Patients With Traumatic Injuries

1. Patients With Traumatic Injuries Condell Medical Center EMS System ECRN Packet CE Module II 2008 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Viewing Packets on the Website • To see the packet in larger print or to review the packet and you no longer have a paper copy, go to the Condell website • www.condell.org/emergency/ • On right side of page choose “ECRN CE” • This will take you immediately to the CE page and then choose your year and module. • Contact your EMS office for a copy of the quiz. • You must complete 4 modules per year to maintain current ECRN licensure

3. Objectives • Upon successful completion of this module, the ECRN should be able to: • Identify the differences between a Category I, II and III trauma patient • State EMS pre-hospital transport decisions for trauma patients based on Region X guidelines • Understand what the mechanism of injury is and the information it provides • Understand the difference between the index of suspicion and the general impression

4. Objectives cont’d • Describe assessment and field treatment appropriate for the patient with traumatic insult based on Region X SOP’s • Burns, tension pneumothorax, sucking chest wound, flail chest, pericardial tamponade, eviscerated organs • Understand where the landmark for chest needle decompression • Review trauma scenarios • Successfully calculate the GCS and RTS given the patient’s parameters • Identify and appropriately state interventions for a variety of EKG rhythms • Identify ST elevation on a 12 lead EKG • Successfully complete the quiz with a score of 80% or better

5. Leading Causes of Death • In the age groups from 1 to 44, unintentional injury is the leading cause of death • 45 and over, the leading causes of death are disease • cardiovascular disease and cancers • These statistics point to a financial burden placed on the patient as well as society for unintentional injuries • Source: National Vital Statistics System, National Center for Health Statistics, CDC

6. Level I Trauma Centers • Prepared and committed to handle all types of specialty trauma 24/7 • Provides leadership and resources to other levels of trauma care in the Region • Participates in data collection, research, continuing education, and public education programs • Level I Region X: Evanston Hospital, St. Francis in Evanston • Level I non-Region X: Advocate Lutheran General, Froedtert (Wisconsin)

7. Level II Trauma Centers • Increased commitment to trauma care for the most common trauma emergencies with surgical capability available 24/7 • Participates in data collection, continuing education, and public education programs • Level II in Region X: Condell, Glenbrook, Highland Park, Lake Forest, Rush North Shore, Vista Medical Center East (VMH)

8. Additional Level II Trauma Centers - Not Geographically In Region X • Centegra – McHenry, Illinois • Good Shepherd Hospital (GSH) – Barrington, Illinois • Northwest Community Hospital (NWCH) – Arlington Heights

9. Region X SOP -Trauma Transport • Systolic B/P < 90 on 2 consecutive readings (or peds < 80) • Transport to the highest levelTrauma Center within 25 minutes • 25 minute clock starts from the time of injury

10. Region X SOP Trauma Transport • Traumatic arrest, isolated burns >20% • Transport to the closestTrauma Center • No airway • Transport to the closest Emergency Department

11. Hospital on By-pass The closest appropriate hospital must still accept any patient in a life-threatening condition even if they are on by-pass

12. Region X SOP Trauma Transport • Category I Trauma Patient • Unstable vital signs • Based on anatomy of the injury • Transport to the highest levelTrauma Center within 25 minutes • 25 minute clock starts from the time of injury

13. Region X SOP Trauma Transport • Category II Trauma Patient • Based on mechanism of injury • High potential for injury but patient is stable for now • Based on existence of co-morbid factors that increase the risk of complications to recovery • Transport to the closestTrauma Center

14. Region X SOP Trauma Transport • Category III Trauma Patient • All other traumatic injuries and where routine care is being provided • Isolated traumatic injury (generally GCS >10) • Isolated fractures • Minor burns • Lacerations • Transport the patient to the closestTrauma Center

15. Transport Decisions When possible, EMS and Medical Control are to honor the patient’s request for hospital destination

16. Mechanism of Injury • The process and forces that cause trauma • Mentally recreate the incident from the evidence noted • Identify strength of forces involved • Identify direction forces came from • Identify areas of the patient’s body most likely affected by the forces • Start to identify the mechanism of injury during the scene size-up

17. Accepting The Radio Report • Start forming a mental picture as you receive report • You are mentally forming an opinion based on mechanism of injury • You’ll think differently for the patient who fell 5 feet versus 30 feet • Form a general impression based on the paramedic report of mechanism of injury with their field assessment

18. Injury Patterns – Pedestrians • Adults • Generally turn away & present lateral surfaces • Anatomically, impact is low on the body • Injuries to tibia, fibula, femur, knee, lateral chest, upper extremity, then head & neck • Pediatrics • Generally turn and face the vehicle • Injuries anatomically higher on the body than adults • Injuries to femur, pelvis and then those sustained when run over or pushed aside by the vehicle

19. Injury Patterns – Motor Vehicle • Rotational (38% of MVC) • Injuries similar to frontal & lateral • Deceleration is usually more gradual & injuries less serious although the vehicles look worse • Frontal (32% of MVC) • Up and over the steering wheel pathway • Femur fractures • Blunt abdominal injury via compression • Lower chest injuries after steering wheel impact • Head & neck injuries with windshield impact

20. Injury Patterns – Motor Vehicle • Down and under the dashboard pathway • Lower leg injuries from sliding under the dash • Chest injuries with steering wheel impact • Collapsed lungs from breath holding at time of impact • Ejection • 27% of fatalities • 2 impacts – with interior vehicle & then the objects outside the car (ground, trees, fences, etc)

21. Injury Patterns – Motor Vehicle • Lateral impact – T-bone (15% of MVC; 22% of all MVC fatalities) • Much less structural steel for protection between victim and impact site • Vehicle damage may not look severe but internal injury potential is high • Upper & lower extremity fractures on impact side • Lateral compression with a large amount of internal injury to chest & abdominal organs • Unrestrained passengers are missiles and add to injuries other passengers already sustained

22. Injury Patterns – Motor Vehicle • Rear end (9% of MVC) • Head rotates backward and then snaps forward • Less neck injury if the head rest is properly positioned • Rollover (6% of MVC) • Occupant experiences impact every time vehicle impacts a point on the ground • Vehicle sides and roof provide less crumple zones for absorbing impact forces • Ejection is common in unrestrained persons

23. Index of Suspicion • Your anticipation of injury to a body, region, organ, or structure based on identification of the mechanism of injury • Your index of suspicion is honed from experience and time on the job

24. General impression • Formed from mechanism of injury and index of suspicion • Will guide the EMS provider regarding a direction on how to proceed in caring for this patient

25. Putting It All Together Sample Report: • The mechanism of injury is a frontal MVC The steering wheel is broken, chest wall is bruised, breath sounds decreased on the right • Your index of suspicion is chest injury • Your general impression is pneumothorax

26. Documentation of The Complaint To Include: • O - onset • P – provocation/palliation • Q - quality • R - radiation • S – severity (0 – 10) • T – timing – when did it start

27. Documentation • Provide answers to: • Who (the patient you’re caring for) • What (happened) • When (did it happen) • Where (which body part) • How (did it occur)

28. EMS Trauma Care – Amputated Parts • Routine trauma care • To remove gross contamination, gently rinse with normal saline • DO NOT use distilled water to irrigate open wounds • Normal saline is isotonic and less harmful to tissue • Cover stump with damp (normal saline) sterile dressing and ace wrap • Ace provides uniform pressure to stump • Cover wounds with sterile dressing

29. EMS Care of Amputated Parts • Place part in a plastic zip lock bag • Place bag in larger bag or container over ice and water • Do not ice the part alone

30. EMS Pain Management Including for Adult Burns • Morphine for pain control • 2 mg slow IVP over 2 minutes • May repeat every 2 minutes as needed to a maximum of 10 mg • Watch for respiratory depression • Monitor for a drop in blood pressure due to vasodilation from the medication

31. Adult Burns - Electrical • Immobilize the patient • High potential for traumatic injury • Muscle spasms during contact with source • Thrown when power source cut • Assess for dysrhythmia – place on cardiac monitor • Assess distal neurovascular status of affected part • Cover wounds with dry sterile dressings

32. Adult Burns - Inhalation • High risk for airway compromise • Note presence of wheezing, hoarseness, stridor, carbonaceous sputum, singed nasal hair • High flow oxygen via non-rebreather mask • Monitor for need of advanced airway device • ETT – consider using ETT one size smaller than normal due to potential swelling of the airway

33. Adult Burns - Chemical • HAZ-MAT team may be involved in the field • If powdered chemical, first brush away excess dry material • Clothing removed if possible • Area flushed with sterile saline • If eye involvement, remove contact lenses and flush continuously with sterile saline • Avoid contamination of noninvolved areas

34. EMS Care for Adult Burns - Thermal • Superficial – 1st degree • Area cooled with sterile saline • <20% BSA involved, apply sterile saline soaked dressings for transport • >20% BSA, apply dry sterile dressing for transport • Do not overcool major burns or apply ice directly to burned areas

35. Adult Burns - Thermal • Partial or full thickness (2nd or 3rd degree) • Wear sterile gloves and mask while burn areas are exposed • Decreases additional risk of wound contamination • Cover burn wound with dry sterile dressings • Preventing air flow over exposed burn areas reduces pain levels • EMS will place a clean sheet over the patient • Protect the patient from hypothermia

36. Infant differences: back 13%, each buttocks 2.5%, each entire leg 14%

37. Case Study #1 • Adult patient reached over a charcoal grill just as the match was thrown onto the soaked coals • Injury is restricted to the right forearm • What type of burn is this? • Using the Rule of Nines, what is the TSBA burned? • What type of care is appropriate? • How can the pain be managed? • What does the documentation look like?

38. Case Study #1 – Patient with Burns Skin is reddened and some blistering is present

39. Case Study #1 – Category III • Combination of superficial and partial thickness burns approx 4.5% TSBA (circumferential around forearm) • Evidence of redness with a blistered area although blister is broken • Appropriate care includes cooling burn, applying sterile saline soaked dressing (<20% TBSA) • Additional helpful care • Elevation of arm, removal of ring before fingers swell • For pain control • Morphine 2 mg slow IVP; can repeat 2 mg in 2 minutes up to 10 mg

40. Chest Injuries – Traumatic Arrest – Category I Trauma • Begin CPR • Transport to closest Trauma Center • A hospital on by-pass must take a patient in life threatening condition if they are the closest appropriate hospital • EMS to perform bilateral chest decompression • Use common sense – does the scene size –up, evaluation of mechanism of injury and general impression indicate a potential chest wall injury?

41. Chest Injuries – Tension Pneumothorax – Category I Trauma • History of injury to the chest wall • On rare occasions can be spontaneous • Diminished breath sounds • Hyperresonance if percussion done • Severe dyspnea • Hyperinflation of chest • Jugular vein distention • Tachycardia • Hypotension

43. Landmarks anterior approach 2nd intercostal space in the midline of the clavicles Place prepared flutter valve needle over the top of the rib Avoids potential injury to vessels and nerves that run along the bottom of the rib In-field Needle Decompression

44. Quick Way to Find 2nd ICS • Feel for the top of the sternum • Roll your finger tip to the anterior surface at the top of the sternum • Feel the little bump near the top of the sternum • This bump is the Angle of Louis • From the Angle of Louis slide your fingers angled slightly downward toward the affected side following the rib space • You are automatically in the 2nd ICS • Identify the midline of the clavicle • The midline is more lateral than persons realize and usually runs in line with the nipple

45. Alternate Method to Find 2nd Intercostal Space • Palpate the clavicle and find the midline • The midline is farther out (more lateral) from the sternum than most persons realize • Move your finger tips under the clavicle into the 1st intercostal space • 1st rib is under the clavicle and is not palpated • Spaces identified for the numbered rib above the space • Feel for the firm 2nd rib and palpate the soft space below the rib • This is the 2nd ICS

46. Field Equipment • Long needle (preferably 2-3 inch) and large bore needle (preferably 12-14G) • Flutter valve – finger cut from a glove • Cleanser to prepare skin overlying the site • Method to secure needle in place • Skin will most likely be diaphoretic • Tape may not stick • May need to maintain manual control of needle

47. Skin Preparation Midline of clavicle 2nd ICS Angle of Louis

48. Inserting the Needle • Remove proximal end cap from needle if present • Will be able to hear trapped air escaping • Needle inserted over top of rib • Once hiss of air heard continue to advance catheter while withdrawing stylet • Stabilize catheter as best as possible • Patient should symptomatically improve • Do not expect to hear improved breath sounds; takes time for the lung to reexpand

49. Case Study #2 • EMS is called to the scene for a 52 year-old male with c/o sudden onset dyspnea with pain between his shoulder blades while watching TV at home. The patient is agitated, short of breath, with increased respiratory rate and SaO2 of 89%. • Further assessment reveals decreased breath sounds on the right and clear on the left • Vital signs: 98/62; HR 118; RR 32 and shallow • Your impression & intervention plan?

50. Case Study #2 • Spontaneous tension pneumothorax • They don’t all develop from trauma • Supplemental oxygen support via non-rebreather, cardiac monitor, preparation for IV BUT • This patient needs needle decompression while the above are being prepared • Patients with a tension pneumothorax can’t wait and will deteriorate without needle decompression