARM TRAUMA IS UNIQUE Farm trauma may be very different from o ther trauma that rural emergency responders arc trai ned to handle in an everyday manner. Farm trauma can be equated to victims caught in buildi ng collapses, with similarities to time of discovery or type of treatment. O n the fa rm , it may be several hours before a victim is even missed, since most fa nners work alone in very remote areas. Victims of a building collapse can be crushed for several hours or more before SAR personnel get to them. Should the quality of care each victim receives be different? In the rural community, probably the most co mmon occurrence that brings fire and EMS personnel together is a motor-vehicle crash. The majority of MVCs are discovered soon after occurrence so responders quite often are presented with victim s in a com pensated state. These individuals may be able to survive in spite of poorly coord inated care. However, when an extended period of time has elapsed before the victim is found or the rescue requires extended time, the patien t may have exhausted his or her ability to compensate for injuries. and without dose coordination between rescuers and EMS. the victim may not survive.

TEAMWORK TRAINING Trad itionally. rescue train ing involves teaching mechanical techn iques such as shoring, door and roof removal, high angle and confined space techniques, hazmat management , and so on. Litt le discussio n takes place about patient care during the rescue process, short of the very basic levels of support necessary to keep the patient alive until the patient was brought to the EMS providers. There is certainly benefit to adding a module to each rescue curriculu m dealing with injury ma nagement specific to each type of rescue and encouraging participation by those responders who will provide patient ca re. Th is is why Pennsylva nia State University developed a true rescue training"program (Agricultural Rescue Course) designed to bring both rescue person nel and EMS personnel together in the sa me classroom to learn how to manage trawna patients injured in agricultural accidents. The Pennsylvania State University has un ited with ITLS in the development of the medical components for several agricul tural rescue training modu.les.

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41 0 • A PPENDIX J Agricultural Rescue Course Overview Many rural EMS responders arc not members of the fire .service so their participation in fire "rescue" training cou rses is infrequent. Even when EMS is part of the fire service, there is often not a solid partnership between perso nnel. For a successfu l rescue to take place, all individuals regardless of rescue fun ction should understand the role of other rescue personnel and work together as a team to facil itate the best pat ient outcome possible.

TRACTOR AND MACHINERY INCIDENTS Tractor overturns and machinery entanglements account for about two-thirds of all farm dea ths and serious injury on farms. It is not uncommon fo r an injured farm er to be found ( usually by the fam ily) several hours after the inciden t occurred. With th is delay in time, traditional t reatment protocols may need to be modified depending on the extent of injury. This is one type of rescue where advanced life support measures must be delivered to the patient prior to extrica tion activi ties. Severe cr ushing injuries (similar to those found in building collapse victims) may need to be t reated prio r to o ther rescue activities. C rushi ng inj uries can occur when a tractor operator is pinned under a tractor for an extended time. T hey also commonly occur when the farmer becomes entangled in a rotating shaft or:l machine's rollers or augers. Another complication to machinery incidents is hydra ulic injection injuries. Hydraulic pressures on fa rm equipment are typically 1,500 to 3,000 psi (pounds per squa re inch). If a pinhole leak develops in a hydraulic line, pressure of the oi l exi ting the leak can exceed 7,000 psi, which when injected into the body can cause serious tissue and structure damage. Rural EMS responders need to be methodical in assessing the pat ient's cond ition and potential injuries. Likewise, those actions involvingslabil izing the machine and extrication activities (lifting. d isma ntling, cutting, etc.) become so technical that fire personnel need to concentrate on those actions and not be concerned with in-depth patient care needs. EMS responders shou ld understand the issues fa ced by the fire personnel but wiIJ nOI need to be involved in their act ions.

FARM CONFINED SPACES There are a host of confined spaces on fnrms that fa rmers enter on a regular basis. High among them arc silos, which are structures used to fe rment and store high - moisture forages. Many " rescue" people would argue that EMS care is not normally provided within a confined space, rather the pat ient is removed to a sa fe area fo r trea tmen t. However, one of the leading causes of involvemen t in a silo entrapment is entanglement in the unloading auger. Crushing injuries and poten tial amputat ions (along with s urgical amputations) are factors that may be encountered. Again. protocols and techniques that work well for other types of incidents need to be revisited when dealing with farm trauma. Emergency responders must realize that Ihe majority of farmers in the United States arc not obliged to follow OSHA confined·space standards that other industry workers must fol low. Th is fact should suggest that those procedures designed to protect the worker may not be in place on the majority of farms. Rescue personnel should not take for granted a backup plan for rescuing someone who is involved in a confined space is in place. The far mer will rely ol1ll1e local emergency responders whether they are trained or not. As confined-space rescue is a specialization itself. rural EMS responders should also be encouraged to become trained in confined-space entry to be able to work hand in hand with the personnel t rained to perform entry. initiate pat ient care, and assist with extrication activit ies.

APPENDIX J Agricultural Rescue Course Overview _ 411

AGRICULTURAL RESCUE-AN OPPORTUNITY Agricultu ral rescue as defined should combine patient care with the mechanics of access, disentanglement, and extrication. As both disciplines arc extremely technical in and of themselves, to expect responders responsible for slabiliz..1tion, disentanglement, and extrication to also provide the level of medical intervention thai may be needed has a potentiaJ to overburden those few personnel who may be cross tra ined and experienced. Farm incidents happen so infrequently that profi ciency comes slowly. Specializing in each aspect of "rescue" is a must. Th is sho uld start with the training programs that acknowledge the importance of all resources necessary and identify and promote an understanding of various roles, integrate rescue practice with patient care, and increase comm unicatio n between aU rescue personnel involved. Fo r more information on the Agricultu raJ Rescue Course a nd availab il ity of courses, please cont act the ITLS International Office at 888-495-4857 (internatio nal call " 630-495-6442 ).

BIBLIOGRAPHY I. Hill, D., S. It Seitz. 2006. Fanll resclle course. University Park: Pennsylvania State Un iversity.

ITlS Access Overview Roy Alson, MD

Objectives Upon completio n of this appendix, you should : I. Be aware of the need in certain localities fo r EMTs to have skills in crashed veh icle en try techniques using basic equipment. 2. Know how to obtain train in g in these skills. Motor-vehicle coll isions rema in a major cause of multiple trauma. Studies have shown that the sooner a trau ma pat ient reaches definitive ca re, the better the outcome for tlmt patient. The goal o f ITLS is to provide the responder wi th the tools and t rain ing to assess,stabil ize, and rapidl y transport th,' trauma patien t to the appropriate medical f:1Cility. Before begin ning assessment and treatment of the t rauma patient, the responder must first be able to access the patient. In most locales, EMS resources respond to motor-vehicle coll isions accompanied by fire and/or rescue personnel or have rescue personnel immediately avai lable. Often in more rural and isolated areas, there are situations in which rescue equipment and person nel are not available or may req uire prolonged t imes to respond. T hose EMS responders may be faced with gai ning access with whatever equipment they ca n ca rryo n their ambulance o r rescue vehicle. To assist the EMS responder in gaining access 10 entra pped victims. lTLS has developed the ITLS Access Course. This tra ini ng gives t he responder th e knowledge base to safely reach the victim of a motor-vehicle collision and begin applying the principles taught in the IT LS course, thereby saving some o f the Golden Hour. The tech niques taught in Access Course involve use of very basic, inexpe nsive tools and eq uip ment that can be carried on any ambulance or rescue vehicle. Th is handS-Oil co urse also teaches where and how to use thosc tools to rapidly stabilize and then gain access to a crashed vehicle. T he first and foremost p rinci ple on an)' accident scene is that of safety. T he appropriate usc of personal protective equipment ( PPE) to prevent injury, as well as contamination with blood or body substa nces, cannot be overemphasi7.ed. Each one of us on the scene is a safety officer and we must remember t hat o ur own safety and that of our colleagues is paramo unt. [f we become injured , we cannot help the victim. Assessment of the sce ne begi ns with dispatch and the informat ion provided. As you approach t he sce ne, begi n to assess for hazards and look at the mechanism o f injury. Are th ere issues with fu el spills, dan gerous ca rgos, downed lines, and so fo rth? Remember that unless yo u have th e appropriate equipment and trai nin g, yo u should no t handle downed power lines. You shou ld always assume a line is live until instructed ot herwise by power co mpany perso nnel. Yo u sho uld place )'our veh icle in a safe location and be su re that it is sa fe fo r you to enter the scene. In a hazm at o r ot her t ype o f ca U, without appro priate PP E, you may not be able to safely enter the sce ne. For many o f us, that

412

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• APPENDIX K ITLS Access Overview _ 413

couJd be t he most di fficult decision of our lives. Yet if we rush in witho ut p roper protective equi pm en t. we may fo rfeit both o ur lives and th ose of t be victi ms. How many victims? What other resources are needed? Th where should those resources respond? All of these q uestions must be answered and transmitted back to the d ispatch center. At this poin t, one of your crew members mus t take control o f the scene and serve as the incident com mander u nt il relieved or the incident ends. We do this info rmally on most calls but o n a major event, this must be determ ined and in itiated promp tJy. You sho uld sweep the scene-looking both toward the incident and away, to locate victims. O nce you have located the victims. are an)' still in the veh icle? If so, how do you rend er the vehicle safe? Even on the wheels, un less it is made stable, a vehicle can roll over a respo nder o r furth er injure a victim. Even after the wheels are chocked, unless it is cribbed , the vehicle can still move on the suspension. If the vehicle is on its side o r roof, il is even mo re unstable and must be rendered stable prior to making entry 10 assess the patient. You ca n usc materia ls from the scene, such as jacks o r spare t ires, etc., to stabilize the vehicle, until additional suppo rt arrives. O nce you have stab ilized the vehicle. entry can be made. Ideally you can o pen the vehicle doors to extricate the patient (s). For vehicles not on the ir wheels or with damage to the doors, you may have to make ent ry by other points. The simplest way to breach the ca r struct ure is to make entry through the windows. Side glass o n most passenger veh icles is made of tem pered glass. When the surface tension is b roken, the glass shatters into t iny but sharp pieces. If you must breach the window, try to do so as far as possible fro m the victims. Ta ke every effort to protect them fro m debris. using blankets. coats, and so o n. Usc of a center punch in the corner of the window will quickly break the window. O nce cleared of glass, you ca n enter and begin patient assessment and management, beginning with Ihe ITLS Prim ary Survey. Be sure that you are wearing the approp riate PPE, as you may need to stay wi th the patient d uring the process of disentanglement and extrication. That p rocess is often complicated b y the fact that the patient will need spinal motio n restriction. th us maki ng it necessa ry to create a larger path fo r egress than if the patient were exiting the vehide un der his o r her own power. During this process it is your responsibility to maintain support of the patient's airway and other vital fun ctio ns. Team effo rt is required fo r the process of extricatio n to work. You sho uld be thoroughly fam iliar with the tools needed and the techniques requi red . T his is best accomp lished through freq uent practice under realistic conditions. followed by a frank and detailed review to ident ify areas for improvement. For mo re informatio n on ITLS Access and availab ility of courses, please contact the ITLS Internatio nal O ffice at 888-495~ 4 857 (international calls: 630-495-6442).

BIBLIOGRAPHY I. Alson, R.. B. P<Jlterson. 2006. Access. 2nd ed. ITLS.

,

Tactical EMS Walter J . Bradley, MD, MBA, FACEP John Wipfler, MD, FACEP William Pfeifer, MD, FACS Bill Bozeman, MD, FACEP Martin Greenberg, MD Objectives Upon completion of this appendix, you sho uld be able to:

I. Descri be the goals of tactica l emergency medici ne supporl (TEMS). 2. Explai n the need for TEMS. 3. Describe the purpose of a TEMS provider.

4. Discuss when the ABCs sho uld be changed to CAB.

INTRODUCTION

Tactical EMS is a growing subspecialty of Emergency Med icine and Emergency

~kdical

Services that is increas ingly more prevalent in the Un ited States. The dangerous atmosphere fa ced during law enforcement tactical t rai n ing and operation s often results in sign ifica nt risk of injury to police officers. hostages, suspects, bysta nders, a nd others. including medical personnel that may be involved. Unfo rtunately, the neareSI available prehospilal medical care is 100 often staged w ith an amblLlance several blocks away, waiting for the scene to become "safe." Their effort s are too often uncoordinated , unprepared, and too laiC. T his older "'traditional" method of utilizing standard EMS providers can expose prehospital perso nnet to great danger. In addition, traditional arrangements that do not integrate the medical team into the tactical unit oflen disrupt or endanger lhe law enforcemen t tactical m ission. Law enfo rcement agencies are increasingly recognizing the need to have em ergency medical care immed iatel y available and integrated with their u nits. To meet these needs, carefull y selected and specially trained and equ ipped prehospital medical person nel and emergency p hys ician s are increasingly supporting tactical units, also known as special weapon s and tact ics (S\VAT) units. This subspecialty is rapidly expa nding and is called tactical emergency medicine support (TEMS). It is weU established in many ci ties and is increasingly prevalent throughout the world. Medical personnel who provide TEM S ideally are equipped , trained, and have developed unique skills to mee t the demands presented by o peratio nal su pport of law enfo rcement tactkal teams. This chapter will discuss these unique aspects and provide a foundation of knowledge rega rding tactical EMS .

414

APPENDIX l Tactical EMS •

WHAT IS TACTICAL EMS? The defini tion of tactical emergency medicine support (TEMS) is as follows: The delivery of {'nlcrgcncy medical services at law enforcement and military spedal operations, and the provision of comprchcnsiw health care 10 members of tactical uni ts on an ongoing basis, maintaining thl.'ir physical and mental health 10 optimize the pcrformanc(' of the tactical Tcam.

The goa l of T EMS is the same as the goal of sp ecial weapons and tactics (SWAT) units: to accomplish the law enforcement m issio n without inju ry o r death resuJting from the team's intervention. and the preservation of life and safety of everyone.

Modern SWAT Teams T he general public sometimes has a n egative image of tactical teams, due perhaps to tele· vision shows and m ovies that unreal istically portray SWAT tcams as sim ply showing up and " blowing away" the bad guys. In fact. modern tactical teams are comp rised of h ighly trained. experienced. and reliable "cream of the crop" law enforcement officers who do everything they can to resolve dangero us situations with out anyone gelling hurt. The fact is, SWAT un its save lives. Approx imately 95 percent of SWAT callou ts arc resolved peaceful ly. Practically speaking, a SWAT team is organized as both a crisis interventio n and rescue team with assa ult and negotiation capabilities. The fo llowing positions are usuaUy incorporated in the tact ical team.

• Illcidefit/Ullit Commallder-supervises the entire operation from the command post.

• Team Leatler--directs the team pcrsonnally and may enter with entry team in third or fourth position.

• Entry Tactical Officers--usuall y a minimu m of two ent ry teams (three to six officers each) are involved and possible th ird backup rescue team.

• Medic/Tactical EMS Provider--offers immediate medical support to ilVi njured team mem bers, suspects, victims, o r bystanders; other roles include preventive medicine.

• Negotiario1/S Team-usually communicate via telephone or throw phone systems. Crisis negotiations resolve an overwhelming majority of SWAT o perations.

Evolution of Tactical EMS The begin nings of T EMS started with the armed services. Napoleon is recognized as having the fi rst modern field med ical evacuation system integrated into units en gaged in combat. Clara Barton helped show the benefits of p roviding medical stabilizat ion of a wounded soldier before and during transport from the site of injury. Her philosophy of t reating soldiers as soon as possible ("'treat them where Lhey lay") led to present-day m ilitary and civilian prehosp ital care systems. For yea rs, milita ry specia l operations u nits have included med ical support in their o rganizational st ructu re, as they have recognized that th is support, especiall y in covert or tactical operations. can enhance t he probability of a successful mission. Significant histo rical events led t.o an increased interest in specially trained tactical units: t he Un iversity of Austin dock tower shootings ( 15 people killed, 35 wounded b)' a si ngle shooter on August 1, 1966) and the Los Angeles Watts Riots of 1965 and 1992. T hese events shook civilian law enforcemen t agencies and forced them to consider how they would react to these violent acts in their own jurisdktion .

415

416 • APPENDIX L Tactical EMS

Why Tactical EMS 15 Ne.d.d The reasons for T EM S 3.re easily explained. Terrorist bombings, kidnappings. bank robberies with hostages, riots, d rug dealers utilizing fuUy automatic we.apons, emo tio nally disturbed persons with weapons, and o ther violent acts have increasingly fi lled newspapers and become a part o f life in the United States. The citizens of o ur commun ities expect law enfo rcement agencies to resolve th ese incidents pro mptly and safely. These agencies usually have a team of highly trained individ uals who respond to these pOlentialJy violent emergencies, and officers (and others) are at high risk for injury and death. In add ition, the 1999 Columbine school shooti ng/bombing incident, the 2005 Beslan Russia school attack, and other critical incidents occur thro ugho ut the wo rld with increasing frequency. When they occur, the response by law enforcement personnel is urgently needed. and office rs who respond increasingly need medical support. The concept of TEMS is supported by the facts in Table I.- I.

Roles of Tactical EMS Tactical EMS providers typically provide support for civilian law enforcement tactical teams and other law enforcement teams such as rio t squads and bomb squads. The prehospital medical providers in volved in this field have a simple goal- to contribute to mission success by preventing injuries and illness and by safely providing the best medical care possible when illness and injuries occur. The medical support is provided in three key areas as listed here. • Befo re a missio n • Provide general medical support fo r team members duri ng training that maxim izes performance. This includes preventive medicine, health maintenance, and injury cont rol (team "doc"). • Provide immediate medical care to team members who become injured or ill duri ng tra in ing (a significant number of major injuries suffe red by tactical offi cers occur during tra ining sessions). • Teach tactical officers self-care and buddy combat medical care. • Participate in mission plannin g and medica.l th reat analysis (MTA). • Prepare a MTA. • Provide approp riate medical advice while keeping missions confidential to avoid any info rmation leaks. • Prepare the T EMS tea m 10 deal with perti nent medical threa ts and hazards expected at a scene.

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An integrated TEMS unit may functi on with less risk and mo re be nefits for the tactical team. The security of tactical ope rations is enhanced whe n the me dical support team is integrated. Time lag occurs if regular EMS care is used ("wait unt il scene is safe" is oft e n t oo late). Prevent ive medicine in training and callouts by TEMS results in decreased injury and illness.

APPENDIX L Tactical EMS •

• During a mission • Primaril y provide immediate medical care to tactical team members and law enforcement officers. • Secondarily provide emergency care to bystanders, suspects, or others in need on-site. • Advise the command staff of developing medical concerns, and be available for medical consultation. • Perform remote assessment medicine (RAM) of any downed victims in exposed positions. • Remain a liaison with the local EMS system, hospital s, and officials from other public safety and law enforcement agencies. • After a mission • Perfo rm incident review and assist command staff with analysis of the operation/training event. • Docu ment and review all medical records relevant to operational or tra ining mi ssio ns. • Appropriately optimize treatment. rehabi litation, and men tal health for injured officers through involvement with hospitals, physicians, fam ily, and police depa rtment officials (while respecting patient confidentiality regulations). • After review and analysis of the incident, provide advice to improve policies.

TACTICAL EMS MODELS A number of different models of TEM S units have evolved over the years. A com mon theme is that there is no single "best" tactical EMS model that will meet the needs of all agencies. All of the models have their own st rengths and weaknesses, and each program must be tailored to fit the needs of specific agencies using the available resou rces.

Provider Models Who is the ideal perso n to be a "tactical medic"? In general, it is easier and less costly if the TEMS provider is primarily employed in a medical profession, and then secondarily trained in law enforcement/tactical medical support. The 1,000 o r mo re hours it takes to train and mainta in skills as a paramedic makes it expensive and impractical fo r a law en forcement agency to train one of their own officers to be able to perform adva nced life su ppo rt (ALS) med icine. Conversely, a medic/paramedic may take a short ened law enforcemen t training course to learn the basics of law enforcement supplemented by tacticaJ EMS training cou rses that wi ll provide a founda tional TEMS knowledge base. The advantage of this approach is that the med ic or other medical profess ional is perform ing medical work on the normal job every workday and is thus able to mainta in medica l skills and also more easily comply with sta te EMS regulat ions and credentialing. So me law enforcement agencies have trained and cert ifi ed their tactical officers in basic life support (BLS) as an EMT-Basic o r EMT- Intermediate and utilized them for TEMS. This approach at least improves the level of emerge ncy med ical care training. decreases the potent ial for accidental "lea ks" of important info rmation, and eliminates the presence of a "civil ian" on the tactical team. If this method is used, however. it is still importan t to designate severa l tactica l officers as "TEMS-medical only," a role that most officers will try to avoid (as they prefer to apprehend or neutralize suspects). Although not mandatory, many TEM S providers wiU arrange to be designated or certi fied as so me type of law en forcement officer (usua lly aux il iary, cert ified part-time police officers, or, rarely, full time). This arra.n gement may allow liability and insurance

41 7

418 • APPENDIX l Tactica l EMS be nefit cove rage to be extended to the individual TEMS offi cers and allows for in creased law enfo rcemen t traini ng opportun ities. The ideal situation is debatable but, in general, the TEMS unit is better integrated and supported jf medics can become part-time o r auxiliary police officers/deput ies. This arra ngement allows the TEMS members to receive additional trai ning, adds to "esprit de corps," and allows most liability concerns to be add ressed. Med ical malpractice mayor may not be covered by the municipa lity and each situation wil l vary. Several states have successfully passed legislation that indemnifies !ned ic.,l professionals when they assist or provide med ical suppurt tu 1m", cnfun': l'mcn t ufficers.

Deployment and Positioning Where is the best location fo r a tactica l medic? Th is is a debatable topic, but in general, when a tactical o peration begins and the SWAT u nit makes entry, the optimal location fo r the TEMS providers is the safest position that is dose enou gh to allow a fast (less than 30seco nd) response time to the tactical team's location, and to any wou nded officers. Ideally, this is a loca tion that allows the medics to visualize the tactical team's exact ent ry poin t. Th is concept is known as the "po int o f relative safety." If the scene is not secured, but conditions allow the injured to be moved to the medics and ha rd cover, they may be moved to obtai n stabilizing first aid. Each situation will va ry, and there may be circumstances that require the TEMS provider to come forward to assist downed officers. In general, during the initial SWAT callout o rganizing stages, the medical team is best located at the command site (tent , vehicle, room), where they are relatively safe, yet can p rovide medical support and inpu t into resolving the iJ1Cident as needed , as well as gct a good grasp of the details of the o peration . When the tact ical team moves into position, (he TEMS providers may move forward to the point of rela tive 5.,fety to stand by beh ind hard cover until needed. However, so me teams keep their medics at the com mand site, and others will bring properly trai ned medics inside o n their entry team. There are pros and cons o f these systems and each unit will need to decide for themselvcs given the p references of the involved persons and departments. Overal l,each TEM S unit will need to work closely with the tactical unit to defi ne policy and procedures regarding the deployment location of their medical officers. There are several locations where the TEMS Qffi cer can be positioned. In a traditional civilian EMS prepositioning system, the SWAT team has no tactical EMS support and they simply call the local ambulance squad and place them at a 5.,fe place nearby, perhaps several blocks away. This, u nfortuniltely, continues as the sole medical su pport fo r many SWAT teams. The newer tactical EMS model utilizes medical perso nnel inside the ou ter perimeter, and often within the inner perimeter. The exact location of TEMS personnel will vary according to the local tactical unit's preference, the type o f tactical callout, and the level ofTEMS training. The three classic wnes arc described as follows: • At the aliter perimeter (cold zOlle). This is frequently the best place fo r TEMS personnel to be loc.lted initiaUy and is also the usual location o f the incident com mand center, o r tactical o perations center (TOe) . • Outside of imler perimeter (warm zotle). As above, this is a good locat io n once the SWAT team has moved into the inner perimeter. The TEMS IInit usually approaches the b uild in g o r structure wi th the tactical team, an d then when a close observa tion po in t with hard cover is reached (i.e., a brick wall or other cover that stops bullets), the TEMS providers may r~lll ain there. ideally alo ng wit h one or two law en forcement officers who can provide security. • JI/tl er perimeter with the SWAT elltry team (hot zotle). This is cont roversial and may depend on the level o f the TEMS additional training and/or experience. Some SWAT teams have a highly trained paramedic or EMT present onlhe actual "stick"

APPENDIX L Tactical EMS • 419

entry team, and thus actually go in side the building initially as the fourth or fifth person on the entry team. This has th e advantage of immediate medi cal care. but at a relatively higher risk to the TEM S medical personnel. A safer method for smaller buildings or single-unit houses is to keep the medical team nearby but behind cover, and to call thc TEM S officers forward only if the need arises. There is one exceptio n to th e inner perimeter zone, which is extremely rare, but ft..mains a possib ility and thus all tactical teams sho uld and usuaUy do train fo r this contin gency. This type of incident would include a large building with muhiple rooms and levels. in which there are known injured victims and the suspect(s) potentially remain inside the building. In this type of incident many TEM S units train to fun ction o n the rescuc team and work with tactical officers to dear the building and simultaneously provide medical care to any injured persons fo und.

Extrication and Transportation TEMS personnel mayor may not have their own patient transport capabilities. If they do not, they may require interfacing with the local EMS system for transportation of injured SWAT team members o r non- law en forcement personnel. This consideration must be kept in mind during the planning of protocols and procedures, especially the location of the TEMS unit and coordination of transportation efforts. Armed Versus Unarmed Controversy Should the tactical medic be allowed to be properly trained and authorized to carry a fi rearm for personal protection of self and patients? It is controversial for so me agencies, while oth er agencies gladly take the time a nd effort to arm th ei r medics fo r th e dangerous tacti"d environment. The official position by national training institution s is neutral on this issue. For those TEM S providers who are not allowed or choose not to be armed, it is absol utely essential that they make arrangements for reliable securit y to protect and watch over them during SWAT callout's. It is important that any efforts to create a new TEMS unit lJot let this co ntroversy block the formati o n and developmen t of the unit. Many teams have been successful in starting a working TEM S relatio nship and then dealing with the firearm issue after mut\JaI respect and understanding is better developed.

SPECIFIC TEMS EQUIPMENT AND TACTICS Equipment and Supplies

U"iforms, Protective Eqllipmem. and Medica l Supplies: The uniforms, protective gear, medical equipment, and medical supplies will vary among individu<\J TEr\'IS units, but Table L-2 presents some ideas fo r consideration. These are simpl y "things to think about," and every unit will carry a slightly d ifferent va riation of each itelll.

Specialized Eqllipment: The medical gear/ medications to provide medical su pport may be organized and/or carried in many different ways. Generally, each unit does it differently. Some TEMS units have adopted this simple philosophy: " If it's not attached to you, you won't have it there when you need it." For example, some TEM S units ut ilize a three-level system.l\'V o remain with the TEM S officers at all times, while the thi rd (Large Advanced Medical Bag) typically remain s secured nearby or in a veh icle.

• u!l'el J: 'Tactical Medical Vest with Belt, Holster. Airway (Leg) Pack • Stethoscope, nitrile rubber gloves, face mask with eye shield o r goggles • Airway management kit: cricothyroidotomy hook, scalpel, pocket mask, tension pneu motho rax decompression kit , hemostats, ET tube (6.5 and 7.5), stylet,

420 • APPENDIX L Tactical EMS

~~~~;;~i ::'~~ un~onm~~r.'inir~ ~.

good all-around tractlon;- waterproof. and ~-

fluid

- ' Balltstic vest (lev.11II prefemtd. with side ~ectors and ceramtc plates l&ewI , IV) considered) •

In

I _ Helmet (Kevlar) with stable sUlpen;~ion syst' f.tix Black Nomex{balaclava (protect identity at scene, E?re~facial burns) ~ • J :w ; .r. . I .~q . I n I ; Eye pr'9tectlveJJ099les With Side shklldlOg (Clear poIycarbonate lenses to protect from flying debrlsltrauma) ~

-

Ear protection (foam plugs, shooting muffs)

-

Gioves (rubber gloves (nitrile ideail. and leather '" N....ox oxt~ gloves) Medical stltndard nrecauUons .....-ective gear: face mask/shield, gloves. hazmilf: ;J -;., . .-J )F", goar ~ needed l! t" : ,~.

..,

Gas mask (with

• • • • • • • • • • • • •

oropharyngeal airway, size 28 nasopharyngeal airway, laryngoscope with #3 blade, BVM or oral ventilatio n system Compression trauma bandages (3), doth tape, small roll of d uct tape l b urniquet (2 or more) Hemostatic agent (QuikClot 1st Response sponge o r Celox) (2) Asherman penetrating chest trauma seal (2) Minor wound medical kit: steri-strips, benzoin, betadine, neosporin ointment, bandaids, 2x2 bandages Common medicine for commo n com plaints: ibuprofen, acetaminophen, antacids, etc. Handcuffs, holster and defensive weapon (pistol), am mo, extra magazines as needed Trauma scissors, knife-folding style utility Communications: rad io with headset, cellular pho ne, pager Tactical flashlight Small binoculars for remote assessment and observation; consider night vision monocularlheadset Digital camera (for evidence preservatio n, documentatio n, interesting cases) Metal detector (handheld, silent vibratory type) for identifying hidden weapons or needles

• Level II: Tactical Medical Backpack • A second (backup) advanced airway management kit, which includes a second set of above airway supplies, bag-valve mask, Magill fo rceps, laryngoscope #1 and #3 blades, fu ll assortment of ET tubes (adult and pediatric) • Large curved hemostats, scalpels • Two I-liter IV LR fluid bags/IV starter kits with two blood tubing IV lines/pressure JV bag • Disposable hot packs (to1<.eep IV fluid warm in cold weather operations) • 7-French change-out catheter set (for cut-downs/IV access) • Additio nal trauma dressings, gauze bandages • ACLS medications: atropine, epinephrine, lidocaine, D50

• Level Ill: Tactical Medical Advanced Emergency Medication Pack.

This pack may be kept locked in a controlled environment at the base hospital. The contents may

APPENDIX L Tactical EMS •

include controlled substa nces, which must be properly stored, controlled, and monitored per DEA requirements (Table L-3). In addition, it is important to prevent exposu re to high heat due to the sensitive medications contained. Many hospitals will"restock" this bag every 6 months and recycle the medications prior to expiration, allowing the net "cost" to be very low. Addi tio nal items included in the Adva nced Medical Supply Kit include the following: • Syringes and needles, alcohol wipes • Suture kits (2) and minor surgical emergency supplies-ga uze, basin, steri le gloves, sut ure ma terial, betadine swabs • Additional IV fluid and IV lines, IV starting kits • Anderson blast gauge • Sterile saline (2 bottles) for irrigatio n/clea ning wounds • Denta l kit: m irro r, dental floss, dove oil, topical anesthesia, tongue blades, sto ma wax, temporary filling material • Addit ional t rauma supplies: antiseptic towelenes, compression elastic ba ndage, trauma pads, cy~ dr~$S in g, Q-tips. SAM splints, triple antibiotic oin tmen t, bandaids, tape, no nstick gauze, ga uze pads, moleskin/blister kit, irrigation syringes/solut'ion, Betadine and Hibidens scrub brushes. cold packs, heat packs, ding wrap, two tension pneumotho rax kits • Extra stethoscope. pen light, trauma scissors, knife/ paratool • Latex gIO\'es, sterile and nonsterile; face mask/shield • Pencil marker, waterproof paper, medical records of unit members • Patient ID/ triage tags, emergency thermal blankets (2), st robe light • Medical waste bags, disposable sharps hard plastic container • Thermometer ( regular and special hypothermia)

Training Considerations There is a significant body of knowledge that is integral to the practice oftaclical medicine that is entirely separate from sta ndard prehospi tal and emergency medical training. These topics come from a variety o f medical disciplines and law enforceme nt/ military operat io ns. They are taught by numerous high -q uality training agencies that speciali ze in l:Ictical medical training (Table L-4). It is in the best interest of the TEMS provider to com plete a forma l T EMS t>ducational co urse and then utilize the un ique sk ills and knowledge in rou tine training with the tactical unit, to gain fam iliari ty and mutual respect of indiv idual roles and abilities.

Special Tactical Medical Procedures There arc several topics importan t fo r the TEMS provider to be ,lware of, and proficient in , during law enforcement su ppo rt.

Make 'lie Scene Slife by DiSllrming Before Treating: If the officer is seriously injured, first remove weapons (do not forget backup guns. any explosives, chemical munitions). If the injured officer is lightly wounded. alert. and under fire, o r still facing a threat, then consider allowing the officer to keep his weapon to protect himself and TEMS personnel. AU criminals should be considered to have hidden weapons, handcuff keys, hypodermic needles, and o ther ha7.ards. Always get help when removing weapons from a suspect/ criminal. Always lise ca ution!

Trauma Combat Casllalty Care: During a SWAT callo ut. a TEMS provider may be called upon to ca re for someone who is shot o r otherwise injured. The tactical com mander and team mllst focus on completing the missio n safely, incl uding calling for additional help if needed. establ ishing fire superiority. abolishing threats, and preventing additional casualties. These arc analogous to making the scene safer. Medical care provided in this situation

421

422 •

APPENDIX l Tactical EMS

Colds/Flu Symptoms

Cough drops Entex PSE decongestant (20) Neosynephrine nasal spray (1 bottle)

Minor Pain Control

Ibuprofen 400-mg tablets (30) Tylenol SOO-mg tablets (30)

Severe Pain Control

Morphine for 1M/ IV use

Allergyl Anaphylaxis

Epinephrine 1:1000, (3) 2-cc ampules Benadryl2S mg capsules (20) Prednisone 20 mg tablets (10) Albuterol inhaler (1) (used for asthmatics also)

GI Ailments

Immodium tablets (20) Peptobismal tablets (approx 20) Mylanta tablets (approx 20)

Unresponsive Patients

Ammonia capsules (2) Dextrose SO%, (1) SQ.cc syringette Oral glucose syrup, (1 tube) Narcan, (2) 2-mg ampules

AClS Drugs

lidocaine 1%, (2) 10-cc syringettes Atropine, (2) 1-mg syringettes Epinephrine 1:10,000, (4) 1-mg 10-cc syringettes Nitroglycerine S.l. spray Baby aspirin, 81 mg (chest pain use)

Seizure Control

Diazepam for IV/1M use, (1 ) 10-mg vial

RSI (Rapid Sequence Intubation) Meds

Diazepam, 10-mg vial Etomidate for IV use-sedation Ketamine for IM/IV use (1 bottle) Vecuronium (Norcuron), 10-mg powder Rocuronium (Zemuron), (2) S-cc vials Normal saline, 2S-cc bottle (to reconstitute Norcuron)

Ear/ Eye Ailments

Gentamycin ophthalmologic ointment (2 tubes) Gentamycin opth. drops (2 bottles) Cortosporin otic suspension (1 bottle)

Skin Ailments

lotrizone cream, 10 gm (3 tubes) Triamcinolone 0.1 % cream, 10 gm (3 tubes) Sunscreen, 30-SPF (1 tube)

Infection Treatment

Cephalexin, SOO-mg tablets (10) levaquin, 750-mg tablets (10) Ancef (2 gm, IVISO-cc bag) Rocephin (2 gm, IV/SO-cc bag)

Other Medications

Oralgel (dental analgesic) (1 tube)

·For use only under the direction of a physician.

APPENDIX l Tactical EMS • 423

• Ope rational Considerations Indications for Tactical Unit Callout leadership Roles and Responsibilities Tactical Unit Entry Strategies: Dynamic Versus Stealth Entry Crime Scene Operations • Deployment Considerations of a TEMS Unit/Operators Staging, Integration with EMS Scene Safety in the Tactical Environment Tactical Movement with light and Sound Discipline Weapons Familiarization and Safe Removal and Handling • Communications • Emergency Medical Care in a Tactical Environment Care under Fire and Modifications of Standard Protocols Downed Officer Scenarios- Immediate Action Drills Medical Threat Analysis (MTA) TEMS Extrication and Evacuation Considerations TEMS Transportation Considerations and EMS Interface • Other Medical Care Topics - Preventative Care and Health Maintenance - Posttraumatic Stress Debriefing and Mental Health • Considerations for lethal Threat Management and Self-Defense Recognition/ Management of the Violent or Potentially Violent Suspect Criminal Countertactics and Threats; Communications and Tactics Use of Fo rce Continuum lethal Force Considerations for the TEMS Provider • Management of Other Specific Threats in a Tactical Environment Terrorism and the TEMS Operator Biological Terrorism Chemical Terrorism Blast and Burn Injuries and Explosive Terrorism (suicide bombers) Penetrating Trauma-Ballistics Clandestine Drug labs/Methamphetamine labs

is abbreviated and the need fo r intervention must be carefull y weighed against the need fo r safety of the medical providers. Priorities of Combat Casualty Care: The classic approach to trauma care involves sequential assessment of the ABCs in a safe environment. In an unsafe situatio n, and in recognition that uncontrolled extremity bleedi,lg represents 80 percenl of preventable trauma deaths in combat environments, there is a temporary modification of this approach when providing care in the tactical setting prior to securing the scene. It is called the CAB approach. Circulatio n (C) is addressed fi rst, with immediate application of a compression bandage or to urniquet to control life-threatening external hemorrhage, followed by rapid assessment of airway (A) and breathing (8 ).

r 424 • APPENDIX l Tactical EMS Mil itary-style combat dressings slich as the Israeli dressing/emergency bandage can be highly effective in this setting. Several easily applied and effective tourniquets arc available and appropriate for tactical EMS usc. Remember to expose gunshot or knife wounds by removing body armor and cloth ing to visualize the wounds, allowing morc accurate assessment and placemen t of comp ressive dressi ngs, chest seals (Asherman or other one-way valve-type dressing), and other hemostatic agents. Several new hemostat ic agents and dressings (Qu ikClot and CeJox) have been developed and deployed by the military for a treatment aflast resort for exs.1.nguinating hemorrhage. Their usc should be considered in civilian TEMS systems as well. If a patient has obvious signs of severe injury, and there are no signs of life, then further medical care is futil e. If critically inju red officers without a pulse o r spontaneous b reathing are found inside the inner perimeter under immediate hostile threat, responders sho uld remember that they are dead. In a hostile ellvirollmCflI CPR is never indicated unless the officer, sllspect, or other can be safely removed or all th reats neutralized.

Rapid Evacuation: As soon as practical, evacuate vict ims to a safe area to p rovide advanced medical care and in itiate transpo rt to a medical facility. This is where planning and immediate action drills are essential. Have a plan , know where to go, which roads to take to get there, and know what type of vehicle you will use, and what medical care can be provided along the way to the hospital. This will help saves lives. Importallt Do's alld Dot/'ts ofTEMS: No one desires to provide medical care in an unsafe situation. Any situation whereby a victi m requires medical care must be carefully evaluated for the risk involved in providi ng medical ca re. If the patient is safe and relatively stable, then let the person lie there until the threat is neutralized. If the patient is critically inju red and dying flOW, but is isolated from medical help and is trapped by gu nfire, then d iffic ult decisions must be made: What are the risks of getting to and treating that patient? What are the benefit s of treating that victim now (versus dragging the victim to other safer areas), and what are the chances of having an additional dead provider? Thisdecision is difficult, but several guiding principles exist. The important principles for treal'ingalJ tactical casualties are as fo llows: • The TEMS operator m ust always assess the tactical situation. Do no t endanger yourself or your team members. If the perpetrator(s) remains a direct immediate th reat, keep behind or under ha rd cover until the threat is neutralized. • Approach the casualty by whispering o r saying "Rescue," to inform him of your purpose for touching him. Quickly e"aluate/remove the perso n fro m danger if possible. This should be to a point of relative safety. • When yOll are presented with a tactical casualty: LOOK-USTEN-THINK-ACf! T here have been very few injuries or deaths to tactical medical operators. There are many mistakes made. The follow ing are four common errors made by tactical medical officers.

• failure to recogllize threats.

Do not u nderestimate the potential fo r violence in female suspects, mentally unstable suspects, senior citizens, and drug addicts.

• Improper search or flO search.

Never trust the search of a fellow officer; sea rch again prior to treatment and transport; be aware and watch for improvised and concealed weapons.

• Failure to cal/ for backup.

Never enter a building or st ructure alo ne. About 20 percent of police officers who die from firea rms are killed with their own guns.

• No operatiollal platt.

Do you and your partner have a contingency plan? Have you made a plan with your partner for hostage situat ions? Who wi ll cover who if you lose your SWAT officer escort?

APPENDIX L Tactical EMS •

In addition, tnetical medics shou ld remember the followin g: • Prepare for the unexpected (it will happen ). • Predetermine hard cover. • Recognize the med ical problem.

• Triage accurately and rapidly.

• Maintain emotional com posure. TEMS Medical Threat Assessment Med ical threat assessmen t (MTA) refers ( 0 the gatherin g of medical intelligence that can have an impact on the physiologica l and psychological health and perfo rman ce o f the tactical team and others for wh ich the tea m is responsible. All tactical operations requ ire med ical threat assessment, including high- risk warrant service, barricaded suspects, train ing exercises, and protection deta ils.

Remote Assessment Medicine RAM is a unique aspect of tactical medicine in which an inju red o ffi cer or suspect/ bystander is assessed fro m a distance, without direct contact. Usually b inoculars are the optic device that is used, but a spotting scope o r ri fl e scope may be used as well. Medicine Across the Barricade One situation in which a SWAT unit is often called for is the barricaded suspect such as a bank robbery with hostages inside. These are resolved peacefully more than 90 percent of the time, but often the hostages may have medical problems that are exacerbated by the stressful sit uatio n, or may be shot o r injured and in need of stabilizing med ical care. If the suspect can be talked into it , hopefully these peopl e may be released . However, if the in jured or ill vict im must rema in in side the "ba rricaded bank," then medical care directions may need to be given to the fellow citi zens inside. Special Medical Procedural Techniques

• In/llba/ion modifications. Due to lhe limited access to poten tial patients, the T EMS provider must practice and be prepared to intubate the victim while in unique situations, such as lying on th e ground next to the victim (keep a low p rofile) and usin g digi tal intubation skills and special bends of the endotracheal tube in o rder to place it properly.

• Resllscila riolllimitat iolls. Each scena rio is d ifferent. The decision of whether to prono un ce a person dead or not is co mplex and involves many fa clors. The TEMS officer must be prepared to q u ickly decide that a perso n is deceased or has injuries inco mpatibl e with life.

• Light discipline. Night operations may result in a tactical sit uation where the suspect is firing upon any police officer fl ashlight/light sou rce, but there arc shooting victims who need medical care, all ly ing within eyesigh t of the suspect's gu n. These situatio ns will require that the rescuers perform their work in the dark, with no visible ligh t seen. Low-light o r no -light med ical ca re will req uire tactile use of the hands in assessing the pat ient , as weUas use of inst ruments and treatment without light.

• Noise discipline. Simi lar to above, if the suspect has a weapon and may shoot in the directi on of noise, it is important to be very quiet. Communications Illay be limited to hand signals or quiet radio microphone use.

425

426 • APPENDIX l Tactical EMS Medical Aspects of Sustained Operations If a SWAT unit is called out, and the situation is resolved in 4.5 hours (actual avcrage time to resolve situations), then the team members are generally able to return to their norlllal duties without great stress to themselves or their fami lies. However, during prolonged tactical operations (i.e., more than 12-18 hours) the SWAT unit members become fatigued , hungry, sore, impatient, bored, homesick, cold, o r hot. It is important in prolonged operations for the TEMS providers to provide support and preventive medical care to the best of their abilities. It is in the prolonged scenario that medical personnel can be a huge asset. ln addit ion to being prepared to treat the following ailments or possibilities, the TEMS officer can advise the inciden t commander of the prel'etltio1l of heat or cold casualties (use proper clothing or gea r). fatigue (rotate officers fairly and often ), and dch),dralion (provide good water or rchydration sources). Contin gency plans should be made bcforchand with the Red Cross. disaster support agencies. and local restaurants and supply stores. Prepackaged kits with necessa ry supplies for extended o perations should be made and available if needed. Consider delegation of TEMS providers tu specific tasks, and alsu consider sendi ng ;IIlY extra help hume tu stay rested and return 12 hours later to replace and rotate out thc initial TEMS providers.

EVIDENCE PRESERVATION It is imperati ve that any evidence that is identified and collected be done with a strict, welldocumented chain of evidence, and it must be sto red in proper containers that win be upheld in courl. In general. TEM S officers should avoid becoming involved in this chain of evidence due to the often insufficient training, and ftlture time and court appearance requirements.

TOXIC MATERIAL HAZARDS One of the growing threats throughout the nation (especiaUy in rural areas) involves the "meth lab," or clandestine drug lab (COL). It is possible to purchase $ 100 worth of chemicals and illegally produce a synthetic type of methamphetamine that can then be sold for $ 100.000. Due to this fact, the addiction potential of this drug. and the relative ease to acqu ire the materials and equipment needed for this production, law enforcement agencies are increasingly finding these CDLs. These labs are often booby-trapped and arc associated with dangerolls criminals, many of whom are armed with fu lly automatic weapons. This makes the recovery and investigation of these labs a very dangerous occupation. Therefore, it is important for TEMS officers to be familiar with the unique hazards associated with CDLs, and be prepared (knowledge and medical treatment gear) to deal with hazardous material-associated injuries, flam e burns, inhalation injuries. acid burns. penetrating trauma, and blast victims. If know n about prior, most law enforcement agencies will get the DEA (Drug Enforcement Administration ) involved to investigate and dean up the toxic CDL. However, sometimes these labs are discovered accidentally during house fi res or during a tactical entry. If practical, the tactical team shou ld immediately withdraw and contai n the area while waiting for the DEA to deal with the lab.

SPECIAL ISSUES AJlyone involved with a TEMS unit should be aware of a number of special issues related to TEMS that are beyond the scope of an introductory chapter. There are many important support, legal , and admin istrative issues. some of which are medical direction and administrative considerations for TEMS providers; adm inistrat ive considerations for forming

APPENDIX l Tactical EMS •

and maintllining a TEMS unit; expanded scope of practice protocols; and unique training considerations for the tactical physicia n assistant, nurse, and physician. These topics are discussed in depth in textbooks elsewhere.

ADDITIONAL RESOURCES FOR TEMS TRAINING The increasingly haz.'lrdous environment faced by special law enfo rcement and military tactical un its may be partially offset by the provision of close- up tactical emergency medical support , or TEMS. The recent growth of this subspC(ialty acknowledges the unique knowledge, equipment, and skill set requ ired of tactical medicine operators. In an everchanging world challenged by criminals, drugs, the methamphetamine d rug lab epidemic, school violence, terrorism, and ot her incidents, today's militaTy and law enfo rcement special operations units are increasingl y arranging for TEMS providers. This addendum provides an int roducto ry awareness of the many important issues and topics that the tactical medic-inc provider must be aware of and prepared fo r. The un ique knowledge. skills, equipment. and teamwork thai arc requ ired must be optimized for the well-prepared team ofTEMS providers. Mutual respect and understanding will develop as med ical personnel train routinely wi th their own community's law enforcement tactical unit o r military special opera tions un it. Modifications of standard civilian EMS treatment protocols are mandatory, given the unique "'hot zone" threats that must be appropriately dealt with in the priority necessary to help save lives. The EMS provider who wishes to learn morc about o r delve into the challengin g tactical medicine arena is best served by seeking qualified educational courses and resources. some of whic h are listed in Table L-S. A baseline education in the principles of TEM S is important fo r a fo undation on which to build YOUT skills but equally important is the routine monthl y tactical training and integration with the provider's local law enforcement tactical unit. It is d uring repetitive realistic tra in ing, drills. and eventual actual callouts tha t the TEMS provider will become recogni7.cd as a trusnvorthy professional with much to add, and help accompl ish the mission of resolving the crisis in as safe and injury-free fas hion as possible. Before, during, and after a mission, the TEMS provider can be a valuable asset that should lead to o n-site preventio n o f illness and injuries. rapid emergen t care if needed. aJld efficient and safe evacuation of casualties that will lead to mo re lives saved.

427

428 • APPENDIX L Tactical EMS

1. EMT-Tactical School This school has several courses offered, and is associated with Inte grated Force Health Protection (lFHP), formerly part of the CONTOMS program (Counter Narcotics and Terrorism Operational Medicine Support). The EMT-T School! CONTOMS program is a five-day. 58-hour TEMS course offered to EMTs. parame dics. nurses, physician assistants, and physicians who are affiliated with law enforcement agencies. To contact: 301-295-6263 or www.casualtycareresearchcentcr.org 2. International School of Tactical Medicine The course is directed by Dr. Lawrence Heiskell, who is one of the pioneers of TEMS. The Basic and Advanced TEMS courses are five-day courses, taught semiannually by board-certified emergency physicians and medics who are actual participants in TEMS units throughout the United States. To contact: 760325-2591 or www. tacticalmed icine.colll . 3. Tactical Operations Medical Support course Cypress Creek TEMS located in Houston, Texas, offers six-day basic and fiveday advanced courses. To contact: 281-440-9650 or www.ccems.com 4. Alabama Ter(orism and Tactical Operations Medical Support Course This is a five-day course. Contact Blake Strickland at 205-387-0511, extension 5730. 5. Tactical EMS Course National Tactical Officers Association (NTOA) offers a 3-day course. To contact: www. ntoa.org/tems 6. International Tactical EMS Association This organization maintains a listing of other TEMS co urses and also hosts an annual conference as well as an online newsletter and Journal of Tactical EMS. To contact: www. tems.org

BIBLIOGRAPHY 1. Ca mpbeU, J.• J. Sm ith, et aI. 2007. Homeltmd security alld emergency medical respOIlSe. New York: McGraw- Hili, Inc. 2. Delorenzo, It , R. Porter. Tactical emergellCY care. Upper Saddle River, NJ: Prentice Hall. 3. Kolm an, J. 1982. A guide to Ihe de velopment of special weapolls and tactics teams. Springfi eld, 11..: Charles C. Thom as. 4. Wipfler, J. , J. Smi lh, et al. 2007. Ttictical EMS-Th e essenfials of tactictil emergency medicine. New York: McGraw-H ili, Inc.

,

abrasion scraping or abrading away of the superficia l layers of the skin; an open soft· tissue inju ry. abruptio placenta early separation of the placenta from the uterus. acidosis a condition caused by accum ulation of acid or loss of base from the body. adventitia the layer of loose connect ive tissue forming the outermost coating of an organ. aerobic requ iring o>.')'gen. air bag a passive restraint system in automobi les and other vehicles. alkalosis a pathologic condition resulting from accumulation of base or loss of acid in the body. anaerobic lacking oxygen. anoxia absence of oxygen supply to the tissue. asphyxia a condition due to lack of oxygen; suffocation. aspirate taking forei gn matter into the lungs du ring inhalation. assessment to evaluate the condition of a patient. ATV all -terrain vehicle. AVPU a description of the level of consciousness. AV PV sta nds fo r: A- alert , V-responds to verbal stimuli , Presponds to pain , V- unresponsive. avulsion an injury in which a piece of a st ructure is torn away. axialloadjng compression fo rces applied along the long axis of the body. Example: a full in which a victi m lands on his feet and force is transferred up his legs to his back, causing a compression fra cture of a lumbar vertebra. bag-valve mask a system of artificial ventilation in which the oxygen inflow fill s t\ bag that is attached to a mask by a one-way valve. Battle's sign swelling and discoloration behind the ear caused by a fracture of the base of the skull. beta agonists medications such as Albuterol lhat stimula te the beta receptors in the smooth muscles of the bro nchi causing bronchodilatation. They arc used to treat asthma and bronchospasm. BIAD bli nd insertion ain v"y device, such as the esophageal tracheal Combitube. 8LS burns, lacerations, swelling. Can also mean basic life support.

body surface area (BSA) percent of a pa tien t's body affec ted by a burn. bronchospasm contraction of the smooth muscle of the bronchi. Broselow tape a tape used to estimate the weight of a child by measuring her length. BVM (bag-valve mask) a system of artificial ventilation in which the oxygen in fl ow ftJl s a bag that is attached to a mask by a one-way valve. caliber the diameter of a bullet expressed in hundredths of an inch (.22 caliber =0.22 inches); the inside diameter of the barrel of a handgun or a rifle. capi1lary blanch or refi ll test for impa irment of ci rcu lation: pressure o n tip of th e nail will ca use the bed to tu rn wh ite, if it does not turn pink aga in by the time it takes to say "capillary refill," the circul ation is im paired. T he test has been found to be unreliable for earl y shock. carbonaceous sputum sputum that is "sooty" or black. carbon dioxide monitor a device used to monitor or confirm endotracheal tube placement by measuring expired carbon dioX'ide. These devices either measure eX'pired carbon dioxide (capnographic) or show a color change when carbon dioxide is present (colorimetric). carina the lowest part of the trachea, where the trachea divides to for m the two mainstem bronch i. catecholamines a group of chemicals of similar structure thai act to increase hea rt rate and blood pressure. C-collar (cervical collar) a device to limit movement of the neck. central cord syndrome an injury to the spinal cord that produces mo re loss of sensory and motor function in the arms than in the legs. cerebral perfusion blood flo w to the brain. cerebral perfusion pressure (CPP) the pressure movin g blood through the brain. eNS central nervoliS system; the brain and spinal cord. COl monitor a device used to monitor or confi rm endotracheal tube placement by measuring expired carbon dioxide. com minuted fracture fract ure in which a bone is broken into several pieces.

429

430 • GLOSSARY

compartment syndrome muscle ischemia t.hat is caused by elevated p ressure with in an anatomic fascial space. compliance the "give" or elasticity of the lungs and chest wall. T his inO uences how easy it is for the patient to brea the. concussion a ja rring injury to the brain resulting in disturbance of bra in functio n. constricted to shrink or co nt ract. contracoup an inju ry to the brain o n rhe o pposite side of the original blow. contralateral situ ated or affecti ng the opposi te side. contusion b ruisi ng; the reactio n of soft tissue to a direct

blow. COP D chronic obstructive pulmonary di sease. The end result of ast hma, chron ic bronchitis, or emphysema. copious large am ount. coup an injury to the b rain on the same side as the original blow. crepitation feeli ng of crackling; the sensation of fragmen ts of b roken bo nes rubbi ng together. Cushing's reflex a reflex whereby the body reacts to increased pressure on the b rain by raising the blood pressure. DCAP defo rmi ties, contusio ns, abrasions, penetrat io ns. DCAP-BTLS deformities, contusio ns, abrasions, penetTations, bu rns, tenderness, lacera tions, swell ing. DCAPP deform ities, contusions, abrasions, penetrations, paradoxical movement. deceleration to come to a sudden stop, decreasing speed . d ecubent position the posi tio n assumed when lying dow n. delivered volume the amount of air that you actmill y deliver to Ihe lungs with each breath when you perform artificial o r assisted vent ilation. d enatured to destroy the usual nature of a substance. d ermis the inner layer of the skin , containin g hair follicles, sweat glands, sebaceous glands, nerve endi ngs, and blood vessels. diaphoresis perspi ring profusely. diffuse axonal injury type of bra in injury characterized by sh ea rin g, stretch ing, o r tearing of nerve fibe rs with su bsequ ent axonal da mage and edema of the brai n tissue. diuretic an agent that promotes the excretion of urine. doll's eyes oculocephalic reflex; a test of b rain stem function that is never performed in the prehospital sett ing. dura the tough fib rous membrane formin g the outermost of the th ree coverings of the bra in . ecchymoses blue-black discoloration o f the skin due to leakage of blood into the tissue. EGTA esophageal gastric t ub,· ai rway; an improved esophageal obturator airway.

EKG electrocardiogram. EMS emergency medical services. endotracheal intubation the insert.ion o f a tube into the tr achea to assist or control ventilation. EOA esophageal obturator airway. epidermis the o utermost layer of skin. epidural outside the du ra; between the dura and the skull. erythema general reddening of the skin due to di latio n of the superficial capillaries. ETA estimated ti me of arrival. An estimation of when you will arrive at the receiving hospital. etiology Ihe cause of a pa rticular disease. ET tube endotracheal tube. evisceration the protruding of internal o rgans through a wound. expeditious quick, speedy. exsanguinate to bleed to death. extrication removal of a patient from a dangerous posi lion o r situation. FROPVD flow -restricted, oxygen -powered, ventilation device. An artificial ventila tion device that pro\' ides 100% oxygen at a flow rale of 40 LJmin at a maxim um pressure of 50 ± 5 COl water. full -thickness burn third degree b urn. gastric insufflation the filling of the stomach by air when perform ing posit ive p ressu re ventilation. GCS (Glasgow Co ma Scale) a method used to measure the severity of a head injury. genioglossus muscle the muscle that pulls the tongue o ut of the mouth . grunting a deep, guttural noise made in breathing; a sign of respiratory d islress in small children. Hare splint a ty pe o f tract io n splint. Heimlich maneuver a method of dislodging food or other material from the throat o f a cho king vict im. hemiparesis partial paralysis affecting one side of the

body. hemoptysis to spit up blood or blood-sta ined sputum. hemothorax the presence of blood in the chest cavity within the pleu ral space, outside the lung. hypercarbia high blood ca rbon dioxide leveL hyperresonant givi ng an increased vibrant so und on percllssion; tympan ic. hypertympany hyperresona nt . hyperventilation increased rate o f breath in g; 20 breaths per minute for an adult. hypoventilation decreased rate ofbrealhing, 10 breaths per minute for an adult; insufficient respiration demonstrated by an elevated blood ca rbon dioxide level. hypovolemic shock hemorrhagic shock; shock caused by insufficient blood or fluid within the body.

GLOSSARY •

hypoxia a deficiency of oxygen reaching the tissues of the body. fCP intracranial pressure. The pressure inside the skull. impaled object a penetrating object that is still in place in a patient's body. Initial Assessment part of the Primary Su rvey. This is a rapid exam of ai rway. breatbingand circulat ion. It is performed on all patients. intra-abdominal with in the abdomen. intracranial within the skull. intrathoractic within the chest. IPPV intermittent positive pressure ventilation. ipsilateral situated on or affecting the same side. JVD jugular vein disten tion. Distended jugular veins in the neck. kinematics the phase of mechanics that deals with possible motions of the body. labial angle corner of the mOllth. laryngeal m ask airway (LMA) an invasive ainvay device to assist ventilation . lateral decubitus position position assumed when lying on onc's side. lesion an injury o r abnormal condition of a part. LMA laryngeal mask airway. An invasive airway device to assist ventilation. LOC level of consciousness. MAP mean arterial blood p ressure. MAST military ant ishock trousers. Also called pneumatic antishock garment ( PASG ). A device that applies circumferenti al pressure to the legs and abdomen to raise the blood pressure in hypotensive patients. MCI muhicasualty incident. An emergency situation in which t here arc multiple injured patients. mcan arterial blood pressure diastolic blood pressure plus 1/3 (systolic minus the diastolic blood pressure). medial towa rd the middle. minute volume the vol ume of air breathed in and out in I minute. This varies from 5 to 12 liters per minute. mortality frequen cy of death or death rate. MVC motor-vehicle collision. nasopharyngeal airway an artificial airway positioned in the nasal cavity. necrosis the death of tissue. neonate newborn in fant. nonrebreather mask an oxygen mask that allows the patient to b reath oxygen at a concentrat ion close to 100%. NP airway nasopharyngeal airway. An artificial airway positioned in the nasal cavily. occult injuries injuries hidden o r concealed from view. OLMD o n-line med ical di rection. OPIM other potentially infectious material (other thun

blood ).

431

oropharyngeal airway an artificial airway positioned in the oral cavity to keep the tongue from occluding the airway. osteomyelitis inflammation or infection of a bone or bones. pallor paleness, absence of ski n colo r. palpate to exam ine by touch. paradoxical motion the motion of the injured segment of a flail chest, opposite to the normal motion of the chest wall. parenchymal the essential elements of an organ. paresis sligh t or incomplete paralysis. paresthesia abnormal sensation; a "tingling" sensation. partial-thickn ess burn a burn that does not inju re the full thickness of the skin. A fi rst degree burn involves on ly the epidermal layer. A second degree burn involves the epidermis and pa rt of the dermis. PASG pneumaticantishock garment. Also called mili tary antishock trousers (MAST). A device that applies circumferential pressure to the legs and abdomen to raise the blood pressure in hypotensive patients. patent open. pathophysiology the basic processes of the disease. perfusion the passage of blood or fluid th rough the vessels of an organ. personal watercraft (PWC) a s mall motorized watercraft that Olle or two perso ns can ride. Much like a motorcycle except it travels on water. pia mater innermost of the three layers of tissue that envelop the brain. placenta previa an abnormal location of [he placenta, so that it covers the opening of t:he uterus (cervical os), PMS pulses, motor fu nction, and sensation. Description of the exam of an injured extremity. pneumothorax the presence of air within the chest cavity in the pleural space, but outside the lung (collapsed lung). pocket m ask a small face mask for performin g assisted ventilation. It is made to be carried in the rescuer's pocket. potential s pace a space that docs not exist except under abnormal circumstances. Example: Normall y th e lungs completely fill the chest cavity so t.hat the pleural space (between the lungs and the chest wa ll ) is on ly a potential space. If t he pleura l space contains blood it is a hemoth o rax. PPE personal protection equipment such as gloves, face shields, and impervious gowns. Primary Survey a brief exam to find immediatel y lifethreatening conditions. It is made up of the Initial As~ sessment and either the Rapid Trauma Surveyor the Focused Exam.

1

432 • GLOSSARY

pulse oxim eter a noninvasive device that mo n itors the oxygen saturation of the blood hemoglobin. p ulse pressure the sensation given by the heart contraction to the palpating finger on an artery. PWC pcrso lMI wntcrcmft. raccoon's eyes swel ling and discoloration around both eyes; a latc sign ofbasi!'t r skull fracture. respiratory reserve lung t issue over and above the body's need to provide oxygenation for the body. rhabdomyolysis disintegratio n (lysis) or dissolution of m uscle; this releases myoglobin into the blood, which can precipitate in the kidneys, causing renal failure. RTSS rad io telephone switch statio n; a type of radio that accesses the telephone lines. Sager splint a type o f traction splint. SAM PLE h isto ry the least amount of information ne("ded o n a trauma patient. S-sympto ms, A-allergies, M- Ill("dicalions, P- past medical hist0f}', L- Iast oral intake (last meal), E----evcnts precedi ng the injury. scaphoid shaped like a boa!. When lIsed TO desc ribe the abdomen, scaphoid means sunken in . scu ba diver a diver who is able to remain under water by breathing compressed air from a breathing apparatus needing no co nnt'Ction with the surface. SCU BA sta nds for self-contained und("rwater breathing apparatus. Secondary Su rvey a comprehensive head- to- toe exam to find additio nal injuries that may have b(.'Cn missed in the brief Primary Survey. Sellick maneuver a maneuver (posterior pressure on the cricoid cartilage) to prevent gastric insufflation and vomiting. sheering fo rces forces Ihat occllr in such a direction to cause tearing of an organ. sibling brother or sisler. skin d iver a diver who holds his breath when swimming under wa ter. He lIses no artificial breathing methods. SMR spi mll motion restriction; the act of srabilizing the spinal column to prevent as much motio n as possible. sn oring to breathe in a hoarse, rough noise, usually with Ih(" mOllth open. s norkeler a diver who uses a short tube (snorkel) in o rd "r to fl oat on the surface and observe u nderwater life. When diving, a snorkeler must hold her breath.

spontaneous p neumotho rax collapsed lung caused by the rupture of a congenitally weak area. on th e surface of the lung. standard precautions procedures used to prevent contamination by a patien t's body nuids. This usually entai ls gloves and possibly a gown and fa ce shield. st r idor breath ing that has a high -pitched , harsh noise; a sign of impending airway obstruction. stroke volume the amount of blood pumped by the heart in o ne bea l. subcutaneous emphysema the presence of air in soft tissues, giving a very characteristic crackling sensation on palpation; the Rice Krispies feel ing. tachypnea adult respiratof)' rate o f 24 or more breaths per minute. ta mpo nade compression of a part of the anatomy, as the co mpression of hea rt by pe rica rdial Ouid. T Bl lra umatic brain injury. tensio n pn eumotho rax a condition in wh ich air co ntinuously leaks out of the lu ng into the pleural space, increasing pressure within the space with every breath the patient takes. Tho mas' splin t a type of traction splint. T IC tenderness, instability, crepitation. An acroll)' m for the desc ription of the exam of a bony area. tidal volume the amount of air that is inspired and expired during o ne respiratory cycle. traction the action of drawing or pulling on an object. trajectory the direction a missile takes in flight o r aft er st riking a body. tra nsected to cut transversely. Trend elenburg position supine with tower body elevated about 30 degrees. vallecula the space between the base o f the tongue and the epiglottis. vasom oto r affecting the size of a blood vessel. ven ous p ressu re pressure of the blood in the veins. viscera any large interior orga n in anyone of the three great cavities of the body. especiai!y the abdo men . volatile a substance that evaporates rapid ly al room tem perature when exposed to air. wheezing wh istling sounds made in breathing; 3 sign of spasm or narrowing of the bronchi.

A Abdominal traum a, 203-210 ana tomy. 204-205 children. 273 (.'viscrration,208 pregnancy, 295 scene SiZl"'UP, 206-207 stabilization. 207- 208 types of injuries. 205-206 Absolllt~ hypovolemic shock. 124 Access (OUrs<.', 412-4 13

Active pr('ventiV<' intervcntion, 396 ACU1(' epidur.ll hematoma, 148- 149

Acute subdural hema toma, 149 Adam's apple, 61

Add"ndulll,363

Aging, 280-281. See alS(l Elderly patients Agricultural

Tl'SCUt',

408-411

AiT bag. 16 AiT embolism, 387 Air splint. 219, 223 Airway adjuncts. 67- 70 AirwaYC<1uipm('nt. 74-75, 81-82

Airway kit, 75 Airway manag('mcnt, 58-93. See a/S{) Oplional skills airway adjuncts, 67-70 airwaycquipmcnt, 74-75, 81-82 anatomy/physiology, 60-64 anchoring the lube, 93 ti1AD,68 BVM.73-74.80 children, 264-265

wmplianc!.',72- 73 confirmation o(tube placemen!. 88-90 t'ndotracheJI inlubation, 68--70 intubalion wrap, 81-82 IJndmJrks,64 laryngoscopic orotnicheaJ intubation, 82-87 MMAI~68-69

moni to ring tulx' placement, 90-93 nasotracheal intuba tion, 87-88 N I'A, 67-68, 79 observatioll,65-66 OPA,6S,79 patent (open ) airway, 64-70 pulse- oximett'r, 80-8 1 skills, 78-93 suctioning the Jir ....'3y, 66--67 supplemental oxygen, 70, SO ventilation, 7 1- 74

Alcohol, JOI, 303 All-terrain vehicle accident, 18 Alson, Roy L, 141,237,327,400,412 AlvcolJr sacs, 63 Al\'oolocapillary membrane, 60 Amphetami nes, 30], 303 Amputation, 214 Anatomy abdomen, 204-205 airw..lY, 60-64 chest, 95-96 external jugular vein, 137 hl'ad,143-144 ski n, 238-239 spinal column, 161- 162 spi nal cord, 162- 163 Anchoring the tube, 93 Ankle dislocation, 214 Anoxic brain injury. 148 Anter ior disloca ted hip, 222 Arachnoid, 143-144 Assessment. See ITLS patiellt assessment Atmospherl' absolute (ATA ), 385 ATV accident, 18 ,\u gustine, James J., 160 Automobile accident. See Motor-vehicle collision AVPU, 32, 46, 366

B nag-\'alve mask ( BVM), 70, 73-74, 80 naldwin, Jere E, 278, 37 1, 400 Ballistics, 21 Iklrotitis media, 385-386 Bilrutr~ul1la, 385-387 Barton, Clara, 415 Battlc's sigll, 152 Ucnds,388 BlAD, 68, 336 Bieniek, Russell B., 377 BIG,348 Blast inj uril'S, 22-23 Blind insertion airway device (BlAD). 68, 336 mown pupil, 152 Blunt inj uries, 8 Blunt spinal-column injury, 164 Blunt spinal-co rd injury, 164 lloard splint, 223 Body collision, 8, 9. II, 12, 13 Bonaparte, Napoleo n, 415 BOOTS, 74 Bougie,86-87

Bol.eman, Bill, 414 Bradley, Walter ,., 288, 414 Brain, 143- 144 Brain injury, 148-150. £'f a/w Head trauma Bronchi. 62 Brosclow tape, 263 Burn centl'r, 246 Burns, 237-257 burn cente r, 246 chemical,248-251 childrl.'n, 242, 255 circumferential,254 classification, 239-240 eil.'ctrical,251-252 flash,245-246 inhalation injuries, 246-248 initial assessment, 244 lighlning injury, 252- 254 patien t management, 245 pregnancy. 2% radiation, 254 rapid trauma survey. 244 rulc of nines, 241-242 scene si7.e-up, 243-244 secondary survey, 244 secondary transport, 254-255 scverily, 240--242 skin, 238-239 Hurst lung, 386 HVM, 70, 73-74, 80

C CAB JPproach, 423--424 Campbell. John E.• 27. 58, [41,21 I, 306, 384 Capillary refill time, 122 Capnography,90-93,123 Capnometry, 90-91 Car acc ident. See Motor-vehicle collision Car scat, 273-274 Carbon monoxide poisoning. 246-247 Cardiac arrest, 306--3 14. Sec also Trauma cardiopulmonary arrest Cardiactamponade, 106--107, 126, 127 Cardiogenicshock, 123, 125-128, 133 Carilla, 62 Catccholamines,l66 C D L,426 Cerebral contusion, 148 Cerebr..1 herniation syndrome, 146-147 Cerebral perfusion pressure (CPP), 145 Cerebrospinal fluid (CSF ). 144 Cervical collar, 184

433

4 34 • INDEX

Cervical vcrll."bral", 161-162 C har\X'nlier. Leon, 27 Chemical burns, 248-251 Chest dt'COmpression, 115-117

Chest wounds. &t Thoracic trouma Child restraint sca ts, 273-274 Childrt'n, 258-277 abdominal injury, 273 airway, 264-265 artificial vent ilation, 266--267 assessmrnt, steps in, 265

bleeding. 269 breathing, 266-268

burns, 242. 255 ,hest injury, 272- 273 child restraint scalS, 273-274 circulation, 263-269

communkation.259-260 crit.ical trauma si tuation, 269-270 l'ndotracheal OX)'Sl'n, 267-268 equipment, 261-263 fluid reslIscil;lIion, 269 Glasgow Coma Scale, 271. 382 head injury, 27 1-272 [0 infusion, 138--139 !englh-hased resusci tation tape, 140

mechanism of injury, 261, 264 parental consent. 261

sct:ondary survey, 271 shock,268--269

spinallrauma, 176, 178,273 sup plemental oxygen, 267- 268 transfer to pediatric trauma center, 270 vital signs, 268 Circumferential burns, 254 Clandestim' drug lab (CDL), 426 Clavicle injuries, 224 Closed forea rm fracture, 213 Closed fractures, 212- 2 13 Closed-space rescue, 17S Cocaine,3QI,303 Coccyx, 162 Cold ('Il\'ironlllcnt, trJUllla ('".Ire, 371 - 376 Colorimetric COl detecto r, 9() Combat situations. Set Tactical EMS Combitube. 68, 339-340 Communications wi th receiving hospital, 356--361 Com partment syndrome, 215--2 16 Compensated shock. 121 Compliance, 72-73 Concus.~ion, 148 Confined-space r('scuc, 410 Constricted pupils, IS3 C.owl{'y, It Adams. 2 C PI~ 14S Crashed vehicle entry techniques. 411-413 Creel, James H., Jr., 1,384 Cricoid,61 Cricothyroid membrane, 61 Critical intervcntklfl, 37-38

Cross-chest lap belt. 15, 16 CSF,I44 Cushing's mponS(', 145, 146

E

intuba tion, 8 1-82 orotracheal intubation, 83 Esophageal tracheal wmbitube, 68, 339-340 ETCO p 90 Evisceration, 208 Exhaled COl' 123 Explosio n, 22-23 ute-mal jugular cannulation, 137 Extremity trauma, 21 [-236 amputation, 214 assessment,2 16 clavicle injuries, 224 compartment syndrome, 2 15-216 dislocation, 213-214 elbow inju ries, 224--225 femur injuries, 221 fibula injuries, 222-223 foot injuries, 226 forearm inju ries, 225-226 fractures, 212-213 hand injuries, 226 hip injuries, 221 - 222 impaled objects, 2 15 knee injuries, 222 neurovascular injuries, 215 open ....uunds, 215 pelvic injuries, 220-221 pclvic slabili7.ation, 2]4, 236 scene size-up/ history, 216 shoulder injurit'S, 224 spi ne injuries, 220 splint ing, 217- 219, 223, 230--235 tibia inju ries, 222-223 wrist injuries, 225 EZ-IO, 348

Early shock, 122 Elbow injuries, 224-225 Elderly patients. 273-287 aging, 280-281 at-SCl"ne intervent ion, 284 chronic diseaS/: !'So ~cUl{, problem, 282 rocused exam, 284 initial assessrnem, 283-284 mooicat;on,281-282 ongoing exa m, 285 primary survey, 283 rapid trauma sUf\'ey, 284 secondary survey. 28S spinal trauma, 178 transport, 284--285 Electrical burns, 25 1- 252 Emergency rescue, 168, 190 EI-. IS staging superviso r, 403 End-tidal COl (£TC0 1), 9() Endotracheal intubation! 68-70 Endotracheal oxygen. 267-268 Endotracheal tube holder, 93 Epidermis, 238 Epiglottis, 60 Equipmem airway, 74-75, 81-82 children, 261-263

Fall, 19-20,295 Farm f('SCU(" 403--411 \'.A.S.T.I,348 r{'mur injuries, 221 Fibula injuries, 222-223 Field triage criteria, 406 FIRESCOPE ICS, 401 Firsl-dcgrl'C burns, 239-240 Flail chest, 99- 103 Flaring, 272 Flash burns, 245-246 Flow-restricted oxygen-powered \'entilation device (FROPVD), 70, 72, 73 Fluid resuscitation skills, 136- 140 F\umar:enil,303 Focused exam, 30, 34 Foot injuries, 226 Football helmets, 179 Forearm injuries, 225--226 r-our-phaS{" communications policy, 356-361 Fowler, Raymond 1-, 1J 8 l'raCluroo clavicle, 224 Fractures, 212-213 FROPVD, 70, 72, 73 Full-thickness burns, 240, 241

o Dashboard injuries, 12 DCAP-BTLS,40 DCS,387- 389 Decerebnlte posturing, 153 Decompensated shoc k, 121 Decom pressio n sick ness (DCS), 387-389 Decort icate IlOSlUring, 153 Definitions (glo:osary), 429--432 Dc1iveroo volume, 71 Demlis, 239 Detaik-d exam, 39, 40 Diagram of injuries. 366 Diaphragmatic tears. 109 Dietrich, Ann Ma rie, 258 Diffuse axo nal injury, 148 Digital intubation, 327- 329 Dilatoo pupils, 153 Direct-visio n orotrach{'al intubation, 69 Disaster plan/ MCl. 400-407 Dislocated shoulder, 224 Dislocation, 213-214 Diving injuries, 384-390 Documentation (patient care record), 362-310 Domestic violence, 295 Drowning, 384--385 Drug abuse, 299--305. See also Substance abuse Dura mater, 143

F

INDEX .

G Gastrointestinal barotrauma, 386 GCS,40, 153, 154,27[,381 Geriatrics. 278-287. Sec also Elderly patients Grrsch, Pam, 377 Glasgow Coma Scale (GCS), 40, 153, 154, 271,381 Glossary, 429-432 Glottic opening, 61. 64 Golden hour, 2 Goth. !'Ncr, 173 Grl'ellbcrg. Marlin. 41 4 Groner, Jonathan 1.,258 Ground rules for Icaching and evaluation, 54-55 Gun wound. 20

I-kpatitis B ( HBV), 3 17-3 18 !-Iepalitis C (HC\'), 318 I-ligh-space shock, 124-- 125, 133 Hill, Davis. 408 Hip dislocat ion. 221- 222 I-lip fractures, 221 I-li p injuries, 221-222 How to? See Proctd urc Hyoid bone. 60 Hyperventilation, 71 Hypopharynx. 60--61 Hypo tension, 120. 121. 145 Hypothermia, 371 - 376 Hypovelllilation,7 1 H),po\'olemic shod:, 124. 132-133 Hypoxemia, 308-310 Hypoxia, 145

H H;lddon's matrix, 394 Hallucinogens, 301,303 Hand injuries. 226 Handgun wound, 20 Hare traction splint. 220 Hastings, DOllna,45, 78,114,136,183,229, 327 HJ]V,317- 3J8 BeV,JIS Head mOlion-restriction device, 184 Head-on collisio n, 10-12 !-Iead trauma, 141- 159

anatomy of head. 143---144 brain injuries. 148-150 cerebral herni~ltion syndrome. 146-147 children, 27 1-272 extremities, 153 head,152 hemorrhage, 148-150 history, 155 initial assess ment, 150-152 intracranial pressure (ICP), 145 mana ge ment, 155-157 neurological exam. 153 ongoing exam, ISS pathophysiology, 144-145 primary/secondary brain injury, 144-145 prima ry survey. ISO- I 55 pupils. 152- 153 rapid trauma sun·cy. \52-\55 scalp wounds, 147 scene size-up. 150 S('Condary survey. 155 sk ull fractures. 147 vital signs, 153--155 vomiting, 150 Heat-inhalation injuries, 247-248 Heimbach. I.eah 1.• 278.380 Helicopter. medical, 377-379 Helmets, 178-180.199---202 Hemorrhage brain inju ries, 148- 150 shock,129-132 Hemothorax, 104

I C I~

145

ICS,401 Impaled ohjl'Cts, 110,215 Incident command system (ICS), 40 1 Inhalation injuries. 246-248 Initial ainvay management. St't Airway management Inju ry, 392 Injur)' epidemic, 391-392 Injury epidemiology triangle, 392 Injury preven tion, )95-398 Injury process, 392- 395 Injury sur\'cillanu, 395-396 intermiuent positive pressun.· venti la tion (\ 1'1'\'),7 1-72 Internal hemorrhage, 131 International Trauma Life Support (lTLS). 3 Intracerebral hemorrhage, 149-150 Intracranial hemorrhage, 148-150 Intracranial pressure ( Iep), 145 Intraosscous (10) infusion. 137- 139, 348-350 Int ratho racic abdo men, %. 205 Intubat ion wrap, 81- 82 10 infusion, 137- 139,348-350 IP]>V, 71- 72 ITLS,3 JTLS Access course, 41 2-413 ilLS communicati ons format, 357 ITl..5 ongoing exam. 41-42, 53-54 ITLS patient assessment ongoing exam. 41--42. 53-54 over\'iew, 4, 30 primary survey, 29-38" &t alw ITLS primary SUI'\'ey S('Condary SUf\'Cy. 38-40. 50-53 ITLS primary survey, 29-38 airway, 32 breathing, 32 cervical-spine stabili7.alion, J I circulat ion, 32-33 con tacting medical direction, 38 critical information, 46-50

435

critical intervention, 37 first impression, 31 ini tial assessment. 31- 33 level of consciousness. 31 rapid trauma survey. 34-36 transport dedsion, 37- 38 what to do, 55-57 ITLS Sl'Condary survey, 38-10. 50-53 ITLS triage decision tree, 404

J law lift, 65 loint dislocations. 213-214 lumpSTART.406

K Kendrick extrication device. 170, 171. 188- 189 Kendrick traction device, 220 KING LT-D airway, 68. 341-344 Knee dislocation, 222 Knee injuries, 222 Knife .....ound, 20

L Lap belt, IS Laryngeal mask airway ( LM A). 68. 345-347 Laryngeal prOlllinence.61 La ryngoscop ic orotra cheal intubation, 82-87 Laryngospasm. 61 l.arynx,61 Lateshock,122 L1lCral -impact collision. 12-13 length-baSt-d resuscitation tape, 139-140 Lighted stylct method, 330-332 Lightning injury. 252-2S4 LMA, 68. 345-347 Log roll, 172 I.og-rolli ng pronl' patient, 19/;-197 Log-rolling supine patient, 194- 1% Long backboard, 191-198 1.over's leal' fall, 20 Low-volume shock. 124 Lumba r \"ertebrac. 162 I.und and Browder chart. 242, 243 Lungs. 64

M ~-laat man, David. 400 Machine collision, 8, 9, II, 12 Magee. Kirk. 58

Maine Pro/ocol for Spinal Mo/ion RestricliOlI (Goth ), 173 Mainstem bronchi, 62 Mallampati score. 70 MAP. 145 1-.·larijuana. 301. 303 Massive hel1lothorax, 104-106 MCI. 400-407 l\'lean arterial blood pressure (MAP ). 145 Mechanical shock, 125-128, 133 Medical bmllch of ICS, 401-403

436 .

INDEX

Medical director, 402-403 Medica! hdico pter, 377- 379 Medical threat assessment (MTA), 425 MClh lab. 427 Mcthamphctamincs. 30 1,303 Midd le ear sq ueeze, 385-386 Mi1Irrbodysplin t, 170, 198 Minute volume, 71 MMAP,68-(i9 Modified jaw thrust, 65 MOlor-vchic1<,' collision, 8-19

ATV, 18 head-on collision, 10-12 moto rcycle, 18 occupant rest raint systems. 15- 17 pedcstrian-vchiclcooJlision,19 pcrsonal ....'lItcrcrafl,I8-19 pregnancy, 294 rear-impact collision, 13, 14 rollove r collision, 14, IS rotational collision, 15

Sl.'Condary collision, 10 small-vehicle crashes, J 8-19 snowmobile, 19 T-bonc/laICr.ll-impact collision,l2- 13 Ihrt't'-coJlision concept, 8, 9 InKlo r accident, 17-18 MO lor vehi d e collision entry techniq ues. 4 12-413 Motorcycle accident, 18 MotorC)'c1e hclmrts, 180, 199-202 Mouth-to-mask venti lation, 73 Mo uth-to-mOUlh,73 MTA,425 Muhicasualty incident (Mel ), 400-407 MVC. $u Motor-\'ehicle collision MrocOlrdiai con tusion, lOS. 109, 126, 127

N Naloxo ne. 303 Napoloo n, 415 Narcotics, 301, 303 Narrative r<'port, 362- 370 Nas.11cavity. 60 Nasal oxygen cannulae, 70 Nasopharyngeal airway (NPA), 67-68, 79 Nasopharynx, 60 Nasotracheal intubation, 87-88 Neck wounds, 181 NC'Cdle decom pression, 115- 11 7 Neison, Richa rd N., 3 15 Neu rogenic shock, 124-125, 166 NeUTO\'ascular comp romise, 212 Neu rovascula r injuries, 2 15 Newman, 10nathan G., 299 New lOn's first Jaw of motion, 8 NIMS ICS, 401 NOll hcmon-hagk hyp(wokm k shock, 1)2-] 33 Nonreb reathing masks, 70 NoSt',60 N PA, 67-68, 79

•

o Obstructive shock, 123, 125-128.133 Occupant restrain t systems, 15-16 Ongoing exam, 4 1-42, 53-54 OPA,68, 79 Opt"nankle, 2 J3 Op<'n fractures, 212-2 13 Open pneumothorax, 97-99 Open skull fractures, 147 Open wounds, 215 Opiates, 30 1,303 Optional skills digital intuoo tion, 327- 329 esophageal t rache-al combitube, 339-340 intraossoous infU5ion, 348-350 KING Lr-D airway, 341-344 lar),nge-al m ask airway (LMA), 345-347 Jightl'
p Pag~', Bob, 78 Pain-only ben d~, 388 PaOl,80 Pape r plan syndrome, 400 Parental consen t, 261 Paris, Paul, 94 Partial-thickness burns, 240, 241 PASG, 129 Passive pTCventi\'C inten·('ntion. 3% I~dtdla dislocation, 222 Pa tent (opt"n ) airway. 64-70 Patient assessment. See 11'1.5 patient assessntl'nt Patient care record. 362-370 Patient cooperation, 302 Pedestrian-vehicle collision, 19 Pediatric aid to resuscitation card system, 263 Pediatric Glasgow Coma Scale, 271, 3S2 Pediatric SMR device, 170 Pediatric trauma score, 383 Pediatrics. See Children Peitzman, Andrew 11.,94 Pelvic injuries, 220-221 Pelvic sling device, 221 Pelvic stabilization, 234, 236 Pt'nc1 rating injuries, 8, 20-22 Penctrating objects in skull, 147 i'cpc, Paul E., lIS Pt.-ricardial tamponade, 126 Personal protcctive equipmen t, 322 Perso nal watercraft collision, 18-19

Pfeifer. William. 414 PharyngotracheallumclI airway (I'tI.), 336-338 Philosophy of 3SSC'SSment and management,

2-3 Pia ma ler, 143, 144 i'i11ow spli nt. 226 Pleu ral space, 64 Pneumatic antishock garmen t (VASG ), 129 Pneumatic splints, 223 Pneumothorax open, 97-99 simple,IIO tension, 103-104, 106 Posith'e pressure (artificial) \-entilation. 71-72 Posterior dislocate hip, 222 Prccautions, 315-J26. See a/sa Standard pr
cardiac tamponade, l06- t07 cardiopulmonary arrest, 312 chemical bums, 249-251 chest drcomprcssio n, 115-117 diaph ragma tic rup ture, 109 ET lube position, capnography, 92-93 ET tube position, reronfirmation, 90 eviscerat ion, 208 external jugular can nulation, 137 tJaiJ chest, 101- 103 Hare traction splint, 231-234 head trauma, 155-157 hemo rrhage, 129- 132 [0 infusion (child), 138-139 Ke ndrick e:ttrication device, 188-189 laryngoscopic orotracheal intuba tion, 83,

,....,

length-based resusci tation tape (child's weight ),140 log-rolling prone patien t, 197 rog-rolling supine patient, 194-1% massive hemotho rax, 105 motorcycle helmct, 199-202

INDEX .

nasotracheal intubation, 87--88 NPA insertion, 79 ongoing exam. <11-42 OPA insertion. 79 open pneumothorax. 99 pelvic stabilization. 236 !"Klckel mask-supplemental oxyge n. 80 rapid ex trication. 191- 193 reporti ng exposure to blood. 323-315 Sager traction splint. 234. 235 secondary survey, 38--40 S('curing patient to backboard, 198 short backboard. 184- 188 splinting, 1 17- 219. 230-235 standard precautions, 32 1- 325 sta nding palient, long backbone, 198 suctioning the airway, 79 tensio n pneumothorax, 104 Thomas traction spli nt, 230, 131 tube placement, confirmation , 89 I>tL,336--338 Pulmonary co ntusion, 109-- 110 Pulmonary overpressurizatio n syndrome, 386 Pulse oximeter, 80--8 1 Pulseless eit'<:triC1lI activity (I'EA ), 3 10 J>WCcoUision, 18--19 l>yriform fossa,61

Q Quali tative capnoffietry. 90 Quantitative capnometry. 91 Q uanti tative waveform capnography. 91 QuikClot 1st Response,1 15

R Raccoon eyes, 152 Radiation burns, 254 Radio communications, 356--J61 RAM,425 Rapid extricatio n, 168.190-191.192-193 Rapid sequence intubation (RSI), 68, 35 1- 354 Rapi d trauma sun'ey, 34--36 Rear-impact collisio n, 13. 14 Rcevessloc\'e, 170, 198, 199 Reflexes, 163 Rel ative hypovolemia, 124- 125 R{'mote assessment mooicine ( RAM ), 425 Reporting exposure to blood, 323-325 Respi ratory ratt'S, 33 Retroperi toneal abdomen, 205 Reve rse middle ear squeue, 386 Revis(''
RS!, 68, 351 - 35<1 Rubin, Jonathan M., 39 1 Rule of nines, 241-242 Rural ....'SCue, 409

s Sacco, Bill, 406 Sacco triage method (STM ), 406 Sacrum, 162 Sager tractio n splint, 220 SAM PLE history, 36-37. 365 SaO), 80 Scalp, 143 Scalp wounds, 147 Scene si7.e-up, 4-8 eq uipmen t, 6 mechanism of injur)', 6--,ij sce ne safety, 4-5 standa rd prccautions,4 total number of patients, 5-{) SCIWORA,273 Scoop streICher, 36, 22 1 Seat belt, 15 Second -degree burn, 240, 24 1 Sccondary brain injury, 144-145 Secondary collision, 10 Secondary injury prevention, 395 SccondJ rr survey, 38-40, 50--53 Securing patienl to backboard. 198 5edalil'{'s, 30 1,303 Seitz., 5, Robert, 21 \, 408 Sellick maneuver, 61,62 Septum, 60 Shock{,\'3luation and man agement, 118--140 C1Ipnography, IlJ children, 268-269 compensated/decompensated shock, 121 early/ lat r shock, 122 ext{'rnai j ugular cannula tion, 137 fluid rrsuscilation skills. 136--140 head injury, 132 hemorrhage, 129- 132 high-space shock, 124- 125, 1J3 intraoSo'iCOus ( to) infusion. 1J7- 139, 3<18-350 length-based resuscitation tape. 139- 140 low-volumr shock. 124 management and trea tment, I 28-1J3 m~'Chanical shock, 12S- 118, 133 neurogenic shock, 124-125 no nhemorrhagic hypovolemic shock. 132- 133 pathophysiology, 119-120 tachycardia, 122- 123 vital signs, 15<1 Short backboa rd, 170, 171, 184-189 Shotgun wound, 20-21 Sho ulder injurirs, 224 Shoulder pad removal, 179, 180 Sim ple pneumothorax, 110 Skin, 238-239

437

Skin bends, 388 Skull , 143 Skull fractul"C5, 147 Slings and swa thes, 219, 224 Siovis, Corey M .. 356 Small -veh icle crashes, 18-19 Smoke-inhalation inj uries, 248 SMR, 167- 174, 184-199,,Seen/soSpinal trauma Snowmobile accident, 19 Soft splint, 219 Span of control, 400 SPARC syste m, 140,261 Spinal column , 16 1- 162 Spinal cord , 162-163 Spinal fluid , 144 Spinal motion restriction (SMR). 167- 174, 184--199. Set Ill${) Spinal trauma Spinal shock. 114-- 125, 166 Spinal trauma, 160-202 airway in ten'ention, 175 ana tomy, 161- 163 aSSCSSlllrnt, 166-167 closed-spac{' rescue, 175 decision tree. 174, 185 elderly patients, 178 emergency rescue. 190 head and n«k, 199 helmets, 178-- 180, 199-202 Kendrick extrica tion device,l88- 189 log roll, ]72 log-rolling prone patient, 196-197 log-rolling supine patient, 194- 196 longoockboard,191- 199 ml'<:han isllls of blunt injury. 164-166 motorcycle helmets, 180, 199-202 n«k wounds. 181 neurogenic shock, 166 obese patients, lBO-I81 pedia tric pat ients, 176, 178,273 prone patients, 175, 196-- 197 protective gea r, 178- 180 rapid extrication, 190--191, 192-193 seatl'
,... 438 • INDEX

Standard precautions (colllillued) procedures, 321-325 reponing exposure to blood. 323-325 tuberculos is (T8), 319, 321 START systelll, 4{l6 Steering wheel injuries, I ! Step-by-step procedure. Ste Procedure Sternal fracture, 110 Stl'rnal no lch, 61. 63

training, 421, 423 trauma combat casualty car~, 411,423 why needed. 416 Tactical medical advanced emergency mrdication pack, 420-421,422 Tactical mooiClI backpack, 420 T13,319,321 TB \' See Head t{"duma Teaching and evaluation, 54-55

Ste\'ens, John T., 27, 118.400

Teeth,6O

Stewart. Ronald D., 58 5TI\1, 406 Strain, 212 Su barachnoid hemorrhagc. 148 Substance abuse, 299--305

Tension pneumothorax, 103-104, 106, 125-126 'Ii.-rminology (glossary), 429-432 Third-dt'gree burn, 240, 241 Thoracic abdomen. 204-205 Thoracic trauma, 94-11 7 airway obstruction , 97 anatomy, 95-96 cardiac tamponade. 106-107 chest dl'CompTC$Sion, 115-117 children, 272- 273 diaphragmatic tears, 109 ilail chest, 99-103 impaled objects, 110 massh'e hemothorax, 104-106 myoGlrdial contusion, 108, 109 open pneumothor-.1X, 97- 99 pathophysiology, %-97 pulmonary contusion, 109-110 rib fractwe, I 10 simple pneumothorax, 110 sternal fraclUrc, 110 tension pneumothorax, 103-104, 106 tracheal or bronchial tree injury, 108 t{"duma!!Caortic ruptUTl.', 107-108 traumatic asphyxia, 110 'Ihoracic vertebrae. 162 Thorax, 96 Three-collision concept, 8, 9 Thn.'C-point rl'Straint, 15, 16 Thyroid G1rtilage, 61 Tibia injuries. 222-223 Tidal volume, 71 Tissue hypoxia, 97 TLJV, 70, 333-335 longue, 60 Trachea. 62 Tracheal or bronchial trt;:t.' injury, 108 Trachral rings, 62 Troction, 168 Tr
aS51.!'S5mcnt and management. 300-302 overview (tables), 301. 303 plItient cooperation. 302 uncoopcrnti\'c paticnt, 302- 303 Sucki ng chct;t wound, 97-99, 100 Suction apparatus, 66 Suctioning the airway, 66-67 Sunburn, 240 Superficial burns, 239-240 Supplemental oxn;en, 70, 80, 267- 268

SWAT teams. See Tactical EMS

T T-oone collision, 12- 13 Tnchycardicine ( RAM ), 425 resuscitation limitations, 425 roles, 416-411 spe<:ial issues, 426-421 tactiCll medical advancoo emergency med ication pack, 410-421, 412 tactical mrdical backpack, 420

toxic material hazards, 426

circulatory problems, 310-311 general approach, 311 hypoxemia, 308-3 10 plan of action, 311-3J3 steps in procedure, 3 12 unsalvagcablr patient, 307-308 Trauma comOOt casualty car~. 423-424 Trauma of ascent, 386-387 Trauma of descent, 385-386 Trauma Koring, 380-383 Traumatic aortic rupture, 107- 108 Traumatic asphyxia, 110 Traumatic brain injury (TBI). See Hrad t.rauma Traumatic diaphragmatic hernia. 109 Treatment supervisor. 403 Triage. 403-406 Triage supervisor. 403 True abdomen, 205 Tuberculosis (T8), 319. 321 Turbinates. 60

U Uncoopcratl\'e patient. 302- 303 Undrr the influence, See Substance abuse Unequal p upils, 153 Unsalvageable patient, 307-308

V Vasodilator), shock, 124 V~hiclr collision, 9, Sec also Motor-vehicle collision Ventilation, 71 - 74 Vital signs child~n, 268 head trauma, 153-155 shock,l54 Vomiting. ISO

W Wa ter rescue, 175,177 Watercraft collision, I S-19 Weitge, Arlo F.. 362 Werman. Howard, 315 West, Katherine, 3 15 White, Melissa, 203 WildernCSll rescue, 375-376 Williams, 'anet M" 391 Windshield injuries, I I Wipiler. John, 414 Wound ballistic, 20-22 Wrist inju ri es, 225

y Yancey, Arthur H" II, 203

Z Zone of coagulation, 239 Zone or hyperemia. 239 Zone of stasis, 239

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