traumatic dyspnea - ucla cpc causes of combat death 60% hemorrhage from extremity wounds 33% tension...
TRANSCRIPT
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Traumatic Dyspnea Barry Jensen, NREMT-P, NCEE
EMT Program Director
UCLA Center for Prehospital Care
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Combat Death
• 31% Penetrating head trauma • 25% Surgically uncorrectable torso trauma • 10% Potentially surgically correctable trauma • 9% Hemorrhage from extremity wounds • 7% Mutilating blast trauma • 5% Tension pneumothorax • 1% Airway problems • 12% Mostly from infections and complications
of shock
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Preventable Causes of Combat Death
60% Hemorrhage from extremity wounds
33% Tension pneumothorax
6% Airway obstruction e.g., maxillofacial trauma
* Data is extrapolated from Vietnam to present day Iraq and Afghanistan
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The Fick Principle
These four elements must exist for perfusion to take place
• Adequate oxygen in the alveoli
• Adequate oxygen exchange to the pulmonary capillaries
• Adequate circulation
• Adequate RBC’s, adequate perfusion pressure
• Adequate oxygen exchange into the tissues
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Airway
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Thorax and Respiratory System
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Respiratory Tree and Perfusion
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Thorax and Respiratory System
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Hypoxia and the Brain
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Oxygenation
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Ventilation
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Respiration
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Biphasic (Bilevel) Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure (CPAP)
• Two Levels (10/5) vs. One Level (10)
• Indications
• Contraindications
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Primary Assessment
Scene
Responsiveness
Airway
Breathing
Circulation
Disability / Deformity
Environment / Expose
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Assessment and Interventions
• Intervene During Primary
• Secondary on-scene vs. enroute
• Most ALS on the way to hospital
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Pulse Oximetry
• Measures oxygenation
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Capnography
• Measure ventilatory status
• ETCO2 35-45 mm Hg is the normal value for capnography
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Hyperventilation
http://medicscribe.com/capnography/ 11/10/2013
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Hypoventilation
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Intubated?
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Arterial Blood Gas
• Partial Pressure of CO2 (PaCO2) and Oxygen (PaO2) in blood and pH
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MECHANISM OF INJURY
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Front Impact
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Lateral Impact
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Pedestrian
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Typical Pediatric Pattern and Considerations
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Ultra slow motion footage of several thousand pounds of black powder exploding, showing very clearly the otherwise invisible shock wave. Music: Paul Haslinger, www.youtube.com 11/6/2012
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Mechanisms of Blast Injury
• Primary
• Over-pressurization wave
• Gas filled structures
• Lungs
• GI Tract
• Middle Ear
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Blast Lung
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Hanging or Near-Hanging?
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Case
32 y.o. in traffic accident, 70 mph frontal impact, unrestrained
Chest exam reveals diminished breath sounds on the left, dullness on percussion
You hear …
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Acute diaphragmatic rupture occurs in 1% to 7% of patients after major blunt trauma and the diagnosis is missed on initial presentation in up to 66% of these patients. Only about 10% diagnosed in acute phase of treatment.
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How Would You Manage This Patient?
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Upper Airway
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Severe facial injuries after intubation on scene.
P P B et al. Emerg Med J 2012;29:767-768
Copyright © BMJ Publishing Group Ltd and the College of Emergency Medicine. All rights reserved.
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Figure 1: A 19-year-old Afghan man sustained extensive facial injuries and lost parts of his
left forearm and left lower leg after a blast from an improvised explosive device, causing
extensive soft tissue, neurovascular and bone injury.
Macdonald J C , Tien H C CMAJ 2008;178:1133-1135
©2008 by Canadian Medical Association
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Needle Cricothyrotomy Procedure
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Why Would This be Needed?
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Combat Device
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Pneumothorax on X-Ray
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How would you intervene?
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What Potential Injuries?
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How would you intervene?
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CASE STUDY: “ROLLOVER”
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Mechanism
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Scene Size-Up
• Saturday, 0754
• Dispatch directs you to a car collision on the outskirts of town
• Highway patrol have diverted traffic
• There is one patient
• The fire department is already on scene, scene is safe
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Initial Assessment
• Awake, supine, lying on ground
• A: Open, patient is moaning
• B: Rapid rate; labored, decreased tidal volume
• C: Skin pale, cool, dry; pulse rapid, weak, regular
• D: Severe due to pain, GCS: 3-3-5=11
• E: Obvious facial bruising and swelling with some right neck swelling
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• What is your general impression of this patient?
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General Impression
• Patient’s airway may be compromised
• She may have impending respiratory failure
• She is in probable shock (hemorrhagic)
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• What are your initial management priorities?
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BLS Management Priorities
• Place patient in spinal immobilization
• Give 15L O2 by non-rebreather mask
• Place patient in supine for shock
• Initiate rapid transport
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ALS Management Priorities BLS management plus . . . • Re-evaluate airway/breathing
• Establish 2 large bore IVs en route to trauma center
• Apply cardiac monitor en route
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Rhythm?
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Case Progression
• Sinus tachycardia @ 136
• Accessory airways not tolerated
• The patient is loaded on a backboard into the ambulance without difficulty
• Transport initiated to the nearest ED with lights and sirens
• En route the patient’s breathing becomes more labored
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Additional Assessment
• Vital signs: RR 32, HR 136, BP 82/53, Wt 50kg
• S: Facial pain, shortness of breath, abdominal pain
• A: Unknown
• M: Unknown
• P: Unknown
• L: Unknown
• E: Patient was unrestrained driver whose face hit the windshield (“spidered”); there is steering wheel damage
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Detailed Physical Exam
• Head: pupils midrange, reactive; facial edema and crepitus over cheeks with deformity
• Neck: swelling on right side; no JVD or tracheal deviation
• Lungs: clear and equal bilaterally
• Chest: no signs of trauma
• Abdomen: soft, non-tender, no distention
• Pelvis: stable, nontender, no instability
• Extremities: stable, nontender; no obvious trauma
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Case Progression
• En route, the patient becomes unresponsive, and her O2 saturation drops to 80%
• Repeat VS: RR 6, HR 42, BP 60/p
• Teeth are clenched
• Cannot visualize the vocal cords
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• What do the vital signs indicate?
• What are your options for airway management?
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Case Progression
• Patient is in respiratory failure
• Options:
• Assist ventilation with bag-mask
• Attempt intubation again - use paralytic
• Perform needle cricothyrotomy
• Bag-mask ventilation is difficult because of facial deformities
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Case Progression
• Needle cricothyrotomy is successful; you are able to oxygenate the patient
• You arrive at the emergency department 5 minutes later without further incident
• The patient was taken to the operating room within 3 minutes of arrival
• A tracheostomy was performed
• She has facial surgery and exploratory abdominal surgery
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Case Outcome
• She was found to have multiple facial fractures and a ruptured spleen
• She was hospitalized in the ICU for 1 week and was discharged after 3 weeks
• After 2 more facial surgeries, she was doing well
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