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Learning Station 3

Environmental Emergency 6

Driver of Car Gets Shot1999 American Heart Association

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Acknowledgments

This teaching material was developed for the

ACLS-EP Course by Paul Berlin, MS, EMT-P.

He has generously donated much creative workto the AHA. B. Keith Chapman, EMT-P, of

Temple Terrace, FL, also contributed to this

material. Eric Fajardo, MD, Maj MC, MadiganArmy Medical Center, contributed graphics and

treatment recommendations.

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Learning Objectives

Different BLS actions to take with trauma

patients vs nontrauma

Different ACLS actions to take with trauma

patients vs nontrauma Where to modify the Primary and Secondary

ABCD Surveys for trauma patients

After completing this learning station you

should be able to describe

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Case Management55-year-old male with GSW to chest

You respond to scene of shooting plus MVA

Victim struck in right chest in crossfire

Car crashed into a pole

Rescuer safety: police have scene secured;

no threat posed by environment

Begin management now.

What is the f irst BLS dif ference younote in out-of-hospital trauma care?

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Initial Assessment at the Scene

Inspection:

Unconscious, unresponsive

Bleeding laceration: left eye

Carotid=148 bpm; no radial

Respiratory rate

=

38/min Skin pale and cool

What are your next actions?

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Primary ABCDDTrauma vs Nontrauma A-B-C-D-D

Perform Primary ABCDD Survey

Airway: for A do the following:

Secure C-spine: until cleared later; highvigilance if any injury above clavicles

Open airway: jaw thrust (no head tilt)

Clear airway: foreign bodies, blood,teeth, debris

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Primary ABCDDTrauma vs Nontrauma A-B-C-D-D

Breathing:

Oropharyngeal airway: keep the airway open

Use BVM + jaw thrustno head tilt!

Assess: must see bilateral chest rise

No rise? Think pneumothorax/flail chest

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Circulation:

Primary ABCDDTrauma vs Nontrauma A-B-C-D-D

Check: bleeding? external and internal?

Control open hemorrhage

PEA: in trauma patient major bleeding

Check: neck for JVD?

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Defibrillation:

Clinical evaluation strongly suggests rhythm is

not VF (empty tank is cause of hypotension) Sudden VF unconsciousMV accident =

well-known sequence

Disability:the 2nd D in trauma ABCDD

Assess for neurologic Disability Glascow Coma Scale (GCS) is commonly used

for trauma victims

Primary ABCDDTrauma vs Nontrauma A-B-C-D-D

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Continue In-Field Treatment

Rapid immobilization on spine board C-collar and head secured on board

Rapid extrication from vehicle Oxygen by mask Low O2 saturation at 84%

Rapid sinus tachycardia

Unequal breath sounds Absent on right side

What is your assessment now?

Getting worse? Getting better?

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Treatment During Transport

Notify nearest appropriate level ED Airway and breathing?

Endotracheal tube

Circulation? IV rapidly infusing

Differential diagnosis

Rapid transport to definitive care

The key factor in trauma care

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In trauma, providers struggle with this issue:

Stay n Play

Advanced treatment at scene? IV? ETT?

Stabilize, then transport

Versus

Load n Go Advanced treatment with transport

During transport: IV and ETT

Secondary ABCDDDifferences in Trauma vs Nontrauma A-B-C-D-D

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Load n Go vs Stay n Play

Current Practice by ACLS Providers:An Approach of Some of Both

General: extricate stabilize resuscitate

transport STAY actions: open airway ventilate

endotracheal tube IV access + fluids GO actions: insert ET tube start IV give

rhythm-based meds push significant amounts

of fluids (first liters wide open)

See if you can provide a short reporta summaryof your assessment and treatment so far.

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ED Arrival

Short report

Backboard/cervical collar

BVET tube with 100% oxygen Ashen, sweaty, cap refill >2 seconds, cold

GCS: eyes=2, verbal=3, motor=3

1 IV of NS running

HR=140 bpm, BP=unable to obtain

Extremities: floppy with no movement

Describe your initial assessment in the ED

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ED Assessment

2nd large-bore, pressure-bag IV

Labs + type and cross

NG, Foley catheter

Cervical, thoracic spine x-rays

Chest, belly, pelvis x-rays

CT scan of head when stable Peritoneal lavage/ultrasound if

belly suspect

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Managing Chest-Penetrating GSW

Management depends

on patients stability

If agonal:

Intubation

Volume

resuscitation

ED thoracotomyEntrance wound

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Deadly Dozen

Lethal 6: you have

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Tension PneumothoraxCommon Causes

Penetrating chest injury

Blunt trauma + parenchymal lung injury

Mechanical ventilation with positive

pressure (PEEP)

Spontaneous pneumothorax; blebs that

failed to seal

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Tension PneumothoraxClinical Presentation

Respiratory distress

Hypotension

No or reduced breath sounds on one side

Hyper-resonance to percussion

Neck vein distention: absent with hypovolemia

Tracheal deviation (late finding) Cyanosis

What do you think a chest x-ray

would show in this patient?

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What would aCT scan of thispatients chest

look l ike?

Left Right

A: Air under tension in

left thorax

A

B

B: Collapsed right lung

Pleural margin;

partial lung

collapse

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Heart

LeftRight

A

A: air, under

tension, in

thoracic cavity

B

B

B: pressure of tension pneumothorax pushing midlinestructures (heart, mediastinum) into patients left

thoracic cavity

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Tension Pneumothorax

Treatment

Stat decompression: must convert tension

pneumothorax into simple pneumothorax Use 12- to 14-g angiocath inserted into the 2nd

intercostal space, midclavicular line, or

5th intercostal space, anterior axillary line

Releases the air under tension

Follow with chest tube

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Penetrating Cardiac TraumaPericardial Tamponade

Pathophysiology

Fluid collects in pericardial sac

Tension blocks venous return to heart

May result from acute accumulation of as

little as 75 to 100 mL of fluid

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Pericardial Tamponade

Chest x-ray

Widenedmediastinum

Pneumothorax orhemothorax

Electrical alternans

Note rounded bottle shape to

left side of heart

Compare with next 2 slides

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Pericardial Tamponade

Echocardiography Pericardialfluid

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Pericardial Tamponade

Treatment: start

Film taken afteremergency

pericardiocentesis

Shows pericardial sac

and space where

fluid removed

Airway control

Rapid, forced fluid

resuscitation

If unstable but with

signs of life:

Pericardiocentesis

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Summary

Caring for your patient Tension pneumothorax

Relieved: needle decompression Chest tube in; better ventilation

Pericardial tamponade

Relieved with pericardiocentesis

Relief from only 20 to 30 mL

Outcome

To OR for GSW repair; stable condition