Condell Medical Center EMS System April, 2006 Site Code: #10-7200-E-1206

1. Curriculum Update:Assessment Based Management; Abdominal & Thoracic Trauma; Neurological Considerations Condell Medical Center EMS System April, 2006 Site Code: #10-7200-E-1206 Revised by Sharon Hopkins, RN, BSN

2. Objectives Upon successful completion of this module, the EMS provider should be able to: 1. Understand the factors that affect patient assessment and decision making capabilities of the EMS provider. 2. Describe the steps of patient assessment. 3. Identify mechanisms of injury that can lead to thoracic and abdominal traumatic injuries. 4. Discuss field interventions appropriate for thoracic and abdominal injuries.

3. Objectives cont’d 5. Discuss a variety of degenerative neurological diseases and their field management. 6. Participate in case scenario review. 7. Participate in the skills of needle decompression. 7. Participate in the skills of obtaining blood pressures in the forearm. 8. Successfully complete the quiz with a score of 80% or better.

4. ASSESSMENT BASED MANAGEMENT • Involves the use of: • critical thinking skills • problem solving abilities • clinical decision making • Includes avoiding: • tunnel vision (can create distractions) • patient labeling or jumping to conclusions based on preconceived ideas • “the drunk”; “the frequent flyer”; “the whiner”

5. Goals of Our Profession Provide competent, compassionate prehospital care for each and every patient interaction You need a strong knowledge base and excellent assessment skills

6. Factors Affecting Assessment and Decision-Making • Paramedic attitudeneeds to be non-judgmental • May “short circuit" information gathering leading to insufficient information gathering • May leap to conclusions before gathering a thorough assessment • Garbage in - garbage out • Patients depend on us for medical assessment/ management and not determination of social standing or "likability"

7. Factors Affecting Assessment and Decision-Making • Uncooperative Patients • Perception of intoxication - drugs or alcohol • In all uncooperative, restless, belligerent patients consider other possible causes • hypoxia • hypovolemia • hypoglycemia • head injury

8. Factors Affecting Assessment and Decision-Making • Patient compliance influenced by: • Patient confidence in rescuers • Prior experiences of the patient and their family • Cultural and ethnic barriers

9. Factors Affecting Assessment and Decision-Making • Distracting injuries • can divert attention from more serious problems • Need to resist the temptation of forming a field diagnosis too early • Gut instincts may lead to snap judgements • Systematic approach to patient care • helps prioritize & avoid being swayed by the wrong impression

10. Factors Affecting Assessment and Decision-Making • Distractors in the environment • Scene chaos • Violent/ dangerous situations • Crowds of bystanders • High noise levels • Crowds of responders • enough help is crucial but they must be used wisely

11. Factors Affecting Assessment and Decision-Making • Manpower considerations • Single paramedic • history gathering and treatment performed in sequential manner • assessment best achieved by one rescuer • Two paramedics • simultaneous history gathering & treatment • Multiple responders • can be more disorganized because of too much “help”

12. General Approach to Patient Assessment • Scene size-up • body substance isolation (BSI) • gloves, gown, mask, eye protection as needed • scene safety • hazards to yourself, the team, the patient • patient location • know where they all are • mechanism of injury or nature of illness • can help determine severity of situation

13. Patient Assessment • Initial assessment • To identify life-threatening conditions • Mental status (AVPU) • Airway assessment • Breathing assessment • Circulation status • pulses? • obvious bleeding? • Forming a general impression • What do you think is going on? Which protocol will you follow?

14. Patient Assessment • Focused history and physical exam performed based on chief complaint and information gathered so far • trauma patient with significant mechanism of injury or altered mental status • needs rapid head-to-toe • trauma patient with isolated injury • focus on body systems related to complaint • medical patient (responsive) - focus exam on c/o • medical patient (unresponsive) • needs rapid assessment with head-to-toe exam when patient input not available

15. Patient Assessment • Vital signs • recommendation is to repeat every 5 minutes if unstable, every 15 minutes if stable • SAMPLE history • symptoms • allergies • medications • pertinent past medical history • last oral intake food or liquids including water • events leading up to the incident • Medic alert bracelet, necklace

16. Blood Pressure • A measurement of the force of blood against the walls of the blood vessels • Reassessment over time gives most accurate reflection of patient state • Changes in B/P can be very significant • Last vital sign to change in decompensation • Cuff should cover 2/3rds of the upper arm • Cuff should not be placed over clothing • Arm should be maintained at heart level • Obese arm? Wrap cuff around forearm; place stethoscope over radial pulse area

17. Tips, Tricks & Pearls on Blood Pressure & Pulses • B/P by palpation can only determine a systolic reading • As cuff is deflated, palpate over the radially area until the pulse returns • Record as “90/systolic” • Guidelines suggest that palpated pulses equate with systolic blood pressures • carotid pulse felt means B/P approx 60/systolic • radial pulse felt means B/P approx 80/systolic • No peripheral pulse? Think circulatory collapse • B/P should always be attempted & documented

18. Patient Assessment • Detailed physical exam • a more detailed & slower head-to-toe exam than the initial one performed • a luxury performed enroute if there is time • clinical experience and patient condition often dictate how & if the detailed exam is done • Ongoing Assessment - always done • used to detect trends, determine changes in patient condition, and assess effectiveness of interventions • mental status, ABC’s, vital signs (pulse, respirations, B/P, SaO2, pain level), EKG

19. Assessment Techniques • Inspection • observation; looking beyond the obvious • Palpation • use your sense of touch to gather information • pads of fingers more sensitive than tips for touch • back of hand is better for sense of temperature • Percussion - not often done in the field • Auscultation • listening for sounds (lungs, heart, intestines) • for lung sounds, note abnormal sounds, location, timing during inspiration or expiration

20. Accurate Decision Making • Relies on: • Patient history obtained • Physical, hands-on exam performed • Looking for pattern recognition • comparing information gathered with what you already know (existing knowledge base) • Making an assessment or field diagnosis • field diagnosis is the most probable cause of the patient’s complaint based on the information gathered during the assessment • used to formulate a plan of action based on the patient’s condition and the environment

21. Use of Protocols & SOP’s • Protocol - policies and procedures of all components of the EMS system • Standard operating procedures (SOP’s) - preauthorized treatment procedures • Exercise judgement when following protocol and SOP’s • know which protocol/SOP to choose • know when and how to follow protocol/SOP’s • recognize when you must deviate from the stated protocol/SOP - allergies, abnormal vital signs

22. Difficulty Establishing An Airway In The Field • If you cannot establish an airway on any patient in the field, EMS is to transport the patient to the closest Comprehensive Emergency Department • A Comprehensive Emergency Department is one that is open 24 hours, 7 days a week and has a physician on duty as well as other support services

23. Communication • Hospital reports are best when they: • Are given in less than one minute • Are clear and concise • Avoid use of unfamiliar or unclear medical or technical terms including “10” codes • Follow a basic format • Include both pertinent findings and pertinent negatives (findings that would be expected but are not present) • Conclude with specific actions, requests, or questions related to the plan

24. Transmission of Patient Information • Identify provider by name and vehicle number • Age, sex, and approximate weight of patient • Level of consciousness • Chief complaint and degree of distress • Vital signs, EKG, pulse oximetry, blood glucose if obtained • If indicated include lung sounds, pupils, skin condition and color, GCS, pain assessment • Treatment rendered and response • Patient history • ETA and destination

25. Calling Report on Trauma Patients • Important to include information the hospital can use to categorize the trauma level for this patient as well as determine which members of the trauma team that need to be activated • mechanism of injury • destruction to vehicle/surroundings • injuries noted or suspected • vital signs, GCS • Restlessness: first think hypoxia, shock

26. Assessment Based Management-Common Complaints Questions ??

27. THORACIC TRAUMA

28. Anatomy & Physiology of the Thorax • Thoracic cage responsible for moving air in and out • Place where carbon dioxide and oxygen exchange takes place to support metabolism • Includes thoracic skeleton, diaphragm, and supporting musculature • Location of major organs and vessels • heart, aorta, trachea, lungs, mediastinum

29. Thoracic Trauma • Classifying thoracic injuries • Blunt trauma - closed injury from kinetic energy transmitted through tissue • blasts • deceleration • compression/crush • Penetrating trauma - open wound; direct or indirect trauma transmitted via kinetic energy

30. Blunt Trauma From Blast Injuries • Blast injury - explosion caused by dust, fumes, natural gas, explosive compounds • Confined space blast/shock wave • pressure wave & debris cannot dissipate as far & so maintains higher energy level longer • danger of structural collapse & flying debris • extremely deadly overpressures created

31. Thoracic cage - rib & sternal fx, flail segment Cardiovascular - contusion, tamponade Pleural and pulmonary- contusions, pneumo’s Mediastinal - pneumomediastinum Diaphragm - tear, laceration, rupture Esophageal - laceration Penetrating cardiac trauma - laceration aorta, vena cava, pulmonary arteries/veins Spinal cord injuries Thoracic Injuries

32. Flail Chest • Definition • 3 or more adjacent ribs broken in 2 or more places • Most common mechanism of injury - blunt trauma • falls, MVC, industrial injuries, assaults • Risks to the patient • reduces tidal volume (air moving in or out) • increases respiratory effort • usually accompanied by pulmonary and possibly cardiac contusions

33. Flail Chest • Signs and symptoms • paradoxical motion of the chest wall • asymmetrical chest wall movement; flail segment moves in opposite direction from the rest of the chest • increased respiratory effort and rate • decreased pulse oximetry readings • increased amount of pain to the chest wall • Treatment • support respiratory effort - supplemental O2 via nonrebreather mask;BVM as needed • support fractured section manually - no taping of the chest or sandbags/IV’s placed on chest • EKG monitoring

34. Sucking Chest Wound • Definition • open wound of the chest with air passage into the pleural space • Risks to the patient • collapse of the lung on the affected side • uninjured lung unable to fully expand • change in intrathoracic pressures negatively affect venous return to the heart • if the chest wall opening is at least 2/3 the diameter of the trachea (normally the size of the patient’s little finger), air will move in & out thru the chest wall defect & not thru the trachea

35. Sucking Chest Wound • Signs and symptoms • open wound to the thorax & frothy blood noted around the chest wall defect • gurgling sound heard near the chest wound • severe dyspnea • possible hypovolemia - associated injury & hemorrhage • increased pulse rate & respiratory rate; decreased blood pressure • evidence of air hunger if, with each breath, more air enters thru the chest wall defect than thru the trachea

36. Sucking Chest Wound • Treatment • Immediately seal the chest wound (gloved hand to start with if necessary); eventually with occlusive dressing taped on 3 sides • Open pneumothorax now converted to closed pneumothorax - watch for increased respiratory distress leading to tension pneumothorax • burp dressing by lifting one corner during exhalation if needed • O2 via nonrebreather mask • Monitor vital signs, pulse ox, EKG

37. Tension Pneumothorax • Definition • An open or simple pneumothorax that generates and maintains a greater pressure than atmospheric pressure within the thorax via a created one-way valve • Risks to the patient • Air is trapped in the pleural space and puts pressure on the affected lung, the structures in the mediastinum, the opposite lung

38. Tension Pneumothorax (JVD) Dyspnea, SOB (rare & late sign not often appreciated) Low pulse ox, narrowed pulse pressure decreased B/P PEA

39. Needle Decompression • Treatment • Provide supplemental oxygenation (nonrebreather mask) or BVM • Perform needle decompression • identify site: 2nd or 3rd intercostal space in midclavicular line; above the rib • prep the site • prepare a flutter valve on a 3 large gauged needle • insert 3 needle largest gauge available (12-14g) straight into the chest wall over the top of a rib • can take the plug off the catheter end and attach a syringe • upon feeling a “pop” or noting air return in syringe, advance catheter & remove needle; secure catheter

40. Needle Decompression

41. Hemothorax • Definition • an accumulation of blood in the pleural space due to internal hemorrhage • more of a blood loss problem than an airway issue • each side of the thorax may hold up to 3000 ml of blood • Risks to the patient • hypovolemic shock • reduction of tidal volume & efficiency of ventilations

42. Hemothorax Signs & Symptoms History blunt or penetrating trauma decreased blood pressure

43. Hemothorax • Treatment • support the patient with supplemental oxygenation (nonrebreather mask) and potentially BVM • IV access for fluid resuscitation • 20 ml/kg normal saline (Routine Trauma Care Protocol) • carefully administer fluids to avoid worsening the edema and congestion of pulmonary contusions • Note: • Hemothorax is primarily a blood loss problem more than a respiratory one

44. Cardiac Tamponade • Definition • A restriction to cardiac filling caused by blood or fluid in the pericardial sac • Most common mechanism of injury • penetrating trauma (could be medical problem) • Risks to the patient • accumulating blood exerts pressure on the heart • pressure limits cardiac filling restricting venous return to the heart • cardiac output is diminished

45. Cardiac Tamponade agitation (JVD) PEA Muffled heart tones Diaphoretic, ashen or cyanotic

46. Cardiac Tamponade • Treatment • keep high index of suspicion • field care limited to supportive oxygenation (nonrebreather mask or BVM) and IV fluids • definitive care must be provided in-hospital • removal of some of the accumulated fluid from the pericardial sac in the ED and then patient needs to go to the OR

47. Review Patient Assessment • Scene size-up - BSI’s, scene safety, identify mechanism of injury • Initial assessment - mental status, ABC’s, identify life threats, form general impression • Focused history and physical exam • Vital signs, SAMPLE history • Detailed physical exam enroute • Ongoing assessments

48. Thoracic Trauma Questions ??

49. ABDOMINAL TRAUMA A high degree of suspicion must be exercised based on mechanism of injury and kinematics.

50. Abdominal Anatomy and Physiology • Boundaries • superiorly the diaphragm • inferiorly the pelvis • posteriorly the vertebral column, posterior & inferior ribs, back muscles • laterally the flank muscles • anteriorly the abdominal muscles