The Traumatically Injured Patient

1. The Traumatically Injured Patient April 2014 CE Condell Medical Center EMS System Site Code: 107200E-1214 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 5.23.14

2. Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Describe the purposes of data collection in injury prevention, trauma registry, and quality improvement. 2. Describe the association between mechanism of injury and anticipated injury patterns. 3. Describe trauma assessment process 4. Describe trauma assessment priorities. 5. Describe the capabilities of a Level I and Level II Trauma Centers.

3. Objectives cont’d 6. Describe the procedure for instituting critical invasive interventions to the critically injured patient. 7. Given a variety of scenarios, assign the appropriate trauma triage criteria to the patient 8. Actively participate in review of selected Region X SOP’s. • Actively participate in review of a variety of EKG rhythms and 12 lead EKG’s. • Actively participate in case scenario discussion.

4. Objectives cont’d 11. Actively participate in return demonstration of insertion of IO, King airway, and Quick Trach at the paramedic level. 12. Actively participate in ventilating a patient via a BVM at the EMT-Basic level. 13. Review responsibilities of the preceptor role. 14. Discuss the use of tourniquets and QuikClot tools in Region X. 15. Successfully complete the post quiz with a score of 80% or better.

5. Data Collection • Processes used to identify problems/issues and remedy them • Process of gathering and measuring information • Accurate data is essential • Results drive decision making • Focus is on objective, not subjective information

6. Focus of Data Collection • Move from “I think there is a problem” to “Data indicates the problem is…” • In past, medical practices have been based on medical knowledge, intuition, and judgment • Care provided needs to be “best practice” (“evidenced based practice”) • Based on best available clinical and scientific evidence available in literature

7. Data Collection – Injury Prevention • Changes over the years driven by data • Restraints consisted of lap belt in the front seat only (early 1900’s) • Now lap and shoulder belts are positioned through-out vehicle • Early air bags for driver only • Now air bags all around vehicle • Opposing roadways had no separation; head on collisions more common • Hard to find a major roadway without some separation (i.e.: concrete barrier, grass)

8. Data Collection –State Trauma Registry • Hospitals submit data to the State of Illinois specifically for patients with traumatic injuries • Again, data drives change • Without specific, accurate data, evidence based changes difficult to formulate

9. Trauma Transports By The Numbers* • Volume of trauma transports in Region X • Total transports reported to IDPH 2011 = 5914 • Total transports reported to IDPH 2012 = 6084 • Total transports reported to IDPH 2013 = 4454** • Snapshot of CMC totals reported to IDPH • Total 2012 – 1361 (Cat I 208; Cat II 729) • Total 2013 – 1256 (Cat I 181; Cat II 792) • Dec 2013 total - 144 (Cat I - 12; Cat II - 54) • * Patients included IF admitted or transferred out • **First 3 quarters 2013 reported*

10. Mechanism of Injury (MOI) • Refers to how a person was injured • Kinetics is the science of analyzing the MOI • Documentation describing the MOI is the data used to drive decisions • Needs to be detailed • i.e.: Why and how patient fell • MOI can influence assessment and interventions • Changes to product design/structure and use can be generated after review of data

11. MOI • Due to collected data, energy patterns can be predicted and allow the rescuer to focus on probable and most likely injuries anticipated • Vehicle collisions • Falls • Penetrating trauma • Explosions

12. MOI • Falls most common but… • Over 1/3 of deaths result from MVC • Best you could do for a patient??? • Maintain a high index of suspicion

13. Trauma Assessment Process • Scene safety and size up • Primary or initial assessment • AVPU, ABC’s and c-spine control • Transport decision • Rapid trauma assessment or focused exam • Detailed secondary assessment • Ongoing assessment

14. Trauma Assessment Process • Be methodical • Be repetitive • Perform the same steps on all calls • Can modify steps based on type of call • Builds muscle memory • If you always do something, you’ll never NOT do something

15. Trauma Intervention Priorities • Identify life threats in primary assessment • Continue to look for life threats with every additional assessment • Correct airway problems • Establish adequate oxygenation & ventilation • Control external hemorrhage • Direct pressure, pressure points, tourniquets, hemostatic agents • Expedite transport to appropriate facility • Need to determine category trauma to make this decision

16. Category I Trauma Patient – Unstable Vital Signs • GCS <13 with blunt head injury • Trying to avoid categorizing all patients with altered level of consciousness NOT due to trauma (i.e.: under the influence of ETOH and drugs • Respiratory rate <10 or >29

17. Category I Trauma Patient – Anatomy of Injury • Penetrating injuries to head, neck, torso, groin • Combination trauma with burns >20% • 2 or more proximal long bone fractures • 2 or more body regions with potential life or limb threats • Unstable pelvis • Flail chest

18. Category I Trauma Patient – Anatomy of Injury cont’d • Limb paralysis and/or sensory deficits above wrist or ankle • Open or depressed skull fracture • Amputation proximal to wrist or ankle

19. Category II Trauma Patient – Mechanism of Injury • Ejection from auto • Death in same passenger compartment • Motorcycle crash >20 mph or with separation of rider from bike • Rollover unrestrained • Falls >20 feet • Peds falls >3x body length • Pedestrian thrown or run over

20. Category II Trauma Patient – Mechanism of Injury cont’d • Auto vs pedestrian/bicyclist with > 5mph impact • Extrication > 20 minutes • High speed MVC • Speed >40 mph • Intrusion >12 inches • Major deformity >20 inches • Basically, a very lucky patient with significant MOI which increases the risk of injury

21. Category II Trauma Patient –Co-morbid Factors Increased risk of morbidity or mortality related to co-existing factors • Age <5 without car/booster seat • Bleeding disorders or on anticoagulants • Pregnancy >20 weeks • Renal disease requiring dialysis

22. Anticoagulants • Why are these an issue with trauma? • Increases the risk of bleeding internal and external • Can you name the 6 more commonly used anticoagulant medications that can increase the risk of bleeding for trauma patients? • Coumadin / Warfarin • Xarelto • Pradaxa • Elaquis • Lovenox (Note: Plavix & ASA are antiplatelets)

23. Transportation DestinationWho Goes Where??? • Highest level Trauma Center within 25 minutes of transport time • Unstable systolic B/P on 2 consecutive readings • Adult < 90 systolic • Peds < 80 systolic • Category I trauma patient • Closest Trauma Center • Category II trauma patient • The lucky patient with a significant MOI!

24. Transport Destination cont’d • Closest appropriate comprehensive ED • Patient NOT categorized as I or II but who has suffered a traumatic injury • Closest comprehensive ED • The patient with NO airway • This includes GEC and Vista’s Emergency Center in Lindenhurst

25. Level I and Level II Trauma Centers • IDPH has printed Administrative Code (i.e.: Rules and Regulations) designating criteria to be met by hospitals • Staffing availability • By title, department, and hours available • Staff training • Equipment • Performance QI program • Operating Protocols

26. Trauma Center Operations • IDPH Rules and Regs require • Staffing availability requirements by specialty • Immediate, 30 minutes, 60 minutes response • Transfer agreements for unique cases (ie: burns) • List of equipment per level trauma center • Minimum performance QI to be performed • Guidelines for contents of operating protocols • Including measures to avoid going on by-pass • Type of public education performed

27. IO Access • When there is a need to have access for medication administration and alternative peripheral sites have failed or are not available • Needle inserted into bone marrow cavity

28. Treatment – Interventions - IO • Indications • Shock, arrest, or impending arrest • Unconscious/unresponsive or conscious critical patient without IV access • 2 unsuccessful IV attempts or 90 second duration or no visible sites

29. IO cont’d • Contraindications • Insertion into extremity with fracture • Infection at insertion site • Previous orthopedic procedure • Knee replacement, previous IO within 480 • Pre-existing medical condition • Inability to locate landmarks • Significant edema

30. IO Sites • Primary site – proximal tibia • Secondary site for adults – proximal humerus • Not developed anatomically in children <5, therefore not recommended < 5y/o • If you are anticipating humeral site in the pediatric patient over 5 years-old, contact Medical Control for guidance

31. Proximal Tibia Insertion Site • Flat surface below growth plate and medial to tibial tuberosity • Palpate 2 fingers below patella to tibial tuberosity (approx. 2 cm) • Leg needs to be straight • Not always palpable in very young • Palpate 1 finger width medially • “EZ IO to big toe”

32. Humeral Insertion Site • Place patient’s hand over navel and elbow adducted to body (tucked back in line with spine) • Palpate with thumb moving up the humeral bone • Palpate to the most prominent rounded protrusion – greater tubercule • Rotate fingers around site to confirm • Site is anterior to midline of arm

33. Humeral Site Alternate Methods to Identify • Keep hand over navel, elbow adducted • Using heel of your hand, strike at prominence top of arm • Site feels like golf ball OR • Slide fingers down from top of shoulder • As soon as drop off palpated, come down 1 finger breadth and anterior 1 finger breadth

34. IO Sizing • Pink – 15 mm; 15 G • Blue – 25 mm; 15 G • Yellow – 45 mm; 15 G • 15 mm – if you can feel bone just under skin; generally for infants 3-39 kg (6.5-88#) • 25 mm – general population for tibial placement • 45 mm – adult humeral site and obese leg

35. IO Equipment • IO needle package • IO needle • EZ-connect tubing • Florescent arm band • Driver • Syringe with NS for flushing • Primed normal saline (NS) IV bag • Material to cleanse site • Pressure bag • Material to secure needle

36. IO Needles • What’s with the black hash marks??? • Purpose – to validate appropriate length of needle for site chosen • Advance needle into site until bone touched • If you can see a black hash mark, you have enough needle left to be secured into bone • If no hash mark visible, withdraw needle from skin, move to next size needle and resume placement

37. Confirming IO Placement • Needle stands up by self • Flushes without resistance • No evidence of infiltration • Fluid flows with pressure bag • Can squeeze bag manually until pressure bag in place but may not be enough pressure

38. Pain Control For IO Infusion • What causes pain during fluid infusion? • Infusion of fluids into a non-expandable space • How do you fix it? • Lidocaine 50 / 60 / 60 • 50 mg over 60 seconds; wait 60 seconds • For peds: 1mg/ kg up to 50 mg • Company recommended to inject Lidocaine before initial flush if anticipated • Infusion can be stopped any time to instill Lidocaine for pain control

39. Why Do IO’s Fail??? • Catheter not flushed following insertion • Pressure bag not in place • FYI - Manually squeezing IV bag may not produce high enough pressure • Wrong size needle chosen • Too short and not entered into bone • Drilled too deep and punctures through the bone

40. Treatment – Interventions – King Airway • Indications • Cardiac or respiratory arrest • Inability to place ETT in unresponsive patient without a gag reflex • Contraindications • Height less than 4 feet • Presence of gag reflex • Ingestion of caustic substance • Known esophageal disease

41. Gag Reflex • Purpose • Protects the airway • How to test for presence • Stroke eyelashes or tap space between eyes looking for blink reflex • Blink and gag reflexes are protective • Disappear at same time • Testing for one sheds light on other one • Note: about 1/3 of adults have  gag reflex

42. King Airway Sizing • Color coded sizes • Size 3 – yellow • Size 4 – red • Size 5 - purple • Based on patient's height • Yellow size 3 for 4 – 5 foot height • Red size 4 for 5 – 6 foot height • Purple size 5 for over 6 foot height

43. King Airway Equipment • King airway – properly sized • Large syringe • Yellow size 3 initial balloon inflation 50 ml air • Red size 4 initial balloon inflation 70 ml air • Purple size 5 initial balloon inflation 80 ml air • Water soluble lubricant • Avoid smearing lubricant over distal air passages on airway

44. King Airway Confirmation • Begin by attempting to start ventilating patient – you should meet resistance • Perform usual steps • Observe bilateral rise and fall of chest • 5 point auscultation • Absent epigastric sounds • Bilateral breath sounds • Capnography • Qualitative/colormetric - yellow • Note: This is a blind insertion • You will not visualize vocal cords

45. Why do King Airways Fail??? • Failure to choose correct size airway • Failure to initially insert airway deep enough • Failure to inflate cuff sufficiently • Failure to pull King airway out far enough

46. Treatment – Interventions – Quick Trach • Indications • All other conventional methods to ventilate patient have failed • Contraindications • Tracheal transection • Other less invasive techniques allows ventilation of patient (i.e.: they are successful)

47. Quick Trach Sizing • Size 4.0 mm ID – patients >77# (35 kg) • Size 2.0 mm ID – patients between 22 and 77# (10 – 35 kg) • Needle cricothyrotomy – patients < 22# (10 kg)

48. Quick Trach Equipment • Contained in one kit • Size 4.0 or 2.0 pre-assembled cricothyrotomy unit • Attached 10 ml syringe • Connecting tubing • Padded neck strap • Add to kit • PPE’s • Cleansing material • BVM

49. Quick Trach Landmark Identification • With patient supine, hyperextend neck if no neck injury suspected • Locate cricothyroid membrane • Located between thyroid cartilage (Adam’s apple) and cricoid cartilage • Start at sternal notch and run finger upward • First rigid landmark is cricoid cartilage • Cricothyroid membrane just above cartilage

50. Landmark Identification Alternative Method • Palpate prominence of Adam’s apple • Slowly palpate finger downward • Finger drops off into cricothyroid membrane