BackToBasicsTraumaEmergInstructorOutline
- 1. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 1 This one-day seminar will provide a review of a variety of trauma topics, including head injuries, shock, chest/abdomen injuries and extremity injuries. It will include lectures, small group discussions and skills stations. This session will focus on the basics, but providers from all certification levels will benefit from participation. Eight hours of EMT-B continuing education for Trauma Management Sponsored by the University of Vermont, (IREMS) Initiative for Rural Emergency Medical Services Back to Basics: Trauma ManagementBack to Basics: Trauma ManagementBack to Basics: Trauma ManagementBack to Basics: Trauma Management 0800 Welcome and Introductions Chris McCarthy (IREMS) and Greg Thweatt (IREMS) 0815 Trauma Cases 0915 Break 0930 “We Deliver - Packaging the Injured Patient” 1045 “Science Detectives - Mechanism of Injuries” 1200 Lunch 1300 “Compare & Contrast Head Injury and Shock” and "Scrambled Eggs" 1430 Break 1430 "Think, Pair, Share" and “Matching” 1530 Rescue Rodeo 1645 Wrap-up 1700 Adjourn
- 2. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 2 Needs for Course Packaging 1. C-collar (x4) 2. Back board with straps (x4) 3. Scoop (x2) 4. Blankets (x4) 5. KED (x2) MOI DVD clips Compare and Contrast Handouts Scrambled Eggs Handouts Think, Pair, Share Handouts Matching Game Handouts Rescue Rodeo Situations (one per instructor) Handouts
- 3. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 3 Trauma Cases Notes: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
- 4. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 4 A. (1 hour 15 min): Group A - Part 1 “We Deliver - Packaging the Injured Patient” Need: 6. C-collar (x4) 7. Back board with straps (x4) 8. Scoop (x2) 9. Blankets (x4) 10.KED (x2) Split group into 3 teams (25 minutes per rotation). Have each team practice each lift at least twice Participants take turns being patient. If extra time, discuss safe lifting principles. Ask participants if they have any unusual situations where creative lifting/moving techniques were utilized. KED Practice … use actual car or chairs Scoop … Scoop to a board for a patient in a narrow space (hallway or heavy bed/wall space, isle) where log rolling the patient is not possible. Scoop > lift > slide board under patient > lower patient > remove scoop > strap patient Standing Take Down … Standing take down for patient ambulatory with suspected spinal injury or patients complaining of sudden back pain (chronic pain) who is standing Blanket Lift … Use blanket to assist with lift for patient without a suspected spinal injury (hip pain, extremity injury). Roll half of blanket against side of patient > log roll patient onto exposed blanket > once patient is lateral recumbent unroll rest of blanket > roll patient supine > roll up exposed blanket for handles > grasping rolled up blanket handles lift patient to a standing position. Straddle Lift … similar to scoop, used for patients in tight locations where at least 3 or 4 rescuers straddle patient. Rescuer 1 at head and explains entire process (positioning other rescuers, talking to patient, saying BEFORE each command what to expect) > rescuer 2 at patient’s armpits > rescuer 3 at patient’s hips > rescuer 4 at patient’s thighs (rescuers 2, 3, and 4 facing patient’s head) > rescuer 1 calls lift (“1-2-3-lift”) > patient lifted approximately 6” off ground and board slid under patient.
- 5. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 5 B. (1 hour 15 minutes) Science Detectives - Mechanism of Injury Need: Video clips of MOI (fall, crushing injury, penetrating trauma, MV Crash) to jumpstart large group discussions on MOI including: 1. Kinematics of the mechanism 2. Suspected injuries or injury patterns 3. Related signs and symptoms to suspected injuries
- 6. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 6 C1 (Part 1) Compare and Contrast (40 minutes): Have participants work in pairs for 10-15 minutes by completing the chart looking for similarities and dissimilarities between a high priority patient suffering from an isolated head injury with increasing intracranial pressure and a patient in shock due to internal hemorrhage. Discuss as a whole group after 10-15 minutes. Isolated Head Injury With Intracranial Pressure Hypoperfusion (Shock) Due to Internal Bleeding Mechanism Of Injury (MOI) MVC, pedestrian vs. MV, falls, blunt trauma, penetrating trauma to head/chest, hanging, diving trauma, recreational MVC, pedestrian vs. MV, falls, blunt trauma, penetrating trauma to chest and abdomen (possibly thigh) Mental Status Change of consciousness Unresponsive combative Restless > anxious > confused > lethargic > unresponsive (worsens as shock progresses) Neurological Findings (other than Mental Status) Possible paralysis Possible posturing (decorticate and decerebrate), Normal > weak Airway/Respirations Slow Maintain with cervical precautions Rapid Pulse Low pulse High pulse Weak peripheral pulses Skin Pallor, cool clammy Flushed with distributive (neurogenic) shock Pallor, cool clammy Diaphoresis (later stages), Blood Pressure • Hypertension, • Hypotension later as ICP increases • Normal to Hypotension (depending on what stage of shock) • Narrowing pulse pressure Other Signs/Symptoms Skull fracture, unequal pupils, blood/CSF from ears and nose, seizures, vomiting (especially children) Bruising, external bleeding, blood in urine/feces, abdomen tender with guarding, weakness, nausea/vomiting, thirst Implications Due to Patient’s Age (children, elder) • Small children can become shocky from loss of blood, not so with adults (isolated head injury) • Children may vomit more compared to adults, especially in low grade injuries • Pediatric - young adult compensates longer then tank quickly • Pediatric have less blood volume, can bleed out sooner and less ability to control body temperature • Pediatric capillary refill delayed
- 7. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 7 1 • Small children have proportionately larger head increasing neck trauma with deceleration MOI • Elderly may have preexisting mental status alterations making assessment confusing without the help of historian • Older patients first signs may be dizziness • Poor circulation decreases ability to compensate • Some medications may mask signs (such as pulse with cardiac drugs that keep HR constant and slow) Treatment High flow oxygen Ventilate? C-spine precaution Rapid transport Elevate head of board? High flow oxygen Maintain body temperature Elevate feet?
- 8. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 8 C2 (Part 2) Scrambled Eggs (40 minutes): Have participants pair up and unscramble words related to trauma sunitoocn = Contusion HINT: discoloration when an injury does not break the skin truhpexooamn = Pneumothorax HINT: when air entering the body is a bad thing ntsoidolcai = Dislocation HINT: injury resulting in a parting of ways rai gasb = Air Bags HINT: (two words) both a safety device and a potential mechanism of injury ovyepicohml = Hypovolemic HINT: Inadequate perfusion due to hemorrhage or extensive loss of body water oicmasnntpoe = Compensation HINT = when the body responds to preserve vital organs nlcrtieoaa = Laceration HINT = jagged or sharp in nature caused by sharp or blunt objects tnaeieicsvor = Evisceration HINT = when what should be inside the body is not sitarn = Strain HINT = muscle injury alcecliv = Clavicle HINT = one of the most common fractures involves this bone
- 9. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 9 D1: (30 minutes) Think, Pair, Share Participants are asked to recall a trauma call that they were part of. What was the mechanism of the call? What made the call serious? How was the patient treated? Take one minute to think about the following situation, then in pairs take 10 minutes to discuss thoughts on each call. The remaining time is used to share the paired discussion to larger group. Take a minute to recall a trauma call that you were part of. • What was the mechanism of injury? • What made the call serious? • How was the patient treated? After a minute take turns sharing your thoughts with a partner. After 10 minutes, take turns sharing thoughts from the paired discussion
- 10. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 10 D2. (30 minutes) Matching Game Matching, pair up and have one student mix up group A and allow partner to match. Then switch matching group B: Group A: A Cavitation A Energy that stretches tissue A Neurogenic Shock A Paralysis of the nerves controlling the vessels leading to widespread vasodilatation A Epistaxis A Nose bleed A Hemothorax A Collection of blood in the chest A Partial Thickness Burn A Associated with blisters in addition to white to red, moist and mottled skin A Rule of Palms A Way to estimate the percentage of the body surface burned A Myocardial Contusion A Bruise of heart muscle A Guarding A Contraction of abdomen muscles A Crepitus A Sound caused when injured bones or joints rub against each other A Perfusion A Circulation of blood to cells
- 11. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 11 Group B: B Mechanism of Injury B The way in which trauma occurs B Avulsion B Injury in which soft tissue is torn completely or hanging as a flap B Compartment Syndrome B edema that may cut off the flow of blood or damage sensitive tissue B Occlusive Dressing B Dressing that prevents air or liquid from entering or exiting a wound B Flail Chest B Three or more rib fractures in two or more places B Pericardial Tamponade B Compression of the heart due to fluid buildup in the pericardial sac B Cheyne-Stokes B Abnormal breathing pattern sometimes seen in severe head trauma with staircase respirations and brief intervals of apnea B Traction B Act of pulling on a body structure in the direction of its normal alignment B Stridor B High pitched inspiratory noise due to laryngeal edema such as with neck trauma
- 12. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 12 Rescue Rodeo #1 - Group #____________ Participants spend 10 minutes with each instructor who will describe a Situation To Engage Educate and Reinforce or STEER. Two participants will write down all findings, the rest of the participants will have 5 minutes to ask any questions related to the scenario as if they were assessing and treating the simulated patient. At the end of the 5 minutes the participants who wrote down the findings will tell the instructor all they found. Groups will circulate to each of the 4 scenarios. After all four assessments have been completed, the whole group will review the 4 scenarios together. Case Study: On a Saturday in February, just after 08:00 AM, EMS is dispatched to a major intersection in town for a motor vehicle crash. Assessment Findings: Scene Size Up: Upon arriving at the busy intersection, the crew steps out onto the snow- covered and icy roadway. They observe one vehicle that appears to have collided head-on with a telephone pole. There are wires dangling from the pole. Two patients in vehicle Once unconscious, other talking and denying injury. Initial Assessment: o General Impression Pt is sitting in the driver’s seat, slumped back and is unconcious. He is not wearing a seatbelt and there is deformity to the steering wheel and the dash has collapsed on his legs. Mental Status o responsive to painful stimuli when the crew chief pinches him. Airway o Snoring respirations. Will go away if someone opens airway Breathing o Slow (approx 10) Circulation o Pulse weak & thready. Bleeding from gash on head Focused History and Physical Exam: S – see below A– NKA M– insulin, nitroglycerin P – angina, diabetes L – breakfast E – Driving vehicle, lost control on ice and hit telephone pole Physical Exam – lump on head w/controlled bleeding, pain on both sides of chest with paradoxical breathing, pain in 4 abdominal quadrants, deformity to left femur high up by hip. Enroute JVD noted, bruising on chest, bruising on abdomen which is becoming rigid BaselineVital Signs: HR 60 , BP 90/60 , RR 10 , Skin gray Second Vital Signs: HR 50, BP 80/60, RR 8 Treatment: Oxygen, Rapid Extrication, Collar/Backboard, assist with ventilations via BVM EMTI: IV access as per local protool
- 13. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 13 Rescue Rodeo #2 - Group #____________ Participants spend 10 minutes with each instructor who will describe a Situation To Engage Educate and Reinforce or STEER. Two participants will write down all findings, the rest of the participants will have 5 minutes to ask any questions related to the scenario as if they were assessing and treating the simulated patient. At the end of the 5 minutes the participants who wrote down the findings will tell the instructor all they found. Groups will circulate to each of the 4 scenarios. After all four assessments have been completed, the whole group will review the 4 scenarios together. Case Study: On Monday morning in May, dispatched to local farm for a worker who has fallen from a hayloft. Assessment Findings: Scene Size Up: Arrive on scene of farm, directed to patient lying prone on wooden floor of barn. Bystander reports patient fell approximately 15 feet from hay loft. Initial Assessment: o General Impression Patient lying prone on wooden floor, appears conscious Mental Status o Conscious, alert, oriented to person and place. Remembers working in hay loft, no recall of the call Bystander reports patient experienced LOC of approx 1 minute Airway o Patent Breathing o Shallow, reports pain in inspiration Circulation o Pulse is rapid, bleeding noted in lower leg Focused History and Physical Exam: S – see below A– penicillin M– lipitor P – cholesterol L – breakfast E – working in hay loft Physical Exam –left sided head pain, neck pain, left abdomen pain, left hip pain, and left lower leg pain. Hand grips are equal, not be able to move your left foot without pain. Small laceration mid tib fib, bleeding is minor BaselineVital Signs: HR 100, BP 120/80 , RR 24 , Skin slightly pale Treatment: Oxygen, collar/backboard, splinting, bleeding control. EMTI: IV access per local protocol
- 14. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 14 Rescue Rodeo #3 - Group #____________ Participants spend 10 minutes with each instructor who will describe a Situation To Engage Educate and Reinforce or STEER. Two participants will write down all findings, the rest of the participants will have 5 minutes to ask any questions related to the scenario as if they were assessing and treating the simulated patient. At the end of the 5 minutes the participants who wrote down the findings will tell the instructor all they found. Groups will circulate to each of the 4 scenarios. After all four assessments have been completed, the whole group will review the 4 scenarios together. Case Study: On a Saturday afternoon, respond to a local residence for a person trapped under a vehicle. Assessment Findings: Scene Size Up: Arrive to find a male patient lying supine on the floor in the garage, a few feet away from a vehicle that is on a jack. Neighbors report that the patient was working on the car when the jack fell, trapping him under the car for almost 10 minutes while they were able to lift car back up on jack. Initial Assessment: o General Impression – lying prone holding chest and moaning. Mental Status o Patient alert and fully oriented, full recall of incident Airway o Patent but reports difficulty breathing Breathing o Very rapid and shallow Circulation o Rapid, no obvious signs of bleeding Focused History and Physical Exam: S – see below A– pollen M– Benadryl as needed P – none L – lunch E – cutting tree down Physical Exam – abrasions and bruising across chest, the left side hurts more on inhalation and palpation with the breath sounds louder on the right side. No JVD, trachea mid-line. BaselineVital Signs: HR 100 , BP 110/80, RR 30 , Skin pale, Treatment: oxygen, collar/backboard EMTI: IV access per protocol
- 15. Vermont EMS Conference 2009, March 26 (Thursday) Back To Basics – Trauma Management Initiative for Rural Emergency Medical Services Page 15 Rescue Rodeo #4 - Group #____________ Participants spend 10 minutes with each instructor who will describe a Situation To Engage Educate and Reinforce or STEER. Two participants will write down all findings, the rest of the participants will have 5 minutes to ask any questions related to the scenario as if they were assessing and treating the simulated patient. At the end of the 5 minutes the participants who wrote down the findings will tell the instructor all they found. Groups will circulate to each of the 4 scenarios. After all four assessments have been completed, the whole group will review the 4 scenarios together. Case Study: It is a Friday night in June and you are dispatched to the local tavern for an assault. Assessment Findings: Scene Size Up: After arriving on scene, a police officer escorts you inside where you find a patient sitting up against a wall. Initial Assessment: General Impression: Patient has noticeable blood on the front of his/her shirt, holding a blood soaked towel over his abdomen, wincing in pain Mental Status o Conscious, alert and anxious Airway o Patent Breathing o Rapid Circulation o Weak radial pulse, significant bleeding from abdominal wound Focused History and Physical Exam: S – see below A– NKA M– methadone P – heroin addiction L – dinner, “a couple” of beers E – drinking in bar when got in a fight and was stabbed Physical Exam – laceration in the left upper quadrant and about 3-4 cm wide, oozing blood BaselineVital Signs: HR 120 , BP 110/70, RR 28 , Skin pale Treatment: Oxygen, bleeding control, bandage/dressing. EMTI: IV access per local protocol