ITLS Flashcards
1
Q
Diaphramtic breathing
A
BVM
2
Q
2 adjacent ribs in 2 or more places
A
flail chest
3
Q
4 sides
A
occlusive
4
Q
always shock first
A
80 of arrest is vtach or vfib
5
Q
always give oxygen by nrb
A
because for exam you never know
6
Q
blunt force trauma is most common moi in general regardless
A
7
Q
aystmetrical pupils
A
stroke
8
Q
myocradical contusion just like heart attack has
A
dysrtyhmia
9
Q
you can’t lose enough blood in the head to show shock
if the patient has a head injury and instead of brachydia and hypertension
they have tachy and hypo tension
they are bleeding somewhere
A
10
Q
Successful placement of an OPA should not give you a false sense of security as patients who tolerate an OPA are likely
patients who will require endotracheal intubation because their protective reflexes are so depressed, they cannot protect their lower airways
from aspiration.
A
11
Q
Endotracheal intubation is the gold standard of airway management and could be
considered in the prehospital setting when all other preceding options have failed
to support the patient’s oxygenation and ventilation
A
12
Q
in increasing icp there is pressure on the medulla which can cause irregular breathing
A
13
Q
Compensatory Mechanisms:
In the early stages of shock, the body may compensate for falling blood pressure through mechanisms like tachycardia (increased heart rate) and peripheral vasoconstriction. This can maintain blood pressure temporarily even as perfusion to vital organs diminishes.
Decompensation:
As shock progresses and compensatory mechanisms fail, blood pressure may continue to fall, leading to severe hypotension and multi-organ failure if not promptly treated.
A
14
Q
ICP is considered dangerous when it rises above 15 mmHg; cerebral herniation
may occur at pressures above 25 mmHg
A
15
Q
cpp the pressure inside the brain must be atleast 50-60 or 60 in order to perfuse the brain
cerbreal perfusion pressure
A
16
Q
ICP: The pressure within the skull.
A
17
Q
MAP is pressure in the vascular system
A
18
Q
If icp increases and map stays the same
a cpp of 60 is no longer good enough to perfuse the brain and it has to be higher
A
19
Q
systolic of 110-120 needed to maintain sufficient cpp
A
20
Q
Placement of an ETT can safely occur under three scenarios: cardiac arrest during
which no pharmacology is required, following administration of a sedative and paralytic as part of a drug-assisted intubation (DAI), or during an awake intubation
facilitated with appropriate topical airway medications (not typically an option in
the prehospital environment), Attempting to place an ETT in a patient with depressed
loss of consciousness (LOC) with intact reflexes and muscle tone is a difficult and
dangerous endeavour with a well-documented incidence of increased difficulty (Frerk
et al. 2015).
A
21
Q
Administration of a paralytic is the only
intervention shown to improve first-attempt success rates with intubation, with the
additional benefit of improving compliance of bag-valve mask (BVM) and placement
of SGA
A
22
Q
. Additionally, the
unrecognized esophageal intubation (often delayed in the prehospital environment
due to equipment limitations (etCO2) or the profound shock states of patients) will
quickly lead to critical hypoxemia and cardiac arrest. Given these considerations,
endotracheal intubation is a procedure that should be deferred when possible until the
patient is in a more stable environment with more experienced personnel and more
equipment and monitoring capabilities
A
23
Q
n. Remember, patients who have spontaneous yet inadequate respiratory effort
are often better off with noninvasive support than the patient who has been given a
paralytic and can neither be intubatex nor mask-ventilated.
A
24
Q
A patient who is maintaining oxygenation and ventilation is often better transported, with continuous observation for deterioration, out of an austere environment
for definitive airway management to occur in a hospital or other monitored setting.
Ventilation with a BVM or SGA and immediate transport of the patient may be a
better option in certain instances than taking the additional time required to perform
rapid sequence intubation (RSI). A spontaneously breathing patient with an appropriate O2 saturation is always better than an ill-equipped RSI.
A
25
A patient who is maintaining oxygenation and ventilation is often better transported, with continuous observation for deterioration, out of an austere environment
for definitive airway management to occur in a hospital or other monitored setting.
Ventilation with a BVM or SGA and immediate transport of the patient may be a
better option in certain instances than taking the additional time required to perform
rapid sequence intubation (RSI). A spontaneously breathing patient with an appropriate O2 saturation is always better than an ill-equipped RSI.
26
ROSC
27
Decontamination must occur before any patients can be properly cared for.
Emergency Medical Responders may be asked to assist with the decontamination process
28
due regard
29
Once the decision to intubate has been made, emergency care providers must identify an appropriate approach for that patient, with consideration given to alternative
techniques available should difficulty be encountered
30
Although direct-vision orotracheal intubation is considered the primary method of
placing an ETT in the trachea, the procedure is not always easy. In the management of
trauma patients particularly, options must be available to permit successful intubation
in even the most challenging of situations and patients. There is evidence that the technique of direct-vision orotracheal intubation results in some movement of the head
and neck, the clinical significance of which is unclear (Robitaille et al. 2008). Although
intubation of supine trauma patients using direct laryngoscopy is a safe option with a
high success rate, emergency care providers must consider that if difficulty is encountered it may be from an inability to optimally align the oral–pharyngeal–laryngeal axis
due to C-spine immobilization. As such, alternative intubating approaches such as
the use of a video laryngoscope (VL) designed to “look around the corner” should be
considered. VL, however, in the soiled or bloody airway may be impossible relative
to direct laryngoscopy.
31
In situations of significant craniofacial trauma with an obstructed airway, rapidly
moving to an emergency surgical airway may be required, even in the prehospital
environment. The indication for a surgical airway is the inability to secure an airway
by any other means, and the provider should perform a cricothyrotomy using a bougie, scalpel, and a small-caliber ETT
32
Those with a low risk of cervical spine injury can be intubated in the conventional
way, using a direct laryngoscope. Intubation by video laryngoscopy, the nasotracheal
route, the tactile or transillumination methods, or a combination should be reserved
for patients with specific indication for alternative techniques. In short, the method
of intubation should be suited to each patient on a case by case basis
33
This decision should not be
taken lightly, however, as several problems may be encountered when you decide to
intubate a trauma patient. Due to the possibility of unstable cervical spine injuries,
all trauma patients should be intubated supine with in-line cervical stabilization, a
practice that makes all trauma intubations potentially difficult
34
The goal of prehospital trauma care is to minimize injury and reduce preventable
death. To accomplish these goals, the prehospital care provider must focus on treating
the preventable causes of death on scene, minimizing secondary insults, and rapidly
transporting to a facility capable of definitively addressing the patient’s injuries. The
organized evaluation of the trauma patient and treatment of the associated signs and
symptoms in a time-sensitive manner can be potentially lifesaving.
35
Unless the patient is
entrapped or the ambulance
has not arrived on scene, start
intravenous therapy while
transporting the patient to
the receiving facility
36
* Control major bleeding.
* Provide airway management.
* Assist ventilation.
* Begin CPR.
* Seal sucking chest wounds.
* Decompress a tension pneumothorax.
* Stabilize impaled objects.
37
ITLS Ask close-ended questions when getting a history from patients. Close-ended
questions can be answered with a yes or a no. Patients may only be able to
concentrate for short periods of time, and they may ramble when asked openended questions that require a full answer. Consider getting as much of the history as you can from relatives, friends, or bystanders. This might help improve
the reliability of what you discover. Get as much relevant history as you can, but
do not delay transport
38
Narcotics/opiates Heroin, horse, big H, Darvon,
codeine, stuff, morphine, smack,
fentanyl, Percocet, opana
Altered mental status, constricted
pupils, bradycardia, hypotension,
respiratory depression, hypothermia
39
When ICP increases, the systemic blood pressure increases to try to preserve blood flow to the brain. The body senses the rise in systemic blood pressure,
and this triggers a drop in the pulse rate as the body tries to lower the systemic blood
pressure by lowering cardiac output. With severe injury or ischemia, the pressure
within the skull continues in an upward spiral until a critical point at which ICP
approaches the MAP and there is no cerebral perfusion. Because CPP depends on
both the arterial pressure and ICP, hypotension will also have a devastating effect
if ICP is high.
40
You must maintain a CPP of 60–70 mmHg (see earlier formula), which
requires maintaining a MAP of greater than 70 mmHg in the patient with severe
TBI. Hypotension due to TBI alone is rare, occurring in about 5% of patients with
isolated severe TBI (Glasgow Coma Scale [GCS] score of 69). A patient with a
significant TBI who is hypotensive is bleeding from somewhere or has a spinal
cord injury causing neurogenic shock
41
number 1 in genreally i think is rapid transport
42
the face and the scalp is highly vascular
43
if there is no
44
adults with a scalp wound probably won't bleed that much
but a child with head face or scalp injury it can be very problamatic
if bone is stable undert there or there you can use direct pressure
you want to consider intubation and suction
you are going to have trouble with intubation with facial injuries
45
if skulll is fractured that is a open head injury
that doesn't mean that the scalp is also exposed
it may be depressed
46
concussion has no structural injury to head
loss of conciossness
variable period of unconciousnss or confusion
followed by return to normal concousness
retrograde short term amnesia
may repeat questions over and over again
dizziness, nausua, ringing in ears
47
The Arizona Excellence in Prehospital Injury Care Traumatic Brain Injury (EPIC-TBI)
project reports that because it is very difficult to identify herniation without a CT
scan, some patients in the field receive hyperventilation when not necessary, which
can cause harm
48
what can reduce the occurrence of concussion
Better protective
equipment can reduce the occurrence of concussion
49
A patient with cerebral contusion (bruised brain tissue) will usually have a history of
prolonged unconsciousness or serious alteration in LOC (e.g., profound confusion,
persistent amnesia, abnormal behavior). Although rare, brain swelling may be rapid
and severe. The patient may have focal neurologic signs (weakness, speech problems)
and appear to have suffered a cerebrovascular accident (stroke). Depending on the
location of the cerebral contusion, the patient may have personality changes such as
inappropriate or rude behavior or agitation.
50
As noted earlier, hyperventilation will decrease
the size of the blood vessels in the brain and briefly decrease ICP. In this situation
the danger of immediate herniation outweighs the risk of cerebral ischemia that can
follow hyperventilation. Cerebral herniation syndrome is the only situation in which
hyperventilation is still indicated. (You must ventilate every 3 seconds [20/minute]
for adults, every 2.5 seconds [25/minute] for children older than 1 year, and every
2 seconds [30/minute] for infants younger than 1 year.) If you have waveform
capnography
51
diffuse axonic
won't have focal symptoms
does have unconciouss
52
hypothermia may prevent axonic injury
53
intercraniel hemmorage presents much like a stroke does
54
acute epirdermal hemota
arterial bleed
55
, if needed,
for chemicals and then application of an eye shield. If there is a possible open globe,
characterized by an irregularly shaped pupil, do not irrigate. Cover with an eye shield.
Do not allow any pressure on the globe itself to prevent extrusion of the eye contents.
Elevate the head of the stretcher if possible.
56
This is just not true. In many parts of the world, babies are born away from medical facilities each and every day. The anatomy of the female, the unborn child, and the structures formed during pregnancy enable the birth process to occur with few problems
57
The fetus grows inside a special sac called the amniotic sac. It is filled with fluid, called amniotic fluid, which surrounds and protects the baby. Although the sac may have ruptured earlier, it usually breaks during labor, and the amniotic fluid flows out of the vagina (birth canal). This is called the rupture of membranes and is an important milestone in the birthing process. When you are assessing the mother, you will ask her if her “water has broken.”
58
In most developing countries, it is quite common for the mother to be receiving prenatal care and have given lots of time and thought to the planning of the delivery of her child. It is appropriate for the EMR to ask about these plans and what her preferences might be. While it is not always possible to accommodate these preferences in the field, it is respectful to at least acknowledge that she had other plans.
59
Interval time. This is the span of time from the start of one contraction to the beginning of the next contraction. As labor progresses, the interval time will become shorter. This is the time that is referred to when discussing the frequency of contractions.
60
Throughout pregnancy the mother might experience light, painless, irregular contractions, which may increase gradually in intensity and frequency during the third trimester.
61
It may be difficult for you and the mother to distinguish false labor pains from true labor. Any pregnant woman who is having contractions should be evaluated by her doctor.
Remember that your primary role is to help the mother deliver the baby when birth is imminent. You will need to make sure that you have the necessary supplies and materials to do this.
62
but during delivery is not the time to find supplies. The items you will need include the following:
63
An apparent life-threatening event (ALTE) is the sudden onset of certain alarming signs such as prolonged periods of no breathing (apnea), changes in skin color or muscle tone, coughing, and gagging in children under 1 year of age.
In almost all cases, apnea occurs while sleeping. For this reason, it is called sleep apnea. Some cases of sleep apnea are related to airway obstruction, while others are associated with failure in the central nervous system to stimulate respirations during sleep. The relationship between ALTE and sudden infant death syndrome (SIDS) is still unclear.
64
Upper respiratory tract infections
croup
caused by a virus and affects the larynx (voice box), trachea, and bronchi. It usually causes the tissues in the upper airway to become swollen, restricting airflow.
65
A less common problem that can affect the respiratory status of a pediatric patient is known as epiglottitis. It occurs when the epiglottis (the flap that closes over the trachea while swallowing) becomes inflamed. Epiglottitis can have a sudden onset in what seems to be an otherwise healthy child. Suspect this respiratory emergency if the child develops a rapid fever, has cold-like symptoms, has difficulty swallowing, and is drooling. Children with epiglottitis will also sit upright in a tripod position (leaning forward with arms braced on the edge of the bed or chair) with the chin thrust out and the mouth wide open. You will notice that they will use the muscles in the upper chest and those around the shoulders and neck to breathe. This effort to breathe is very tiring for the child. The Emergency Medical Responder must act quickly. Although uncommon, epiglottitis is considered life threatening.
66
croup and epilogtitis
Do not place anything in the child’s mouth (a tongue depressor, for example) in an attempt to examine the airway. Probing the mouth can cause spasms that will further close the airway. Avoid any actions that might agitate or stimulate the child.
If you see a child presenting with signs and symptoms of croup or epiglottitis, call for transport immediately and keep the child comfortable and calm.
Signs and symptoms of respiratory distress include the following:
Cyanosis (late sign)
Capillary refill of more than two seconds (late sign)
Slow heart rate (late sign)
67
It can become life threatening if left untreated. Most children who have asthma
Whenever possible, listen for evidence of wheezing. A child with a history of asthma who is in respiratory distress and who is not wheezing is at serious risk of respiratory failure.
Sleepiness or slowed response
Wheezing that can be heard with a stethoscope and possibly without
68
Administer oxygen. (Follow local protocols.) Ask the child to breathe in normally but to blow out air forcefully, as if blowing out the candles on a birthday cake or blowing up a balloon. Show the child how and breathe with him or her.
If you are allowed to assist in giving medications, help a parent or caregiver administer the child’s medication.
69
Seizures caused by fever (febrile seizures) should be taken seriously. If a child is having prolonged or multiple seizures, consider it a life-threatening emergency and call for transport immediately.
In many cases, a patient’s seizures stop before EMS arrives. After a seizure, it is normal for children to be lethargic (drowsy) and difficult to arouse
70
Has the child had prior seizures? How long did they last? What part of the body was affected?
Has the child had a fever recently?
Has the child had an injury or fall in which the head may have been struck?
Is the child taking any medications, specifically medication for seizures?
Did the child’s skin (nail beds and mucous membranes) change from its normal color to pale or bluish during the seizure?
71
Any child who has had a seizure must have a medical evaluation. Arrange for transport as soon as possible. In the meantime, provide the following emergency care steps after the suspected seizure:
Maintain an open airway and insert nothing in the mouth.
Look for evidence of injury sustained during the seizure.
If you do not suspect a spinal injury, position the child on his or her side.
Be alert for vomiting.
Provide oxygen or assisted ventilations with supplemental oxygen if allowed to do so.
Monitor breathing and altered mental status.
72
crush syndrome: a systemic
condition that results from
crushing injury to muscles with
cell death. The release of toxic
products, including myoglobin,
results in development of shock
and acute renal failure and
eventual death. Also known as
traumatic rhabdomyolysis
In addition, the damaged
cells can leak potassium and myoglobin, a protein from muscle. Most extremities can
tolerate up to 4 hours of ischemia due to compromised flow before cell death occurs,
although tissue injury can happen in as little as an hour of circulatory compromise.
73
When this bleeding or swelling is
contained within the muscle by the fascia, pressure in the compartments can rise. This
results in what is called the compartment syndrome.
Late signs and symptoms of compartment syndrome are the “five Ps”: pain, pallor,
pulselessness, paresthesia, and paralysis. The early symptoms are usually pain, typically described as pain out of proportion to the injury, and paresthesia (numbness
and tingling)
74
Stage 1 begins with the onset of regular contractions and ends when the cervix is fully dilated (approximately 10 centimeters), allowing the baby to enter the birth canal.
Stage 2 begins when the baby enters the birth canal and ends when he or she is born.
Stage 3 begins when the baby is born. It ends when the placenta, commonly referred to as the afterbirth, is delivered
75
Throughout pregnancy the mother might experience light, painless, irregular contractions, which may increase gradually in intensity and frequency during the third trimester.
This is known as false labor, also referred to as Braxton Hicks contractions. False labor pains are not as regular and rhythmic as true labor contractions.
76
Throughout pregnancy the mother might experience light, painless, irregular contractions, which may increase gradually in intensity and frequency during the third trimester.
This is known as false labor, also referred to as Braxton Hicks contractions. False labor pains are not as regular and rhythmic as true labor contractions
77
This is the regular care and monitoring of the fetus by a healthcare provider throughout the pregnancy. A woman who has been receiving regular prenatal care will be more informed if there are any expected complications with the delivery.
78
If the expectant mother is in active labor (contractions that are two minutes apart or less) and complains that she feels as if she needs to go to the bathroom or have a bowel movement, tell her that this is normal and that it is caused by pressure on her bladder and rectum. Encourage her to remain lying down. Explain that her body is reacting normally to all the changes that are taking place. In preparation for delivery of the baby, place clean sheets or towels under her buttocks. If she does have a bowel movement or urinates, tell her that this is normal.
79
What is the expected due date?
Has she been seeing a doctor during her pregnancy?
Does she have other children?
80
The baby is delivered directly from the uterus instead of through the vaginal canal. This procedure is done for many reasons that include abnormality of the fetus, placenta, uterus, or mother’s medical history that interferes with normal vaginal delivery.
81
Is she aware of any known complications, particularly a multiple birth (twins or triplets)?
Does she have any significant medical history such as seizures, diabetes, or vaginal bleeding during the pregnancy?
82
If the mother says she feels the baby trying to be born or that she has the urge to bear down,
83
She may insist on using the bathroom during the delivery process. Be prepared for this, and never allow a mother in active labor (contractions that are two minutes apart or less) to use the restroom because there is risk that she may deliver the baby into the toilet
84
As each contraction begins, have the mother take a deep breath, hold it, and encourage her to gently bear down, or push.
Encourage her to rest between each contraction and to breathe normally.
If available, have the father or someone appropriate at the mother’s head to help coach her through each contraction.
85
Position the mother on her back with her knees bent, feet flat, and legs spread wide apart. If this position causes her to feel dizzy and faint, it may be because the weight of the baby is pressing on the inferior vena cava, the vessel that returns blood from the lower part of the body to the heart, and is restricting blood flow back to the heart. Allow the mother to sit up slightly and support her back with pillows and/or blankets.
86
Palpate the mother’s abdomen to feel for contractions when she says she is having a contraction. Explain what you are going to do, and place the palm of your hand on her abdomen above the navel. It is not necessary to remove any of the patient’s clothing to feel for contractions. If the mother says she can feel the baby coming, skip this step. Feel for, and time, several contractions to help determine if birth is near. As birth nears, the interval time will decrease, and you will feel the uterus and the abdomen become more rigid. If the interval time between contractions is three minutes or less, consider that birth may be imminent.
87
Control the scene so the mother will have privacy. Ask unnecessary bystanders to leave. You may have to move her a short distance to a more private place. If labor is not too severe, it may be appropriate to allow the mother to walk. If she appears to be in early labor and this is her first child, her labor pains will typically have long contraction and interval times.
88
Position the mother on her back with her knees bent, feet flat, and legs spread wide apart.
89
Palpate the mother’s abdomen to feel for contractions when she says she is having a contraction. Explain what you are going to do, and place the palm of your hand on her abdomen above the navel. It is not necessary to remove any of the patient’s clothing to feel for contractions. If the mother says she can feel the baby coming, skip this step.
90
Prepare the mother for examination. Tell her that you need to see if her baby has entered the birth canal. Help her to remove clothing or underclothing that obstructs your exam of her vaginal opening. Use clean sheets or towels to cover the mother. If you have a commercial obstetric (OB) kit, use the materials provided
91
Check for crowning. See if any part of the baby is visible at the vaginal opening. In a normal headfirst birth, you will see the top of the baby’s head; this is called crowning, although any part of the baby may present first. The area of the head that you see on your first inspection may be only a couple of inches. The mother is now in the second stage of labor because the baby is in the birth canal. Do not try to transport the mother at this point.
92
Do not attempt any type of internal or vaginal exam. Touch the vaginal area only as necessary during the delivery process.
93
Because the patient will be rendered apneic, hypoxia will rapidly
follow. To extend the time for intubation, nitrogen in the lungs is “washed out” by
having the patient breathe 100% oxygen for 2–3 minutes or eight full tidal breaths.
Washout of the nitrogen allows the patient to tolerate up to 5 minutes of apnea (only
2–3 minutes in children) during intubation without becoming hypoxic. In patients
with airway compromise or other problems, ventilations can be assisted
94
Another useful technique to increase the time until the patient becomes critically hypoxic is apneic oxygenation. Instilling oxygen via a nasal cannula
(>12 liters per minute) maintains a high oxygen concentration gradient from the
nasopharynx down to the alveoli. As oxygen is absorbed in the alveoli, more oxygen moves down this gradient into the alveoli, even if there is no ventilation. However, because there is no ventilation, carbon dioxide levels in the blood do rise, and
with the hypercarbia, the patient does become acidotic.
95
Wash your hands with soap and water, or use a commercial hand wash. Don personal protective equipment (gloves, mask with eye shield, and gown) if you have not already done so.
Drape the mother and place her on top of clean sheets or towels. Place a folded blanket, towels, or sheets under her buttocks to lift her pelvis about two inches. You may place a pillow under her head and shoulders for comfort.
Position someone near the mother’s head or use the mother’s coach to reassure and offer her encouragement and to turn her head in case she vomits. If no one is on hand to help, talk with the mother during the delivery process and be alert for vomiting.
Place one hand below the baby’s head as he or she delivers. Spread your fingers evenly around the head to support the baby but avoid pressing the soft areas known as fontanels, at the top of the baby’s skull. They are areas where the skull bones have not completely closed together. Apply a slight pressure on the baby’s head as he or she emerges to control the speed of delivery. Sometimes the head can “pop out” too quickly from the birth canal, which can tear the skin at the vaginal opening or perineum. (Some stretching and tearing is normal.) Use your other hand to help cradle the baby’s head. Do not pull on the baby.
If the amniotic sac has not yet ruptured, use a cord clamp or your gloved fingers to tear the membrane and pull it away from the baby’s mouth and nose.
Most babies are born face down as the head emerges. Then they rotate to the right or left. Once the head is delivered, instruct the mother to stop pushing. You need a few seconds to check for the presence of the umbilical cord wrapped around the baby’s neck. This is called a nuchal cord. If you find the cord is wrapped around the baby’s neck, use two fingers and attempt to slip it over the baby’s head or shoulders. We will discuss later what to do if you are unable to easily slip the cord over the baby’s head.
The upper shoulder usually delivers next, followed quickly by the lower shoulder. Continue to support the baby throughout the entire birth process. On the next contraction, gently guide the baby’s head downward, which will assist the mother in delivering the baby’s upper shoulder. Then gently guide the baby’s head upward to facilitate the delivery of the bottom shoulder. Scan 23.1 illustrates hand placement during delivery.
Once the baby’s feet deliver (the end of the second stage of labor), lay the baby on his or her side with his or her head slightly lower than their body. This position will enable blood, other fluids, and mucus to drain from the mouth and nose. Wipe the baby’s mouth and nose with gauze pads.
Once the baby is completely delivered, note the exact time of birth.
Keep the baby at the level of the vagina until the cord is cut.
Wait at least one minute following delivery, and clamp or tie the umbilical cord. The first clamp should be placed approximately six inches from the baby’s abdomen. The second clamp should be placed approximately two inches away from the first (farther from the baby). Then cut the cord between the clamps. If you do not have sterile equipment, do not cut the cord. Simply clamp it. Follow local protocols.
Monitor and record the baby’s and mother’s vital signs. Support the ABCs as necessary.
96
However, because the patient is rendered apneic, the emergency care provider must be able to provide airway and ventilation for the patient.
Not all EMS systems allow use of paralytic drugs and may instead utilize sedation
only to assist with intubation
97
Loss of airway remains the leading cause of early preventable trauma deaths, and hypoxia has been shown to worsen outcomes for trauma
patients, especially those with closed head injury.
98
Unless there is a critical need, the procedure should be performed during transport.
In the urban setting where there are short transport times, the need for a definitive
airway should be balanced against use of other airway methods and the impact on
transport times
99
Multiple studies have shown that EMS personnel can be effectively taught to use
DAI and apply it in the field setting. Other studies have shown a potential for prolonged hypoxia during this procedure, so constant recording of pulse oximetry reading should be done, and there should be a strict quality improvement program that
monitors intubation time, oxygenation of the patient, and scene time.
100
The worst thing you can
do in airway management is take a spontaneously breathing patient and place
him or her into a “can’t intubate and can’t ventilate” situation. All personnel
who utilize DAI should be familiar with and able to use one of the many SGAs
and should also be able to perform a cricothyroidotomy if unable to ventilate or
intubate the patient
101
A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma
102
Indication: Cricothyrotomy is for emergency, temporary airway access, while a stoma (specifically a tracheostomy) is usually for long-term airway management
103
FAST is an ultrasound scan and triage tool routinely performed in the emergency department to assess patients presenting with blunt abdominal trauma. A potential benefit of FAST exam use in the prehospital setting is accelerated diagnosis of intraperitoneal hemorrhage from blunt abdominal trauma
The use of the FAST exam in the prehospital setting may allow patients to be triaged to a higher acuity level with blunt abdominal trauma. By alerting emergency departments with the transmission of ultrasound images, trauma centers could be better prepared to allocate resources in anticipation of the patient’s arrival. An early diagnosis in the prehospital setting may also give the physician knowledge enough to prioritize relevant treatment. Ultrasound in the prehospital setting is becoming more common in systems in Europe and the United States, especially as size and cost of units have decreased in the past few years. Studies have shown ultrasound can also be used to help detect the presence of pneumothoraces, tamponade, and endotracheal tube position in the field as well as help with IV access and to assess for cardiac activity during management of cardiac arrest. It must be stressed that a FAST exam should not delay transport of trauma patients to the appropriate facility.
104
Management of abdominal trauma in the field not only focuses on rapid transport to an appropriate facility, but also on the identification of internal bleeding. Exsanguination is a common cause of death in trauma patients
105
TXA has been studied and its use decreases mortality. No benefit is seen if given beyond 3 hours after the time of initial injury
106
Lactate has been shown to be a biochemical marker of developing shock. Newer systems to measure lactate levels at the bedside have been developed and are proving useful to identifying patients in shock before clinical symptoms develop. This may be another clue to ongoing internal hemorrhage, which would be an indication to transport directly to a trauma center or other facility capable of managing internal trauma.
Prompt diagnosis and treatment of patients with abdominal trauma is considered essential in the successful management of the trauma patient. Continued study of these and other innovative prehospital diagnostics and treatment options is needed.
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In the field setting, it is impossible to determine the extent of the damage in electrical burns because much of the burn injury is deep within the muscle. Therefore, all patients with electrical burns should be transported for hospital evaluation. Due to the potential for arrhythmia development, routine IV access should be initiated in the ambulance, along with continuous cardiac monitoring. IV fluid resuscitation should be started during transport in this situation. Because of extensive tissue destruction, the fluid needs during interfacility transport of an electrical burn patient are often higher than for patients with thermal burns. The rule of nines may underestimate fluid needs.
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Patients with electrical burns are at risk for developing rhabdomyolysis, which is the breakdown of muscle with the release of myoglobin into the circulation and renal failure, as the myoglobin crystals block the kidney tubules. In those cases, the rule of nines is not applicable, and formulae such as the Parkland formula do not adequately estimate the fluid needs of these patients. Resuscitation is guided by the response to fluid therapy with the target being to maintain a urine output of 0.5–1 cc/kg body weight per hour. This level of urine flow also helps to reduce the risk of renal failure from rhabdomyolysis. Also with breakdown of muscle cells, potassium is released into the circulation and can lead to hyperkalemia, which can result in cardiac arrhythmias and death. Tall peaked T-waves on the ECG may be a sign of hyperkalemia. Intravenous calcium (gluconate or chloride) along with intravenous sodium bicarbonate, 50% dextrose, and insulin can temporarily reduce the effects of hyperkalemia on the heart.
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Lightning is a significant cause of weather-related deaths in North America each year. A lightning injury is very different from other electrical injuries in that lightning produces extremely high voltages (>10,000,000 volts) and currents (>2,000 amps), but has a very short duration (<100 msec) of contact.
Lightning produces a flashover phenomenon, in which the current flows around the outside of the victim’s body. Consequently, the internal damage from current flow seen with generated electricity is not seen in a lightning strike. Most of the effects from a lightning strike are the result of the massive direct current (DC) shock that is received. Classic lightning-strike burns produce a fernlike or splatter pattern across the skin (Figure 17-17)
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