Paramedic update part 3
- 2. Objectives • Identify incidence and morbidity/mortality in neonatal complications. • Review leading causes of death in the <1 year bracket. • Discuss the assessment format and interventions for a newborn child. • Review a mnemonic to assist the paramedic in remembering steps and interventions on a neonate.
- 3. Introduction • In utero, the fetus is totally dependent on the mother for survival. • Once born, the neonate now needs to rely on his own body processes for survival. • Many times, there are congenital or acquired anomalies that disturb the body's processes.
- 4. Epidemiology • 2 percent to 5 percent of all live births have some type of congenital anomalies. • 20 percent to 30 percent of perinatal deaths are the result of congenital anomalies.
- 5. Epidemiology • 10 percent of births will need some medical help at birth to begin life. • 1 percent will need aggressive resuscitation to survive the neonatal period.
- 6. Terminology • Review of terminology related to newborns – Fetal or in utero – Gestational period – Premature – Term – Late term – Perinatal – Infancy
- 7. Transitioning • Review the anatomic and physiologic changes from in utero to the extrauterine environment. • The lungs must open and allow gas to be exchanged for the first time. • Discuss how meconium aspiration, structural defects, and infection can affect the neonate.
- 8. AABBCCss ““IInn TThhaatt OOrrddeerr,, EEvveerryy TTiimmee”” • Airway – Anatomical differences make positive pressure ventilation challenging. – Do not place pressure on the trachea. – The insertion of an oropharyngeal airway or a nasopharyngeal airway may help control the airway. – The use of a bag-valve-mask does not require much force or strength.
- 9. To provide positive pressure ventilation, use a bag-valve mask. Maintain a good mask seal. Ventilate with just enough force to raise the infant’s chest. Ventilate at a rate of 40–60 per minute for 30 seconds, then reassess
- 10. Pathophysiology • Breathing – Rate of 40–60 per minute. • 30–40 for older neonate.
- 11. Pathophysiology • Breathing – Tidal volumes • 15–25 mL for a newborn. • 25–50 for a neonate up to 1 month of age. • “Just enough to move the chest.” – Use a manometer to keep airway pressure <30 cmH2O.
- 12. Pathophysiology • Breathing – If adequate: • Rapid improvement in color and perfusion will occur. • Heart rate will normalize. • Spontaneous respirations may return. • Use a blended mix of oxygen to achieve a desired pulse oximetry level.
- 13. Pathophysiology • Careful and efficient basic airway management is preferred over advanced techniques. • Meconium aspiration should only be performed to distressed babies. • Review the 2010 AHA Guidelines for achieving the desired SpO2 levels.
- 14. Pathophysiology • Circulation – If persistently bradycardic (<60 bpm), signs of poor perfusion after 1 minute of BVM with oxygen, start compressions. – “Thumb technique” is recommended. – Compression: Breath ratio 3:1
- 15. To provide chest compressions, circle the torso with the fingers and place both thumbs on the lower third of the infant’s sternum. If the infant is very small, you may need to overlap the thumbs. If the infant is very large, compress the sternum with the ring and middle fingers placed one finger’s depth below the nipple line. In the newborn, compress the chest one-third the depth of the chest at the rate of 120 per minute and a ratio of 3:1 compressions to ventilations.
- 16. Pathophysiology • Circulation • Obtain intravenous access – Can be challenging. – Use intraosseous if needed. • Consider 1:10,000 epinephrine if heart rate does not increase. • Determination of poor perfusion
- 17. WWhhaatt iiss aafftteerr AABBCC?? DDEEFFGG ““DDoonn''tt EEvveerr FFoorrggeett GGlluuccoossee”” • Fuel stores in infants are quickly exhausted. – Coordinating feeding and breathing is exercise enough for a sick infant. – Ascertain feeding and sleeping patterns. – Always access a blood glucose level. – Glucose (D10W) administration in the neonate. – 5-10ml/kg iv over 20 min.
- 18. H is for Hypothermia • Hypothermia – Environmental temperature is important – The best resuscitation efforts will fail on a cold neonate. – If the temperature in the back of the ambulance is comfortable for you, then it is too cold for the neonate.
- 19. I is for Infection • Infection – Major killer of neonates – ANY of the following requires physician evaluation: • ANY history of fever, cyanosis, apnea, rapid or shallow breathing. • ANY history of poor feeding, decreased urine output, or vomiting. • ANY blood in stool, urine, or emesis. • ANY rash beyond “baby acne.”
- 20. Safe Transport of the Infant • Transport in parent's arms is not acceptable. • Transporting the neonate in an isolette is ideal. • Use a commercially available age-appropriate car seat, or an integrated car seat.
- 21. Case Study • You are called to care for a 3-week-old baby who has “stopped breathing.” Upon your arrival, you are met at the door by a frantic young mother holding a limp baby. The mother is crying and, through her sobs, you can barely understand her saying something about “sleeping,” “blue,” and “not breathing.”
- 22. Case Study (cont'd) • What kinds of problems could this neonate have? • What are your priorities?
- 23. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no entry or egress problems. – 3-week-old male, about 6 or 7 pounds. – Patient found in mother's arms, limp.
- 24. Case Study (cont'd) • Scene Size-Up – Mechanism of illness/nature of injury is unresponsiveness. – First child, no prenatal care, minimal hospital stay at birth.
- 25. Case Study (cont'd) • Primary Assessment Findings – Patient unresponsive. – Airway looks clear with manual technique. – Breathing slow and irregular. – Carotid pulse 98/min, peripheral pulse absent. – Peripheral skin cool and blue. – Poor muscle tone, neonate is very limp.
- 26. Case Study (cont'd) • Is this patient a high or low priority? Why? • What are the patient's life threats, if any? • What care should be administered immediately? • Should endotracheal intubation be initiated immediately?
- 27. Case Study (cont'd) • Medical History – Born 1 week early, recent diagnosis of upper respiratory infection. • Medications – Nebulized med for upper respiratory infection. • Allergies – Mother does not think infant has any.
- 28. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils sluggish to respond to light. – Airway patent, patient being ventilated at 30/min. – Central pulse present now only 60/minute.
- 29. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Skin is still cool, cyanosis has resolved some. – Pulse oximetry only 90 percent with PPV and supplemental oxygen. – Patient still limp, no response to interventions.
- 30. Case Study (cont'd) • Is the infant improving or deteriorating? • Is there any additional treatment or change in treatment required? • What is the likely underlying cause for the emergency?
- 31. Case Study (cont'd) • Care provided: – Patient positioned supine, secured for transport. – Ongoing PPV with oxygen. – Compressions administered when heart rate dropped below 60/min with poor perfusion.
- 32. Case Study (cont'd) • Care provided: – Temperature maintained with ambulance heater and warm blankets. – Rapid transport with paramedic intercept.
- 33. Case Study (cont'd) • What signs and symptoms would indicate that the patient’s condition is still deteriorating?. • What additional interventions will you provide?
- 34. Case Study (cont'd) • Additional care provided: – Peripheral IV access or IO access. • Fluid administration with use of buretrol. – Administration of epinephrine. – Reassess and monitor the patient.
- 35. Summary • Neonatal emergencies are stressful for the parent as well as EMS providers. • Remember the mnemonics for assessing and managing neonates: – ABCs “In that order every time” – DEFG “Don't ever forget glucose” – H is for hypothermia – I is for infection
- 36. Summary • Also ensure proper and secure transport to hospital in ambulance. • Paramedics must remember that good basic interventions are preferred when managing for this age group, but they must be competent in providing advanced interventions when needed.
- 37. 55 TOPIC OObbsstteettrriiccss ((AAnntteeppaarrttuumm CCoommpplliiccaattiioonnss))
- 38. Objectives • Review rates for complications seen during pregnancy. • Discuss specific pathology related to obstetric emergencies. • Review specific questions to ask when obtaining an obstetric history. • Review assessment parameters and current treatment standards for a patient with antepartum complications.
- 39. Introduction • Antepartum refers to the period of pregnancy prior to the onset of labor. • Emergencies that occur during this time may be benign or even life threatening. • The goal of the paramedic is to differentiate between these and provide safe, and occasionally lifesaving, treatment to these patients.
- 40. Epidemiology • 4 percent of all pregnancies develop third trimester complications. – 22 percent are placenta previa cases. – 31 percent are abruptio placentae cases.
- 41. Pathophysiology • Placenta Previa – Placenta implants over the internal cervical os. – Types include complete, marginal, and partial. – Cervical effacement can lead to hemorrhage at the implantation site.
- 42. Placenta previa.
- 43. Pathophysiology • Abruptio Placentae – Placental lining separates from the uterus. – The expanding collection of blood continues to force the placenta away, which increases bleeding. – Complete and partial abruption occurs.
- 45. Pathophysiology • Ectopic Pregnancy – Pregnancy in which the ovum implants outside the uterine cavity. – Still the leading cause of pregnancy-related deaths in the first trimester. – Almost 100 percent result in fetal death.
- 47. Pathophysiology • Preeclampsia and Eclampsia – Preeclampsia has hypertension, edema, protein in the urine, visual disturbances, and headaches. – Eclampsia is all the above, but in addition the patient has now developed generalized tonic-clonic seizures. – Preeclampsia is the third leading cause of pregnancy-related death. • New hypertension >140/90 mmHg • Previous history of hypertension > 30/15 mmHg above norm
- 48. Pathophysiology • Spontaneous Abortion – Loss of pregnancy before the age of viability. – Spontaneous means abortion was unintentional, involuntary, and due to some natural cause. – Patient will commonly have abdominal cramping, discharge, and expulsion of tissues of conception.
- 50. Assessment • Physical exam should follow the standard primary and secondary assessments. • Assessment techniques should be the same as those for a non-pregnant patient.
- 51. Assessment • Patient interview should include a focus on: – When was last menstrual period? – Have you been pregnant before? – Are you experiencing any pain or discomfort? – Are you having any vaginal discharge? – Any prenatal care? – When is your due date?
- 52. Antepartum Complications and Associated Signs and Symptoms
- 53. Emergency Medical Care • Consider spinal immobilization. • Assess and maintain the airway. • Determine breathing adequacy. – Provide oxygen if adequately breathing. – Provide high-flow oxygen via positive pressure ventilation if inadequately breathing.
- 54. Emergency Medical Care • Assess circulatory components. – Check pulse, skin characteristics. – Control major bleeds. – Suspect internal hemorrhage
- 55. Emergency Medical Care • Position patient left lateral recumbent tilted to the left side. • Provide aggressive care for seizures. – Magnesium sulfate – Benozdiazapines • Initiate IV access and administer fluids based on presentation. • Expedite transport to facility. • Reassess and reassure while en route.
- 56. Case Study • At about 0230 hours, your EMS unit is dispatched to a local battered women's shelter in the downtown area. Upon your arrival, you find a 19-year-old female, 8½ months pregnant. She has bruises and cuts on her face, and dried blood on her shirt. She states her boyfriend beat her up and kicked her in the stomach. She now has abdominal pain and bleeding.
- 57. Case Study (cont'd) • What kinds of injuries could this patient have?
- 58. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no entry or egress problems. – 19-year-old pregnant female, 160 pounds.
- 59. Case Study (cont'd) • Scene Size-Up – Patient found in sitting position. – Mechanism of injury is physical altercation. – The police have been summoned but not on scene yet. – First pregnancy with no prenatal care.
- 60. Case Study (cont'd) • Primary Assessment Findings – Patient responsive. – Airway appears open. – Breathing fast but adequate. – Carotid and radial pulses present. – Peripheral skin cool and slightly diaphoretic. – Pants soaked with blood from vaginal bleeding.
- 61. Case Study (cont'd) • Is this patient a high or low priority? Why? • What are the patient's life threats, if any?
- 62. Case Study (cont'd) • Medical History – None other than pregnancy. • Medications – She takes OTC multivitamin. • Allergies – Patient denies any.
- 63. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils reactive to light bilaterally. – Airway patent, patient’s breathing is rapid. – Central and peripheral pulses present. – Pulse oximeter reading 99 percent on oxygen. – Soft tissue injuries to face are minor.
- 64. Case Study (cont'd) • Pertinent Secondary Assessment Findings – BP 100/60, heart rate 122, respirations 22. – Painful dark red blood escaping from the vagina. – Abdomen is tense to the touch, tender also.
- 65. Case Study (cont'd) • What is the patient's para and gravida status? • What do you think is the patient's primary problem? • Why is the abdomen tense? • What complications could the patient have as a result of this condition? • What care will you provide?
- 66. Summary • Antepartum emergencies can be the reason for the EMS call, or a consequence of some other trauma or medical problem. • In many instances, there are two lives at stake—the mother and the unborn child. • The paramedic must properly assess, treat, and transport these patients.
- 67. 51 TOPIC TTrraauummaa iinn SSppeecciiaall PPooppuullaattiioonnss:: GGeerriiaattrriiccss
- 68. Objectives • Discuss statistical rates pertinent to the aging population. • Discuss incidence rates for geriatric trauma and death. • Identify pathophysiologic changes that accompany injuries in geriatrics.
- 69. Objectives • Differentiate early from late assessment findings. • Review current treatment strategies for the geriatric patient suffering from trauma.
- 70. Introduction • In trauma, age is one of the most important determinants. • Elderly patients do not survive trauma, and concurrent chronic diseases make survival even more unlikely. • It is important to reconsider the assessment and management of the geriatric trauma patient
- 71. Epidemiology • Over 40 million geriatric people in the United States • Geriatric patients use a disproportionate amount of EMS and health care services. • Geriatric patients account for 75 percent of fall-related deaths.
- 72. Epidemiology • The elderly drive fewer miles, but have a three times higher death rate in motor vehicle crashes.
- 73. Pathophysiology • Head and Brain Trauma – Brain atrophy increases injury. – Higher risks of blood occupying lesions. • Findings may be delayed. – Patient or family may not remember injury. – Pupillary findings may not be reliable.
- 74. Pathophysiology • Neck Trauma – Perception of pain is diminished. – C1 and C2 fractures common with minimal traumatic mechanisms. – Immobilization concerns
- 75. Pathophysiology • Spinal Trauma – Degenerative bone disorders are more common. – Presence of kyphosis or scoliosis increases injury risks. – Anterior cord syndrome is almost exclusively a geriatric emergency.
- 76. Neck injuries are common in patients with a history of either head or chest wall trauma.
- 77. Pathophysiology • Thoracic Trauma – Ribs become brittle. – Disease states of lung tissue decrease function. – Compensatory mechanisms are unable to recover when a thoracic injury occurs.
- 78. Pathophysiology • Abdominal Trauma – Liver and spleen are more exposed to injury. – Internal bleeding can be masked by what is thought to be a “normal” systolic pressure.
- 79. Pathophysiology • Musculoskeletal Trauma – Bones are more at risk of injury due to decrease adipose tissue, weakening cartilaginous support, and underlying disease. – Osteoporosis contributes to bone weakness and fractures. – Isolated fractures can become life threatening.
- 80. Pathophysiology • Burn Trauma – Fourth leading cause of death in geriatrics. – Changes in the skin make burns more severe. – Burn shock occurs more readily as does airway occlusion due to burns. – Linear increase in mortality of a burn injury based on age alone.
- 81. Common Manifestations of Trauma in Geriatric Patients
- 82. Common Manifestations of Trauma in Geriatric Patients
- 83. Common Manifestations of Trauma in Geriatric Patients
- 84. Emergency Medical Care • Spinal immobilization considerations – Allow for cervical/spinal curvature. • Assess and maintain the airway. • Assess and manage circulatory components.
- 85. Emergency Medical Care • Determine breathing adequacy. – Apply high-flow oxygen via nonrebreather to maintain a normal oxygen saturation with adequate breathing. – Provide positive pressure with high-flow oxygen if inadequately breathing.
- 86. Emergency Medical Care • Provide full immobilization. • Initiate transport to an appropriate trauma facility. • Consider establishing IV access to keep systolic blood pressure >90 mmHg. • Treat any minor injuries, time allowing. • Frequently reassess for rapid deterioration.
- 87. Case Study • You are called to a residential address where an elderly male was trying to retrieve Christmas ornaments from his attic, when he slipped and fell down the attic steps. Upon your arrival, the patient is at the bottom of the steps, moaning, with blood coming from a temporal laceration. His right ankle looks angulated.
- 88. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no entry or egress problems. – 82-year-old male, 160 lbs. – Patient found in lateral fetal position. – Mechanism of injury is fall down 10–12 wooden steps. – No additional resources needed at this time.
- 89. Case Study (cont'd) • What kinds of injuries could this patient have? • What will be your assessment approach to him? • What is your first priority?
- 90. Case Study (cont'd) • Primary Assessment Findings – Patient moaning, but responsive to yes/no questions only. – Airway open, breathing adequate, rate fast. – Carotid and radial pulses present, tachycardic.
- 91. Case Study (cont'd) • Primary Assessment Findings – Peripheral skin cool and slightly diaphoretic. – Bleed to right temporal region. – No other major bleeding noted.
- 92. Case Study (cont'd) • Is this patient a high or low priority? Why? • What interventions should be provided at this time?
- 93. Case Study (cont'd) • Medical History – Hypertension, myocardial infarction, COPD, constipation, hemorrhoids • Medications – Coumadin, Nitro PRN, Proventil, Colace, Preparation H • Allergies – Morphine
- 94. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils equal and reactive, membranes hydrated. – Airway patent, minute volume adequate, breath sounds diminished. – Central and peripheral pulses present. – Pulse oximeter reading 94 percent on ambient air.
- 95. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Patient is becoming more unresponsive. – BP 180/90, heart rate 108, respirations 28. – Right ankle angulated with swelling, pain, and tenderness noted.
- 96. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Physical assessment reveals no other skeletal trauma. – No other findings are contributory to this report.
- 97. Case Study (cont'd) • Provide two different explanations for his change in mental status. • What else about this patient's medical history could make managing him more difficult?
- 98. Case Study (cont'd) • Will his age or his medical history make you alter your treatment any? • If the patient starts to improve, what would be the expected findings for: – Mental status – Heart rate – Muscle tone
- 99. Case Study (cont'd) • Care provided: – Patient cervical spine manually immobilized. – High-flow oxygen via mask initially, PPV with supplemental oxygen after patient is in respiratory failure. – Patient carefully immobilized to supine. – Patient loaded and transported to appropriate trauma center.
- 100. Case Study (cont'd) • Care provided: – Intravenous access should be established and fluids should be administered only to maintain SBP of 90 mmHg. – Patient reassessed and reassured during transport without change in condition. – Treat laceration and ankle en route if possible.
- 101. Summary • Although they are adults, approaching a geriatric patient should be given the same consideration as approaching the pediatric patient. • Many times the paramedic will need to anticipate deterioration, modify treatment to fit the patient, and not expect all care to have the same effect as it would on a younger patient.
- 102. 49 TOPIC CCoommpplleettee aanndd IInnccoommpplleettee SSppiinnee aanndd SSppiinnaall CCoorrdd IInnjjuurriieess
- 103. Objectives • Discuss the predisposition, incidence, and mechanism of spinal cord injuries. • Review normal spinal cord anatomy. • Discuss the pathophysiology of spinal cord injuries. • Review motor and sensory findings for incomplete spinal cord injuries.
- 104. Objectives • Review assessment tests that ascertain spinal cord involvement. • Review current treatment standards for cord injuries.
- 105. Introduction • Cord injuries in the traumatized patient may be subtle or obvious. • The paramedic must keep a high index of suspicion for possible spinal cord damage. • Failure to manage, or the mismanagement of, a cord injury can have permanent, if not fatal, outcomes.
- 106. Epidemiology • 11,000 new cases of spinal cord injury per year in the United States • About 80 percent occur to men, average age 38 years. • Incidence of elderly spinal cord injury is on the rise.
- 107. Illustration of the spinal nerves (a) laterally and (b) posteriorly. The ganglia are detailed as well.
- 108. Cross section of spinal cord showing corticospinal, spinothalamic, and posterior columns.
- 109. Ligaments and intervertebral disks of the spine. Lateral view of the spinal column (anterior to the right). The lower vertebrae have been cut sagittally to reveal the spinal canal and some of the ligaments.
- 110. Pathophysiology • Injury to the spinal cord – Flexion, rotation, compression, hyperextension, lateral bending, distraction, penetration – Primary cord injury (structural damage) – Secondary cord injury (ongoing damage from swelling or ischemia/necrosis)
- 111. Pathophysiology • Complete spinal cord injury – Total loss of motor and sensory function. – Fairly easy to detect. – Can be mimicked by spinal shock. – Management still remains the same.
- 112. Pathophysiology • Incomplete spinal cord injury – A portion of the spinal cord is injured – Partial neurologic function – Requires immobilization – Specific presentations of incomplete spinal injury include: • Central cord syndrome • Brown-Séquard syndrome • Anterior cord syndrome
- 113. Cross sections of the spinal cord, showing the H-shaped gray matter surrounded by white matter. Illustrated here are the three most common types of incomplete spinal cord injury (the areas of the injury are highlighted in red): (a) Central cord syndrome results from injury to the central cord. (b) Brown-Séquard syndrome results from injury to the right or left half of the cord. (c) Anterior cord syndrome results from injury to the anterior cord.
- 114. Incomplete Spinal Cord Injury Syndrome Assessment Findings
- 115. Pathophysiology • Spinal shock – Loss of neurologic function and autonomic tone distal to injury site. – Neurogenic hypotension, hypothermia, bradycardia may result.
- 116. Differential Assessment Findings: Hypovolemic Shock Versus Neurogenic Shock
- 117. Assessment Findings • Dispatch information may provide a clue. • Assess spinal tracts by testing for pain, light touch, and motor function. • Goal is to assess the cord at multiple levels to ensure presence/absence of injury.
- 118. Spinal Cord Motor Assessment and Level of Loss of Function
- 119. Level of Spinal Cord Injury Correlated to Loss of Sensory Function
- 120. Emergency Medical Care • The following patients should always be immobilized – Significant mechanism of injury. – Patient has an altered mental status. – Patient has pain or tenderness to vertebral column. – Patient is unreliable. – Any sensory or motor dysfunction is found.
- 121. Emergency Medical Care • Manual cervical spine considerations • Assess and maintain the airway. • Determine breathing adequacy. – Administer oxygen to maintain SpO2 above 94 percent – Provide positive pressure ventilation with high flow oxygen if inadequate
- 122. Emergency Medical Care • Assess circulatory components. – Check pulse, skin characteristics. – Control major bleeds. • Initiate transport to an appropriate facility and reassess patient’s ABC’s and neurologic function en route.
- 123. Emergency Medical Care • Initiate intravenous access with a large-bore catheter. – Administer IV fluids to keep systolic blood pressure >90 mmHg. – If hypoglycemic (blood glucose level <60 mg/dL), administer 25 g of 50% dextrose in water. – Consider vasoactive agents in severe cases of spinal shock.
- 124. Case Study • You have a 31-year-old construction worker who fell from a scaffolding onto a pile of waste material from about 20 feet. Bystanders state he landed on his back and was unresponsive for about 15 seconds. Upon your arrival, the patient can speak to you, but is not sure what happened.
- 125. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, workers have cleared area of debris. – 31-year-old male patient, 180 lbs. – Mechanism of injury appears to be a fall – Additional resources are not requested at this time
- 126. Case Study (cont'd) • Scene Size-Up – Patient found supine, no gross hemorrhages. – Patient entry made, egress not problematic. – No additional resources needed at this time.
- 127. Case Study (cont'd) • Primary Assessment Findings – Patient responsive, but amnestic to fall. – Airway open, breathing adequate, no dyspnea. – Carotid and radial pulses present, normal rate.
- 128. Case Study (cont'd) • Primary Assessment Findings – Peripheral skin warm and slightly diaphoretic. – No major bleeds noted to body. – Patient keeps telling you that he cannot move his arms.
- 129. Case Study (cont'd) • Is this patient a high or low priority? Why? • What interventions should be provided at this time?
- 130. Case Study (cont'd) • Medical History – Asthma • Medications – Proventil inhaler PRN • Allergies – No drug allergies
- 131. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils equal and reactive, membranes hydrated. – Airway patent, good minute ventilation. – Central and peripheral pulse and perfusion good.
- 132. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pulse oximeter reading 98 percent on ambient air. – Patient has normal lower extremity motor tone; however, he cannot move his arms.
- 133. Case Study (cont'd) • Pertinent Secondary Assessment Findings – He can feel light touch in all extremities, but not painful stimuli to arms. – Deformity and abrasion to base of neck noted. – B/P 104/80, heart rate 70, respirations 12. – BGL is 120 mg/dL
- 134. Case Study (cont'd) • Do you suspect a spinal cord injury? If so, what type? • Explain the reason for the conflicting assessment findings. • What spinal nerve tract is injured on this patient? • What treatments would you provide to this patient?
- 135. Case Study (cont'd) • Care provided: – Patient’s cervical spine manually immobilized. – Administer oxygen to maintain SpO2 above 94 percent. – Patient carefully immobilized. – Transported to an appropriate facility. – Initiated intravenous access and provide fluids to maintain SBP >90 mmHg.
- 136. Summary • As mentioned, the traditional method for assessing motor, sensory, and perfusion is not sufficient for incomplete spinal injuries. • Incomplete SCI need immobilization as well to prevent the incomplete from progressing to complete.
- 137. TOPIC 48 TTrraauummaattiicc BBrraaiinn IInnjjuurryy
- 138. Objectives • Discuss the predisposition, incidence, and death rates for brain injuries. • Review the pathophysiology behind the types of brain injuries. • Define assessment considerations and findings for patients with brain injuries. • Review current treatment parameters for patients with herniating and non-herniating brain injuries.
- 139. Introduction • Brain injuries may manifest themselves now, or weeks later. • The physiology of the brain and surrounding structures leaves itself open to certain types of brain injuries. • Understanding the pathophysiology of brain injuries will allow the paramedic to provide optimal treatment.
- 140. Epidemiology • 1.5 million head injuries occur per year in the United States • It is the leading cause of death in accident victims younger than 45. • 50,000 people die each year from brain injury.
- 141. Pathophysiology • Intracerebral hemorrhage – Extraaxial hemorrhage • Epidural, subdural, subarachnoid – Intraaxial hemorrhage • Occurs within brain tissue itself • Intracerebral hemorrhage – Intraparenchymal hemorrhage – Intraventricular hemorrhage
- 142. Pathophysiology • Diffuse axonal injury (DAI) – Most devastating of traumatic brain injuries – Acceleration-deceleration mechanism – Frequent outcome is coma – Stretching and swelling of axons
- 143. Pathophysiology • Diffuse axonal injury – Concussion • Mild DAI • GCS 13-15 – Epidural hematoma • Serious complication of head injury • Bleeding between dura and skull
- 144. Pathophysiology • The rise in ICP causes a cascade of signs and symptoms, including: • Decreased mental status • Severe headache • Fixed and dilated pupils • Vomiting • Altered or absent breathing • Posturing • Systolic hypertension with associated bradycardia (Cushing reflex, a late finding)
- 145. Figure 48–1 Epidural hematoma. Pt. will suffer a loss of consciousness and then a period of responsiveness. Shortly thereafter, his level of consciousness will deteriorate rapidly. Result from low velocity impact skull Fx is common occurring in 90% of pt.
- 146. Pathophysiology • Diffuse axonal injury – Subdural hematoma • Bleeding between arachnoid and dura • Low-pressure bleed • Phases include acute, subacute, and chronic
- 147. Pathophysiology • Acute phase—Signs and symptoms begin immediately • Subacute phase—begins three to seven days after the injury • Chronic phase—begins two to three weeks later • Subdural hematoma is seen in child abuse cases and incidents involving shaken baby syndrome. • typical mortality rate around 60 percent.
- 148. Pathophysiology • Signs and symptoms of acute subdural hematoma include: • Declining level of consciousness • Abnormal or absent respirations • Dilation of one pupil • Weakness or paralysis to one side of the body • Vomiting • Seizures • Increasing systolic blood pressure • Decreasing heart rate
- 149. Figure 48–2 Subdural hematoma.
- 150. Pathophysiology • Diffuse axonal injury – Subarachnoid hemorrhage • Brain tissue becomes ischemic • Severe headache common • May rapidly progress to seizures and cardiac arrest
- 151. Assessment Findings • Dispatch information – Seizures, headache, trauma, etc. • Soft tissue injuries to skull • Closed or open skull injuries • Alteration in mental status • Possible loss of airway patency • Breathing may be irregular and slow • Changes to vitals (Cushing response)
- 152. Assessment Findings • Response to painful stimuli – Purposeful vs. nonpurposeful – Decorticate vs. decerebrate • Assess and reassess mental status. – Compute Glasgow Coma Score, look for trends. • Assess vital signs – Trends of vitals may also help identify brain injury.
- 153. Nonpurposeful responses to painful stimuli include (a) flexion (decorticate) posturing and (b)extension (decerebrate) posturing.
- 154. Glasgow Coma Scale
- 155. Implications of Changes in Vital Signs with Head Injuries
- 156. Emergency Medical Care • Manual cervical spine considerations • Assess and maintain the airway. • Determine breathing adequacy. – Administer oxygen to maintain SpO2 above 94 percent. – Positive pressure ventilation with high flow oxygen if inadequate. – Consider hyperventilation (at no more than 20/min) with brain herniation.
- 157. Emergency Medical Care • Assess circulatory components. – Check pulse, skin characteristics. – Control major bleeds. • Transport immediately to an appropriate medical facility.
- 158. Emergency Medical Care • Initiate a large-bore intravenous catheter. – Administer fluids to keep systolic blood pressure >90 mmHg. – Do not cause hypertension with IV fluids.
- 159. Emergency Medical Care • Be prepared to manage seizure activity. • Constantly monitor airway, breathing, and circulation. • Mental status changes are key to determining improvement or deterioration.
- 160. Case Study • You are called to a motorcycle accident where a rider who was not wearing a helmet lost control of his cycle on a turn and hit a tree. When you arrive, the patient is lying supine, blood covering his face and shirt, and the patient is actively seizing. The police are already on scene and you can hear the wail of the fire department sirens approaching.
- 161. Case Study (cont'd) • Scene Size-Up – Standard precautions taken. – Scene is safe, police stopped traffic – 43-year-old male patient, 200 lbs. – Patient supine, blood on face and shirt. – MOI- motorcycle accident – Entry made, egress not problematic. – PD on scene, FD pulling up. – Additional resources requested
- 162. Case Study (cont'd) • Based on the information provided and the scene size-up, what differential diagnosis might you suspect? • What types of additional resources may you consider requesting? • What are your priorities at this time? • Would you consider this a high-priority patient? Why?
- 163. Case Study (cont'd) • Primary Assessment Findings – Patient unresponsive, active tonic-clonic seizures. – Mouth clenched shut, blood on face, sonorous breath sounds with gurgling. – Breathing is ineffective due to seizure activity.
- 164. Case Study (cont'd) • Primary Assessment Findings – Carotid and radial pulses present. – Peripheral skin warm and sweaty. – No major bleeds noted to body.
- 165. Case Study (cont'd) • What interventions should be provided at this time? • How would you manage the airway of this patient? • What could be the cause of his seizure activity?
- 166. Case Study (cont'd) • Medical History – Unknown • Medications – Unknown • Allergies – Unknown
- 167. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils unequal, sluggish to light. – Airway patent, spontaneous breathing still ineffective. – Patient is still unresponsive and seizing. – Pulse oximeter reading 82 percent initially with attempts at PPV. 93 percent on high-flow oxygen.
- 168. Case Study (cont'd) • Pertinent Secondary Assessment Findings – B/P 198/90, heart rate 56, spontaneous respirations 4 and irregular. – Crepitus noted to posterior vertebrae. – Depressed right frontal skull fracture noted. – Sinus bradycardia on monitor – Blood glucose level 65 mg/dL
- 169. Case Study (cont'd) • What type of brain injury would you suspect? • Is this patient displaying any indications of herniation? Why? • What interventions might you provide at this time?
- 170. Case Study (cont'd) • Care provided: – Stabilize cervical spine – Considering hyperventilation based on protocol – Maintain airway, oxygenation, and ventilation
- 171. Case Study (cont'd) • Care provided: – IV initiation and fluid therapy – Stop seizures (based on protocol) – Full spinal immobilization – Rapid transport to appropriate facility
- 172. Summary • Brain injuries are a common cause of death and disability following traumatic events. • Prehospital recognition and proper management can help reduce the long-term effects of brain injuries. • As with any trauma, focus first on supporting lost function.
- 173. 45 TOPIC SSoofftt TTiissssuuee IInnjjuurriieess:: CCrruusshh IInnjjuurryy aanndd CCoommppaarrttmmeenntt SSyynnddrroommee
- 174. Objectives • Review the occurrences and mechanisms of soft tissue trauma. • Discuss pathophysiological changes at the cellular level of crush and compartment syndrome injuries. • Review assessment findings and current treatment interventions for these types of injuries.
- 175. Introduction • Crush injury is a mechanism of blunt trauma, whereas compartment syndrome is an injury pattern. • Crush injuries are caused by excessive compressive forces on the body. • Can occur to small localized areas (thumb), or to large regions (thorax).
- 176. Epidemiology • A broad definition of soft tissue injury accounts for the vast majority of traumatic injuries. • Crush injuries are a small portion of this category. • Crush injuries result from a wide range of mechanisms.
- 177. Mechanism • Direct force – Tissue destruction from compressive forces • Entrapment/Weight-based compression – Compression caused by patient's position • Internal compression – Internal swelling causing compartment syndrome
- 178. Direct force can cause crush injuries, some resulting in open wounds.
- 179. A stroke patient who has fallen and trapped her right leg beneath her body weight.
- 180. Pathophysiology • Direct compression destroys tissue cells. • Pressure can also inhibit normal blood flow to tissues, worsening tissue damage. • Compression > four hours may result in muscle breakdown with toxin release. – Can have devastating systemic effects.
- 181. Pathophysiology • Compartment syndrome – Compression from the opposite direction. – Swelling or bleeding in muscle occurs. – Fascia enveloping muscle is nondistensible. – Pressure builds, causing changes to blood flow.
- 182. Assessment Findings • Common findings – Pain to traumatized area – Possible entrapment of extremity – Bruising, tenderness, ecchymosis – Deformity, loss of function – Diminished or absent distal circulation, motor, or sensory findings – Internal hemorrhage, shock
- 183. Assessment Findings • Specific compartment syndrome findings – Pain, discomfort, burning sensation – Pain that continues after immobilization – Tenderness, unusual firmness at injury site – Altered CMS distal to the injury – Weakness or paralysis of muscle
- 184. Assess circulation in an extremity following a crush injury.
- 185. Emergency Medical Care • Spinal immobilization considerations • Assess and maintain the airway. • Determine breathing adequacy. – Maintain adequate oxygenation. – Positive pressure ventilation with high flow oxygen if inadequate. • Assess circulatory components. – Check pulse, skin characteristics. – Control major bleeds.
- 186. Emergency Medical Care • Relieve any compression pressure if possible. – Cellular waste products may be released into the blood stream. – May result in massive internal bleeding. • Initiate intravenous therapy. • Consider the administration of medications.
- 187. Emergency Medical Care • Prepare for cardiac arrest. • Treat any minor injuries, time allowing. • Consider full spinal immobilization. • Transport to appropriate facility.
- 188. Emergency Medical Care • Preventing and treating compartment syndrome. – Elevate extremities. – Beware of constricting immobilization. – Apply cold. – Monitor distal CMS.
- 189. Case Study • You are called to a remote area of your response district where a man was injured while cutting down trees. The man was reportedly trapped by a fallen tree for hours prior to being found missing by his family. When you arrive, the patient's abdomen and legs are still entrapped, and the fire department is extricating him. The patient is able to respond to you.
- 190. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no further fear of pinning. – Adult male, 40 years old, 230 lbs. – Patient found supine, large tree stump across his abdomen and legs.
- 191. Case Study (cont'd) • Scene Size-Up – Patient entry made, egress problematic due to woods and distance to carry. – Additional resources of FD on scene already.
- 192. Case Study (cont'd) • Primary Assessment Findings – Patient responsive, seems lethargic though. – Airway open and maintained by self. – Breathing is rapid, alveolar sounds present.
- 193. Case Study (cont'd) • Primary Assessment Findings – Carotid and radial pulses present, cannot assess lower extremities. – Peripheral skin cool, pale, sweaty. – You see some evidence of bleeding from legs, but nothing current.
- 194. Case Study (cont'd) • Is this patient a high or low priority? Why? • What interventions should be provided at this time? • What type of injuries do you expect from this mechanism? • Describe how this mechanism could cause compartment syndrome.
- 195. Case Study (cont'd) • Medical History – High cholesterol. • Medications – Patient denies any, watches his diet. • Allergies – “Some antibiotics,” he states.
- 196. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils dilated but reactive, membranes pale. – Airway patent, breathing tachypneic. – Peripheral perfusion diminishing to arms. – Breath sounds present bilaterally.
- 197. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Patient's mental status still continuing to deteriorate. – Pulse oximeter reading 98 percent on high flow. – BP 100/82, heart rate 114, respirations 20. – Unable to assess lower extremities or abdomen.
- 198. Case Study (cont'd) • The fire department reports that it will take them at least 10 minutes to lift the tree stump off of the patient. • They ask you if you need anything else ready or set up. What would be your response? • What additional emergency medical care might you consider while waiting for extrication?
- 199. Case Study (cont'd) • After lifting the tree from the patient, he arrests about 30 seconds later. Explain why this may have happened. • What emergency care will you provide?
- 200. Case Study (cont'd) • Care provided: – Patient immobilized. – Open and maintain airway. – PPV with oxygen due to apnea. – Cardiopulmonary resuscitation initiated upon arrest.
- 201. Case Study (cont'd) • Care provided: – Advanced cardiovascular life support provided accordingly. – All lower extremity fractures managed by immobilization to backboard. – Rapid transport.
- 202. Summary • Crush injuries are a rare, but potentially fatal mechanism for soft tissue trauma, since the injury pattern could be so widely dispersed. • The paramedic should indentify and treat life threats before managing the soft tissue trauma and compartment syndrome issues.
- 203. TOPIC 43 CChheesstt TTrraauummaa
- 204. Objectives • Review annual injury and death rates for chest trauma victims. • Understand pathophysiologic changes that occur with chest trauma. • Discuss common clinical findings of chest trauma. • Identify the importance of mechanism of injury in determining presence of chest trauma.
- 205. Introduction • Chest injuries can be obvious and dramatic, or small and easy to miss. • The assessment of the chest must be comprehensive in order to find all injuries. • The paramedic must understand the physiology of the chest wall and its response to trauma.
- 206. Epidemiology • 20 percent to 25 percent of trauma deaths each year are due to thoracic trauma. • The most common mechanism is motor vehicle collision.
- 207. Epidemiology • Immediate deaths are due to myocardial or aorta rupture. • Early deaths are due to tension and open pneumothorax, tamponade, flail segments, and hemothorax.
- 208. Pathophysiology • Chest trauma distorts the normal thoracic anatomy. • Distortion injures body system and causes a change in physiology. • V/Q ratio disturbances, hypoxemia, and hypercapnea ensue. • Ultimately, cellular death occurs.
- 209. Pathophysiology • Tension pneumothorax – Disruption of visceral pleura – Accumulation of intrathoracic air – Collapse of lung tissue – Shifting of mediastinum – Changes in hemodynamics – Assessment • Early findings • Late findings
- 210. In a tension pneumothorax, air continuously fills the pleural space, the lung collapses, pressure rises, and the trapped air compresses the heart and the other lung.
- 211. Pathophysiology • Open pneumothorax – Disruption of parietal pleura from hole in chest – Accumulation of intrathoracic air – Collapse of lung tissue – Injury may turn into tension pneumothorax – Assessment findings
- 212. In an open pneumothorax, air enters the chest cavity through an open chest wound or leaks from a lacerated lung. The lung then cannot expand.
- 213. Pathophysiology • Flail chest – Fractured ribs (2 or more in 2 places) – Creates “free floating” segment of chest – Paradoxical motion inhibits adequate ventilation – Resulting pulmonary contusion – Assessment findings
- 214. Flail chest occurs when blunt trauma causes the fracture of two or more ribs, each in two or more places.
- 215. With a flail chest, (a) the flail segment is drawn inward as the rest of the lung expands with inhalation; (b) the flail segment is pushed outward as the rest of the lung contracts with exhalation.
- 216. Pathophysiology • Hemothorax – Similar to pneumothorax – Pleural cavity fills with blood (chest trauma) – Collapse of lung tissue creates hypoventilation – May also cause hypovolemia – Assessment findings
- 217. In a hemothorax, blood leaks into the chest cavity from lacerated vessels or the lung itself, and the lung compresses.
- 218. Pathophysiology • Acute pericardial tamponade – Injury to heart causes blood to collect in pericardial sac – Pericardial sac nondistendable – Collapsed ventricles, poor stroke volume – Assessment findings
- 219. In pericardial tamponade, accumulating blood compresses the heart inward.
- 220. Assessment Findings • Inspection – Any open chest injuries – Any structural abnormalities • Auscultation – Type, quality, location of breath sounds • Palpation – Structural abnormalities – Subcutaneous emphysema
- 221. Differential Field Diagnosis of Chest Injury
- 222. Emergency Medical Care • Spinal immobilization considerations • Assess and maintain the airway. • Determine breathing adequacy. – Provide positive pressure ventilation with high-flow oxygen @ 10-12/min if inadequately breathing. – Occlude any punctures to chest wall. – Decompress a tension pneumothorax.
- 223. Emergency Medical Care • Assess circulatory components – Check pulse, skin characteristics – Control major bleeds • Provide full immobilization • Initiate safe and expeditious transport • Establish a large bore IV en route. – Avoid aggressive fluid administration • Consider pain medication
- 224. Case Study • Your EMS unit is summoned for a patient who was injured while hunting. Upon your arrival, you find a male patient holding his hand over his right thorax. Some blood is seeping past his fingers, and the breathing looks labored. Friends report he was accidently shot with an arrow.
- 225. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no sign of struggle. – Young male, 18 years old. – Patient found sitting along edge of road. – No patient entry nor egress problems. – No additional resources needed presently.
- 226. Case Study (cont'd) • Primary Assessment Findings – Patient responsive. – Airway open and maintained by self. – Breathing is rapid, patient is dyspneic. – Breath sounds diminished on the right. – Carotid and radial pulses present but radial gets weaker with inhalation. – Peripheral skin cool, pale, sweaty. – No other major bleeds or concerns.
- 227. Case Study (cont'd) • Is this patient a high or low priority? Why? • What interventions should be provided at this time?
- 228. Case Study (cont'd) • What are your differentials thus far that the patient could be suffering from? • Do you think that this patient will have a problem with the ventilation or perfusion side of the V/Q ratio? Why?
- 229. Case Study (cont'd) • Medical History – Patient states he has attention deficit hyperactivity disorder and Tourette syndrome • Medications – Patient states he takes Vyvance, Tenex, and Albilify • Allergies – Patient states he is allergic to penicillin
- 230. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils dilated but reactive, membranes pale. – Airway patent, breathing tachypneic. – Peripheral perfusion diminishing. – Absent breath sounds to right thorax. – Patient's mental status still continuing to deteriorate.
- 231. Case Study (cont'd) • Pertinent Secondary Assessment Findings – No jugular venous distention noted – No tracheal deviation noted – Penetration injury fourth intercostal space, right anterior chest. – Pulse oximeter reading 98 percent with supplemental O2.
- 232. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Occlusive dressing “burped.” – B/P 82/palp, heart rate 114, respirations 20. – Pulsus paradoxus noted
- 233. Case Study (cont'd) • What would be key clinical indications the patient is deteriorating despite treatment? • What advantage does “burping” the occlusive dressing have? • Why would PPV possibly be detrimental to the patient?
- 234. Case Study (cont'd) • Based on the assessment findings, what is your differential diagnosis? • What additional treatments would you perform? • How would the patient benefit from your interventions?
- 235. Case Study (cont'd) • Care provided: – Patient immobilized. – High-flow oxygen via nonrebreather mask, switched to PPV due to failing ventilations. – Occlusive dressing to chest injury which is burped.
- 236. Case Study (cont'd) • Care provided: – Needle decompression. – Transport to trauma hospital initiated. – Established intravenous access to maintain systolic BP of 90 mmHg.
- 237. Summary • Chest wall injuries can result in significant disturbances to the V/Q ratio. • Although these injury typically require surgery, the paramedic can provide treatments that will support lost function.
Editor's Notes
- #3: Discuss the objectives.
- #4: Review what the fetus the fetus can do independently in utero and what he is dependent on the mother for. Review that after birth, the infant must rely on himself for survival. Discuss the complexities of development and genetic anomalies. Explain why a paramedic should always consider that every baby might have an anomaly.
- #5: Review the basic statistics. Discuss how congenital anomalies—birth defects or anatomic maldevelopments affecting one or more organ systems—are the leading cause of death in the pre- and postnatal periods.
- #6: Review the basic statistics. Discuss how congenital anomalies—birth defects or anatomic maldevelopments affecting one or more organ systems—are the leading cause of death in the pre- and postnatal periods.
- #7: Review and discuss the terms as needed.
- #8: Review the anatomic and physiologic transition from in utero to the extrauterine environment. Discuss the importance of preparing and maintaining a comfortable environment for the neonate. Discuss the progression from respiratory distress to cardiopulmonary failure as a result of complications in neonates. Explain the need to have the appropriate sized and proper equipment for management of these patients.
- #9: Review the anatomical differences between the neonate and the adult airway. Stress the importance of proper BVM ventilation techniques for the neonate. Early use of manual techniques and simple mechanical techniques will help keep a closing airway open.
- #10: Stress that assisted ventilation should be performed in any neonate with significant respiratory distress, apnea, or significant hypotonia (e.g., a floppy baby). Review the proper way to provide positive pressure ventilations: Use a bag-valve mask Maintain a good mask sea Ventilate with just enough force to raise the infant’s chest Ventilate at a rate of 40–60 per minute for 30 seconds Reassess
- #11: Review the rates and tidal volumes for newborns. Discuss the importance of having the appropriate equipment and tools for successful resuscitation. Explain why the aggressive use of positive end-expiratory pressure (PEEP) is usually not necessary because of the very compliant lungs and chest walls of the infant.
- #12: Review the rates and tidal volumes for newborns. Discuss the importance of having the appropriate equipment and tools for successful resuscitation. Explain why the aggressive use of positive end-expiratory pressure (PEEP) is usually not necessary because of the very compliant lungs and chest walls of the infant.
- #13: Blended oxygen to achieve SpO2 levels: 60 to 65 percent after 1 minute 65 to 70 percent after 2 minutes 70 to 75 percent after 3 minutes 75 to 80 percent after 4 minutes 80 to 85 percent after 5 minutes 85 to 95 percent after 10 minutes If the heart rate is less than 60 bpm after 90 seconds of resuscitation, the oxygen concentration should be increased to 100 percent until the heart rate increases to more than 100 bpm.
- #14: Discuss the importance of basic airway management over advance techniques. Discuss the anticipated response to good oxygenation and ventilation. Discuss when and how to aspirate meconium under direct laryngoscopy. Blended oxygen to achieve SpO2 levels: 60 to 65 percent after 1 minute 65 to 70 percent after 2 minutes 70 to 75 percent after 3 minutes 75 to 80 percent after 4 minutes 80 to 85 percent after 5 minutes 85 to 95 percent after 10 minutes If the heart rate is less than 60 bpm after 90 seconds of resuscitation, the oxygen concentration should be increased to 100 percent until the heart rate increases to more than 100 bpm.
- #15: Discuss the importance of gauging peripheral perfusion in a neonate as a measure of cardiovascular function. Discuss when to begin chest compressions.
- #16: Review the techniques of providing CPR to the newborn. To provide chest compressions, circle the torso with the fingers and place both thumbs on the lower third of the infant’s sternum. In the newborn, compress the chest one-third the depth of the chest at the rate of 120 per minute and a ratio of 3:1 compressions to breaths.
- #17: Discuss the challenges of IV access in the neonate. Attempt peripheral access and consider intraosseus access based on protocol. Explain why a buretrol should be used whenever fluids are to be administered to a neonate. Discuss how the administration of 1:10,000 epinephrine (at 0.01 mg/kg) should be considered to increase the heart rate if it does not increase after proper ventilations and compressions. Determination of poor perfusion Heart rate &gt;180. Delayed capillary refill over 2 seconds Poor peripheral perfusion. Blood pressure determination is not necessary. Review how to calculate a mean systolic blood pressure. Newborns. An acceptable mean systolic blood pressure is equal to or greater than the gestational age in weeks. In the first month of life, a systolic BP less than 60 mmHg is considered hypotensive. In the infant (1 month–1 year) it is 70 mmHg. Up to 10 years of age the lower acceptable systolic limit is 70 + (2 × age in years).
- #18: Discuss the feeding and sleeping patterns of newborns and infants. Review questions to ask about the infant&apos;s feeding (amount, duration, frequency, and whether there was any emesis, sweating, or frequent coughing). Explain why a lethargic infant should be tested for hypoglycemia. If glucose is to be administered to a neonate, D10W should be used at a dose of 5 to 10 mL/kg IV over 20 minutes. Follow local protocols.
- #19: Once again, it cannot be overemphasized how important attention to the environmental temperature is to the care of an infant. Stress that even the best resuscitation skills and efforts will fail if the infant is cold. Discuss how the inability of the neonate to generate heat is directly related to heat lost from the head, the lack of insulating fat, and the high proportion of metabolically active brown fat.
- #20: Stress that infection is a major killer of neonates and can have a very rapid presentation. Discuss the importance of physician evaluation for a child with: ANY history of fever, cyanosis, apnea, rapid or shallow breathing. ANY history of poor feeding, decreased urine output, or vomiting. ANY blood in stool, urine, or emesis. ANY rash beyond “baby acne.” Stress that the paramedic must be looking for the clues and pay attention to the little details when assessing a baby. Remind students that no other patient age group will require such basic resuscitative care and yet have such a high potential for recovery and good outcome.
- #21: Discuss the safety risks of not properly securing the patient. Review acceptable ways to transport infants and children. Isolettes are ideal for neonates. A car bed that lies across the stretcher and is strapped down using the stretcher&apos;s harnessing is next best method for neonates. Convertible child passenger restraint system (car seat) with two belt paths and a five-point harness system that can be adjusted to the size of the child is the standard of care. Discuss the importance of training in neonatal care and transport.
- #22: Discuss the case study.
- #23: A limp infant is the worst case scenario. The infant may be circling cardiac arrest or be in cardiac arrest. The problem could be airway (the number one cause for arrest in infants), the problem could be a congenital problem with the heart, the problem could stem from poor feeding and dehydration, or from some traumatic event. That being said, the goal is to first assess ABCs and support lost function. The differential diagnosis will come eventually, but not if the baby is dies first!
- #24: Discuss the case progression.
- #25: Discuss the case progression.
- #26: Discuss the case progression.
- #27: This patient would be categorized as unstable due to color, pulse, breathing, and mental status. The primary life threat is that the infant is not breathing effectively, which will quickly turn into cardiopulmonary arrest (that carries with it dismal resuscitation outcomes). The patient should be laid down supine and the airway opened carefully using a manual technique. Positive pressure ventilations should be initiated at 30/min with supplemental oxygen, providing just enough tidal volume to create chest rise and fall. Cover the infant to help preserve/promote normothermia. Advanced airway decision making is essential for a paramedic. Students should consider how basic techniques may be effective for the patient and weigh the benefits and risks. Ultimately the decision to intubate will be at the discretion of the paramedic. Stress that careful and efficient basic airway management is preferred over advanced techniques.
- #28: Discuss the case progression.
- #29: Discuss the case progression.
- #30: Discuss the case progression.
- #31: Although the color improved slightly, more importantly the body is still limp and the heart rate is now declining. The paramedic should initiate external compressions at a 3:1 ratio, at a rate of 120/min. The patient was probably fatigued and weak from trying to breath with the URI. The patient just got to a spot where they could no longer maintain and started to acutely deteriorate.
- #32: Discuss the care provided.
- #33: Discuss the care provided.
- #34: Discuss the case progression. Determination of poor perfusion after compressions and assisted ventilations Heart rate &gt;180. Delayed capillary refill over 2 seconds Poor peripheral perfusion. Blood pressure determination is not necessary. Additional treatments that should be provided by the paramedic include: Attempt peripheral access and consider intraosseus access based on protocol. Administration of 1:10,000 epinephrine (at 0.01 mg/kg).
- #35: Discuss the care provided.
- #36: Review as appropriate.
- #37: Review as appropriate.
- #39: Discuss the objectives.
- #40: Review that antepartum emergencies can occur anytime between conception and delivery of the fetus. Discuss how antepartum emergencies carry a variety of clinical manifestations that can be as subtle as abdominal cramping and as life threatening as massive hemorrhage. Discuss how these emergencies can pose a significant risk not only to the pregnant patient but also to the fetus.
- #41: Review the basic statistics.
- #42: Review how in placenta previa, placental implantation is initiated by the embryo adhering to the lower end of the uterus. Discuss how as the placenta grows, it may approach or cover a portion or all of the cervical os. Differentiate between complete, marginal, and partial placenta previa. Discuss how cervical effacement for impending labor can disrupt the placental attachment and leads to bleeding at the site.
- #43: Discuss how a great majority of maternal deaths associated with placenta previa are related to uterine bleeding and complications from disseminated intravascular coagulopathy. Review risk factors associated with placenta previa. Discuss the classic presentation of placenta previa is painless, bright red vaginal bleeding that usually occurs in the third trimester. Disucss how the color of the blood or lack of bleeding should not preclude the consideration of placenta previa.
- #44: Discuss how abruptio placentae begins with avulsion of the anchoring placental villi from the expanding lower uterine segment which leads to bleeding after the 20th week of gestation. Discuss the cascade of events that results in reduced maternal fetal oxygen and nutrient exchange, membrane rupture, uterine contractility, and clotting abnormalities in addition to severe blood loss.
- #45: Discuss the clinical manifestations include abdominal pain, dark vaginal bleeding (80 percent), premature contractions, and fetal distress or death. Differentiate between partial and complete abruption. Review the risk factors for abruptio placentae. Discuss how the amount of vaginal bleeding is a poor indicator to the extent of compromise.
- #46: Discuss how ectopic pregnancy occurs when the fertilized ovum implants outside the normal location and the ovum starts to generate its own vascular supply from the surrounding tissues. Since the ovum is not in the uterus, the surrounding tissues the ovum it is attached to will eventually tear as the size and the weight of the ovum increases. When this occurs, it results often in fetal death and in many times, maternal death.
- #47: Review implantation sites and risk factors for ectopic pregnancies. Review how ectopic pregnancy occur in 1 out of 44 pregnancies in the United States. Discuss how nearly half of all ectopic pregnancies that are left untreated will resolve without treatment. Discuss the signs and symptoms of early and late ectopic pregnancy.
- #48: Preeclampsia is a medical condition that may develop after 20 weeks gestation, in which hypertension, edema, and protein in the urine develop during the pregnancy. Discuss the diagnostic criteria for hypertension. New hypertension &gt;140/90 mmHg Previous history of hypertension &gt; 30/15 mmHg above norm Eclampsia refers to the development of generalized tonic-clonic seizures in women with pregnancy-induced hypertension or preeclampsia, when the seizures cannot be attributed to another cause. Discuss how maternal seizures cause hypoxia to the fetus.
- #49: A spontaneous abortion , or miscarriage, is a loss of pregnancy before the age of viability (20 weeks gestation). Differentiate between a spontaneous and induced abortions. Discuss how the frequency for miscarriage decreases with fetal age. Review the signs and symptoms of a spontaneous abortion.
- #50: Review the types of abortion. Review risk factors for spontaneous abortion. Discuss the association between maternal age and risk of miscarriage. Discuss the importance of being empathetic when conducting the interview.
- #51: Discuss how the same assessment and treatment techniques for a pregnant patient should be performed as you would for a patient who is not pregnant. Use the secondary assessment to determine specific information about the patient and her pregnancy.
- #52: Review questions that should be included in the patient interview. Discuss how the answers will influence your differential diagnosis.
- #53: Review the different antepartum complications. Discuss how the signs and symptoms should be used to accurately diagnose your patient and treat her according to her presentation. Although the pregnant patient may appear to be relatively well, especially in the early stages of shock and hemorrhage, the fetus may be severely compromised.
- #54: Prehospital emergency care for antepartum complications should always consider the mother and the fetus. Provide the pregnant patient the same emergency medical care you would provide to any patient displaying the same signs and symptoms. Discuss the importance of maintaining a high concentration of oxygen regardless of the SpO2 reading to maximize the oxygenation to the fetus. Stress that not all hemorrhage will be external, and the paramedic should consider internal hemorrhaging.
- #55: Prehospital emergency care for antepartum complications should always consider the mother and the fetus. Provide the pregnant patient the same emergency medical care you would provide to any patient displaying the same signs and symptoms. Discuss the importance of maintaining a high concentration of oxygen regardless of the SpO2 reading to maximize the oxygenation to the fetus. Stress that not all hemorrhage will be external, and the paramedic should consider internal hemorrhaging.
- #56: Discuss ongoing management. Discuss the importance of patient positioning, especially in the later phases of pregnancy. Explain why magnesium sulfate is the first-line drug of choice for stopping convulsions in pregnancy. Discuss the possible risks to the fetus associated with the administration of benzodiazapines. Discuss the need to transport to a facility capable of obstetric care.
- #57: Discuss the case study.
- #58: Given the 8 1/2 month pregnancy, she could have sustained injuries to the: Uterus Fetus Abdominal organs Birth canal Beyond this, she seems to have some non-life-threatening soft tissue injuries to the face.
- #59: Discuss the case progression.
- #60: Discuss the case progression.
- #61: Discuss the case progression.
- #62: This patient would be categorized as potentially unstable. The life threats would include the vaginal hemorrhage (causing massive blood loss), and if it is not due to blood loss, it is due to the mechanism causing the blood loss (e.g., the injury).
- #63: Discuss the case progression.
- #64: Discuss the case progression.
- #65: Discuss the case progression.
- #66: She is Gravida 1, Para 0 The patient is probably suffering from an abruptio placentae due to blunt abdominal trauma. Due to the injury of the placenta tearing away from the uterine wall, it causes the uterus to tighten. Discuss the cascade of events that results in reduced maternal–fetal oxygen and nutrient exchange, membrane rupture, uterine contractility, and clotting abnormalities in addition to severe blood loss. Labor is also a consideration. Care provided: Patient’s cervical spine manually immobilized. High-flow oxygen via nonrebreather mask. Sterile dressings placed over vagina to catch blood. Patient placed backboard and tilt on left side for transport. Intravenous access started en route. Treat minor injuries. Reassess and reassure.
- #67: Review as appropriate.
- #69: Discuss the objectives.
- #70: Discuss the objectives.
- #71: Discuss how a single preexisting medical condition raises the mortality from any specific injury by 30 percent, and two or more preexisting conditions increase the expected mortality by 60 percent. Discuss why the paramedic must reconsider the assessment approach and management techniques when faced with a geriatric trauma patient compared to that of a younger adult.
- #72: Review basic statistics. Discuss the most common injuries from falls and how geriatric falls account for 75 percent of all fall-related deaths. Describe what occurs in post-fall syndrome and how it can lead to a greater risk of future falls.
- #73: Review basic statistics. Discuss the most common injuries from falls and how geriatric falls account for 75 percent of all fall-related deaths. Describe what occurs in post-fall syndrome and how it can lead to a greater risk of future falls.
- #74: Review the facts: The brain shrinks. They have a higher propensity to bleed in the cranial vault from trauma. The blood accumulation may have delayed effects due to the smaller brain. Additionally, organic brain syndromes make establishing a baseline mental status harder. Dicuss how the assessment of the pupils may not yield reliable findings of brain herniation due to medications or other preexisting conditions.
- #75: Recall these characteristics for neck trauma for any geriatric victim who is found in a lying position on the floor (or in a bed) when there is not a clear history of no traumatic incident. Discuss how the absence of neck pain in a geriatric patient, with or without tenderness on palpation, is not a sufficient criterion for ruling out cervical trauma.
- #76: Review how degenerative disorders can alter the strength and structure of the vertebrae. Discuss the presentation of anterior cord syndrome in the elderly.
- #77: Review how the presence of kyphosis or scoliosis in the spine also increases the likelihood of spinal and cord trauma and poses an additional complication when trying to immobilize the patient properly. Be creative by using rolled towels and tape for a makeshift collar if necessary.
- #78: Review as appropriate. Discuss what may seem to be a minimal mechanism of injury to the chest, can severely hamper the effectiveness of the respiratory system. Discuss how the respiratory system may not have the compensatory mechanisms needed to overcome this pulmonary insult, and the patient’s respiratory status can fail rapidly in patient with chronic lung diseases. Stress that pulmonary dysfunction from trauma will cause quick deterioration in the geriatric patient.
- #79: Discuss how the changes to the ribs and muscles can increase the likelihood of abdominal injury. Discuss why hypotension or tachycardia may not be noticed in geriatric patients with abdominal trauma or internal hemorrhage..
- #80: Discuss the physiological changes that make elderly patients more susceptible to musculoskeletal injuries. Discuss how osteoporosis affects bone density and is a significant risk factor for fractures. Discuss why isolated fractures in the geriatric patient can result in significant blood loss.
- #81: The geriatric patient has thinner epidermal and dermal layers of the skin, and with a diminution of the subcutaneous layer as well, with geriatric exposure to a heat load, exponentially more damage occurs to the skin and underlying structures. Discuss how the changes in physiology in the elderly, compounded by the presence of underlying disease states, result in the development of burn shock with much lower body surface involvement.
- #82: Review some of the earlier and later clinical findings of trauma in the geriatric patient. Stress that because of the effects of aging, pathologic findings, and concurrent medications, the presentation of trauma is different in the geriatric patient than in the younger adult. Review how the relative absence of robust compensatory mechanisms in the elderly will allow the clinical progression from stable to unstable to occur extremely rapidly.
- #83: Review some of the earlier and later clinical findings of trauma in the geriatric patient.
- #84: Review some of the earlier and later clinical findings of trauma in the geriatric patient.
- #85: Review and discuss the slide. Initial goal is to still properly manage the: Airway Breathing Circulatory mechanisms Review the need to gently ventilate to decrease the chance of barotrauma in the geriatric patient. Discuss the need to manage hypoperfusion with high flow oxygen, proper patient positioning, and maintaining normothermia.
- #86: Review and discuss the slide. Initial goal is to still properly manage the: Airway Breathing Circulatory mechanisms Review the need to gently ventilate to decrease the chance of barotrauma in the geriatric patient. Discuss the need to manage hypoperfusion with high-flow oxygen, proper patient positioning, and maintaining normothermia.
- #87: Review and discuss the slide. Discuss why the paramedic should have a lower threshold for transporting a geriatric trauma patient to a trauma center than when treating younger adult.
- #88: Discuss the case study.
- #89: Discuss the case study.
- #90: Really, the patient may have almost any kind of traumatic injury or multiorgan trauma. Due to the fall the patient may have chest wall/lung trauma, the curled up position suggests intra-abdominal injury, there could be brain trauma or soft tissue trauma hidden beneath the clothes. All that is known at this time is that the elderly patient had a significant fall and will likely be unstable. Keeping with traditional assessment, the paramedic should provide cervical immobilization while establishing the mental status. The paramedic should then evaluate the quality of the airway, breathing, and circulatory components of the primary survey before making an ultimate decision about the patient&apos;s stability.
- #91: Discuss the case study.
- #92: Discuss the case study.
- #93: The patient should be considered a high priority (potentially unstable) due to the height of the fall, and the fact that the patient has some early indications of shock (tachypnea, tachycardia, potential change in mental status). The patient should be placed in a supine position with cervical immobilization maintained. A primary survey should be completed along with the application of oxygen, probably by non-rebreather mask.
- #94: Discuss the case progression.
- #95: Discuss the case progression.
- #96: Discuss the case progression.
- #97: Discuss the case progression.
- #98: The mental status may be changing due to increasing hypoxia from a failing pulmonary system since the patient does have a history of COPD—his compensatory mechanisms would be marginal. The patient may also have a bleed occurring in his head, especially since he fell and he takes Coumadin (blood thinner). The patient also has a history of MIs. This means the patient has a diseased heart which has already suffered one heart attack—chances are the heart is weakened and with the stress of this injury, the patient may reinfarct, enter into pulmonary edema, or have some other dysrhythmia-related emergency.
- #99: At this time, no, but the paramedic must maintain a high index of suspicion. If the patient continues to deteriorate, the paramedic may have to begin ventilations, which on a COPD patient may be difficult to do. With patient improvement, the mental status should improve, the heart rate should drop back to a normal rate, and muscle tone should start to improve.
- #100: Discuss the care provided.
- #101: Discuss the care provided.
- #102: Review as appropriate.
- #104: Discuss the objectives.
- #105: Discuss the objectives.
- #106: Spinal cord injuries can be among the most traumatic injuries seen by a paramedic. Identify various mechanisms that can result in spinal cord injuries. The paramedic must be able to identify injuries that could damage the spinal cord or spinal column and to provide appropriate emergency care. Discuss how improper movement or management of patients with spinal cord or spinal column injuries can lead to: Permanent disability Death
- #107: Review the basic statistics. Review the etiology of the majority of cases is associated with: motor vehicle crashes falls, especially in the elderly penetrating trauma sports and recreational activities Explain how elderly patients are more prone to suffering from SCI from minor trauma resulting from degenerative vertebral disorders. In addition, elderly patients have become more active over the years; thus, the incidence of SCI in the elderly is on the rise.
- #108: Discuss why understanding the basic anatomy of the spinal cord is important to adequately comprehend clinical assessment findings related to incomplete spinal cord injuries. The spinal cord is housed within the vertebral column and has 31 pairs of spinal nerves attached to it that exit at different levels. Review the anatomy of the spinal cord. Discuss how an injury below the level of the second lumbar vertebra (L2) is not necessarily considered a spinal cord injury because it involves segmental spinal nerves or the cauda equina.
- #109: Review the anatomy of a cross section of the spianl cord. The central portion of the cord contains gray matter that consists primarily of cell bodies of neurons and forms an “H” pattern. Discuss the three major motor and sensory nerve tracts and what they carry: the dorsal or posterior column. the lateral pyramidal tract, which carries the corticospinal tracts. the anterior spinothalamic tract. Review and discuss the mnemonic LMNOP—This refers to Light touch, Motor, and NO Pain. This means that light touch sensation and motor impulses are carried by nerve tracts on the same side of the spinal cord, but the pain sensation is carried by pain tracts on the opposite side of the spinal cord.
- #110: Review the anatomy of the spine and spinal cord.
- #111: Discuss how complete anatomic transaction of the spinal cord is rare, whereas a physiologic or functional transaction is more common, leading to a loss of function below the level of injury. Differentiate between primary and secondary cord injuries. Primary injury is associated with direct injury of the cord and initiates a complex cascade of events leading to secondary injury secondary spinal cord injury results from ischemic gray and white matter and progresses in severity Explain that hypoxia, hypoglycemia, hypotension, hyperthermia, and improper immobilization can lead to more significant secondary injury to the patient.
- #112: Complete spinal cord injury is defined as a total loss of motor or sensory function distal to the site of the cord injury. This condition is fairly easy to detect during the assessment, owing to the complete bilateral loss of neurologic function. Discuss how complete spinal cord injury could be mimicked by spinal shock, in which the patient presents with complete neurologic dysfunction following the injury but recovers motor and sensory function within 24 hours after the injury. Review that the management by the paramedic remains the same.
- #113: Discuss how the undamaged spinal nerve tracts allow the patient to maintain partial neurologic function. Discuss how the partial neurologic function can contribute to confusing assessment findings if incomplete spinal cord injuries are not well understood by the paramedic. Explain that the paramedic should provide complete spinal immobilization.
- #114: Review and discuss the three most common types of incomplete spinal cord injury: Central cord syndrome results from injury to the central cord. Brown-Séquard syndrome results from injury to the right or left half of the cord. Anterior cord syndrome results from injury to the anterior cord.
- #115: Review and discuss the different assessment findings for each spinal cord injury syndrome.
- #116: Review that signs and symptoms of spinal shock. Discuss how neurogenic hypotension may result from spinal shock. Explain the heart rate would increase as a reflex response to the decrease in blood pressure, as seen in hypovolemic shock; however, interruption of the sympathetic trunk that fails to elicit an appropriate sympathetic response, including epinephrine release, does not allow an increase in the heart rate. Thus, the patient presents with hypotension and bradycardia. Administration of intravenous fluids may be the initial therapeutic measure to maintain adequate perfusion if the systolic blood pressure is below 90 mmHg, but vasoconstrictive agents may be added later in the patient’s course of treatment.
- #117: Differentiate between the assessment findings of hypovolemic and neurogenic shock. Review that most of the findings for neurogenic shock are totally opposite those associated with hypovolemic shock. Neurogenic shock—Because of the peripheral vasodilation and pooling of blood, the skin is initially flushed. The skin is also dry owing to the lack of sympathetic stimulation of sweat glands. Hypovoleimc shock—If the patient presents with hypotension, tachycardia, and pale, cool, and clammy skin, always suspect blood loss and treat for hypovolemic shock.
- #118: Stress that in the assessment of the patient with a spinal cord injury, it is imperative to assess the various spinal tracts by testing for pain, light touch sensation, and motor function. Beyond the traditional assessment, realize that the traditional grip test is ineffective in determining if all motor nerve tracts are intact, thus it will miss an incomplete spinal cord injury. Stress that a thorough assessment of the various levels of the cord must be tested.
- #119: Review how to test the corticospinal tract at various levels of the cord.
- #120: Review how to test the posterior column and spinothalamic tracts. Posterior column—lightly touch each hand and foot while having the patient distinguish which hand or foot is being touched. Spinothalamic tracts—pinch each hand and foot and have the patient distinguish which hand or foot is being pinched. Discuss why the patient’s eyes should be closed during the light touch and pain testing. Explain how redundancy is built into the assessment to identify any neurologic dysfunction that may indicate the potential for an incomplete spinal injury.
- #121: Discuss as needed. In all the following instances, the patient must be immobilized regardless of the neurologic assessment findings: A significant mechanism of injury is evident. The patient has an altered mental status. The patient complains of pain or tenderness to the vertebral column. The patient is unreliable because of intoxication, head injury, stress reaction, or other distracting injury (fractures, abdominal injury). Any sensory or motor dysfunction is found during the neurologic assessment.
- #122: Initial assessment and management should be geared towards supporting lost function found during the primary assessment. Review that spinal cord tissue is basically the same as brain tissue, so it is essential to establish and maintain an adequate airway, ventilation, and oxygenation. If the SpO2 reading is less than 95 percent, administer supplemental oxygen. If the tidal volume or respiratory rate is inadequate, provide positive pressure ventilation.
- #123: Initial assessment and management should be geared towards supporting lost function found during the primary assessment.
- #124: Discuss the emergency care. Discuss why vasoactive drugs should be considered to maintain adequate perfusion for severe cases of spinal shock. Follow protocols.
- #125: Discuss the case study.
- #126: Discuss the case study.
- #127: Discuss the case study.
- #128: Discuss the case study.
- #129: Discuss the case study.
- #130: The patient should be considered a high priority (unstable) due to the height of the fall, and the fact the patient is amnestic (cannot remember) the traumatic event. In addition, the early indications that he may have some type of motor deficit is of concern. The patient&apos;s head should be carefully maintained in the inline position manually. Oxygen should be administered while the immobilization equipment is prepared and the secondary assessment is completed.
- #131: Discuss the case progression.
- #132: Discuss the case progression.
- #133: Discuss the case progression.
- #134: Discuss the case progression.
- #135: This patient is displaying findings consistent with an central cord syndrome (incomplete spinal injury). With central cord syndrome, there is damage to the central region of the cord which takes out the medial portion of the corticospinal tracts (patient cannot move his arms), but the lateral portion still innervates the legs. In addition, pain cannot cross over at that level, so painful stimuli from the arms is not sensed by the brain due to spinothalamic damage that prevents the impulse from reaching the brain.
- #136: Discuss the care provided.
- #137: Review as appropriate.
- #139: Discuss the objectives.
- #140: As a paramedic, you will be faced with caring for patients suffering from head injuries. These injuries require a high level of suspicion, as signs and symptoms can manifest days and even weeks after the original injury, especially in the very young and elderly. Assessment of these patients can be complicated because altered mentation is a common presentation in head injuries. In addition, drugs or alcohol may also compound the situation, making assessment even more difficult. You must overcome these challenges in order to promptly evaluate the condition and prevent further neurologic damage to your patient. Understanding the anatomy of the skull and its contents is imperative for determining the specific type of head or traumatic brain injury your patient is displaying.
- #141: Review the basic statistics.
- #142: Discuss the new arrangements for categorizing brain injuries. The underlying pathophysiology is a space-occupying lesion existing in the cranial vault, that is going to increase intracranial pressure and cause shifting of the tissues (structural cause for altered mental status). Discuss how intracerebral hemorrhage is a serious medical emergency because of the increase in intracranial pressure. Discuss why if left untreated, intracerebral hemorrhage leads to coma and death. Review signs and symptoms associated with intracerebral hemorrhages.
- #143: Discuss how DAIs occur when axons are stretched and twisted by rotational shearing forces that occur during rapidly changing movement. Explain how the damaged axons swell and separate from each other, causing interference between the communication and transmission of nerve impulses throughout the brain. This injury is one of the major causes of unconsciousness and persistent vegetative state after head trauma.
- #144: Concussion is defined as a trauma-induced alteration in mental status or other neurologic function that may or may not involve loss of consciousness. Discuss why concussive exhibit only temporary functional disturbances. Explain that with epidural bleeds, the bleeding takes place between the dura and the skull which causes an increase in intracranial pressure (ICP). This rise in ICP causes the cascade of signs and symptoms, including: Decreased mental status Severe headache Fixed and dilated pupils Vomiting Altered or absent breathing Posturing Systolic hypertension with associated bradycardia (Cushing reflex, a late finding)
- #146: Explain how the time required to diagnose this injury and transport the patient to an appropriate medical facility greatly affects the patient’s outcome. Morbidity and mortality are associated with level of mentation and location of the hematoma. Epidural hematoma originates from deceleration injuries or low-velocity impact to the head. Skull fractures are common with these injuries, occurring in 90 percent of adult patients. Epidural hematoma is frequently seen in the temporoparietal region, where the skull fracture crosses the path of the middle meningeal artery. Explain that 20 percent of these pateints have a lucid interval. The patient will suffer from a loss of consciousness and then a period of responsiveness. Shortly thereafter, his level of consciousness will deteriorate rapidly.
- #147: Subdural hematoma is a collection of blood over the surface of the brain, between the dura mater and arachnoid meninges. Subdural bleeding occurs as a result of shearing action along the subdural space and traumatic stretching of small bridging veins. Discuss how it can occur spontaneously in patients who receive anticoagulant therapy such as warfarin (Coumadin) or have a coagulopathy condition. The three phases are acute, subacute, and chronic. Acute phase—Signs and symptoms begin immediately Subacute phase—begins three to seven days after the injury Chronic phase—begins two to three weeks later Explain that subdural hematoma is seen in child abuse cases and incidents involving shaken baby syndrome. The typical mortality rate for this type of hematoma is around 60 percent.
- #150: Manifestations of subdural hematoma can vary greatly, ranging from clinically silent to expansion large enough to cause brain herniation. Signs and symptoms of acute subdural hematoma include: Declining level of consciousness Abnormal or absent respirations Dilation of one pupil Weakness or paralysis to one side of the body Vomiting Seizures Increasing systolic blood pressure Decreasing heart rate
- #151: Subarachnoid hemorrhage refers to an accumulation of blood in the subarachnoid space. Explain that the immediate danger in subarachnoid hemorrhage is ischemia which can lead to permanent neurologic damage or death. The three most common complications that promote ischemia to the brain are: Vasospasm Hydrocephalus Intracranial hypertension The classic symptom of nontraumatic subarachnoid hemorrhage is a thunderclap headache often described as the worst pain ever felt. The majority of studies have shown that patients progress from being pain free to experiencing severe excruciating pain in a matter of seconds. Loss of consciousness typically follows but can take several hours. Other signs and symptoms of subarachnoid hemorrhage include: Restlessness Confusion Motor and sensory dysfunction Vomiting Seizures Severe neurologic deficits develop and become irreversible within minutes.
- #152: Discuss the symptomotology of brain injuries and, whenever possible, relate it back to underlying pathophysiology. Obvious signs of a possible head injury include facial lacerations, scalp hematomas, a starred windshield, a cracked helmet, or evidence of a fall. The AVPU mnemonic (Alert, Voice, Pain, Unresponsive) is used to assess mentation. Keep in mind that the patient may be alert originally but then may decline according to the location and type of injury to the head.
- #153: Discuss the symptomotology of brain injuries and, whenever possible, relate it back to underlying pathophysiology. Signs of brain herniation include unequal pupils, fixed pupils, posturing, hemiplegia or hemiparesis, Cushing reflex, or a deteriorating GCS of two or more points.
- #154: Differentiate between purposeful and nonpurposeful movement. Differentiate between decorticate and decerebrate posturing. Decorticate posturing is associated with an injury in the upper portion of the brainstem. On the other hand, decerebrate posturing is indicative of an injury in the lower portion of the brainstem. Stress that the patient is considered unresponsive when there is no response to verbal or painful stimuli. This is an ominous sign of head injury.
- #155: Be sure to document the patient’s level of mentation accurately and often. Further evaluation of mental status can be done by using the GCS. Review the GCS.
- #156: Discuss the implications of changes in vital signs. Explain why it is important to determine how long the patient was unresponsive, when the loss of consciousness occurred in relation to the time of the injury, whether the loss of consciousness was sudden or gradual, and whether there was more than one episode of unconsciousness.
- #157: Unfortunately, head injuries can be severe and life threatening. Prompt recognition and treatment of these injuries is paramount for patient survival and limiting permanent disability. Discuss the concept of hyperventilation in head injury is controversial. It may produce some short-term improvement but has no role in long-term management of herniation or elevated ICP.
- #158: Unfortunately, head injuries can be severe and life threatening. Prompt recognition and treatment of these injuries is paramount for patient survival and limiting permanent disability. Explain why pressure should not be applied to open or depressed skull fractures.
- #159: Unfortunately, head injuries can be severe and life threatening. Prompt recognition and treatment of these injuries is paramount for patient survival and limiting permanent disability. Discuss how fluids can contribute to a worsened cerebral edema and increased intracranial pressure; however, maintaining an adequate mean arterial pressure is imperative in achieving adequate cerebral perfusion pressures and cerebral blood flow.
- #160: Ongoing assessment should focus on: Maintaining the airway Managing seizures Monitoring the mental status Ensuring a rapid transport to an appropriate facility
- #161: Discuss the case study.
- #162: Discuss the case study.
- #163: Discuss the case. Even though obvious trauma is involved, the paramedic should not discount underlying medical conditions as to the initial cause of the accident. Some traumatic injuries include multi system trauma, head injuries, spinal injuries, and hemorrhage. Additional resources might include another unit, or help from the fire department depending on availability and protocols. Priorities include assessing and managing life threats. The overall impression and active seizing of this patient would indicate criticality even before performing a primary assessment.
- #164: Discuss the case study.
- #165: Discuss the case study.
- #166: Discuss the case. Airway management decision making should be discussed. The patient should have their head manually stabilized and a modified jaw thrust technique should be used to try to open the airway. Suction is needed. Advanced airway options may be warranted to protect him from aspiration and maintain a patent airway. Consider PPV to enhance alveolar ventilation, and oxygenation should be provided. Hyperventilation should be avoided unless obvious signs of brain herniation become present. The seizures may be a result of head injury, diabetic emergency, hypoxia, and medical condition. Whatever the possible cause, this type of seizure will deprive the brain of oxygen and can negatively impact the patient.
- #167: Discuss the case progression.
- #168: Discuss the case progression.
- #169: Discuss the case progression.
- #170: This is likely a hemorrhagic syndrome or diffuse axonal injury. In any instance, the key is the recognition that they are displaying signs of acute herniation. Yes, they have: Unresponsiveness Cushing response Unequal pupils Seizures Additional interventions might include: Considering hyperventilation based on protocol Spinal immobilization Maintain airway, oxygenation, and ventilation Rapid transport IV initiation and fluid therapy Seizure management
- #171: Discuss the care provided.
- #172: Discuss the care provided.
- #173: Review as appropriate.
- #175: Discuss the objectives.
- #176: Differentiate between crush injury and compartment syndrome. Crush injury is a form of blunt trauma. Compartment syndrome is a complication of blunt trauma. Compartment syndrome requires a paramedic to think long term and prevent ongoing injury, whereas crush injuries force the paramedic to consider some very different treatment modalities. Recall that when dealing with soft tissue injuries you must consider not just the outside of the skin, but also the potential for injury beneath the skin.
- #177: Review the description. Describe some mechanisms that may result in crush injuries.
- #178: Discuss how the mechanism can change for these types of injuries, but they all deal with excessive pressure on tissues.
- #179: Direct force crush injuries are the most common types of crush injuries. In this case, an object (or objects) applies force and destroys tissue by direct compression. Examples of this include injuries caused by falling objects and blunt trauma distributed over larger areas.
- #180: In this situation, compression of tissue is caused by the patient’s position. This damage typically manifests over hours—and sometimes days. The inability of a patient to shift position causes compression and restricts blood flow. Cells are deprived of oxygen, and waste products build up. Dramatic examples of this include victims trapped and pinned by earthquakes and bomb blasts, but more common examples occur in patients who fall and are unable to get up; their weight causes the crushing force on dependent structures.
- #181: Explain that direct compression destroys cells in the same manner as any other direct force trauma does. Discuss how crush injuries can restrict and even stop blood flow to the areas that are being compressed. Explain that if compression continues over an extended time (typically longer than four hours), the muscle tissue will actually begin to break down. Discuss how the byproducts of rhabdomyolysis can be leached into capillary circulation and distributed systemically and can lead to: Life-threatening cardiac dysrhthmias damage the kidneys leading to renal failure severe metabolic acidosis systemic vasodilation sudden death
- #182: Compartment syndrome is compression from the opposite direction. Explain that fascia does not stretch, so these muscular compartments form relatively closed containers. When bleeding or swelling occurs inside these compartments, pressure can build up. Discuss that if this pressure continues to rise, it can reduce perfusion and destroy cells; this buildup of pressure is compartment syndrome.
- #183: With crush injuries, the assessment findings will be similar to most any other soft tissue trauma scenarios. Remember, crush injuries come from a “crushing” mechanism—the injuries will appear like any other soft tissue trauma situations. Compartment syndrome can take hours to develop, so it is not commonly seen in the prehospital environment. The goal is to prevent it from occurring through appropriate management.
- #184: Remember that assessment of soft tissue injuries will often be a lower priority than treating the ABCs. Always ensure that the primary assessment has been completed prior to evaluating such wounds.
- #185: The paramedic should assess for altered motor function, circulation, or sensation in the distal areas of the extremity. Explain that a loss of a distal pulse is an unusual finding in compartment syndrome. Typically a pulse is present, even though circulation may be impaired. This pulse may feel weaker than the same pulse in the unaffected extremity. Explain why delayed capillary refill time may be a more important finding.
- #186: Review and discuss the slide. The initial goal is to still properly manage the: Airway Breathing Circulatory mechanisms
- #187: Although generally normal blunt trauma treatment for the most part is warranted in these patients, two specific things the paramedic must remain alert for is when a patient has been entrapped for a long period, muscle breakdown will occur. And, when the oppressive pressure is removed, the patient may hemorrhage into that space. The paramedic can administer fluid to replace what was going to be lost once the weight is lifted from a crush injury. ( Fluid amounts based on protocol) Consider the administration of medications based on protocol. Sodium bicarbonate to reverse acidosis Pain medication.
- #188: As stated, compartment syndrome generally develops over long periods of time. As a result, it is typically not a major concern for the short contact times of most EMS systems. However, in many situations EMS may be in prolonged contact with patients, and in such circumstances preventive measures will help avoid compartment syndrome.
- #189: Discuss the prevention and treatment of compartment syndrome.
- #190: Discuss the case study.
- #191: Discuss the case study.
- #192: Discuss the case study.
- #193: Discuss the case study.
- #194: Discuss the case study.
- #195: This is an unstable patient due to a mental status change and unknown extent of injury. At this time, the treatment will revolve around maintaining airway, oxygenation, ventilation, and perfusion. Also verbally reassure the patient all possible is being done. Possible abdominal or pelvic trauma such as: Perforated diaphragm Perforated bowel Solid organ fracture Pelvic fracture Long bone fracture of the lower extremities Muscle/nerve damage Soft tissue trauma with potential hemorrhage Due to the excessive compressive forces of the tree, there will likely be damage to muscle which will result in bleeding and edema. The fascia wrap that goes around the muscle will entrap this pressure causing it to rise and further inhibit blood flow.
- #196: Discuss the case progression.
- #197: Discuss the case progression.
- #198: Discuss the case progression.
- #199: Bulky dressings for external hemorrhages, pneumatic anti-shock garment for pelvic/abdominal trauma, PPV for ventilating the patient should they become apneic, cardiac monitor, advanced airway devices, and full immobilization equipment so the patient can be readied for transport in a hurry. Depending on protocol, you might establish IV, apply monitor, and administer fluid and medication.
- #200: After lifting the heavy weight, the toxins that have developed in the lower extremities and abdomen are now able to reperfuse back into core circulation—when these toxins hit the brain and heart, they typically cause a detrimental effect to the efficiency of organ function. Secondly, any vascular trauma that is under the heavy weight will now bleed when blood can again reperfuse back down into the abdomen and lower extremities.
- #201: Discuss the case provided.
- #202: Discuss the case provided.
- #203: Review as appropriate.
- #205: Discuss the objectives.
- #206: Discuss that most every major body system is represented in the thorax. Stress that as a paramedic, it is important to have a high index of suspicion with regard to chest injuries because of the vital nature of the underlying organs. Discuss how even minor injuries can have a significantly impact on the mechanism of breathing and disturb the ever-important exchange of gases at the alveolar level.
- #207: Relate epidemiology to the frequency with which the paramedic will have patients with chest trauma. Discuss some of the traumatic injuries that can result in death. Discuss the importance of suspecting internal and structural injury.
- #208: Relate epidemiology to the frequency with which the paramedic will have patients with chest trauma. Discuss some of the traumatic injuries that can result in death. Discuss the importance of suspecting internal and structural injury.
- #209: With chest trauma, the change in physiology is due to a structural change in the thoracic cavity. Discuss how these changes ultimately produce changes in cellular integrity which can compromise ventilation, oxygenation, and circulation.
- #210: Discuss the etiology, pathophysiology, and basic assessment findings for a tension pneumothorax. Review how aggressive ventilation may convert a simple pneumothorax to a tension pneumothorax.
- #211: Review the early and late signs and symptoms of a tension pneumothorax. Explain that the mediastinum will shift away from the injured hemithorax and contralaterally toward the uninjured hemithorax, resulting in compression of the uninjured lung, right atrium, and vena cava. (Late finding) Stress that a tension pneumothorax causes both significant respiratory and circulation compromise, making it an immediate life-threatening condition that requires rapid identification and intervention.
- #212: Discuss the etiology, pathophysiology, and basic assessment findings for an open pneumothorax.
- #213: Review the following are the signs and symptoms of an open pneumothorax: •Open wound to the thorax •Decreased breath sounds on the affected hemithorax •Tachypnea •Tachycardia •Dyspnea •Subcutaneous emphysema •Deteriorating SpO2 reading •Frothy blood at open wound •Other signs of respiratory distress Explain that it is imperative to carefully reassess the patient because the open pneumothorax can develop into a tension pneumothorax, especially if the visceral pleura is injured, allowing air to escape internally into the pleural space from the injured lung.
- #214: Discuss the etiology, pathophysiology, and basic assessment findings for a flail chest. Discuss how a pulmonary contusion may be more lethal than the flail chest.
- #215: Discuss how the flail could be anterior or posterior, or it could involve the sternum with ribs on both sides fractured. Explain that it typically takes a significant blunt force applied to the thorax to produce a flail segment. Discuss how diseases such as osteoporosis can cause the ribs to weaken, so less force may be required to create a flail chest.
- #216: Review that a true flail segment has the ability to move independently of the remainder of the chest wall. During inhalation, the negative intrathoracic pressure will draw the free-floating flail segment inward as the remainder of the chest is moving outward. Discuss how the patient may intentionally limit his breathing, causing the flail segment initially to be stabilized and can be missed on inspection (it will be found on palpation). Discuss how stabilization of the flail segment with sandbags or other devices is NO longer recommended. The patient may be able to self-splint using a pillow and his own arm.
- #217: Discuss the etiology, pathophysiology, and basic assessment findings for a hemothorax. Stress that because blood, and not air, is the source of lung collapse, not only is the patient prone to respiratory compromise, but he can also experience hypovolemia. Explain that it is common for a pneumothorax and hemothorax to occur together resulting in a hemo pneumothorax.
- #218: Review how blood fills the pleural space and collapses the lung tissue. Explain that gravity helps allow the blood to collect in the lower bases of the lung in the seated patient or posteriorly in the supine patient. Relate this to the assessment of the patient’s breath sounds.
- #219: Discuss the etiology, pathophysiology, and basic assessment findings for an acute pericardial tamponade. Pericardial tamponade occurs when an injury to the heart causes blood to collect in the pericardial sac.
- #220: Explain that as the volume of blood in the pericardial sac increases, it compresses the atria and ventricles and does not allow them to fill adequately. Discuss how this reduces the stroke volume, which causes a decrease in cardiac output and then decreases the blood pressure. Explain why the blood backs up in the venous system, causing the veins—especially the jugular veins—to become distended.
- #221: Discuss how with chest trauma it is a collection of symptoms coupled with the mechanism of injury that will identify the underlying pathology. Stress the importance of performing a thorough assessment.
- #222: Review and discuss the table. Discuss how to differentiate between the injuries. Stress that some of the injuries may present with more subtle signs and symptoms initially, so the paramedic must have a high index of suspicion.
- #223: Review and discuss the slide. Stress the need to ensure life threats are properly managed. Discuss the priority in management of an open pneumothorax is to occlude the open wound to the thorax immediately upon its identification. Use a gloved hand until an occlusive dressing taped on three sides can be applied. Stress the importance of reassessing the patient for a tension pneumothorax. The first priority of management upon identification of a tension pneumothorax is to reduce the pressure of the affected pleural space. Allow any air that has been built up to escape from an occlusive dressing. If this is ineffective or if the patient does not have an open pneumothorax, needle decompression of the affected pleural space. Review the proper way and locations to perform a needle thoracostomy. The true indicator for needle thoracostomy is the identification of a pneumothorax with hemodynamic side effects—all the potential signs and symptoms of a collapsed lung (respiratory distress, pain, unequal breath sounds, for example) plus signs of hemodynamic dysfunction (low blood pressure, poor perfusion).
- #224: Emergency care focuses on management of the airway, ventilation, oxygenation, and circulation. Explain why the paramedic is limited in managing a hemothorax or pericardial tamponade in the field. Stress that early recognition and expeditious transport could be life saving. Discuss why administration of fluids to expand the existing blood volume should be restricted, even in a hemothorax. Discuss that some protocols require that the systolic blood pressure be maintained between 70 mmHg to 90mmHg in order to reduce the incidence of hemodilution. Follow your local protocol. Consider pain medication, such as fentanyl, for pain associated if protocols allow.
- #225: Discuss the case study.
- #226: Discuss the case study.
- #227: Discuss the case study.
- #228: This is a potentially unstable patient for two reasons. First, the soft-tissue injury the patient is applying pressure to may be deep enough to pierce into the pleural cavity of the thorax. Or, it may be a significant bleed, or it may be neither and it is just a soft-tissue wound. Treatment at this time would be high-flow oxygen, and the application of an occlusive dressing over the chest wall injury and then reapplication of direct pressure to help minimize the bleeding.
- #229: At this time, the differentials include: An open pneumothorax Major bleed Tension pneumothorax Flailed chest wall Underlying pulmonary injury The paramedic should recognize that the type of injury will determine the type of V/Q disturbance. More information will be needed to form a differential diagnosis before a complete answer can be provided. If the underlying injury is an open pneumothorax, then there is a disturbance on the ventilation side of the equation. If the patient has a hemothorax, the patient will have perfusion disturbances as well.
- #230: Discuss the case progression.
- #231: Discuss the case progression.
- #233: Discuss the case progression.
- #234: Deterioration may be noted if there are changes to the mental status, drop in pulse oximeter, declining breath sounds, increased agitation, and worsening lung compliance. Burping the dressing during exhalation would allow the expulsion of any accumulating air in the chest, which should allow the subsequent breaths to start inflating the lung. In a patient with a penetrating chest wall injury, the provision of PPV could allow air to escape the lung tissue (if the visceral pleura is also damaged), and accumulate in the pleural cavity. This then will collapse the lung and interfere with normal ventilation.
- #235: The paramedic should recognize the early signs and symptoms of a tension pneumothorax. Because the dressing has already been burped and the patient is continuing to deteriorate (distress and hypotension), the paramedic should perform a needle decompression of the affected side. The decompression will reduce the pressure of the affected pleural space.
- #236: Discuss the care provided.
- #237: Discuss the care provided.
- #238: Review as appropriate.