Trauma Jared Sessum, EMT-I Objectives • Student will have a better understanding of Trauma. • Student will have a better understanding of proper assessment in Trauma patient. • Student will have a better understanding of medications given for Trauma patients. What is trauma? • an injury to living tissue caused by an extrinsic agent. Mechanism of Injury (MOI) • Blunt Trauma – Motor Vehicle Collisions – Assaults – Falls – Sporting Events Mechanism of Injury (MOI) • Penetrating Trauma – Gunshot Wounds – Stabbings – Explosions • Patients should be treated based on injuries not solely on their MOI. • All patients should receive a thorough trauma assessment. A low mechanism MOI does not excuse not performing a thorough assessment. Failure to perform a thorough assessment constitutes neglect and is considered a TDSHS violation. CDC Field Triage • Not all injured patients can or should be transported to a Level I Trauma Center. Other hospitals can effectively meet the needs of the patients with less severe injuries and may be closer to the scene. Transporting all injured patients to Level I trauma centers, regardless of severity, limits the availability of Level I Trauma Center for those patients who really need the level of care provided at those facilities. Proper field triage ensures that patients are transported to the most appropriate healthcare facility that best matches their level of need. CDC Field Triage CDC Field Triage Initial Assessment • Initial Rapid Trauma Assessment (RTA) should take no longer than 90 seconds. • Recognize serious or life threatening injuries. • RTA should only be interrupted in the event that your discover life threatening injuries. Head • Check for DCAP-BTLS • Assess Pupils and note reactiveness and size • Check for missing teeth or anything that may interfere with airway. • Check ears and nose for bleeding – If blood from ears perform Halo or use Glucometer to check for CSF. • Check Mental Status of patient – Check patient’s BGL to rule out Hypoglycemia as cause of AMS. Head • Halo Test – To perform a HALO test take a 4x4 and fold it in half twice. Take the tip and dip into the blood coming from patient’s ear. If CSF is present it will separate from the blood and form a “Halo”. • Glucometer – CSF contains a higher concentration of sugar. When performing the test the meter will read higher than normal for the patient. Perform a finger stick to be able to obtain a baseline for the patient. • These tests are not definitive tests to diagnose head injury, they are simply a tool that we can use in the field. Neck • Check for DCAP-BTLS • Assess neck veins for Jugular Vein Distention • Assess Trachea and note its position • Trachea that is moved to one side or the other is a life threatening condition that needs to be addressed immediately. Chest • Assess for DCAP-BTLS • Check breath sounds times 4 • Assess rise and fall of chest • Check for Paradoxical Motion (unequal rise and fall of chest). This is indicative of a Flail Chest • Check for Pericardial Tamponade Abdomen • Assess for DCAP-BTLS • Palpate all four quadrants • A hard, distended abdomen can be a sign of internal bleeding. Pelvis • Assess for DCAP-BTLS • Check to make sure pelvis is stable • A fractured pelvis has the potential of being a life threatening injury. Extremities • Assess for DCAP-BTLS • Assess Pulse, Motor, and Sensation (PMS) in all four extremities Back/Spine • Assess for DCAP-BTLS • The spine should be in a straight line • Ensure that from the Cervical to the Coccyx region that there is no trauma or abnormalities. • Once you have assessed the Back/Spine place patient on backboard. Treatment for Trauma • Treatment for trauma will depend on the injuries that you encounter. • Minor trauma with no life threatening injuries should be treated according to injuries. • Serious traumas should have bilateral large bore IV’s (14-18 gauge) • Fluid replenishment should be based on vital signs obtained on patient and injuries discovered during assessment. Titrate pressure in adults to 90 Systolic and age appropriate for pediatrics. Tension Pneumothorax Signs and Symptoms • Anxiety, agitation, apprehension • Diminished or Absent breath sounds on affected side. • Rapid, shallow breathing • Distended neck veins • Cool, clammy skin • Tracheal deviation, this is a late sign and hard to detect without X-Ray. • Perform Chest Percussion and listen for Hyper- resonance sound. Treatment • Locate the second intercostal space with is in between the second and third ribs. • Insert the large bore needle (preferably 14 gauge 2 1/2”) just above the third rib at a 90 degree angle. Be sure to avoid the bottom of the rib since this is where the nerves are located. • Apply ACS or any other type device to allow air out and not in over the insertion site to allow for air to escape but not for air to enter. Pericardial Tamponade Signs and Symptoms • Chest Pain • Tachycardia • Narrowing Pulse Pressures • Muffled Heart Sounds • Jugular Vein Distention Treatment • Treatment for Pericardial Tamponade is to perform a Pericardiocentesis. • This procedure can only be performed by a CLEMC Supervisor. • A needle is inserted into the patient’s Pericardial Sac and fluid is removed. • The ultrasound is used to ensure that the needle is inserted to the proper depth and not too far to cause damage to heart. Pericardiocentesis • http://www.youtube.com/watch?v=z8- ke3zMvGg Airway Management In-line Intubation • Airway management of a trauma patient is always top priority. Without an airway your patient does not have a chance. • In-line intubation is to be performed when a patient has already been placed onto a backboard and cervical collar is already applied to patient. • The following are the steps to properly perform an in-line intubation. • The first step is to have a crew member hold and maintain manual c-spine immobilization. In-line Intubation • The crew member at the head will undo the patient’s c-collar. • Perform intubation following Basic Trauma Life Support procedures. • Once you have visualized the cords, confirmed proper placement, and secured the tube then you would re-secure the c-collar. • The crew member maintaining manual immobilization will not let go until the c-collar is re-secured. In-line Intubation • The reason for performing the intubation by undoing the c-collar is to be able to manipulate the jaw. • You will not be able to properly manipulate the jaw while the c-collar is still secured. • You must remember to never release manual immobilization prior to the c-collar being re- secured. Airway Management • Airway management for patients with burns and head injuries is extremely important. With these patients airway management should be considered as early as possible. • Remember that patients with airway burns you may only have one attempt at intubation before the swelling causes the entire airway to close. • In the event of facial injuries or trauma to the mouth your supervisor may elect to perform a surgical airway including Retrograde or QuickTrach. Retrograde Intubation • A retrograde intubation is performed by inserting the wire that is included in the kit into the patient’s Cricothyroid Membrane. • The wire is then advanced toward the head of the patient until it comes out of the patient’s mouth. • Slide the Endotracheal Tube onto the wire and follow the wire into the patient’s trachea. • Confirm tube placement the same as any other intubation. QuickTrach • The QuickTrach is performed by inserting the device into the Cricothyroid Membrane of the patient. • Once you have found the Cricothyroid Membrane advance the QuickTrach until you no longer feel resistance. • Remove the needle and advance the catheter into the patient’s trachea. • Secure the device using the materials provided in kit. • Reassess the airway frequently after securing. • QuickTrach should only be performed in the event that there is an upper airway obstruction. Medications for Trauma Pain Medications • Fentanyl • Morphine Fentanyl • Mechanism of Action § Synthetic opioid – Analgesic – Sedation • Side Effects § Respiratory depression § Skeletal muscle rigidity • Onset/Duration § Onset of 2 minutes § Duration of 30–60 minutes Morphine • Mechanism of Action § Opium alkaloid – Analgesic – Sedation – Anti-anxiety § Reduces vascular volume and cardiac preload – Increases venous capacitance • Side Effects § Respiratory depression § Vasodilation § Histamine Release Paralytics • Succinylcholine • Rocuronium Anectine (Succinylcholine) • Mechanism of Action § Depolarizing medication – Causes fasciculations • Onset and Duration § Onset: 30–60 seconds § Duration: 2–3 minutes • Precaution § Paralyzes ALL muscles including those of respiration § Increases intraocular eye pressure • Contraindication § Penetrating eye injury and digitalis • Side Effects § Potassium Shift Rocuronium • Mechanism of Action – Non-depolarizing neuromuscular blocking agent • Therapeutic Effect – Neuromuscular blockade • Indications – Need for aggressive airway control and maintenance during RSI. • Dosage – Adult and Pedi 1mg/kg • Contraindications – myasthenia gravis Hetastarch (Hespan) ● Mechanism of Action – Raises human plasma volume – Increases erythrocyte sedimentation rate – Improves efficiency of granulocyte rate ● Therapeutic Effects – Volume expansion, increases blood pressure in shock states ● Dosage – 500 to 100 mL IV Bolus ● Indications – Volume expansion in shock due to hemorrhage, burns, surgery, sepsis and trauma ● Contraindications – Severe bleeding disorders, cardiac congestions and renal failure.