carla smith rn, bsn, cen, nremt-p, ce-ioccur-chest-abdomen-pelvis-thighs-externally * * txa...
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![Page 2: Carla Smith RN, BSN, CEN, NREMT-P, CE-Ioccur-Chest-Abdomen-Pelvis-Thighs-Externally * * TXA Tranexamic acid-inhibits natural clot breakdown * Cardiac Tamponade can cause hypotension](https://reader033.vdocuments.net/reader033/viewer/2022042018/5e765ec736a0e3432634f8a7/html5/thumbnails/2.jpg)
*Trauma is the 4th leading
cause of death in the US
*Leading cause of death in
people under the age of 45
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*First peak instantly (brain,
heart, large vessel injury)
*Second peak minutes to hours
*Third peak days to weeks
(sepsis, prolonged
hypoperfusion, MSOF)
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*ATLS focuses on the second
peak, minutes to hours.
*Death from:
TBI, skull fractures, spinal cord
syndrome, penetrating injuries, cardiac
tamponade, tension pneumo, flail chest,
liver lac, splenic injury, pelvic fractures,
femur fractures…
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*Treat the greatest life threat first
*Utilize and ABCDE approach
*A detailed history should not delay
evaluation and treatment
*Lack of a definitive diagnosis should not
impede treatment
*Subsequent mortality and morbidity are
tied directly to the initial assessment
and resuscitation
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*Scene size up
*Initial primary assessment
*Rapid resuscitation
*More thorough secondary
assessment
*Disposition
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*MOI (Mechanism of Injury)
*Falls (distance, surface)
*GSW (long/short barrel, caliber, distance)
*MVC (speed, damage, location of impact,
seatbelt, airbag, windshield damage, steering
wheel damage)
*Drowning (length of submersion, water temps)
*Number of patients
*Utilize trauma triage to prioritize status
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*Rapid- 60-90 seconds
*A-airway
*B-breathing
*C-circulation
*D-disability
*E-exposure
*Only interrupt primary survey to treat life threats
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*Airway should be assessed for patency
*Is the patient able to communicate verbally?
*Inspect for any foreign bodies
*Utilize jaw thrust technique
*Examine for stridor, hoarseness, gurgling, pooled secretions or blood.
*Assume c-spine injury in patients with multisystem trauma
*Maintain C-spine precautions in any patient
with injury above the clavicle
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*Supplemental oxygen
*Suction
*Chin lift/jaw thrust
*Oral/nasal airways
*Definitive airways
*ETI for comatose patients (GCS<8)
*RSI/ETI for airway protection or expected clinical
course (obstruction from blood or vomitus, neck
hematoma, facial burns or trauma)
*RSI for agitated patients with c-spine immobilization
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*Airway patency alone does not
ensure adequate ventilation
*Observation of respiratory rate,
oxygen saturation, and overall work
of breathing
*Inspect, palpate, and auscultate
*Deviated trachea, crepitus, ecchymosis, flail
chest, sucking chest wound, absence of breath
sounds
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*Ventilate with 100% oxygen
*Needle decompression if tension
pneumothorax suspected
*Occlusive dressing to sucking chest
wound
*PPV for flail chest
*If intubated, evaluate ETT position
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*Rapid assessment of hemodynamic status
*Level of consciousness
*Skin color
*Pulses in four extremities
*HR
*Blood pressure
*Hemorrhagic shock should be assumed in any
hypotensive trauma patient
*Control external bleeding
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*Cardiac monitor
*Apply pressure to sites of external hemorrhage
*Establish IV access
*2 large bore peripheral IV’s (at least 18 gauge)
*Volume resuscitation
*“3:1 rule” 3cc crystalloid for every 1cc of blood loss
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*New treatment standard
*R. Adams Crowley Shock Trauma Hospital at The University of Maryland Medical Center
*Research shows attempts to restore blood pressure with crystalloids resulted in increased hemorrhage volume and higher mortality*Dilutes remaining circulating blood
*Hampers bodies compensatory mechanisms
*Hinders clot formation
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*Use of SBP and HR not completely accurate
*Medical history
*Medications (ie: beta blockers)
*The Journal of the American Medical
Association published a study showing
patients managed with a MAP of 50 mmHg
had decreased mortality rates then those
maintained at the previous standard of 65
mmHg
*250 ml boluses
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*5 Places life threatening hemorrhage can
occur
-Chest
-Abdomen
-Pelvis
-Thighs
-Externally
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*
*TXA
Tranexamic acid
-inhibits natural clot breakdown
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*Cardiac Tamponade can cause
hypotension with little blood loss.
*Becks triad: hypotension, distended
neck veins, muffled heart sounds
*Pericardiocentesis
*Blunt chest trauma
*Cardiac arrest
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*Abbreviated neurological
exam
*Level of consciousness
*Pupil size and reactivity
*Motor function
*GCS
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*Completely expose patient
*Inspect both axillae and
peritoneum
*Logroll to inspect back
*Warm blankets/external warming
device to prevent hypothermia
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*
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*28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.
*HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask
*Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle
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*What are the management priorities at this
time?
*What are this patient’s possible injuries?
*What are the interventions that need to
happen now?
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*Physical exam from head to toe
*DCAP-BTLS
*AMPLE history
*Allergies, medications, PMH, last meal,
events
*Frequent reassessment of vitals
*Some patients you may never make it to
the secondary survey
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*Level of consciousness or loss of consciousness
*Headache
*Pupillary assessment
*Speech
*Increased ICP
*Posturing
decerebrate, decorticate
*Seizures
*Elevate Head
*Cushing’s reflex
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* Bleeding between the Dura
and the brain
*Usually venous
* Typically caused by trauma
* Tearing of the vessels along
the surface of the brain
* Places pressure directly on
the brain and causes
swelling and shifting
* Deadliest of the injuries
* Bleeding between the skull
and the Dura
*Often associated with skull
fractures
*Usually arterial
* Patients may exhibit a LOC,
followed by alertness, and
then decreased mentation
or another LOC
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Raccoon Eyes
Battle’s Sign
Rhinorrhea
Bleeding from the ears
CSF leakage (halo)
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*Common source of traumatic injury
*Mechanism is important
*Bike accident over the handlebars
*MVC with steering wheel trauma
*High suspicion with tachycardia, hypotension, and abdominal tenderness
*Can be asymptomatic early on
*Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis
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*Most commonly
injured organ in
blunt trauma
*Often associated
with other injuries
*Left lower rib pain
may be indicative
*Graded I-V
*Second most
common solid organ
injury
*Can be difficult to
manage surgically
*Graded I-VI
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*Bowel sounds in the chest cavity
*Left > right due to liver protection of the diaphragm.
Trace the Diaphragm Outline. Where is theDiaphragm on the left?
Abdominal contentsUp in the chest on theleft
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High risk for
hemorrhage into the
pelvis
Severe pain
Instability
Open Book Pelvic
Fracture
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*Femur and Humerus fractures present greater
risk for blood loss.
*Stability is best intervention for pain
management
*Consider application of traction for femur
fractures.
*Don’t delay transport to stabilize long bone
fractures in critical patients
*Consider MOI with femur fractures
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*Key is SUSPICION!!!
*Incongruent stories of mechanism
*Delay in seeking treatment
*Multiple stages of injuries
*Pattern Injuries
*Multiple hospital visits
*Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed)
*Bite marks, submersion injury, cigarette burns
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So where does your patient need to go and how
fast do they need to get there?
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*Central Ohio Trauma System (COTS) has
devised specific guidelines as to what
constitutes a level I or level II trauma and must
be transferred to a Trauma Center
*0-15 years of age – pediatric
70+ years of age - geriatric
*If your ground transport time exceeds 15min
consider air medical transport
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*Respiratory compromise
* Intubation
*Hemodynamic instability
*GCS <8
*GSW to abd, chest, neck
*ERP direction
* GCS <13
* Flail chest
* Blunt abd trauma with pain
* Amputation proximal to wrist/ankle
* 2 or more proximal long bone fxs (1 in geriatric)
* Open long bone fx
* Clinically apparent pelvic fx
* Traumatic paralysis
* Major burns (>10%)
* Open/depressed skull fracture
* Penetrating injury to the head, neck, chest, abd, or proximal extremities
* Geriatric, falls from any height with TBI or on anticoagulants
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*ATLS Student Course Manuel, 6th edition.
*Emergency Care in the Streets, 6th edition.
*UNC College of Medicine, Approach to Trauma
Management