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ECRN:
Assessment Based Management; Thoracic & Abdominal Trauma; Neurological Considerations
Condell Medical Center EMS System
2006
Site Code: #10-7214-E-1206Revised by Sharon Hopkins, RN, BSN
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ObjectivesUpon successful completion of this module, the ECRN
should be able to:
1. Understand the factors that affect patient assessment and decision making capabilities.
2. Describe the steps of patient assessment based on ITLS guidelines.
3. Identify mechanisms of injury that can lead to thoracic and abdominal traumatic injuries.
4. Understand EMS interventions appropriate for thoracic and abdominal injuries.
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Objectives cont’d
5. Describe a variety of degenerative neurological diseases.
6. Review case scenarios.
7. Successfully complete the quiz with a score of 80% or better.
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ASSESSMENT BASED MANAGEMENT
Involves the use of:critical thinking skillsproblem solving abilitiesclinical 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”
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Goals of Our Profession
Provide competent,
compassionate care
for each and every
patient interaction
You need a strong knowledge base and excellent assessment skills to care for patients
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Factors Affecting Assessment and Decision-Making
Attitude needs 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"
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Factors Affecting Assessment and Decision-Making
Uncooperative PatientsPerception of intoxication - drugs or alcoholIn all uncooperative, restless, belligerent
patients consider other possible causeshypoxiahypovolemiahypoglycemiahead injury
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Factors Affecting Assessment and Decision-Making
Patient compliance influenced by:Patient confidence in the medical
teamPrior experiences of the patient and
their familyCultural and ethnic barriers
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Factors Affecting Assessment and Decision-Making
Distracting injuriescan divert attention from more serious
problems
Need to resist the temptation of forming an initial diagnosis too early
Gut instincts may lead to snap judgements
Systematic approach to patient carehelps prioritize & avoid being swayed by
the wrong impression
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Factors Affecting Assessment and Decision-Making
Distractors in the environmentScene chaosViolent & dangerous situationsCrowds of bystandersHigh noise levelsCrowds of responders
enough help is crucial but they must be used wisely
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General Approach to Patient Assessment in The
Field & The EDSize-up the situation
Identify need for body substance isolation (BSI)gloves, gown, mask, eye protection as
neededEvaluate scene safety
hazards to yourself, the team, the patient Identify mechanism of injury or nature of illness
can help determine severity of situation
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Patient Assessment Initial assessment
To identify life-threatening conditionsMental status (AVPU)
A - awake, not necessarily orientedV - responding to verbal stimulationP - responding only after touch or lite pain appliedU - unresponsive (absolutely no response)
Airway assessmentBreathing assessmentCirculation status
pulses present?obvious bleeding to be controlled?
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Initial assessment cont’d
Forming a general impressionWhat do you think is going on? These answers drive the care you want
to start providing.Which protocol will you follow?
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Patient AssessmentFocused history and physical exam performed based on
chief complaint and information gathered so far trauma patient with significant mechanism of injury or altered
mental statusneeds rapid head-to-toe
trauma patient with isolated injury (ie: ankle sprain)
focus on body systems related to complaintmedical patient (responsive) - focus exam on c/o medical patient (unresponsive)
needs rapid assessment with head-to-toe exam when patient input not available
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Patient AssessmentVital signs
CMC ED policy: take and record vital signs minimally every 2 hours or more often as needed
SAMPLE history - reminds you to obtain:symptomsallergiesmedicationspertinent past medical history last oral intake food or liquids including waterevents leading up to the incident
Check for medic alert bracelet, necklace
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Blood PressureA 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
Is 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
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Tips, Tricks & Pearls on Blood Pressure & Pulses
B/P by palpation can only determine a systolic readingAs cuff is deflated, palpate over the radially area until the pulse
returnsRecord as “90/systolic”
Guidelines suggest that palpated pulses equate with systolic blood pressurescarotid pulse felt means B/P at least 60/systolic radial pulse felt means B/P at least 80/systolic
No peripheral pulse? Think circulatory collapse
B/P should always be attempted & documented
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Patient AssessmentDetailed physical exam
a more detailed & slower head-to-toe exam than the initial one performed
clinical experience and patient condition often dictate how & if a detailed exam is done in the field & if there is time before ED arrival
Ongoing Assessment - always doneused to detect trends, determine changes in patient
condition, and assess effectiveness of interventionsmental status, ABC’s, vital signs (pulse, respirations, B/P,
SaO2, pain level), EKG
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Assessment TechniquesInspectionobservation; looking beyond the obvious
Palpationuse your sense of touch to gather informationpads of fingers more sensitive than tips for touchback 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
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Accurate Decision MakingRelies on:Patient history obtainedPhysical, hands-on exam performedRecognizing a pattern
comparing information gathered with what you already know (existing knowledge base)
Impression or field diagnosis made the first diagnosis is based on 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
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Use of Protocols & SOP’sProtocol - 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’sknow which protocol/SOP to chooseknow when and how to follow protocol/SOP’s recognize when you must deviate from the stated
protocol/SOP - allergies, abnormal vital signs (ie: hypotension)
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SOP’s/Protocols & The ECRN
An ECRN, by the restriction of their license, cannot give a medical order; the ECRN is only authorized to give an order if it is printed in the SOP/protocol
The ECRN must consult with the ED MD to give an order to EMS that is not listed in the SOP (ie: lidocaine drip after bolus given for stable ventricular tachycardia)
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Difficulty Establishing An Airway In The Field
If EMS cannot establish an airway on any patient in the field, EMS is to transport the patient to the closest Comprehensive Emergency Department even if they are on by-pass
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
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CommunicationHospital reports are best when they:Are given in less than one minuteAre clear and conciseAvoid use of unfamiliar or unclear medical or technical
terms including “10” codesFollow 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
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Transmission of Patient Information
Provider identified 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, lung sounds, pupils, skin condition and color, GCS, pain assessment
Treatment rendered and patient response
Patient history
ETA and destination
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Calling Report on Trauma Patients
Important for EMS 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 activatedmechanism of injurydestruction to vehicle/surroundings injuries noted or suspectedvital signs, GCS
Restlessness: first think hypoxia & shock
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THORACIC TRAUMA
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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 vesselsheart, aorta, trachea, lungs, mediastinum
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Thoracic TraumaClassifying thoracic injuries
Blunt trauma - closed injury from kinetic energy transmitted through tissue
blastsdecelerationcompression/crush
Penetrating trauma - open wound; direct or indirect trauma transmitted via kinetic energy dart
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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 longerdanger of structural collapse & flying debrisextremely deadly overpressures created
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Thoracic InjuriesThoracic cage - ribs & 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
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Flail ChestDefinition3 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 and out) increases respiratory effortusually accompanied by pulmonary and possibly
cardiac contusions
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Flail ChestSigns and symptomsparadoxical 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 ratedecreased pulse oximetry readings increased amount of pain to the chest wall
Treatmentsupport respiratory effort - supplemental O2 via nonrebreather mask; BVM as
neededsupport fractured section manually - no taping of the chest or sandbags/IV’s
placed on chestEKG monitoring
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Sucking Chest WoundDefinitionopen wound of the chest with air passage into the pleural space
Risks to the patientcollapse of the lung on the affected sideuninjured lung unable to fully expandchange 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
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Sucking Chest WoundSigns and symptomsopen wound to the thorax & frothy blood noted around
the chest wall defectgurgling sound heard near the chest woundsevere dyspneapossible hypovolemia - associated injury & hemorrhage increased pulse rate & respiratory rate; decreased blood
pressureevidence of air hunger if, with each breath, more air
enters thru the chest wall defect than thru the trachea
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Sucking Chest WoundTreatment 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
if needed, burp dressing by lifting one corner during exhalation
O2 via nonrebreather maskMonitor vital signs, pulse ox, EKG
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Tension PneumothoraxDefinitionAn 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 patientAir is trapped in the pleural space and puts
pressure on the affected lung, the structures in the mediastinum, the opposite lung
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Tension Pneumothorax
(rare & late sign not often appreciated)
decreased B/P
Low pulse ox, narrowed pulse pressure
(JVD)
Dyspnea, SOB
PEA
tachycardia
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Needle DecompressionTreatmentProvide supplemental oxygenation (nonrebreather
mask) or BVM Initially perform needle decompression
identify site: 2nd intercostal space in midclavicular line; above the rib
prep the siteprepare 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 ribcan take the plug off the catheter end and attach a syringeupon feeling a “pop” or noting air return in syringe, advance
catheter & remove needle; secure catheter
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Needle Decompression
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HemothoraxDefinitionan accumulation of blood in the pleural space due
to internal hemorrhagemore of a blood loss problem than an airway issueeach side of the thorax may hold up to 3000 ml of
blood
Risks to the patienthypovolemic shock reduction of tidal volume & efficiency of ventilations
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Hemothorax Signs & Symptoms
decreased blood pressure
History blunt or penetrating trauma
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HemothoraxTreatmentsupport 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
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Cardiac TamponadeDefinitionA restriction to cardiac filling caused by blood or fluid in the
pericardial sac
Most common mechanism of injurypenetrating trauma (could be medical problem)
Risks to the patientaccumulating blood exerts pressure on the heartpressure limits cardiac filling restricting venous return to the
heartcardiac output is diminished
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Cardiac Tamponade
Muffled heart tones
agitation(JVD)
Diaphoretic, ashen or cyanotic
PEA
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Cardiac TamponadeTreatmentkeep high index of suspicion field care limited to supportive oxygenation
(nonrebreather mask or BVM),IV fluids, and rapid transport
definitive care must be provided in-hospitalremoval of some of the accumulated fluid
from the pericardial sac in the ED and then patient needs to go to the OR
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ABDOMINAL TRAUMA
A high degree of suspicion must be exercised based on mechanism of injury and kinematics.
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Abdominal Anatomy and Physiology
Boundariessuperiorly the diaphragm inferiorly the pelvisposteriorly the vertebral column, posterior
& inferior ribs, back muscles laterally the flank musclesanteriorly the abdominal muscles
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Abdominal Anatomy and Physiology
The 3 abdominal spaces peritoneal space
organs or portions of organs covered by abdominal (peritoneal) lining
retroperitoneal spaceorgans posterior to the peritoneal lining
pelvic spaceorgans contained within the pelvis
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Abdominal QuadrantsRUQgallbladder, right kidney, most of the liver, some
small bowel, portion of ascending & transverse colon, small portion of pancreas
LUQstomach, spleen, left kidney, most of pancreas,
portion of liver, small bowel, transverse & descending colon
RLQappendix, portions urinary bladder, small bowel,
ascending colon, rectum, female genitalia
LLQ - sigmoid colon, portion urinary bladder, small bowel, descending colon, rectum, female genitalia
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Blunt Abdominal TraumaProduces least visible signs of injury
Responsible for 40% of splenic injuries
Responsible for 20% or liver injuries
Bowel and kidneys next most frequently injured organs
Injuries must be anticipated by evaluating mechanism of injury with force & direction of impact
Maintain high index of suspicion based on mechanism of injury
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Blunt Mechanisms
Compression forces
Shear forces
Deceleration forces
Motor vehicle crashes
Motorcycle collisions
Pedestrian injuries
Falls
Assault
Blast injuries
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Penetrating Abdominal Trauma
Low velocity - injury limited to the direct areaKnife, ice pik
Medium velocityHandgun & shotgun wounds
• High velocityHigh power hunting riflesMilitary weapons
Ballistics - study of projectiles in motion
Trajectory - path a projectile follows
Distance traveled a consideration
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Evisceration of the bowel caused by a knife wound
Cover eviscerated area with sterile, moistened dressing
Minimize patient movement, coughing
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Hollow Organ InjuryHollow organsStomach, small bowel, large bowel, rectum, urinary bladder,
gallbladder, pregnant uterus
Anticipated injuriesMay rupture due to forces especially if the organ is full and
distendedCan cause hemorrhage and spillage of the contents into the
peritoneal, retroperitoneal or pelvic spacesContents spilled may have high bacterial counts, contain
irritating chemicals, have high acid counts, or contain digestive enzymes
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Solid Organ Injury
Solid organsspleen, liver, pancreas, kidneys
Anticipated injuriesProne to contuse resulting in organ damage; bleeding often
minimal if organ intact and contained within the organ but could be severe
If organ torn or lacerated may cause life-threatening hemorrhage
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Patient AssessmentMaintain high index of suspicion
Serious trauma to the abdomen is often a surgical problem and requires prompt and rapid transport with frequent reassessment
Identify additional causative forces of injuryseatbelt worn above the iliac crestno seatbelt restraint used, steering wheel
deformity type of weapon used in penetrating trauma
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Patient Assessment For Abdominal Trauma
Early signs of serious or continuing internal hemorrhage diminishing level of consciousness increasing anxiety or restlessness thirst increasing pulse rate decreasing pulse pressure - systolic and diastolic
numbers moving closer together increasing capillary refill time (>2 seconds) increasing abdominal distention, bruising
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Abdominal AssessmentInspectionRedness, ecchymosis, contusions, open wounds, distentionMay hold up to 1.5 L of blood before distended
PalpationGently palpate each quadrant individually with tips of fingersQuadrants with pain or injury are palpated lastDistention, tenderness, crepitus, instability, guarding,
pulsations
Auscultation - Not often done in field in trauma - too much time and need for quieter environment
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Initial Abdominal Trauma Treatment
Timely, thorough assessment repeated oftenCritical findings: rigid or distended abdomen or
guarding; presence of shock; shock out of proportion to findings (maybe haven’t found all the sources of bleeding yet)
Supportive oxygenation (nonrebreather mask)
IV access
EKG monitoring
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Neurological Emergencies
The human body’s ability to maintain a state of homeostasis results primarily from the nervous system’s regulatory and coordinating activities
A disruption in the nervous system affects the functioning of the body and can be in a variety of forms from simple to severe
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Headache
Common ailmentDescribed as a symptom rather than a disorderCan accompany many disordersCan be brought on by emotional eventsRecurring headaches may be an early sign of a more serious diseaseMost are caused by vasodilatation in tissues surrounding the brain
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HeadacheImmediate attention is needed if:Severe and sudden in onsetOther neurological impairments such as visual
disturbances, confusion, motor dysfunction or sensory loss also occur
Accompanied by fever or stiff neck
Patient states “the worse headache in my life”
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Types of HeadacheMigraineUsually one sided and accompanied by nauseaPersonal or environmental triggersDietary substances or medication triggers
Cluster Unilateral intense pain over and behind the eyeLasts about an hour and occur in clusters (bunches)
TensionProlonged overwork or stressUsually occipital region
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HeadacheTreatment in general Medications based on individual history, symptoms and
needsAnalgesics may or may not be effectiveMild diuretics may be effective at timesDark environmentRestDetermine trigger and use avoidance
Accurate diagnosis necessary in case of more severe problem!
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Neoplasms - Tumor Any abnormal growth of cells
May be benign or malignant
Cell multiplication is fast and uncontrolled
Classified by origin
Treatment - depends on type, location & age of tumorObservationChemotherapyRadiation therapySurgical removal
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Malignant Neoplasms
Cancerous tumorEmbryonic or poorly differentiated
cellsGrow in a disorganized mannerNecrosis and ulceration is common sign Invasion of surrounding tissue for nutritional
needsMetastatic in nature (i.e.: Initiates growth of like
tumors in other areas)
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Benign Neoplasms
Usually not dangerous to life unless they occur in a vital organ
Slow growth
Do not invade tissue for nutrition
Usually encapsulated
Do not form secondary tumors in other organs
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Assessment of Neoplasms
Some are painful yet some have no pain at all
External presentation Irregular borders Rough texture Brown/black in color
Capsule formation under the skin
Ulceration of overlying skin
Dependant on the organ or organ system affected
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Neoplasm
When to be concerned:Change in bowel or bladder habitsA sore throat that does not healUnusual bleeding or dischargeThickening on breast or other soft tissue Indigestion or difficulty swallowingObvious change in a wart or moleNagging cough or hoarseness
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Neoplasm Treatment
Chemotherapy Intravenous pharmacological therapy to
slow growth or kill tumorsCytotoxic to all cells of the body even
though target is cancerous cellsCan cause lethargy, hair loss, unsteady
gait, weakness and nausea
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Neoplasm Treatment
Radiation therapy Ionizing radiationDose of particulate or electromagnetic
radiation to a specific area of the organ or body
Can come from outside the body or inside the body (implanted radiotherapy)
More effective and less harmful than when first introduced
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Neoplasm Treatment
Surgical interventionDependant on type and amount of tissue
involvement with the tumorCan be radical or preciseCan be used in conjunction with other
therapy methodsCan cause self esteem issues
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Neoplasms Prevention strategies to include in patient teaching:Self breast examsMammogramsPAP smearsYearly physical examsSelf testicular examsProstate screening
PSADigital inspection
Seek medical evaluation early after abnormal finding
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Bell’s PalsySeventh cranial nerve inflammation or trauma
Temporary weakness or paralysis in facial muscles
Can reoccur
Good to complete recovery with nerve regeneration
Conditions that compromise the immune system increase odds of disease Lyme disease, herpes viruses, mumps and HIV infections
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Degenerative Neurological Disorders
Muscular fatigue usually attributed to interruption in the ability of the axon to communicate with the muscular endplate for various reasons
Symptoms can be mild to severe depending on manifestation and advancement of the disease process; can come and go; can be localized or systemic
Chronic conditions can be debilitating and affect quality of life
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Degenerative Neurological Disorders
Pathophysiology is variable and dependant on the specific diseaseSome are caused by an autoimmune type response to a toxic invaderExample: Multiple sclerosis
Some are the muscle’s inability to use the proteins provided by the body as fuelExample: Muscular dystrophy
Some are actual nerve tissue breakdown Example: Parkinson’s disease
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Degenerative Neurological Disorders
Partial facial paralysisExample: Bell’s Palsy
Degeneration of the cell bodies in the gray matter of the anterior spinal cord, brain stem and pyramidal tractExample: Amyotrophic Lateral Sclerosis (ALS)
Contraction of muscles or muscle groups that can contribute to convulsive disordersExample: Myoclonus
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Degenerative Neurological Disorders
An abnormal closing of the protective bony casement for the spinal cord. Nervous meninges may or may not be exposedExample: Spina bifida
Non-inflammatory lesions that affect the peripheral nervous systemExample: Peripheral neuropathy
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Degenerative Neurological Disorders
General disease manifestationsWeaknessGeneral body achesPartial paralysis that comes and goesParasthesia - pins & needles sensationPeripheral sensory impairmentRespiratory insufficiency (chronic stages) Immunosuppression - more vulnerable to
contract communicable diseasesMultiple medication interactions
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Degenerative Neurological Disorders
Pharmacological interventions range from anti-inflammatory drugs to experimental protein altering medicationsMedication usage depends on the organ system involved and the severity of symptomEnvironmental changes (living in a cool area) can help some diseasesDecreased exercise or production of muscular heat can decrease symptoms
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Degenerative Neurological Disorders
Caring for the patient in crisis must include maintaining ABC’sEndotracheal intubation or bagging the patient through an in-place tracheostomy may be necessarySupportive care for hypotensionPatients may need total lift assistance to move
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Muscular DystrophyInherited through DNA degeneration of muscle fibersEarly recognition in children who are slow to sit and walkCalf muscles become bulky as wasted muscle turns to fatPulmonary infections and heart failure are frequent causes of death
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Multiple SclerosisMyelin in the brain and spinal cord are destroyed. Autoimmune system sees myelin as foreign material.
Experience numbness to paralysis
Damage to white matter causes fatigue, vertigo, unsteady gait, slurred speech, pain
Some disable at onset; others degenerative over many years
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Structure of the Neuron and Multiple Sclerosis
The myelin sheath is a membranous extension of specialized cells called oligodendrocytes. These form an insulating substance. Non-myelinated axons (not insulated) conduct impulses very slowly
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Parkinson’s DiseaseDegeneration of nerve cell in basal ganglia in the brainLack of dopamine inhibits basal ganglia from modifying nerve pathways that control muscle contractionTremors, joint rigidityLeading cause of neuro disability in those over 60 years old
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Lou Gehrig’s Disease - ALS
Progressive motor neuron diseaseTypesSpinal muscular atrophyBulbar palsyPrimary lateral sclerosisPseudobulbar palsy
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Amyotrophic Lateral
Sclerosis (ALS)
Upper motor neurons affected in the central nervous
system; lower motor neurons affected in the
peripheral muscles
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Amyotrophic Lateral Sclerosis (ALS)
More common men over 50 Weakness, quivering (fasciculations)Unable to speak, swallow, move, breath on own Intellect and awareness maintainedBecome ventilator dependentAspiration pneumonia constant threatStarvation, failure to thrive
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Trigeminal NeuralgiaTrigeminal nerve – 5th cranial nerve with opthalmic, maxillary and mandibular functionsAffects skin of upper eye, side of nose, half of scalpAffects mucous membranes of nose, forehead, upper lipAffects lower teeth and tongue
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Peripheral NeuropathyAxon or myelin sheath in peripheral nervous system damaged/irritated causing blockage of electrical signals
Can affect:muscle activitysensation reflexes internal organ function
Can be caused locally - trauma, compression (tight casts, tourniquet use), carpal tunnel, infections
Can be demyelination or degeneration of peripheral nerves - diabetes, Guillain-Barre syndrome
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Myoclonus
Temporary, involuntary rapid, uncontrolled muscular contractions (jerking) or twitching of a group of muscles
Generally considered a symptom more than a diagnosis
Can occur at rest or during movement
Can distort normal movement and interfere with the ability to eat, walk, and talk
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Spina BifidaDefect of neural tube closure
Portion of vertebra fails to develop leaving a portion of the spinal cord unprotected
Lower back most affected
Nerve damage is permanent
Long term effectsphysical & mobility limitations loss of bowel & bladder control most have some form of a learning disability
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Spina Bifida
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Degenerative Neurological Diseases
Make treating the chief complaint a priorityDo not overlook the underlying history but do not
allow it to cloud judgement for a more serious issue
Management PlanHistory
Acute or chronic complaint for today?General health?Previous medical conditions?Medications?
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Degenerative Neurological Diseases
ManagementOxygenPosition of comfortVenous accessPharmacological interventions
Check for hypoglycemia in setting of altered level of consciousness
Antihistamine - benadryl for dystonic reactions (impairment of muscle tone (peculiar posturing & difficulty speaking) after exposure usually to certain meds)
Psychological support
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Degenerative Neurological Diseases
Treatment concerns:mobility often limitedcommunication often difficult - hearing, speech
unclear respiratory compromise - especially
exacerbations of underlying problemsanxiety - coping with debilitating disease
difficult on patient and family & stress and anxiety levels can run high
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Case Study #132 year old male unrestrained in head-on MVC at 55 mph
Awake & oriented, increased respiratory rate, weak & rapid radial pulse
Major complaint is pain to the left side of the chest with evident redness, crepitation felt on palpation
Vital signs: B/P 102/50; P - 108; R - 24 pulse ox 94%; EKG - sinus tachycardia
Breath sounds - decreased left side
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Case Study #1General impression (what are possibilities)? Cardiac contusions Lung contusions Pneumothorax
The patient is becoming more restless with increased anxiety; pulse ox dropping to 84%; respiratory rate climbing to 38 and now shallow with increasing dyspnea
What’s going on now?
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Case Study #1Reassess ABC’sAirway still openBreathing getting more difficultBreath sounds absent on the leftPulse more rapid and thready and barely palpable
radially
Impression:Tension pneumothorax
Treatment: Initially needle decompression
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Case Study #1Landmarks for needle decompression? 2nd intercostal space in the midclavicular line Be above the rib (avoid vessels & nerves that run under
the rib)• Equipment used in the field
Largest gauge & longest needle available12-14 G and 3 inches long
Flutter valve prepared Skin prepped Needle must be secured in place
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Case Study #255 year old extremely obese female unrestrained rear seat passenger of taxi cab involved in 60 mph MVC
Patient is agitated, complaining of pain all over (was thrown around back of cab)
Patient is pale, slightly diaphoretic (apologizes because she says she is always somewhat sweaty), unable to feel radial pulse “because of fat wrists”
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Case Study #2If unable to take a blood pressure in the upper arm, what are alternatives?
Place the cuff around the forearm and place the stethoscope over the radial pulse area.
Not acceptable to not attempt any kind of blood pressure.
Why is this patient so restless?
Don’t be fooled by the obvious and don’t dismiss her concerns to her “weight”
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Case Study #2What can cause restlessness?
Hypoxia
Hypovolemia
Internal injury
Hypoglycemia
Pain
Anxiety; being scared
Being uncomfortable (pain, positioning, full bladder)
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Acknowledgement
NIMSCA contribution for packet by:Kathy Wexelberg RN, Advocate ChristMarlene Blacklaw, RN, Advocate ChristLonnie Polhemus, EMT-P, Silver Cross
Additions made by:Sharon Hopkins, RN, BSN,
Condell Medical CenterRegion X SOP’s, Effective March 2005