trauma assessment february 2014 continuing education silver cross hospital ems system erika ball,...

Trauma Assessment

FEBRUARY 2014 CONTINUING EDUCATION

SILVER CROSS HOSPITAL EMS SYSTEM

ERIKA BALL, RN, BSN

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Review of mechanisms of injury.

Understanding extremity trauma and amputation; prehospital treatment and protocol review.

Care of the patient with chest and abdominal trauma. Review of structures and potential complications associated with injury.

Review of SMO Code 72 for Decompression of Tension Pneumothorax

2 Objectives

Phases of Trauma Pre-event

Injury prevention

Not usually accidental

Event

Interact with people, demonstrate professional attributes

Act as mentor, demonstrate good safety practices

Phases of Trauma

Post-event

Optimal patient care

Appropriate clinical decisions

Treat patient

Continues until patient delivery to ED, complete report

Trauma Systems Parts

Injury prevention

Prehospital care

Emergency department care

Interfacility transport (if needed)

Definitive care

Trauma critical care

Rehabilitation

Data collection, trauma registry

Trauma Systems Trauma center

Categories

Level I

Regional resource center

Specialized services (Burn ICU)

Level II

Comprehensive trauma care

Not all resources in level I are immediately available

Research not essential component

Trauma Systems Trauma center

Categories

Critical access

Communities without level I or II

Provide evaluation, resuscitation, operative intervention for stabilization

Non-designated

Rural, remote areas

Provides initial stabilization, transfer to level I

Trauma Systems

Transport considerations

Time

Single most important factor

Golden period

Do not sacrifice care for speed

Platinum 10 minutes

Most appropriate facility may not be closest

Trauma Systems

Transport considerationsGround transportation

Use if “reasonable” timeGenerally within 30 minutesProtocols may alter time frame

Trauma Systems Transport considerations

Aeromedical transportation

When time critical to patient condition

Scene times extended from extrication

Road, traffic conditions seriously delay access to definitive care

Critical care personnel above ground ambulance training needed

Trauma Assessment Process

Scene Size-UpPrimary SurveyDecision for transport, A B C

interventionsReassessment and continued

exam

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Scene Size-Up

PPE Scene safety Triage/ number of patients (need for

START Triage?) Help and equipment needs

assessment Determine Mechanism of InjuryDetermine Mechanism of Injury

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Mechanism of injury:

Common Trauma Injuries

What are the predictive injury patterns associated with these incidents?

BLUNT TRAUMA

Motor Vehicle CollisionMVC

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What are the mechanisms?

Look at the impact locations:

Front-end

Side

“quarter panel” = potential for rotational injuries

Rear-end

Rollover

Crush (under a semi)

Blunt Trauma: MVC

Machine collisionBody collisionOrgan collision

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Blunt Trauma: MVC Vehicle collisions

Frontal (head-on) impact

Down-and-under pathway Occupant continues forward

Moves downward in seat

Knee – primary impact point

Tibia – Dislocated knee, torn ligaments, knee joint dislocation

Popliteal artery lies behind knee, possible blood clot

Femur impact – Fracture, hip dislocation, pelvic fracture, acetabular fracture, blood clots, vascular injury

Injuries may be subtle

Blunt Trauma: MVC Side Impact:

Head injuries

Cervical spine injury

Pneumothorax/ hemothorax/ tension pneumo

Splenic or liver injury

Pelvic injuries

Extremity injury

Aortic Laceration

Rotational Injury C-spine injury

Vascular tears

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Blunt Trauma: MVC

This horizontally oriented skull fracture was a result of a side impact when the side of the driver's head impacted a tree as the vehicle slid to a stop against the tree.

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MVC: What mechanisms of force would injure the

spleen?Side, Steering wheel, restrained passenger,

unrestrained hitting seat or dashboard

Spleen injuryPatient has B/P of 70/palp with no rigid

abdomen or distension…

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Note the AMOUNT of blood that lurks within a spleen injury…(you may need to click play)

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Blunt Pelvic Injury 21

What else is BLUNT trauma?

Baseball bats, sports injuriesFall from height Ejection from moving vehicles

(motorcycle, ATV, horses, bicycles, snowmobiles)

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Blunt Trauma: Pedestrian Causes fractures of long bones [arms and legs],

and causes fractures of spine, pelvis, and vertebrae

Often causes internal injuries that may be severe

Commonly causes head injuries in adults and children

Pneumothorax common in this injury

Two mechanisms of injury:

Vehicle hitting body

Secondary injuries from impact with ground

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Pedestrian 24

Pedestrian Trauma

Look for the impact locations on the vehicle.

The height of the person can also immensely affect the patient’s injury patterns (for example, children are lower at bumper level).

Be aware if the vehicle stopped, or did it continue in it’s path causing tertiary crush injuries?

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Bicycle Injuries

Similar to pedestrian versus auto, have several potential impact sites and multiple system injuriesDid they have a helmet on?Speeds of bicycle?Were they struck by a vehicle?Surface of landing?Did they hit anything during fall? (trees,

signposts, other bicyclists)

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Blunt Trauma: Falls

Vertical deceleration

You must determine the following:

Distance the person fell

What part of the body they landed on (head, feet first, back)

Did they strike anything on the way down?

What surface did they land on?

All of these are determinants for their injury patterns

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Trauma: Penetrating InjuriesHigh or low velocityFirearms are high velocityDetermine all wounds involved

NEVER document ballistics as “entry” or “exit” ALWAYS document as “Wound #1” “Wound #2” etc.

You could inadvertently place the location of a murder suspect and cause them to be released…

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Penetrating Injury: GSW

There are shock waves with a bullet, damages surrounding tissue

Causes more damage to solid organs: kidney, liver, spleen.

Not always a straight line in the body- may hit bone and change direction

Head, thorax, or abdomen should be transported IMMEDIATELY. Focus on ABC’s, trauma assessment, then transport.

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Where are thepotential injuries?

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Intestines/ bowel

Vena cava and Aorta

Mesenteric Artery (the artery that supplies blood to intestines)

Solid organs: kidneys, liver, pancreas, spleen

Base of lung

Pelvis and spine

Penetrating Trauma:Impalement

Basic reminders:Leave object in place with exception

to occlusion of the airwayStabilize object for transport

The severity of the situation is relative to size, force, and location of object.

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Note the tourniquet… 32

Transport decisions… Is the airway clear?

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Trauma : A Short Burn Care Review

Remember: burns are a trauma!Transport to a trauma centerBe aggressive with airway controlAssessment for soot on face,

nose, and hands.

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Burns Basic review of burn care:

Determine severity

Begin trauma assessment

AIRWAY! AIRWAY! AIRWAY!

Breathing

Circulation

Remove burning source

Cool burn with clean water, (dry if >20% BSA) no longer than two minutes to avoid hypothermia

Patient is at risk for hypothermia, use precautions

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Trauma:A Short Drowning Review 150 ml is all it takes to cause profound

hypoxia (ITLS, 2008) Rapid evaluation and management of

ABC’s C-spine considerations Rapid initiation of CPR Cold water does not indicate death,

remember “warm and dead”

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Trauma Assessment Review

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So here we go… head-to-toe

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Airway/C-spine

While repositioning airway/doing airway assessment, maintain c-cpine.

Delegate someone to do this or hold c-spine so the primary assessor can do the head-to-toe

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ASSESS AVPU

AlertVerbalPainUnresponsive

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Airway: Patent or non-Patent?

Readjust the airway

Do they need suction: teeth, blood, vomit?

Are they maintaining an airway or do you need to get an adjunct or intubate?

Make these decisions then move to…

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Breathing Are they breathing?

No? Begin assisted ventilations

Yes? Assess the rate and quality.

Is the rate under 12? ASSIST VENTILATIONS

Is the rate over 30? Suspect shock and make load-and-go decision.

Quality. Are they shallow or abnormal?

Yes? ASSIST VENTILATIONS

All of these are within normal limits, place on NRB and move to…

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CIRCULATION

Do they have a pulse?No? Begin CPRYes? Note rate, skin color, and any

hemorrhaging. Hemorrhaging or bleeding profusely?

Yes? Control bleeding

No? Assess skin and need for fluid bolus

Keep in mind the need to start 2 large-bore IV or IO while enroute to Trauma center

If circulation is addressed, move to…

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Trauma Assessment

Head injury? Contusions, lacerations? Does the patient have facial injury?

If yes, do NOT use nasopharyngeal airway.

Signs of facial fractures, CSF from the nose or ears, blood from the ears

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Trauma Assessment

Neck wounds? Stepoff on the posterior cervical

spine? Trachea assessment… midline?

Place patient in Cervical collar

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Trauma Assessment Chest injury?

Wounds, gunshots, penetrations, bruising (seatbelt?)

Flail chest

Sucking chest wound? Treatment?

3 sided occlusive dressing

Muffled heart tones? Tamponade?

Tension pneumothorax? Decompression

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Sucking chest wound(you may need to click play)

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Assessment Finding:Beck’s Triad

In cardiac tamponade a narrow pulse pressure is regularly observed. The cardiologist, Claude Beck, who was a Professor

of Cardiovascular Surgery first identified the triad of medical signs which was later termed “Beck’s Triad.”

Beck’s Triad (in basic terms): 1. Distended Neck Veins;

2. Muffled Heart Sounds;

3. Hypotension.

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Assessment Finding:Tension Pneumothorax

Created from blunt or penetrating trauma. “Collapsed” lung that causes an increase in

pressure in the chest (intrathoracic pressure) This pressure pushes on the vena cava,

restricting the blood return to the heart. Also creates pressure on intact lung, making

the situation worse

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Assessment Finding:Tension Pneumothorax

Symptoms of tension pneumothorax: Dyspnea (difficulty breathing)

Absent lung sounds on affected side

Anxiety (because of decreased O2)

Tachypnea

JVD (distended neck veins)

Respiratory distress and cyanosis

Loss of radial pulse

Tracheal deviation (often a late sign of this condition)

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Assessment Finding:Tension Pneumothorax

Needle decompression: this will be covered in the skill of the month

Emergent life saving skill not to be delayed until transport.

Find the S/S perform the skill

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Trauma Assessment:Abdomen

Check for wounds/ bruising/ objects Tenderness Rigidity Pulsations Check all four quadrants Are they pregnant?

Move on to…

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Trauma Assessment:Pelvis

Do NOT rock the pelvis to check it!This can cause further injury and

bleeding

3-4 Liters of blood loss potential into the abdominopelvic cavity

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Trauma Assessment:Pelvis Assessment

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Inward pressure one time, and down on the pubic symphysis

Trauma Assessment:Extremity Trauma

Open or closed trauma Both have potential for bleeding

Sharp bone fragments can cause damage to surrounding vessels and tissue causing bleeding

Closed femur fracture can cause 1 liter of blood loss

Assess need for traction splinting

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Trauma Assessment:Extremity Trauma

Assessment of PMS

Perfusion

Movement

Sensation

Also called CSM

Circulation

Sensation

Movement

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Extremity Trauma: Amputations

Potential for life threatening blood loss Blood loss is quickly minimized with

pressure/ tourniquet Small parts should be covered with gauze

and placed in a bag. Place bag in ice/water mix and transport.

Reassurance of patient’s well-being. Psychological distress may be immense.

DO NOT DELAY TRANSPORT TO WAIT FOR LIMB RECOVERY

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Extremity Trauma: Amputations From Blast Injury

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Jeff Baumann, Boston Marathon victim

Blast amputation with exposed tibia

Extremity Trauma: Amputations From Blast Injury

Parts are generally non-recoverable

Focus on ABC’s

Don’t let the gore become a distraction

Maintain C-spine

Remember, there are three impacts from blast injuries:

Primary air impact. Effects on hollow structures- lung, bowel, and eardrums.

Secondary blast from shrapnel. This is the zone where limbs are amputated, although the primary blast is also responsible.

Tertiary blast from hitting ground.

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Extremity Trauma: Amputations From Blast Injury

Tourniquet bleeding limbsThis saved MANY lives in Boston.

Bystanders and available medical personnel applied tourniquets using belts and clothing fragments

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He recovered and has prosthetic limbs. 61

Extremity Trauma: Compartment Syndrome

Bleeding and swelling within the enclosed compartment of the limbs (generally, but this can happen with the abdomen as well)

Caused by crush injuries, fracture (open or closed), and compression of limb for extended period. Blunt force injury to a muscle can also be a

cause of compartment syndrome

May loose pulse, sensation, and movement Severe pain is an early symptom

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Skill/SMO of the month, Needle decompression

Code 72

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Equipment

Antiseptic 2-3 inch, large-bore (10-14#)catheter One-way valve if available Chest tape for stabilization

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Decompression location

2nd intercostal space

Mid-clavicular line

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Needle Decompression Pearls

If the patient is lying supine, the proper site to decompress for trauma is 2nd or 3rd ICS in the Mid-clavicular line

If the person is in a sitting position, the proper site is in the 4th or 5th ICS in the Mid-axillary line

This is to protect the lung tissue from being penetrated by the initial needle introduction into the pleural space

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Skill and SMO of the month67

Thank you for your time and attention!

Questions or comments?

Erika Ball, RN, BSN

Silver Cross EMS System Educator

815-300-7426

eball@silvercross.org

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