Assessment of the Trauma Patient

1. Assessment of the Trauma Patient 2nd Trimester, June 2013 CME Prepared by Leslie Livett RN, MS Presence St. Joseph Medical Center

2. Objectives • Upon successful completion of this module, the EMS provider should be able to: • Understand what the mechanism of injury is and the information it provides • Describe assessment and treatment appropriate for the patient with traumatic insult • Tension pneumothorax, sucking chest wound, flail chest, eviscerated organs • Successfully identify the landmark and perform chest needle decompression • Actively participate in trauma scenario discussion

3. Definition • Damage to the body caused by an exchange of energy beyond the body’s resilience.

4. Epidemiology of Trauma • Leading cause of death in ages 1-44 • 3rd leading cause of death for all ages • 100,000 deaths/year • 60 million injuries/year

5. Overall Approach • Anticipate the worst • Never make any assumptions • History and Exam have to make sense • Don’t take short cuts • Document frequently • TEAMWORK

6. Don’t get distracted with “ugly injuries”

7. Your Initial assessment findings will determine how you will proceed • Caveats in Elderly: • Loss of Reserve Function • Assume that every organ has some degree of loss • Improve outcomes

8. Trauma System Mortality is decreased when The RIGHT patient Gets to The RIGHT hospital In the RIGHT AMOUNT of TIME

9. A B C’s of Trauma Care • Many ways to interpret that • The original way A Airway with C-spine B Breathing C Circulation

10. The New Way A Airway B Be Careful of the Airway C Concentrate on the Airway

11. (An Amusing Variation) • A Antibiotics • B Blood Cultures • C Consults • A Always • B Bring • C Camera

12. Approach to Trauma Challenging Systematic Approach to Patient Care Logical & Organized Mechanism of Injury

13. General Assessment Pearls • With restlessness and agitation, you must consider • hypoxia, • shock, • influence of alcohol and/or drugs • need to assess for all reasons of restlessness. • don’t not just stop when you discovered one cause • there may be more than one pathology going on at a time

14. AIRWAY • Way back in 1983, studies showed us that NO Airway or a DELAYED airway was the single most important cause of mortality in trauma If you THINK you need an airway …. YOUDO

15. Airway Assessment Maneuvers in Trauma • Inspection • Color, contour, symmetry, smell, audible abnormal sounds, obvious wounds • Palpation • Textures, moisture, pulsations, deformities, crepitus, masses, temperature • Percussion • Resonant = normal • Hyperresonant = more air • Dull = solid, fluid • Auscultation

16. Focused History Physical Exam • As you approach: OBSERVE • Level of Consciousness • Appearance • Restlessness • Distress/Pain • Hemorrhage/Gross Deformities • Unusual odors • Kinematics

17. Airway & C-Spine Access Assess Maintain Cervical Spine Control

18. Airway Compromised What are some etiologies of a compromised/ obstructed airway in trauma?

19. Airway Compromised Discuss: What are some causes of a compromised/ obstructed airway in trauma?

20. Airway Assessment • Observe for Respiratory effort • Symmetry • Accessory muscles • Audible sounds • What should ventilations sound like? • Ability to talk • Impaired laryngeal reflexes

21. Airway Intervention • Position Appropriately • Reposition Mandible • Chin lift, jaw thrust • DO NOT • Hyperextend or Hyperflex • Remove Debris/Suction • Maintain with Adjuncts

22. Airway Adjuncts • Nasopharyngeal if awake • Oropharyngeal if unconscious/no gag • Rescue: • BVM, Intubation,King LTS-D,

23. Airway Adjuncts • Lower Airway • Needle Cricothyrotomy • Quick-trach Need to secure your airway & always reassess!

24. Spine Precautions • Manual in-line stabilization • Maintain axial alignment • Apply c-collar • Provide lateral immobilization

25. Airway Caveats in special populations • Obese • Sleep apnea, elevate head of bed, difficult access to airway • Elderly • Spine/arthritic changes • Dental appliances

26. Breathing • Inspect • Expose the chest • Palpate • Percussion • Auscultate

27. Breathing Inspect RATE, PATTERN, DEPTH, EFFORT • Appearance • Symmetry • Signs of past trauma • Accessory muscles • Speech • Jugular veins • Cough

28. Breathing Palpate Pain, point tenderness Deformity Chest wall expansion Mobility Crepitus Skin temp/moisture SQ emphysema Tactile fremitus Position of the trachea

29. Breathing Percussion • Hyperresonance • Pneumothorax or emphysema • Dull • Blood from hemothorax

30. Breathing Auscultate • Perform immediately if in distress • Audible • Listen • Ominous sound = silence • Tissue mismatch: reflects sound away

31. Breathing Auscultate • Where to listen? • Epigastrium (first after intubation) • Anterior • Lateral • Posterior

32. Breathing Compromise Dyspnea Bradypnea: weak/shallow Tachypnea Cough Diminished or absent breath sounds Signs of chest trauma Increased effort using accessory muscles SQ emphysema Unequal pulmonary excursion Hypoxia/cyanosis Restlessness

33. Breathing Intervention Pulse OX (SpO2) Oxygen (NRB)

34. Breathing Life Threats • Tension Pneumothorax • Open Pneumothorax • Flail Chest • Massive Hemothorax

36. 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 Needle Decompression

37. 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

38. 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

39. Needle Decompression • Find your own 2nd ICS • Now find your neighbor’s 2nd ICS • Use both methods to find the landmark and decide which is easiest for you • Documentation • To include signs and symptoms • Size of needle used (length and gauge) • Site needle inserted into • Response from the patient

40. Equipment • Long needle (preferably 2-3 inch) and large bore needle (preferably 12-14G) • Flutter valve • Not required by system, but can be helpful • Commercial devices, or finger from a glove • Cleanser to prepare skin • Method to secure needle in place • Skin will most likely be diaphoretic • Tape may not stick • May need to maintain manual control of needle

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

42. Inserting the Needle • Remove proximal end cap from needle • 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

43. Case Study #1 • 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?

44. Case Study #1 • Spontaneous tension pneumothorax • They don’t all develop from trauma • Begin supplemental oxygen support via non-rebreather, cardiac monitor, preparation for IV BUT • Quickly prepare for needle decompression while the above are being prepared • Patients with a tension pneumothorax can’t wait and will deteriorate without needle decompression

45. Sucking Chest Wound • Most common with penetrating wounds • Free passage of air between the atmosphere and pleural space if the open wound is at least 2/3rd the size of the diameter of the trachea • Size of trachea about the size of pt’s 5th finger • Air is drawn into the chest cavity • Air replaces lung tissue • Lung collapses

46. Sucking Chest Wound • Severe dyspnea • Open chest wound • Check anterior, posterior, axilla areas • Frothy blood at wound opening • Sucking sound as air moves in and out • Tachycardia with hypovolemia

47. Treatment Sucking Chest Wound • Immediate treatment is to seal the opening • May start by placing a gloved hand over the wound • When able, place an occlusive dressing, taped on 3 sides, over the wound • Wound now converted to a closed pneumothorax • Monitor for signs of tension pneumothorax • May need to lift a corner of the dressing to release trapped air via burping dressing

48. Flail Chest • 3 or more adjacent ribs broken in 2 or more places • Segment becomes free with pardoxical chest wall motion during respirations • Paradoxical movement more evident after the muscles splinting the flail segment fatigue • Usually takes a tremendous amount of blunt trauma to cause a flail chest • Often present will be associated severe underlying injury (ie: pulmonary contusion) • Respiratory volume reduced and respiratory effort increased

49. Treatment Flail Chest • Place patient on the injured side (may not be possible to do this in the field based on mechanism of injury) • High flow oxygen – nonrebreather mask • Monitor for need to assist ventilations via BVM to deliver positive pressure ventilations • Evidence of underlying pulmonary injury • Effort and fatigue • Pulse oximetry • EKG monitoring • Tremendous amount of force is delivered to the chest wall and cardiac injury is highly likely as a result

50. Breathing Caveats • Elderly: • Pulmonary system is the leading cause of post-traumatic complications • Consider the need to intubate • Caution to over-correct patients with COPD • But Never withhold oxygen to any patient who needs it