Trauma Morbidity and Mortality

1. Trauma Morbidity and Mortality Mod III 2012 ECRN CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the ECRN will be able to: • 1. Identify by mechanism of injury and signs and symptoms major causes of increased risk of morbidity & mortality related to a traumatic injury (airway obstruction, flail chest, open pneumothorax, tension pneumothorax, cardiac tamponade, aortic tear). • 2. Identify the significance and signs and symptoms of crush injuries and compartment syndrome. • 3. Describe field treatment based on injury presented.

3. Objectives cont’d • 4. Identify transport destination decision per Region X SOP. • 5. Review case scenarios presented. • 6. Review the skills of needle decompression, cricothyrotomy, and QuickTrach • 7. Successfully complete the post quiz with a score of 80% or better.

4. Thoracic Trauma • Responsible for 20-25% of all trauma related deaths • Purpose of primary assessment • Determine the presence of any LIFE THREATS!!! What’s going to kill the patient the fastest?? Hypoxia Hemorrhage

5. Trauma Stats • Deaths at the scene are usually due to injury of the heart and/or great vessels • Deaths delayed by hours are usually due to airway obstruction, tension pneumothorax, hemorrhage, and tamponade • Note: only a small portion of patients with traumatic injuries to the chest need OR

6. Tissue Hypoxia • Inadequate delivery of oxygen to tissues can be caused by a variety of mechanisms • Start patient assessments with primary assessment • Any change in the patient condition and you should repeat the primary assessment A – B - C

7. Causes of Tissue Hypoxia • Hypovolemia from loss of blood volume • Ventilation/perfusion mismatch due to injury of lung tissue • Compromise to ventilations and or circulation due to a tension pneumothorax • Pump failure from severe myocardial injury or pericardial tamponade

8. A skeletal protection to many organs Lungs Heart Great vessels Spinal cord Liver Trauma to the protective rib cage may also cause some injuries Stomach Spleen Pancreas Kidneys Transverse colon Thoracic Cage

9. Diaphragm • Position: lies at the level following the curve of the lower 6 ribs and connected to the xyphoid process • Main function: respirations • Descends/flattens on inspiration • Rises on exhalation • Innervation: phrenic nerve which begins C3 to C5 level • Injury above C3 patient unable to breathe • Injury below C5 patient can still initiate breathes

10. Diaphragm

11. Diaphragm – A Moving Target • Palpate and place your finger tips at the lower edge of your rib cage • Keep your fingers in contact with your skin • Take a deep breath • Feel your rib cage flare out • Diaphragm drawn downward moving lungs and abdominal organs downward to accommodate lung expansion • Now exhale • Feel your rib cage decrease in size • Your diaphragm rises as lung capacity decreases

12. Anatomy – Chest Contents • Contents above the diaphragm • Lungs • Lower trachea • Main stem bronchi • Heart and great vessels • Esophagus • These organs sit above the diaphragm

13. Anatomy – Chest Contents • Contents in the lower chest cavity in upper abdominal region • Stomach Kidneys • Spleen Pancreas • Liver • These organs are separated from the upper chest by the diaphragm • If diaphragm ruptures, abdominal organs can migrate into chest cavity

14. Is the injury thoracic or abdominal??? • Trauma below the nipples (T4 or 4th intercostal space (ICS) can cause both intrathoracic and intra-abdominal injuries

15. Did you know??? • The adult thoracic cavity can hold up to 3 L of blood for each side • What is the average adult blood volume? • 5.5 – 6.5 liters (or quarts) • 1 liter = 1 quart • Approximately 1.3 gallons • Formula: 0.07 x weight in kg=liters of blood • Ex: adult 0.07 x 80kg = 5.6 L • Ex: newborn 0.07 x 3kg = 0.2 L (200ml)

16. Pleural Space • A small area between 2 layers of pleura • Normally filled with minimal fluid • Can potentially expand if filled with air or blood • Expansion is at the sacrifice of other organs in the area • Visceral pleura • Directly lines lungs • Parietal pleura • Inner lining of the chest wall

17. Mediastinum • Midline area of the thoracic cavity • Contains • Heart • Aorta and pulmonary artery • Superior and inferior vena cavas • Trachea • Major bronchi • Esophagus

18. Mechanisms of Injury • Thoracic cage injuries can result from a variety of sources • MVC • Motorcycle incidents • Falls • Crush • Blunt • Penetrating – firearms, knives

19. MOI • Blunt trauma • Injuries more predictable • Penetrating injuries • Unpredictable organ injury • Path of destruction can vary widely

20. Shortness of breath Chest pain Contusions Open wounds Sub Q emphysema Hemoptysis Distended neck veins Tracheal deviation Cyanosis Shock Tenderness Instability Crepitation Altered breath sounds Asymmetrical chest movement including paradoxical motion Major Signs/Symptoms of Chest Injuries

21. Patient Assessment • Starts with scene size-up – safety a concern • Primary assessment performed • Remember: ABC assessment repeated any time there is a change in patient condition • Moves into history taking with secondary assessment • EMS patients rarely have just one isolated injury with traumatic MOI • Signs and symptoms blur when injuries are mixed together

22. Airway Obstruction • Results in hypoxia • Tissue insult occurs quickly • Once cells die, they are gone • Primary assessment starts with the question: • Is the airway open and do I need to apply manual c-spine control??? • If the airway is not open, what do I need to do to open it???

23. Opening a Blocked Airway • If traumatic injury is suspected • Modified jaw thrust • In absence of trauma • Head tilt/chin lift • Are secretions present? • Limit suctioning generally to <10 seconds • Are adjuncts required? • Is there a gag reflex? • If necessary, stroke eyelashes to check for blink reflex- if absent, then gag reflex is absent

24. Airway Maneuvers • Modified jaw thrust • Used in presence of suspected or known trauma • Head tilt/chin lift • Used when no trauma suspected

25. Interventions for Obstructed Airways Used by EMS • Cricothyroid membrane - Need to know landmarks now – patient can’t wait for you to look them up!

26. QuickTrach • Device sized for adult (4.0 mm) or peds (2.0 mm) • Kit contains items noted to the right • Need to add skin prep material and BVM

27. Adjuncts for Obstructed Airway • QuickTrach – emergency cricothyrotomy • 1 person assembles equipment • 1 person locates and palpates cricothyroid membrane • Runs finger up from sternal notch • Cricoid cartilage first rigid ring palpated • Membrane is above the cricoid cartilage • Skin prepped • Needle inserted at 90 degree angle • Air aspirated to confirm needle entry into trachea

28. Quicktrach cont’d • Angle of insertion changed to 600 sliding catheter sheath forward until red stopper is flush with skin • Red stopper removed • Needle & syringe held firmly and plastic cannula slid forward til hub of catheter snug to skin • Needle and syringe removed • Patient ventilated via BVM – equipment held securely • Placement assessed – BS, chest rise & fall • Catheter secured with ties provided

29. Needle Cricothyrotomy • Provides emergency access to an otherwise blocked airway

30. Needle Cricothyrotomy • Cricothyroid membrane located • Site prepped • Large gauge catheter with syringe attached inserted into trachea – midline 450 angle • Aspiration of air with syringe confirms placement • Catheter advanced while withdrawing stylet • 3.0 mm ETT hub attached to needle • Ventilated with BVM via the 3.0 mm ETT hub • Assessed for BS and chest rise • Catheter secured • Note: Will need to allow extra time for exhalation

31. Flail Chest • Fracture of 3 or more (2 or more in some sources) adjacent ribs in 2 or more places each • Section becomes free floating • Be suspicious for the presence of pulmonary contusions • It takes tremendous force to break that many ribs • Organs under the rib cage most likely traumatized • Compromise to normal diffusion of O2 and CO2 is usually present • Flail chest does NOT automatically equal the presence of a tension pneumothorax

32. Flail Chest • Can be suspicious of condition during the primary assessment • Patient states “I can’t breathe” • The rib fractures cause significant pain as the patient tries to take any breaths • Patient is anxious • May see paradoxical motion on visual inspection • This is often a later sign due to initial splinting

33. Flail Chest and Primary Assessment • Primary assessment DOES NOT stop • Note made to go back to address why there is respiratory distress • Remember: the only 2 times to interrupt a primary assessment is to (1) correct an obstructed/closed airway or to (2) control major hemorrhage

34. Flail Chest • Tremendous force to fracture this many ribs • Notice how lateral the clavicular midline really is!!! • Landmark essential IF patient develops a tension pneumothorax

35. Flail Chest Key Signs /Symptoms • Paradoxical motion on visual inspection • Potential bruising or other marks on chest wall • Crepitation and tenderness on palpation • Decreased breath sound depending on degree of injury, splinting and presence of pneumothorax

36. Flail Chest

37. Flail Chest Treatment • Supplemental oxygen therapy • Non-rebreather O2 if intubation not needed • Cardiac monitoring • Potential high for cardiac contusion • Stabilizing the chest wall is controversial • Chest wall no longer taped for support • Providing positive pressure ventilation (i.e.: intubation on a ventilator) is the preferred method of support which can be done in the ED if not necessary in the field)

38. Open/Sucking Chest Wound • Air allowed to enter the thoracic space due to an opening in the chest wall • Results from penetrating trauma • Air drawn into pleural space • Air will enter via the largest opening • The hole created in the chest wall versus the glottic opening • Air entering the pleural space does not reach the alveoli

39. Open/Sucking Chest Wound • Visual inspection reveals a wound • May hear a sucking or bubbling sound • May feel subcutaneous emphysema around the area • Lightly palpate the area and feel a crackling sensation under your finger tips • Noticed skin “puffed up”

40. Open/Sucking Chest Wound • Immediate treatment as soon as the wound is found is to cover the wound with a gloved hand • Then place an occlusive dressing over the site • Secure occlusive dressing on 3 sides • Leaves a means of escape of air on the 4th side to avoid the potential of converting the injury to a tension pneumothorax • If wound is large, try defib pad over wound

41. Open/Sucking Chest Wound • Question • If the patient develops a tension pneumothorax after a sucking chest wound is sealed with an occlusive dressing, do you need to perform a needle decompression? • NO!!! – not usually • There is already a BIG hole in the chest wall that air can escape from • Just lift a corner of the dressing during exhalation for air to escape • If there is no improvement, you might have to decompress with a needle

42. You Evaluate… • What’s right? • Wound immediately covered with hand • What’s wrong? • The care provider has no gloves on

43. Tension Pneumothorax • A pneumothorax that generates and maintains pressures greater than atmospheric pressure in the thorax • A one way valve is created and air flows into the pleural space and cannot escape • Most often associated with a traumatic event but can be spontaneous • Can be a complication of treatment of an open/sucking chest wound

44. Tension Pneumothorax – A Cascade of Events • Air enters pleural space •  intrapleural pressure collapses lung, intercostal bulging occurs, pressure exerted against mediastinum • Uninjured lung becomes compressed • Vena cava compression  venous return • Cardiac output (CO)  causing  pulse;  B/P • JVD present, narrowed pulse pressure • Tracheal shift is a late but rare sign (hard to view)

45. X-ray - Tension Pneumothorax • What’s wrong with this x-ray? • It should never have been taken! • Diagnosis is clinical • Arrow points to completely collapsed lung • Dark filled images indicate air filled spaces • Note tracheal shift to the right

46. Tension Pneumothorax • Typical signs and symptoms • Severe dyspnea • Hyperinflation of affected side • Diminished, then absent breath sound • Hyperresonance of affected side • Diaphoresis • Cyanosis • JVD • Tachycardia • Altered mental status • Eventual hypotension

47. Simple Pneumothorax • There is a difference • These patient DO NOT require needle decompression • May not even auscultate decreased breath sounds if collapse is small • There is a clinical difference in presentation (i.e.: vital signs) from a simple to a tension pneumothorax

48. Jugular Vein Distention - JVD • JVD present when venous pressures are high and blood cannot easily drain into the right atrium • Typically seen with tension pneumothorax, cardiac tamponade, right sided heart failure and volume overload • Most appropriately measured with patient sitting at 450 angle and evaluating right side of neck • May not be possible with traumatic injury to  HOB • Note: Lack of JVD in supine position with physical findings may indicate hypovolemic shock

49. JVD • Jugular vein is prominent if distended at a point slightly higher than 1 inch above right clavicle

50. Tension Pneumothorax Treatment • Rapid recognition is key!!! • Severe dyspnea • Distinct signs and symptoms • Needle decompression to relieve intrapleural pressures • Administer supplemental O2 via NRB • Equipment • Longest and largest needle you have – 3 inch long and 12-14 gauge • Skin prep material