trauma assessment february 2014 continuing education silver cross hospital ems system erika ball,...
TRANSCRIPT
Trauma Assessment
FEBRUARY 2014 CONTINUING EDUCATION
SILVER CROSS HOSPITAL EMS SYSTEM
ERIKA BALL, RN, BSN
1
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
11
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
12
Mechanism of injury:
Common Trauma Injuries
What are the predictive injury patterns associated with these incidents?
BLUNT TRAUMA
Motor Vehicle CollisionMVC
14
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
15
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
17
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.
18
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…
19
Note the AMOUNT of blood that lurks within a spleen injury…(you may need to click play)
20
Blunt Pelvic Injury 21
What else is BLUNT trauma?
Baseball bats, sports injuriesFall from height Ejection from moving vehicles
(motorcycle, ATV, horses, bicycles, snowmobiles)
22
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
23
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?
25
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)
26
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
27
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…
28
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.
29
Where are thepotential injuries?
30
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.
31
Note the tourniquet… 32
Transport decisions… Is the airway clear?
33
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.
34
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
35
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”
36
Trauma Assessment Review
37
So here we go… head-to-toe
38
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
39
ASSESS AVPU
AlertVerbalPainUnresponsive
40
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…
41
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…
42
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…
43
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
44
Trauma Assessment
Neck wounds? Stepoff on the posterior cervical
spine? Trachea assessment… midline?
Place patient in Cervical collar
45
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
46
Sucking chest wound(you may need to click play)
47
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.
48
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
49
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)
50
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
51
Trauma Assessment:Abdomen
Check for wounds/ bruising/ objects Tenderness Rigidity Pulsations Check all four quadrants Are they pregnant?
Move on to…
52
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
53
Trauma Assessment:Pelvis Assessment
54
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
55
Trauma Assessment:Extremity Trauma
Assessment of PMS
Perfusion
Movement
Sensation
Also called CSM
Circulation
Sensation
Movement
56
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
57
Extremity Trauma: Amputations From Blast Injury
58
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.
59
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
60
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
62
Skill/SMO of the month, Needle decompression
Code 72
63
Equipment
Antiseptic 2-3 inch, large-bore (10-14#)catheter One-way valve if available Chest tape for stabilization
64
Decompression location
2nd intercostal space
Mid-clavicular line
65
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
66
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
68