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Not ice on Ca.., l>rocn1 urr$ It is Ihe inlell' of the authors and publisher that this Ic)(tbook lli: used as PUI of an educalion "r"'Sram taughl by 4Uho lo: Mark Ide Composit ion: S4C:arlisle Publishin g Ser"ices Prillt ing ~ nd Bind ing: Couri.. r K.. ndJU"iU .. Cl"cr I'rinter: Coral GI"Jphics
If )'Oll purchased this book withinlhe United Sla tes or Canada you should be aware thJ' il h:.s ll \·Villiarn Pfeifer, rvto. FACS Mar)' M. Radanovich RN, BSN, EMT-P John T. Stevens, ErvIT-P Ron Stewart, M D, FACEI' Arlo Weltge, J\ol D, FACEP Brian J. Wi lson, NREMT-P
We lVis/l to thallk the EMS professio/w/s who rev;clVet/materia/ especi(lll), for this 6th Editioll of Interna ti onal Tr:lll ma Life Su pport fo r Prehospital Clf(' Providers. Their assist(lllee is appreciated. Chris Cousar, BS, NREMT- P, EM S Educator, University o f New Mexico EM S Academy Steve Creech, EMT- P, Training Officer, Washington Cou nty EM S, Plymouth , Nort h Ca rolina John S. Molnar, N REMT- P, Manage r, CPR/ere; Inst ructor. Cleveland Cli nic Heal th S)'s tem ; Adjunct IPRN, BTLS affiliate fa culty at School of EMS, Euclid, O hio
Tim Swa im , Para m ed ic Instructor, Rockingh'lm Com mu nit y Co llege, Wentworth, No rth Carolina Jason I~ Z ielewicz. MS, NREi\IIT- P. EMS Su pervisor and In structor, O ffi ce of EMS, Th e Pennsylvania State University
Allotller special tha nks goes to the following photographers wllo dOllated tlteir work to "elp jill/strate tile text. Roy Also n, MD, I:ACEP Brant Burden, H 'IT- I) Antho ny Cd litti , NREMT-P Leon Charpentier, EM T- P Buddy Den so n, EMT- P Pamela Drexel, Bra in Traum3 ]:oundation David Effron, ~'lD, FACEP Ferno Washington, Inc. KING Ai rway Systems Kyee H. Him, MD. FRCS, HAEM
Edu 'lrdo Romero Hicks, MD leff Hinshaw, MS, PA-C, NREMT- P 130n nie Mcneely, EMT- P Noni n Medical, Inc.
Ilob Page. NREM T-P William Pfeifer, tvl D, FACS Don Resch Sam Spl ints Surefi re '[1ctiClory) Vital Signs (Measured Pul~, Respirations, Blood Pressure) Pul:IB Oximeter, Cardiac Monitor, Blood Sugar, C02 MoniiOf GIoKOW Como Scale Score !Eyes, Voice, Movement); EmoliOflol Slate Hood !pupils, Bottle's Sign, Roc;coon Eyes, Drainage; Deformities, COflIuSiOflS, Abrasions, Penetrations, Burns, Tenderness, locerotiOfls, Swelling [OCAP.anslJ Ne Circulation • What is the ratc and quality of thc pulse at the wrist (and at the neck. if not palpable at the wrist)? • Is major external bleeding present? • What are the skin color. condition, and temperature? Decision • Is this a critical situation (Table 3-1)? • Are there interventioos that I must make now?
Ra pid Trauma Survey (See Figure 3-2. ) Head and Neck • Are there obvious wounds of the head or neck? • Are the neck veins distended? • Does t.he trachea look and feel midline or deviated? • Is there deformity or tenderness of the neck? Chest • Is the chest symmetrical? Is there paradoxical movement ? Is there any obvious blunt o r penetrating t rauma?
• Are there any open wounds? • Is there TI C of the ribs? • Are the breath sounds presen t and equal? • If breath sounds are not equal, is the chest hyperresona nt ( pneumothorax ) or dull (hemothorax)? • Are heart sounds normal o r decreased? Abdomen • Are there obvious wounds? • Is the abdomen soft, rigid, or djstended? • Is there tenderness?
__
I \ ",1 I
,I
'
'
Critical trauma situations are characterized by any of the following: • Decreased level of consciousness • Difficulty with airway or breathing • Shock or uncontrolled bleeding • Tender abdomen • Unstable pelvis • Bilateral femur fractures • High-risk group
CHAPTER 3 Patie nt Assessment Skills •
IlLS PRIMARY SURVEY SCENE SIZE·UP Stondard Precautions, Hazards, Number of Polients, Need for Additional Help/Equipment, Mechanism of Injury
-------------------------------}-----------------------------INmAl ASSESSMJ:NT GeMfollmprenion (Age, $ex, Weight, General Appearance, Position, Activity, Obvious In juries/Bleeding)
lOC (AVPU) Conlfol Cervicol Spine Airwoy
(Snoring, Gurgling, Slridor, Silence) Breothiog jPresent? Role, Depth, Effort)
Radial/Carotid Pul:les !presefll? Rate, Rhythm, Ouality) Skin COIOf, Temperature, Moisture; Capillary Refill
Uncontrolled Ex\ernol HOlTlOfrhogei
-------------------------------!-----------------------------RAPID TRAUMA SURVEY
Inspect Head and Ned: (Mojor Facial In juries, Bruising. Swelling. Penetrations, 511bc;uh;meQu5 Emphysema)
(Neck Vein Distention? Trocheal Deviation?) Insped Chesl (Asymmetry, ConllJsions, Penetrations, Paradoxical Molion, Instability, Crepitation! Breath Sounds (Present? Equal?) (If unequal: Percussion) Heart Tones Abdomen (BruiSing, Penetration/ Eviscerotion, Tenderness, Rigidity, Distention) Pelvis £Tenderness, Instability, Crepitation) lower/Upper Extremities (Swelling, Deformity, Instobility, Motor and Sen$Ory) Place Potient on Ihd:boord Posterior !penetrations, Deformity, Presacral Edema) If Critical Siluotion, Transfer to Ambulance to Campletll Exam. Bose-line Vitol Signs Measured Pulse, RespiratiOlU, Blood Pressure Pupils (Size? Reactive? Equal?) (If Altered Mental StoIuS:) Glascow Como Scale Score Eyes, Voice, Motor, Orientolion, Emotional Stole
FIGURE 3 -2 The Rapid Trauma Survey as pari orlhe ITLS Primary Sur vey.
Pelvis • Are there obviolls wo unds o r deformity? • Is there TI C? Upper Legs • Are there obvio us wounds, swelli ng, or deform ity? • Is there TI C?
49
so •
CHAPTER 3 Patient Assessment Skills
Lower Legs and Arms • Are there obvious wounds, swelling, or deform ity? • Is there TIC? • Can the patient feel/move fin ge rs and toes?
Posterior This exam is performed during tran sfe r to th e backboard. • Is there any deformity, contusions, abrasions, penetrations, burns, tenderness, lacerations, or swelling (DCAP-BTLS) of the patient 's posterior side?
Decision • Is there a critical situation? • Are there in terventions that I must make now?
History • \,\Ihat is the SAMPI.E history (ma)' have been obtained during the exa m )? Baseline Vital Signs • Are the vital signs ;lbnormal? Disability Perform th is exam now if there is altered mental statu s. Otherwise, postpone this exam until you perform the IT LS Secondary Survey. • Are the pupils equal and reactive? • What is the Glasgow Coma Scale score? • Are there signs of cerebral herniation (unconscious, dilated pupil (s), hypertension , bradycard ia, posturing)? • Does the palient have a medical identification device?
PROCEDURE
• • • • •
Short written scell 60 with decreased LOC
Neurological Exam
Consider increased intracerebral pressure. Maintain systolic blood pressure of 110-120. To 8e Done If Altered Mental Status
PUPILS Unequal. ................................. Suspect head injury unless patient is alert, then suspect eye injury. Give 100% oxygen. Unequal or dilated and fixed with GCS :::;; 8 ...... Give 100% oxygen; do not let patient get hypotensive. [Target systolic BP of 110-120.) Intubation and hyperventilation (20 breaths per minute) are indicated. (Unequal pupils or dilated and fixed pupils and GSC 8 or less are suggestive of cerebral herniation.) Pinpoint (with respiratory rate < 8) ............. Consider naloxone. Dilated/ reactive (with GCS :s: 8) ............... Give 100% oxygen; consider intubation. GLASGOW COMA SCALE score (for decreased LOC) :::;; 8 ................................. Give 100% oxygen. Don't let patient get hypotensive (target systolic BP of 110-120). Intubation en route is indicated. Consider hyperventilation only if patient shows signs of cerebral herniation: -
GCS :::;; 8 with extensor posturing
-
GCS
-
s 8 with pupillary asymmetry or nonreactivity GCS s 8 with a subsequent drop of more than 2 points
ALL PATIENTS WITH DECREASED LOC ......... Check for medical identification devices. Do blood-glucose check.
Dan, Joyce, and Buddy of the Emergency Transport System (ElS) have been ca lled to the scene of a house fire. Their Scene Size-up reveals that the fi re service is present, the scene is safe. and there is on ly one victim. a young woman. She had been asleep in a back bedroom where the firefighters found her and pulled her out of a win dow. She is covered in soot and is coughing. How would you approach this patient? What is the
mechanism of injury? What type of assessment would you perform? What would you do first? Is this a load-and-go situation? Keep these questions in mind as you read the chapter. Then, at the end of the chapter, find out how the rescuers completed this ca ll.
INTRODUCTION Of all the tasks expected of fie ld teams c.1ring for the trauma patient, none is more important than th at of ai rway control. Mai ntaining an open airway and adequate vent ilation in the trauma patient can be a challenge in any setting, but it can be almost impossible in the adw rse environment of the field with its poor lighting, the Ch:IOS that often surrounds the ('wnt, the position of the patient, and perhaps hostile onlookers. Ai rway cont rol is a task th:lI YO ll must master, becallse it fn.'q uently " mnot wai t until you get to the hospital. PlItients who arc cyanotic, und(·rvcntilated. or both. are in need o f immediat e hel p-help that o nl y you can give them in the in itia l stages of their ca re. it fall s 10 you, theil , to be fa miliar with Ihc basic structure and func tion of th(' airway, to be versed in how to achieve and main tain an open airway, and to know how 1'0 oxygenate and ventilate a patient. Ikcause of the unprcdictabk nature of the field environment, YO LI will be called on to manage patien t airways in almost every conceh'able si tuation: in wrecked " Irs, dangling above ri ver», illihe middle ur i l »i.uppingccntcr, o r at the »ide of a l.IUsy hil)lm' .. y. You therefore need optiolls and altt.·rnatives from which to choose. What will help o ne pat ient may not work for ano thn. One patient may requ ire a sim ple jaw thrust to open an :lirwa)" whi le another may requi re a surgical procedure to pn!\'ent impending dea th . Wh atever the methods required, )'OU must always st:lrl with the basics. It is or lillie value--a nd in some cases it may be downright dangerous- to apply "adva nced" techniques of airway cont rol before begi nning basic maneuvers. The discussion o f airw:IYco ntrol in the traumll p:ll ient wi ll be rooted in several fu ndamental truths: Air should go in and ou t, oxygen is good, and blue is bad. Everyth ing else follows from this.
59
60 •
CHAPTER 4 Initial Airway Management
SOFT PALATE
TONSIL
ANATOMY AND PHYSIOLOGY
....t 7L NOSE
i~~;i== TEETH
MOUTH
The airway begins at the tip of the nose and the lips and ends at the alveolocapillary membratle, through which gas exchange takes place between the air sacs of the lung (the alveolt) and the lung's capillary network. The airway con~ sists of chambers and pipes, wh ich conduct air with its 21 percent oxygen con tent to the alveoli and carry away the waste carbon dioxide that diffuses from the blood into the alveoli .
TONGUE
Nasopharynx
HYOID BONE
,)f,f-- /-- -
VOCAL CORDS
I L L - - J L - - - TRACHEA
ESOPHAGUS
FIGURE 4-1 Anatomy of the upper airway. Note that the longue, hyoid bone, and epiglollis are allachcd to the mandible by a series of ligaments. Lifting forward on the jaw will therefore displace all theS(' structures anteriorly.
The beginning of the respiratory tract (the nasal cavity and oropharynx) is lined with moist mucous membranes (Figure 4~ 1). This lining is delicate and highly vascular. It deserves all the respect that you can give it, and that means preventing undue trauma by using liberally lubricated tubes and avoiding unnecessary poking about. The nasal cavity is divided by a very vascular midline septum, and on the lateral walls of the nose are "shelves" called the turbinates. These projections can get in the way when tubes or other devices need to be inserted into the nostrils. Care~ full y sliding a weJl ~ lub ricated tube's bevel along the floor or the septum of the nasal cavity will usually prevent traum a~ tizing the turbinates.
Oropharynx The teeth arc the first obstruction we meet in the oral part of the airway. They may be more obstructive in some patients than in others. in any case. the same general principle always applies: Patients should have the same /llImber and conditio/l of teeth at the end ofall airway procedure as they had at tile begirmil1g. The tongue is mostly a large chunk of muscle and represents the next potential obstruction. These muscles are attached to the jaw anteriorly and through a series of muscles and ligaments to the hyoid bone, a wishbone~like structure just under the chin from which the cartilage skeleton (the larynx) of the upper airway is suspended. The epiglottis is also connected to the hyoid, so elevating the hyoid wiUlift the epiglottis upward and open the airway furthe r.
Hypopharynx Th e epiglottis is one of the main anatomic landmarks in the ainvay. You must be famil~ iar with it and be able to identify it by sight and by touch. It looks like a floppy piece of cartilage covered by mucosa-which is exactly what it is-and it feel s like the tragus. the cartilage at the opening of the car canal. Its function is unclear, but it is nonetheless im~ port ant to you when you must assume control of the airway. The epiglottis is attached to the hyoid and thence to the mandible by a series ofligaments and muscles. In the un ~ conscio us patient, the tongue can produce some airway obstruction by falling back against the soft palate and even the posterior pharyngeal waU. However, it is the epiglottis that will produce complete airway obstruction in the supine unconscious patient
-
CHAPTER 4 Initial Airway Management _ 61
whose jaw is relaxed and whose head and neck arc in the neut ral position. In such pat ien ts the ep iglo tt is will fa ll down :lgainsl the glo ttic opening and prevent vent ila tion. It is essen tial to u ndnsl'and this crucial fact in the management of the a ir ~ wa)'. To ensu re an o pen (patent) airway in an unconscio us supi ne patient, you can displace the hyoid anteriorly by lifting forward o n the jaw (chin lift, jaw thrust) o r by p ull ing o n the tongue. Th is will lift the tongue out o f the way and keep the epiglo ttis elevated and away from the posterior pha ryngea l wall and glottic opening (Figure 4-2). Both nasotfacheal and o rotracheal int ubalion req ui re elevatio n of the epiglottis b)' a laryngoscope o r the fi ngers, by pulli ng o n the to ngue o r by lift ing fo rward o n the jaw.
Larynx On eith er side of the epiglottis is a recess called the pyriform fossn. An e nd o ~
FIGURE 4-2a The epiglottis is attached to the hyoid and then 10 the ma ndible. When the mand ible is relaxed and fa lls bac k, the to ngue falls upward and agai nst the soft palate and the posterior pharyngeal wall, while the epiglott is fa lls over the glottic opening.
!rachcOlI tube ca n "catch up" in either o ne. Pyriform fossa placement of an e n ~ dotracheal tube can be identified easily by "tenting" o f t.he skin on eit her side of the superior aspect of t he laryl/geal promil/ellce (Adam's apple) o r by t ra n s~ illumination if a lighted stylct (or " lightwand") is being used to in tubate. The vocal cords arc prot('('ted by the tl/yroill cartilage, a boxlike struct ure shaped like a "C," with the o pen part of the "'c" representing its posterior wall , which is covered with muscle. In some patients, the cords can dose ent irely in laryngospasm, prod ucing complete airway obstruction. The thyroid cartilage can easily be seen in most people on the anterio r surface of the neck as the laGlottic ryngeal prominence. Infer ior to the thyroid ca rt ilage is another part of the larynx, the crieoirl, a cartilage shaped like a signet ring with the ring in fro nt and the signet behi nd. It ca n be pa lpated as a small bu mp on the anterio r surface o f the neck inferior to the laryngeal prominence. The esophagus is just beh ind the posterior wall o f the cricoid cartilage. Pressure o n the cricoid at the fro nt o f the neck win d ose o ff the esophagus to pressures as high as I OOcm H 20. T his maneuver (t he Sellick /ll1It/ell ver, I:igure 4- 3) can be used to reduce the risk o f gastric regurgital io n d uring t he p rocess of intubatio n a nd to p revent insum at ion of air into the sto mach d uring positive pressure ventilatio n by mo ut h-toFIGURE 4-2b Extension of the head and mouth , bag-valve mask, o r fl ow. restricted oxygen-powered V('ntila to r. If lifting the chin will pull the tongue and there is any danger of cervical-spin e injury, you m ust ca refully support and the epiglottis upwa rd and forward, stabilize the neck while perfo rm ing the Sell ick maneuver. exposing the glott ic open ing and en suring Con necting th e inferior bo rder o f t he thyroid cart ilage with the superior the patent airway. In the trauma patient, only the jaw, or chi n and jaw, should be aspect o f the crico id is the cricothyroid membra lie, a very impo rt ant la n d ~ displacro forwa rd, while the head and mark through which )'O U can gai n d irect access to the airway below the neck should be kepi in alignment. cords. Yo u can palpate the cricothyroid mem brane o n most pat ien ts by find· ing the most p romi nent pa rt of t he thyroid cartilage and then slidi ng your index fi nger down u ntil you feel a second "bump" just before you r finge r palpates the last depressio n before t ht., stenwi llotch. That second bu mp is the crieoitl CIIrtilage, and at the upper edge o f t his is the cricothyroid membrane (Figu re 4 ~4). In so me p:ltients, especially those wi th a th ick neck, you may fi nd the cricoid cartilage mo re easily by goi ng fro m the sternal notch upward unt il yo u fed th e fi rst pro minent cart ilage " bu mp." Just over the ~ top" of this b ump is the cricothyro id membrane. The sternalno lch is an impo rtant la nd· mark as well beca use it is the poi nt at wh ich the cu ff of a properly placed endo t racheal tube sho uld lie ( Figure 4-5) . The sternal notch is readi ly palpa ted at the junct io n of the clavicles with the uppe r edge o f t he sternu m.
62 •
CHA PTER 4 Init ial Airway Management
FIGURE 4-3 The Sellick maneuver.
FIGURE 4-4a External vie"" of the an terio r neck, showi ng the surface landnlarks for the thy roid cart ilage (laryngeal) prominence, the cricothyro id membrane, and the cricoid cartilage.
FIGURE 4-4b Cutaway view showing the importan t la nd ma rks of the larYI!;': and upper airway: hyoid, thyroid cart ilage, cricothyroid membrane, Il nd cricoid cartilage.
Trachea and Bronchi The tracheal rillgs (C-shapcd c:lrtilaginoLis supports for the trachea ) conti nue beyond the cricoid cartilage, and the I rachea soon divides into the left and right /1/ai1l5lem brOllchi. The point at which the trachea divides is called the mrill(l. lt is import.lIl t to note that the right mai nstem bronchus takes off at an angle that is slight ly more in li ne with the trachea. As a result , tubes or other fOTi.'ign bodies usually end up in the right ma instem bronchus. One of the goals of a properly performed endotracheal intubation is to avoid a right (or left ) mai nstem bronchus int ubation. YOLI should know how fu r some of these major anatomic l:tndmarks arc from the teet h. Not o nly wil l a knowledge of these help )'ou place an endotracheal tube at the correct level, but also by remembering on ly three numbers you wi ll be able to detect a lube that is too far into the ai rway or not in far enollgh. The three numbers to remember arc 15, 20, and 25. T he first number, 15, is the d istance (in c('ntimel'ers) fro m the teeth to the vocal cords of the average ad ul t; 20 (5 cm far ther down the airway) is the stern:11notch; and 5 cm fn r-
CHAPTER 4 Initia l Airway M anagement _ 63
J;:"~~==~ Nasal Passage Sinus
~
~'=--~- Pharynx
Epiglottis
Thyroid cartilage
La""" Cricoid cartilage
Trachea
Upp."
Pleura
of rlght"'"''·.,.- ---....
Right main _~" ......:----~ Left main bronchus
bron - OPNNPA definitively ventilate the patient in the worst-case scenario ( Figure 4-14).
~..
- Two-per~ bog
"
- Consider obstruction
c
·, .5 7 -SIAD V
. Laryngoscopy arid intubation
FIGURE 4-14 Response 10 difficult bag-mask \·cntilation.
Airway Equipment The most important rule to follow in regard to .lirway equipment is that it should be in good worki ng order and immediately ava ilable. It will do the patient no good if you have to run back to the amb ulance to get the suction apparatus. In other words, be prepared. This is not difficult. Five basic pieces of equipment arc necessa ry for the initial response to all pre hospital trauma calls.
CHAPTER 4 Initial Airway Management _ 75
• Personal p rotection equ ipment (see Chapter I) • Lo ng backboard with attached head mot io n-restriction device • Appropriately sized rigid cervical extrication collar • Ai rway kit (see below) • Trau ma box (see Chapter 1) The airway kit should be com pletely sel f-con tained and should contai n everything needed to secure an airway in any patient. Eq uipment now available is lightweight and portable. Oxygen cylinders are aluminum , and newer suction devices arc less bu lky and ligbter. It is no longer acceptable to have suctio n units Ihal arc bulky and stored separa tely from a sou rcc of oxygen. Suction unitssbould be contained in a ki t with oxygen and other essen tial airway lools. A ligh tweight airway kit should consist of the followi ng (Figure 4- 15): • Oxygen D cylinder, preferdbly aluminum
FIGURE 4-15 An airway ki t containi ng the essentials for airway management. Note thai portable suction is included in this dcsign. The to tal .....cight (with aluminunl " I)" oxygen cylinder) is app roxi mately 10 kg (22 lb), about the samc as a slee' ''E'' cylinder.
• Portable b,ltlery- powered and hand-powered suction units • Oxygen cannulae and masks • Endotr a re:.u lt o f a ll{'asl a 1,500 C( bllx)(i lo:.s in ll) til(' thOr:.lCic ca\·it}'. Each thorack cayit}' mit)' ("(m tain u p 10 .\.000 n." of blood . !\Ias:.i\"(' IWlllothorax i:. mor(' often dUl' to rellt,traling tra u ma than til blunt trauma, h UI I,'ither iniury I1MY d i,rupt 11 major pulmonary or systemic \'i.'~.1>llch ,1h injury to Ihe ch c~ t will be p ink un k' ~ Ihert" are other probl(,I1l~.
Tr;.lUlllalk a!>phyxia ind icale!> that tnt' paticnI has sulTerl·d a 1>t.'n.'re' blunI thorad.. injur'\', and major thoracic injuries arC' likdy to be present. Management includes a i ~OIy nl.li ntt'nance, IV access, treating o theTinjurI(,s., and rapid transport.
• • • • •
PfAtU
.mplr PnrumetltonIX
--1**1:1--.,...
........,. pw.-poy;
I'
oi
.~~c.C4*
PI
••
.,.-..on
J I M - - nepulM ....... .
'"''''''''-
Simple Pneumothonlx: SimplC' pneumothorax milv result fro m blunt or penetrating trauma. Fract ured rib::. art' the u~u.ll C3US(' ill blunttrOltlma. Pm'umothor;u: L;; cau5e(i by dCcumulation of air within the potC'ntiaJ spacC' be1"'et'n thC' vi.scernJ and pari(1al ple-ura. 1 M lung may be totally or p.trtiallv collap..~.'d Ihe ai r con li nul'S 10 at'crue in the thoracic cavity.ln a healthr patient this ;;;;hould nol acutd r compro mi~ \'entilation, if a tension pnnJ l11othorax does nol ('\'oln'. Pa lit'nt." wit h Ie-55 rl'Spiratory rCSt'rye illay not tolerate.' e\'en a simple pneumothorax. Dj,lgnosis of .t pneumothorax i.. bilM.-d o n plcuntic chl'::.l r.t in, drSpnt'.I. dec-rea!>'".-\oy be normal Breath Sounds Norma l Extremities Absent motor/sensory (usually from neck or upper chest down) FIGURE 8-2 nd increases, the systemic blood pressure increases to try to preserve blood flow to the bra in. The bod)' senses the rise in system ic blood pressure and th is triggers a drop in the pulse rate as the body tries to lower the blood pressure. With scvere injury andlor ischemia, the pressure with in the sku ll continues in an upward spiral until a critical point at which the ICP approaches the MAP and there is no cerebral perfusion. All vital signs deterio rate, and the patient dies. Because CPP depends on both the arterial pressure and the Ie p, hypotension will also have a devastating effect if the Ie p is high .
••••• PEARLS Hypoxia ami Hypote:tlSiotl
Patients with serious head i~uries cannot tolerate hypoxia or hypotension. Give high·fIow oxygen and monitor oxygenation with a pulse oximeter. • Usual~ pediatric patients have a better recovery from ml. ~ an adult and a child have the same injury, the child has a much better char.c:e of recovery. However, hypoxia and hypotension appear to eliminate any neuroprotectiw! mechanism normally afforded by age. ~ the child with a serious brain injury is allowed to become hypoKic or hypotensiYe, the rnar.c:e 0/ recovery is even worse than an aduh with the same injury.
146 • CHAPTER 10 Head Trauma
As stah.'d above, the injured brain loses the abilit), to autoregula te blood fl ow. In this situatio n perfusion o f the brain is directl y dependen t on t he C PP. You Illllst maintain a cerebral perfusion pressure of at least 60 mmH g (see earlier formu la), which requircs maintaining a systolic blood pressure of at least 110 to 120 mmH g in the patient with a severe head inj ury. T his will rarely be a problem, as hypotension o nly occurs in about 5 percent of patients with severe T BJ (GCS of < 9). Aggressive attempts to maintain CPP above 70 mmHg with flu ids and presso rs (dopam ine, epinephri ne) should be avoided because of the risk of adu lt respiratory dist ress syndrome (ARDS).
Cerebral Herniation Syndrome
• • • • • PEARLS
Brain Injury A. patient who, after correction of
hypoxia iII!d tr,-polension, shows rapid progression of brail injury (e.g., \.WIf~ with cilated pupil; decet-Knte posn.ing; or drop .., GCS score of >2 with an ioitiaI GCS score of < 9) should be toosported rapidly to a tr.tuma center capable of IT\iI'oaQing sevete rnI patients. This is the only situation .., -Mlich hypetwntIlation is d flclicated (see Table 10-1). ttyperventiation, while krown to cause ischemia, maydeaelSl! brain
swelling temporamy. Although a despeme measu-e, this might 00y enough tine to get the patient to surgery thai migflt be r~e-saving. 1Ia60 ahead so that a nelXOSllgeotl CiIIl be available and the oper.Iting room prepared by the tine )'OU arrive at the hospital.
Whenl he brain swells, pa rticularly after:t blow td the head, a sudden rise in IC P may occur. This may force portions of the brain downward , obst ru cting the flow of cerebrospinal fluid and applying great pressure to the brain stem. T he classic find ings on exam. in this li fe- threatening situation, arc a decreasing level of consciou sness ( LOC) tha t rapidly progresses to co ma, di lation of the pupi l and an o lltward-downward devhltion of the eye on the side of tile injury. paralysis of the arm and leg on the side opposi te the injury, o r decerebrate posturing (arms and legs extended). As the cerebral hern iation is occurring, the vital signs frequently reveal increased blood pressure and bradycardia (Cushing's response). The patient may soon cease all movement, stop breathi ng, and d ie. Th is syndrome often fo llows an acute epidural or subd ural hemorrhage. If these signs are developing in a head-injury patient, cerebral hernia tion is imminent and ilggressive therapy is needed. As noted earlier, hyperve ntil ation will decrease the size of the blood vessels in the brain and briefl y decrease IC P. In this situation the danger of immedia te herniation ou tweighs the risk of cerebral ischem ia that can follow hyperventi lation. The cerebral hern iat ion s)'ndrome is Ihe only situatio n in which hyperventilation is still indicated. (Vou must ven tilate every 3 st.·conds /20/min l for adults, every 2 ~ seconds [25/min J for children, and every 2 seconds [30/m in l for infants.) -10 simplify knowing when to hyperventilate in the fiel d , the cli nical signs of cerebral herniation in the patient who has h:ld hypoxemia and hypotension corrected :1fe any one (or more) of the following: • T Bi patient wit h il GCS < 9 wi th extensor posturing (decerebrate posturing)
• TI3l patient wit h a GCS pu pi ls
< 9 with as),mmet ric (or bi lateral ), d ilated, Or nonreactive
• T BI patient wi th an ini tial GCS 2 points
< 9 who then drops his or her GCS by mori,.' than
For the above, "asymmetric pupils" means 1 mm (o r more) difference in the size of o ne pupil, "fixed " means no response « 1 mm ) to bright light. Bila teral di lated and fixed pupils usually arc a sign of b rain stem inj ury and arc associated with 91 percent mortality. A unilateral dilated and fixed pupil has been associated wi th good recovery in up to 54 percent
Age Group
Normal Ve ntilation Rate
Hype rve ntitation Rate
Adult Children Infants
8-10 breaths/ minute 15 breaths/minute 20 breaths/minute
20 breaths/ minute 25 breaths/minute 30 breaths/minute
I!
CHAPTER 10 Head Trauma _ 147
of pa tients. Remember that hypoxem ia, orb ital t ra uma, d rugs, ligh tning stri ke, and hypo therm ia also afTect pu pillary reaction , so take t his in to accou nt befo re begin ning hyperventi lat ion. F];ICcid par;llysis usually means spinal injury. If t he pat ient has signs of hern iatio n as listed above and the signs reso lve with hypervent ilatio n, you shou ld d iscontinue the hyperventi latio n.
HEAD INJURIES Scalp Wounds The scalp is hi ghl y vascular and oft en blt'eds briskly when lacerated . BeC:luse many of the small blood vessel s arc suspended in an inelasti c mat rix of support ing ti ssue, the norn1--20. .t Chest nut. It ~L L F. Marshall. M. R. Klauber. and others.I993. The role of secondary brain injury in determining oUlComc from severe head injury. !ollmal o/Tr(/lIm(/ 34: 216-22. 4. Cruz, J., G. Minoja, K. Okuchi. 2001. Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: Arandomized trial. NCllrosurgery49(4): 864-71. 5. Davis, D., D. Hoyt, M. Ochs. et al. 2003. The effect of paramed ic rapid k'que nce intubation on outcome in patien ts with severe traumatic brain injuT)" !oumal ofTmllma-llljury /,,/cC/ioll do Critical Girl! 54(3): 444-53. 6. Davis. D. , J. Du nford, J. Poste, et al. 2004. The impact of hypoxia and hyperventilat ion on outcome after paramedic rapid sequence intubation of severely head-injured patients. Journ(/I of "[mrllllll 57( I ): 1-8.
7. Davis, D., J. Du nfo rd, M. Ochs, ct al. 2004. The use of quantitative end-tidal capnometry to avoid inadvertelll seveTC hyperventilatio n in patients with head injury after paramedic rapid sequence intubation. JarmUlI ofTrmmUl-llljllry IttJcetioll do Crit;CtI/ Care 56(4): 80S-14. 8. McKeag, D.B. 2003. Understanding sports+rcJatcd concussion. Coming into focus but sti ll fuzzy. JAMA 290: 2604-5. 9. Pigula, F. A., S. L. Wald, S. R. Shackford, and others. 1993. The effect of h)'J>otension and hypo.'(ia on children with severe head injuries. JOllrnal of Prdiatric SlIrgl!ry 28: 310- 16. 10. Wang, H., A. Peitzman, et al. 2004. Out-of-hospital endo tracheal intubation and outcomc after traumatic brain injur),. Antrals ofEmag!!rrcy Melliej,,!!44: 439-50.
Dan, Joyce, and Buddy have been called to a public swimming pool. They are told that there has been a diving injury. What injuries should they expect with a mechanism
of this
(Pholo 0 IkJb Kri~t/ CO Rltl S)
type? Is a spinal injury likely? What other emergency may be associated with a diving injury? Keep these questions in mind as yo u read the chapter. Then, at the
end of the chapter, find ou t how the rescu ers completed this call.
INTRODUCTION Spinal-cord injury is a devastati ng and life-th reatening result of modern trauma. If a patient with a spinal-cord injury survives, he could lose his independence hod. with the patient experiencing hypotension. normal skin color I!lC' temperature, and an inappmpMte~ b hnn lite.
Neurogenic Shock Injury to the cervical or thoracic spinal cord can produce high-space shock (see C hapter 8). Neu rogenic shock results from the malfunction of the aulonomic nervous system in regu· lating blood vessel tone and cardiac output. Classically, neurogenic shock in the injured patient results in hypotension, with normal skin color and temperature and an inappropri· ately slow heart rale that contrasts with hypovolemic shock. In the healthy patient, blood pressure is maintained by the controlled release of catecholamines (epinephrine and norepinephrine) from the adrenal gla nds. Sensors in the aor· tic and carot id arteries monitor the blood pressure. Catecholam ines cause constriction of the blood vessels, increase the heart rate and the strength of heart contraction, and stimulate sweat glands. The brain and spinal cord signal the adrenal glands to release catecholamincs to keep the blood pressure in the normal range. In pure hemorrhagic shock, these sensors detect the hypovolemic state and compensate by constricti ng the blood vessels and speeding the heart ra te. The high levels o f catecholamines cause pale skin, tachycardia. and sweating. The mechanism of shock from spinal -cord injury is just the o pposite. There is no sig· nificant blood loss, but the injury to the spinal cord destroys the ability o f the brain to reg. ulate the release of catccholamines from th e adrenals ( the spinal cord cable is out), so no ca techolam ines arc released . When the levels of catecholamines drop, the blood vessels di· late ca using the blood to pool. This drop in preload causes the blood pressure to fall. The bra in cannot correct this because it cannot gettne message to the adrenal glands. The pa tient with neurogenic shock can not show the signs o f pale skin, tachyca rdia, and sweating beca use the cord injury prevents release of catecholam ines. Intra-abdom inal injury is d ifficult to eval uate because the patient with neurogenic shock usually has no sen· sat ion in the abdomen. The multiple-trauma pat ient may have both neurogenic shock and hemorrhagic shock. Neurogenic shock is a diagnosis of excl usio n, aft er all other potenLial ca uses of shock have been ruled out. In the prehospital setting. neurogenic shock is treated in the same way as hemorrhagic shock (sec C hapter 8).
ASSESSMENT AND MANAGEMENT OF THE TRAUMA PATIENT Assessing for Possible Spine Injury
• • • • • PEARLS
Motor and Sensory
Function Pctionn bnef motor and $eI\SOIy cheW il the upptf and lower e~ before and Ifte( mooMg 1IyY patient
All trau ma patients are evaluated in the same manner using the ITLS Primary Survey, of which evaluation of spinal-cord function is a pa rt. Clues to spinal-cord injury are given in Table 11 -2. Parts of the neurologic,ll exam are performed during the ITLS Primary Sur..-ey and the remainder of the neurological exam is performed during the ITLS Seco ndary Sur· vey. This is frequently done after the patient is loaded into the ambulance. The pat ient who requires extrication is a special situation. Before begin ning ext rica· tio n, you should check sensory and motor function in the hands and feet, and document these findin gs later in the written report. Not only docs this pre-extricatio n neu rological exa m alert you to any spinal inj ury, it also provides documentat ion o n whether o r not t here was loss of fUllctio n lxfore extric,ltio n was beg ull . Sadly, then: "re" few reports of patiellU who have claimed that their spinal injuries were caused by their rescuers. You will not have time to perform the pre-extrication neurological exam on the patient who requ ires Emer· gency Rescue ilnd you may not have time on those requiring Rapid Ext rication.
CHAPTER 11 Spinal Trauma _ 167
Mechanism of Injury • Blunt trauma above the clavicle • Diving accident • Motor vehicle or bicycle accident • Fall • Stabbing or impalement anywhere near the spinal column • Shooting or blast injury to the torso • Any violent injury with forces that could act on the spinal column or cord Patient Complaints • Neck or back pain • Numbness or tingling • Loss of movement or weakness Signs Revealed During Assessment • Pain on movement of back or spinal column • Obvious deformity of back or spinal column • Guarding against movement of back • loss of sensation • Weak or flaccid muscles • loss of control of bladder or bowels • Erection of the penis (priapism) • Neurogenic shock "The -dues· listed are indicators that the spine may have been injured. These patients may require $MR. (Please refer to Figure 11-8.)
The neurological exa m is described in more detail in Chapters 2 and 10, but we will review Lhe exam of the peripheral nervous system here. The JTLS Primary Survey must be time efficient. If the conscio us pal"ient can move his fingers and toes, the mo to r nerves are int3Ct. Anything less than normal sensation (tingling or decreased sensation ) is suspicious for cord injury. The unco nscious patient may withdraw if you pinch his fin gers and toes. If so, you have demonstrated int act motor and sensory nerves and LhllS an intact cord . However. this docs not mean SMR is not needed. All unconscious trauma patients should ha\·c SMR. Flaccid paralysis and no reflc.xes o r withdrawal, even in the unconscious head injury patient , usuaUy means spinal-co rd injury. Document these important findings.
Managing the Trauma Patient Minimizing Spinal Movement: Based on the mechan ism of injury, it is appropriate to place the head and neck in a neutral position as you first evaluate the patient. The purpose ofSMR is to minimize spinal movement to avoid aggravating any spinal-cord o r column injury. Preparation for managingspinal· cord or column injury ca n begin when yO li are dispJtched 10 the scene of a motor-vehicle collision, fall , explosion, head injury, or neck injury. There arc two types of situations that require modificatio n o f the usual SMR. The pa tient who is in immediate danger of dealh in a hostile environment or in an immediate lifethreateni ng positio n in a structu re o r vehicle may "-"'quire emergency rescue. An example ...."Quld be the patiellt who is in an MVC and , when you arrive, the aulO is on fire. In cases
168 • CHAPTER 11 Spinal Trauma
where even a few seconds may mean the difference between life and death , you are justified in saving the patient in any way possible. Anytime this manner of rescue is used, you should document the reason and req uest a review of the chart by medical direction. Some examples of situations that might require emergency rescue arc when Scene Size- up identifies a condition that may immediately endanger you or the patient, such as: • Fire o r immediate danger of fire or explosion • Hostile environment , gunfire o r o ther weapons • Danger of being carried away by rapidly moving water • Structure in immed iate danger of collapse • Continuing immediately life-threatening toxic exposure
.. - . -
PEARLS Emergency Rescue
Emergtney Rescue is reseNed for those situations ~ then is inrned-'ate (within seconds) environmental threat 10 the rife of the victin and/OI rescuet. PJtienu should be mewed to a safe area in a manner that places the rescuer at the least risk.
R.,;d _
""'*I t.
consKItred for patients whose ~ conditions 01 situations requile fast intervention (one 01 two rninutes-but not seconds) 10
"""" """
- ... -
PEARLS TrQc,jon Do not apply traction 10 the head iInd ned. Maintain n.ine stabiWtion of the head, ned, iInd spine.
The second situation that requires modification of usual SM R is for patients whose ITLS Primary Survey indicates a critical degree of ongoing danger that requires an intervention within I o r 2 minutes. Indications for rapid extricatio n are the foll owing: • Airway obstruct ion that cannot be relieved by modified jaw thrust or finger sweep • Ca rdiac o r resp iratory arrest • Chest or airway injuries req uiring ventilation o r assisted ventilation • Deep shock or bl eeding that cannot be controlled Rapid extrication requires multiple rescuers who remove the patient alo ng the long axis of the body, usin g their hands to minimize spinal movement (see skills in C hapter 12). When the rapid extrication technique is used, the written report sho uld also be carefull y reviewed to ensure appropriate documentation of the techn ique and its indication. The most easily applied and readily available method of cervical-motion restrictio n is with your hands o r knees. Your hands should be placed to stab ilize the neck in relation to the long axis of the spinal column ( Figure 11 -5). "Pulling traction" is not a prehospital 0p· tion, and the term traction is not an app ropriate descriptio n fo r motion restriction of the spine. Traction will usually result in further instability of any spinal-column injury. The correct approach is stabilization , without pulling on the neck. When packaging the body on a backboard, the neutral in-line position allows the most room for the spinal cord, so that is the optimal posit ion for SM R. You can place an appropriately sized cervical-spine extrication collar on the patient as airway assessment is bein g done. Commerc ial cervical motio n-restriction devices may be left in place o n the backboard. These one· or !'ovo-piece collars are not definiti ve devices for restricting cervical-spine motion. but should be used only as a reminder that SM R is necessary and to prevent gross neck movement. The rescuer's hands can be removed o nly when the patient (head and body) has been strapped on a backboard with an attached head motion -restriction device. Fo r the conscious patient. positioning the head and neck in a position of comfort is a good guideline. Adequate strappi ng must secure the head , to rso. and upper legs to the backboard. Inadequate strapping will to rque the neck aga inst the body if the patient moves, rolls, is d ro pped. or is rotated. Placin g and strapping a patient on the board effecLively eliminates the patient's ability to protect the airway; therefore , the rescuer is responsible. Once the patient is secured to the board, a rescuer must be present and capable of rolling the board if the patient begins to vomit or loses his airway. This rule continues in effect in the emergency department, where an emergency depanment staff person must assume responsibility for airway protect ion. Definitive SM R occurs when the body is strapped securely to the board with cushions, blanket , or towel roils, maintaining the head, cervical spine, torso, and pelvis in line. In the past, sandbags have been used for motion restriction of the head and perform well when the patient is kept supine. However, if the board is tilted or the patient and the board are
CHAPTER 11 Spinal Trauma _ 169
8.
"
c. FIGURE 11· 5 Neut ral spinal positioning fOf infant, child, and adult patients. (a) Due to the large heads of younge r children, yo u nla y need to raise the shoulders with padding. (b) In older children, obtain neutral positioning with shoulders and head on a nat surface. (cl With adults, elevate the head I to 2 inches.
170 • CHAPTER 11 Spinal Trauma
..
b.
o.
FIGURE 11 -6 (a ) Ree\'es slccve; (b ) fo.·liller body splint ; (cl ped iat ric SM R device; (d ) Kend r ick ext ric;uioll device; (el shorl backboard; (f) Shorl backboard app lied 10 scaled pal ien t.
.... -
PEARLS
Neulral Alignmenl PlOper padding is ohtn le:juiled 10 obtain and milntaln nel.Itf1I aligrunenl oIlIle patient's rervical spine when you periorm spiMl motion reslriction.
rotated (to prevent aspi ration when the patient \'om its). the weigh t of the sandbags ma)' calise a dangerous ilmount of head movement. Therefore sa ndbags are an extremely poor option for prchospital SMR. Ligh ter-weight bulky objects, such as towel rolls. blan ket rolls, or head cllshions, are better tools for this job, When applied properl )', these devices allow r,'moval of the fro nt portion of the cervical coUil r ilnd obS('rviltion of the neck, as in the patient with open neck wounds. T here are some patien ts (frig htened child ren and patients with altered menta l stat us) who will stfllggle so violent ly that they defeat )'O Uf attem pts to di minate spinal movement. Th('re may be no good solution to this. T he Reeves sleeve ( Figure 11-6) may be the best de-
CHAPTER 11 Spinal Trauma _ 171
I d.
••
t.
FIGURE 11-6 (continued )
vice to restrict sp inal motion in the combative adult patient. You should always carefully documen t those situations in which tht· pat ienl refuses to cooperate with SMR. A trul y neutra l ccn' i cal ~s pin(' position for an adult is lIsually obtained with the lI SC o f 1102 inches of occipital padding on a long backboard. This slightly elevates the head and brings the neck into a neu tral position th:lI tends to make the pal ient more comfortable and also makes endotracheal intubat ion easier if needed. This is accomplished. with Ihe head pad o n a cerv ical mo tion resiriClion device or thc padding that is uSc.--d with many backboard devices. Elderly patients whose necks ha\'c3 natural flexed posture wil l require more padd ing. Children, because thei r heads are proportionately larger. usually req uire padding under the shoulders to pre\'ent neck flexion on the backboard. In cerlain si tuations, once the patien t is packaged o nto Ihe backboord, the boa rd and patient may have to be rolJed up o nto his side (Figure 11-7). Ca refu l slrapping can prevent lateral movement of the spine in this situation , bu t usc of the vacuum backboard is far superior for this. Women who arc more than 20 weeks pregnant should al\\'3ys be transported with the backboard tilted 20 to 30 degrees to the patient's left side in o rder to keep the uterus off the inferior vena cava. Patients wit h airway problems who arc not intuba ted arc better transported on their side. This is especially cri tical when there is FIGURE 11 -7 Palienl in vacuum backboard uncont rolled bleed in g in to t he airwa), or if there is massivc facc or turned on side. Nolin' thai the body is mai ntai ned nt'(k tra uma. In t hese sit uat io ns gravit), helps dra in fluid s O ll l of Ihe in a siraight line. 4
172 • CHAPTER 11 Spinal Trauma
••••• PEARLS
Protecting tile Airway A patient in spinal motion restriction is at risk for aspiration and other problems. You are responsible IOf
checking and maintaining the airway.
airway and may prevent aspiration if the pat ient vomits. Beca use of the danger of voron iting and aspiration. unconsc ious patients who arc not intubated shouJd be transported rolled to the side. The Log Rol! : The log-roll technique is used for moving a patient onto a backboard. It is commonly used beca use it is easy to perform with a minimum number of rescuers. As yet no movement technique has been devised that maintains complete spinal immobilization while moving a patient onto a backboard. Properly performed. the log-roll tech nique will minimize movement of the spinal col umn as well as any other technique. The log-roll technique moves the spinal column as a single unit with the head and pelvis. It can be performed on patients lying prone or supine. Using three or more rescuers- Ihe:- lxxly is Iranslaloo u r magnifie:-J with in tht;> lissut:s, where
circulation initially and after any
the end of the object m ay lacerate o r harm sensi tive structures. Impaled objects in the neck that obstruct the airway or those in the cheek of the face are exceptions to this rule.
",,""',,",
Compartment Syndrome The extremit ies cont ain muscle tissue in closed spaces that a rc su rrounded by to ugh me m branes that will no t stretch. Trau ma (cr ush injuries, closed o r o pen fracture, o r sustained compression) to these areas (fo rearm and lower leg most com mo nly) m ay cause bleeding and swell ing wit hin the closed spaces. As the a rea swell s, p ressure is transm itted to the
"""""'" ..,.,,,,,.
21 6 .
CHAPTER 14 Extremity Trauma
blood vessels and nerves. This pressure may compress the blood vessels in such a manner that circulation is impossible. The nerves may also be compromised. These injuries usu· ally develop over a period of hours. Late symptoms are the five Ps: pain, pallor. pulsd~ ness. paresthesia. and paralysis. The early symptoms are usually pain and paresthesia. As with shock, you should think of this diagnosis before the later symptoms develop.
ASSESSMENT AND MANAGEMENT
- ----
PEARLS
Priorities Follow the ABU and do not be cistrKted by otMoca txtrI!'!Iity
"""".
• E>ooog~ ~. "" IJICe9tion to the eboYe tfoIow CAB ""'" """ ASCI. ... 1'" IIUt not
for9It to iSIISli6YRf
.. In""",. Be very IIert to the mecNnism of ~ 10 INt )'OU know wl\at bctures to suspect IIId 10 !hit 1"'<M> _ _ COij~t$.
Scene Size-up and History When assessing the patient with extremity trauma, it is especially important to get a history because the mechan ism of injury may not be apparent in your Scene Siu- up. The mechan ism of inju ry and your assessment of the extremity may give you im portant dues to the potential severity of the injury. If th ere are rescuers eno ugh. one rescuer can obtain the history while you are performing the ITLS Primary Survey. If no t, you should not attempt to elicit a detailed verbal history until you have assessed the status of the airway, breathing, and circulation. In the conscio us patient, obtain most of the history at the end of the ITLS Primary Survey. Foot injuries from long jumps (fuJis landing on the feet) often have lumbar spine injuries associated with them. Any injury to the knee when the patient is in the sitting position may ha'·e associated injuries to the hip. In a like manner, hip injuries may refer pain to the knee, so the knee and the hip are intimately connected and must be evaluated together rather than separately. Falls onto the wrist frequently injure the elbow, and so the wrist and elbow must be evaluated together. The sa me is true of the ankle and the proximal fibula of the o utside of the 100...er leg. Any injury that appears to be in the shoulder must becarefullyexamined because it may easil y involve either the neck, chest, o r sho ulder. Fractures of the pelvis are usually associated with very large amounts of blood loss. Whenever a fracture in the pelvis is identified. shock must be suspected and proper treatment begun.
Assessment During the ITLS Primary Su rvey. you are concerned with obvious fractures to the pelvis and large bones of the ext remities. You sho uld also find and cont rol major bleeding fTOm the ext remities. Duri ng the ITLS Secondary Survey, quickl y assess the fulli engih of each extr emity, looking for deformity. contusions, abrasions. penetrations, burns, tenderness, lacerations, and swell ing (DCAP-BTLS). Feel for instab ilit y and crepi tation (see Chapters 2 and 3). Check the joints for pain and movement. Check and record d istal PM S. Pulses may be marked with pen (ballpo int or felt tip) to identify the area in which the pulse is best felt (Figure 14-6). Crepitatio n or grat ing of bone ends is a definite sign of fracture. and once identified. the bone ends should be immediately immobilized to prevent further soft -tissue injury. Checking fo r crepitation should be do ne very gentJy. especially when checking the pelvis. Crepitation meanli hone endli are grating o n one another, and th is means yo u arc causing furt her tissue injury.
Management of Extremity Injuries Proper management of fractures and dislocations will decrease the incidence of pain, disability, and serio us complicatio ns. Treatment in the prehospital setti ng is directed at proper immobilization of the injured part by the use of an appropriate splint. Even with proper immobilization of fractures, the patient may req uire analgesic medica tio n.
CHAPTER 14 Extremity Trauma _ 217
FIGURE 14-6c Palpate the posterior tibial
pulse. (Photo COIlrtesy of Michal Heron )
FIGURE 14-6b Palpate the do rsalis
pedis pulse. ( Photo COllrtesy of Michal FIGURE 14-6a Palpate the radial artery. (Photo courtesy of Midm/ Heron )
HerOl')
Purpose of Splinting: The objective is to prevent mo tion in the broken bone ends. The nerves th at ca use the most pa in in a fract ured ext remity lie in the memb ra ne su rrounding the bonc. The broken bone ends irritate these nerves, causing a very deep and distressing type of pain. Splinting not on ly decreases pa in, but also el iminates further damage to mu scles, nerves, and blood vessels by preven ting fur ther motion of the broken bone ends. When to Splint: There is no simple rule that determines the p recise sequen ce to follow in every trau ma patient. In general, the seriously injured patient will be better off if you splint only the sp ine (long backboard) before transport. The patient who requires a loadand-go approach ca n have extremity fractu res temporarily stabilized by careful packaging on thc long backboard. This docs not mean that you have no responsibility for identifying and p rotecting extremity fractures, but impl ies that it is better 10 do so me splinting in the vehicle en route to the hospital. It is never appropriate to sacrifice time splinting a limb to prevent disability, when that ti me may be needed to save the pa tient 's life. Conversely, if the patient appears to be stable, extrem ity fract ures should be splinted before moving the palient.
PROCEDURE
£iJ
Rules of Splinting
• You must adequately visualize the injured part. Clothes should be cut off, not pulled off. unless there is only an isolated injury that presents no problem to maintaining immobilii'..ation . • Check and record distal sells'ltion and circulation before and after splinting. Check movement distal to thc fractu re if possible (for example, ask the conscious patient to wiggle his fi ngers or observe the motion of the unconscious patient when a painful stimulus is applied). Pulses may be marked with a pen to identify where they were palpated.
• • • • • PEARLS
The Golden Hour Do not waste the Golden Hour. Be cautious but be rapid, and priorim life 0Yef limb.
•
Sp~nt at an appropriate time.
n-.e
axial s.\;eletoo is splinted after the ms Primary Survey. Extremities should be splinted en route if a aitical situatiOfl exist$.
218 •
CHAPTER 14 Extrem it y Trauma
1. Confirm loss of pulse 2. GenUy gmsp extremity above and below break 3. Apply tmction steadily and smoothly 4 . Maintain tmction while splint
is applied 5. Recheck pulse and sensation
FIGURE 14-7 Straightening angulated fract ures to restore pulses.
• If the cxtremity is severely angulated and pulses are absent. apply gentle traction in an attempt to stra ighten it (Figure 14-7). This traction sho uld never exceed 10 pounds of pressure. If resista nce is encounter(.>d. splint the extremity in the angulated position . When you arc attempting to straighten an ex tremity, it is very impo rtant to be honest with you rsel f with regard to resistance. It takes very little force to lacerate the wall of a vessel o r to in terrupt the blood supply to a large nerve. If the trauma center is ncar, always splint in the position found. • Open wounds should be covered with a sterile dressing before you apply the splint. Splints should always be applied on the side of the extremity away from open wounds to prevent pressure necrosis.
• Use the splint that will immobilize one joint above and below the injury. • Pad the splint well. This is particularly true if there is any skin defect or if bony prom inences might press against a hard spUnt. • Do not attempt to push bone ends back under the skin. If you apply traction and the bone end retracts back into the wound, do not increase the amount of traction. You should not usc your hands or any tools to try to pull the bone ends back Ollt, but be sure to notify the receiving physician. Carefully pad bone ends with bandages before
CHAPTER 14 Extre mity Trauma _ 219
apply ing pne um,ltic splints to the lower ext remities. T he healing of bone is improved if the bone ends arc kept moist when transport time is prolonged . • In a li fe-threate ning situatio n, injuries may be splinted while the patient is being transported. When the patient appears stable, splint all injuries befo re mO\'ing him . • If in doubt, splint a possible injury.
Types of Splints Rigid Spli"ts. This type o f spli nt ca n be made from many different ma terials and includes all Gudboard, hard plnstic, metal, or wooden lypes of splints. The type of spli nt that is made rigid by evacuating air fro m a moldable splint (vacuum splin t) is also clnssified as a rigid splin t. Rigid spli nts shou ld be padded well and should always extend one join t above and below the fractu re. Soft Spli"ts. T his type o f splint includes air spl ints, pillows, and sling- and swathe-type splints. Air spl ints arc good fo r fr;l ctures of the lower arm and lower leg. Air splints have the advantage of compression, which hel ps to slow bleeding, but they ha\'e the diSOldva ntage of increasi ng pressure as the tempe rature rises or thc altitude increases. They should not be put o n angula ted fractures since they will automaticall y apply straightening pressure. O ther major dis.1dva ntages of air splints include the fac t thai the extremity pulses can not be monitored wh ile the splint is in place, a nd the splints also o ften stick to the skin and arc painrulto remove. Inflating the splints requi res you to blow the splints up by mouth or by hand or foot pum p (never by co mp ressed air) u ntil they give good su pport and yet can easily be dented with slight pressure from a fingert ip. When using air spli nts, )'ou must constantly check t he pressure to be sure that the splint is not getti ng too tigh t o r too loose (they often leak ). Remember that if aiT splints arc applied in a cold e nvironment and the pat ient is moved into the \"'arm e nvironment of the am bulance, the pressure will increase as the splints warm up. "Vhere ai r ambulances a re available, it must be rememben."!! that the pressu re in air splints increases if they tire applied on the grou nd and then subseq uentl), the patien t is airlifted to the hospi tal. Contin uous monitoring of circulation in the frac tu red extremity is requi red . Also remember that if pressure is released durin g the Aight, the pressure wi ll be too low when the patien t is retu rned to the ground. Pillows make good splints for injuries to the ;mkle or foot. They are also helpful , along with a sling a nd a swa the, to stabili ze a dislocated shou lder. Slings a nd swathes arc excellent for injur ies to the davicle, shoulder, upper arm, elbow, and sometimes the forearm. They utilize the chest wall as a solid foundation and splint the arm agai nst the chest \\'al1. Some shoulder inj uries cannot be brought close to the chest wall witho ut significa nt force being applied. In these insta nces, pillows arc used to bridge the gap bctWl."Cll the chest wall a nd the upper arm. 'f rac'ion Splint. This device is designed for fractu res of the femur. It holds the fra cture immobile by the applica tion of a steady pull on the ankle whi le applying counter traction to the isch ium a nd the gro in. This steady traction overcomes the tendency of the vcry strong thigh muscles to spasm. If t raction is not a pplied, tht· pain worsens because the bone ends tend to impact o r override. Traction also prevents free Illotion of the ends of the femur, which could lacerate the femoral nerve, artery, or vein. T here ,Ire many designs and Iypes of spl ints available to a ppl y tractio n to t he lower extremi ty ( Figure 14-8 ), bu t each m ust be ca refull y padded a nd applied wit h care to prevent excessive pressure on the soft tissues arou nd the pelvis. It is also necessary to usc a great deal of care in a pplying the ankle hitch so as not to interfere with the circulation of t he foot. Man), of t h e~ devices cun be used with a buck's boot as an altern ative to the a nkle hitch.
220 •
CHAPTER 14 Extremity Trauma
FIGURE 14-88 Kendrick traction dc\·ice. (P/IO/O COllrtesy of
FIGURE 14-8b Hare tract ion splint.
Etfrlflrdo ROllh'ro H icks, AU»)
FIGURE 14-8c Sagcr trdctio n splint.
---------
PEARLS
Spit'f! Injuries
In major trftM'l'la. tIlf ami skeleton is .ways sp6nted on along baaboard or appropriate $C:OOI) streicher.
PEARLS
Shock
So """"'" """"""'" when there is'" a peMc or feru"'"
""""
Management of Specific Injuries Spine Injuries: Spine injuries arc cover('d clsewhen.' in the book bu t includ('d h('re to rem ind you thaI if Ih('re is an)' chance of one, proper SM R (spinal motion rcstrictio n) must be done to prevent lifelong para lysis o r even death from a spinal-cord injury. In the most urgent cases, car('ful packaging o f the patient on the long backboard may be adequate splint ing for a number of different extrem ity injuries. Rcm('mber that certain mech:misms of injury, such as a fa ll from a height in which Ihe pat ient lands o n both feel, may cause lumbar sp ine fracture because forces
Gloscow Como Scole Sc(lfe Eyes, Voice, Motor, OrientotiOl'l, Emotional Slole
FIGURE 1704 Steps in the assessment and management of the trauma patient are the same for both children and adults.
10 Ihc neck can be life threatening. A deviated trachea is difficult to detect in a small child, but has the same significance as in adults. Make a mental note o f the child 's initial level of conscio usness as you begin your survey. Although a preschool child may appea r to be slec p ~ ing rathe r than unconscio us from an injury, remem ber that most children will no t sleep th ro ugh tlu.: arrival o f cll'lc:rgcn cy vchick-s. Al;;k lilt: pilrt:nts tu wake tilt: child so you 1..'1 II gc:l an in itial assessment o f thc airway and level of conscio usness. I:ollowing a IrOlu llla t-ic evenl , a decreased level of consciollsness may suggest hypoxia, shock, hl'ad tra uma, or seizure.
265
266 •
CHAPTER 17 Trauma in Children
Assessment of Breathing Assess the ch ild fo r bre.lI hing difficulty. Coun t the child's respinllory rate. Most children brellthc fas t when they arc havi ng trouble and then, when they can no longer compellS1 2yr
Weight (kg)
(per minute)
(per minute)
l-4 8-10
30-50
120-160 120-140
12-16
20-30 14-2() 12-2() 12-16
18-26 26-50 >50
3().40
100-110
90-100 80-100 80-100
i Pressure (mmHg)
>60 70-80 80-95 90-100 100-110 l00-l2()
CHAPTER 17 Trauma in Children _ 269
longe r feel the pul se, and allow ai r to leak slowly while observing the dial o n t h(· blood press ure cuff. Record the pressure at which you first fee l the pulse and label it "p," for pal pation. This will be a systoli c blood pressure on ly and will be slightl y lower than a b lood pressure th at can be ausc ultated. A systoli c blood pressure less than 80 in children, and less th an 70 in young in fants, is a sign of shock. Shock Illay be secondary to occult blccding in the abdOlllen, chest, or in a femur fraclufl'. AJso, alt hough we leach that patients do not go into shock from intracranial blood loss, in ra re ci rcu mstances, this can happen in the very young infa nt. NOTE: T he ant ishock ga rmen t ( MAST or PASG) is no lo nger recoll1 lllended for treatment of sh ock except in specia l ci rcumstances.
Fluid Resusdtation: If hypo volemic shock is present,
•
FIGURE 17-6 Equipment for giving bolus treatment for shock. (I'hoto CoUrIN)' oj Roy A/sc",. MI) )
the child requires fluid resuscitation. You sho uld establish vascular .1CCCSS and give a fluid bolus. The initial bolus sho uld be 20 m U kg of no rmal s.,line, given as rapidly as possible. See the appro priate eq uipment set up to do this in Figure 17-6. If there is no response, anot her 20 m llkg ca n be given. If the child is in laIc shock and you Gl11not sec o r fee l a vein. o r canllot Slart an IV in two at tempt s or 90 !>econds. yo u Ill:ly need 10 perform intraosscous infu sio n (sec Figure 17-7; and Chapler 9). There is 110 scientific dat a avai lable at this time to suggest that any child in hemorrhagic shock should not be given IV fluids.
Control of Bleeding Obvious bleeding sources must be controlled to ma intain circulation. Remember, the child's blood volume is abollt 80-90 IllUkg,::>o a 10-kg child has less than I liter of blood. T hree or four lacera tions c:ln ca lise ;1 200- m L blood loss, which is about 20 percent of the child 's total volume. Therefo re, pay closer attention to blood loss in a child than you do in an adult. Usc pressure firm eno ugh to control arterial bleeding if necessary. If ),ou ask the parent o r a bystander to help hold pressure, mo nito r them to be sure they are applying enough pressure to sto p the bleeding. Usc a bandage lighll.·llough to control veno us bleedi ng, not one that will just soak up the blood so that YOll do not sec it. Elevating an injured extremi ty .llso can help to control bleeding. Hemostatic 'lgenrs can be used to control c'xsanguin:lting hemo rrhage in children.
FIGURE 17·7 An intraoSS('Ous needle in child's proximal tibia bei ng used for ve nous access. (P/W/I} Courll'syoj /Job Page, NRIiMT. P)
The Critical Trauma Situation If you have found a critical trauma situatio n, the child needs ra pid transport. Log-roll the child o nto a pediatric backboard and leave the scene as q uickly as possible. Remember to usc a pad under the torso to align the neck in a neutral position. Appropriately sized rigid cervical collars arc useful , especially in children over 1 year of age, and Gi n help remind the pat ient and prov iders not to move the head . Do not depend on the cervical collar alone;
270 • CHAPTER 17 Trauma in Children
• • • • • • • • •
Obstructed airway Need for an airway intervention Respiratory distress Shock Altered mental status Dilated p upil Glasgow Coma Scale score d . Pati ~ nl S without d ish:l1d cd lll"Ck veins may appea r to be in PEA but will not respo nd to Advanced Cardiac Life Support (AC LS) protocols. Acute myoca rdial infarction and myoca rdial contllsion can produce inadequate blood Ilow (circulation ) by either one or a combinatio n of th ree m echanisms. T hese mecha nisms are dys rhythmias, acute pump f.lilure, o r pericardial tamponade. The patient with a myoca rdial contusio n has usually been in a d eceleration accident. There may be a chest wall or sternal con tusion . A full arrest fro m an electric shock usually presents as ventricular fibrillati o n. It responds readily to AC LS protocols if you arrive in time. The ca rdiac arrest is frequentl y due to the prolonged ap nea that Illay follow electrocution or lightning strike. The victim o f an electrical shock has sulTered severe muscle spasm and may well have been thrown down or fallen a great distance. Thus the sa me systematic approach to th e patient is required ( 0 identify all as" sociated injuries and to give the patient the best chance for a good outcome. Be sure the patient is no longer in contact with the electricity source. Do not become a victim yourself! Patien ts with card io pulmonary arrest related to inadequate circu latio n have either of the foll owing: • In adequate retum of blood to the heart because o f • Increased pressure in the chest ca usin g increased resistance to the venous return to the heart , as in tension pneumo thorax o r pericardialta mponade • Hemo rrhagic shock wi th inadequate blood vo lume to be retu rned to the heart
CHA PTER 21 The Trauma Cardiopu lmonary Arrest _ 311
• Inadequate pumping of the heart because of • Rhyth m d istu rba nces as in myocardial co ntusion, acute myocardial infarction, or elect rical shock • Acute heart fa ilure with pulmonary edema, as in large myoca rd ial co ntusion or acute myocardial infarction
APPROACH TO TRAUMA PATIENTS IN CARDIAC ARREST Trauma patients in cMdiac arrest arc a special group. Most are young and do not have prcexisting cardiac condirions or coronary disease. Ensuring a complete Scene Size-up is impo rtan t as some involve crim inal activity (stabbings. shootings), so carefully rL--cord (after the ru n) your observations of the scene. Some of these patients lllay be resuscitated if YOll arrive soon eno ugh and you pay attention to the di ffe rences from the usual med ical ca rdiac arrest. The ex t remely poor resuscitation rille for tramllil patient s in card iac arrest is probably due to t he fact that many of t hem have been hypoxic for a prolonged period of time before thc arrest occu rred. Pro lo nged hypoxia ca uses such scvere acidosis that the patient wi ll not respond to attem pted resusci tation. Patien ts who suffer cardioresp iratory arrest from isolated head injury usually do not survive. b ut these pat ients should be :lggressivei y resuscitated because the extent of injury (annO( always be determined in the field and, therefore, yOll can no t predin the Ollicome for the indi vidual patien t. (They arc also potential orga n donors.) Patients who arc fOllnd in asystole after massive blunt t rau ma arc dead; they may be pronou nced dead in the field. Children are a special case. \ adequate number of rescuers are
required to handle this situation well: one to drive the ambulance, one to ventilate, one to do chest compressions, and one 10 diagnose and treat the cause of the arrest.
312 • C HAPTER 2 1 The Trauma Cardiopulmonary Arrest
• • • • • PEARLS
Asy$tole Patients found in asystole aher massive blunt trauma are dead. There is no reasonable expectation of resuscitation.
• • • • • PEARLS ITLS Primary Survey The pu!seless Ir.Juma patient requires atttfltion to the IllS Primary Swvey to identift treatable problems in the """,priority-
termination of reSliscitation. If the patie nt has penetrating trauma, check the pupils. 1ft pupils are dilated and nonreactive yO lI should consider termination of resliscitatio n. Resusl citation efforts for patients with injuries incompatible with life or those who have evidenc of prolonged time si nce the a rrest Crable 2 1- 1) should not be in itiated or should have ler mination of resuscitation efforts as directed by your local m edical direction. For pat ients with an organized rhythm on EKG, you must quickly evaluate and treat fo r Ihe ca lise of the arrest. This should be done in the am bu lance during transport, if pos-sible. Follow the ITLS Primary Survey that you follow for every trauma patient.
PROCEDURE
E:!J Initial Assessment and Critical Actions 1. Establ ish a nd control the airway (with a n e ndotracheal tube if possible) and ven tilate with 100 percent oxygen. Wh ile the othe r two rescuers arc ventilating and performing chest compressions, you must systematically look for the correctable cause(s) of the arrest.
2. Look for breathing problems as a cause of the arrest. Answering the following quest io ns will allow you to identify a ny breathing proble ms that may be the cause or a co ntributing factor. a. Look a t the neck: ( 1) Arc the neck veins flat or distended? (2) Is the trachea midline? (3 ) Is the re evidence of soft-tissue t rauma to the neck? b. Look at tbe chest: ( I) Docs the chest move symmetrically each time you vent ilate? (2) Are there chest injuries (penetrat io ns, bruising, flai l segm ent)? (3) If there is spontaneo us respira tion, is there any paradoxical motion noted? c. Feel the chest: ( I ) Is there any instability? (2) Is there any crepitation? (3) Is there any subcutaneous emphysema? d. Listen to the chest: ( J) Are breath sounds present on both sides?
(2) Are the breath sou nds equal? Ifbreath sounds arc no t equal, percuss thccncst.ls Ihe side with the a bsent or decreased breath sounds hyperresonant or dull? If in tubated, is the endotracheal tube inserted too f'lf? If there are distended neck veins, decreased breath so unds on one s ide of the chest, with th c t rachea deviated away from the s ide of the injury, and hype rreso nance to percussion of the c hest on the affected side, then the patient probably has a tension pneumothorax . An imprope rl y posit ioned endotrac hea l tube can cause un equal b reath sou nds and w ill be harmful to t he patie nt . since on ly one lung ca n be venti lated. You should always recheck the position of the endotrachea l tube before you make a diagnosis of tension pneumothorax. It is much more com mon to have a poorly positioned e ndo tracheal t ube than to have a tension pneumothorax. A tension pn eumo th orax requi res need le decompression ( if you ar e trained, and protocols allow). If required, call medical direct ion immediately for permission to decompress. Continue ventila tion with 100 percent oxygen.
CHAPTER 21 The Trauma Cardiopulmonary Arrest _ 313
Do not discontinue chcst comprcssio ns until there is a palpable pulse. Even though you have found a cause, there may be other cau ses for the patient's arrest. O ther breat hing problems (suckin g chest wound, nail chcst, simple p neumothorax ) will be adequatel y treated by endotracheal intubatio n and vcntilation with high- now oxygen. Once you have intubated the patien t, yo u no longer have to sea l suckin g chest wounds or apply ex ternal stabilization to flail s. Remember that positive pressure ven tilation ca n convert a simple pneumothorax to a tensio n pneumothorax. Now that the patient has both an adequate airway and is being ventilated, you may concen trate o n the ci rculatory system . As soon as IV access is o btained, rapidly give 2 liters of normal 5.1 Iine. Once again, do no t delay at the scene. An treatment past establishing the airway should be done during transport. Hemo rrhagic shock is the most common circulatory ca lise of traumatic card iopul monaq' arrest. If th ere is no ex tern al bleeding, the patien t must be ca refully examined for evidence of internal bleeding. Reexamine the neck vei ns. Flat neck veins with sinus tachyGlrdia favor the presence of hypovolemic shock (empty hea rt synd rome). Attempt to sta rt two large- bore IV lin es while en route. If during the chest exam there ,Ire decreased breath sollnds on o ne side with percussion dullness on the same side, this confirms a hemothorax o f such degree that shock will be pTople in the Un ited 5t,lIes are infected each year. In 1995, OS HA reported that about 800 health-ca re workers acquired the d isease thro ugh occupatio nal exposure. Because of the un ive rsal vaccinatio n program, these nu mbers have decreascd by almost 90 percent si nce 1992. Followin g acute infect io n, 5 to 10 perc('nt of these p~\ t ie nts cont inue to be chron ic carriers of the viru s. These carriers arc potentia lly infec tious. HBV is sp read b)' con tact with conta minated blood o r O PI M (o ther po tenti ally infectious material ), sex ual transm ission, and d irect contact with a contami nated item and nonilltaci skin. Infect io n usuall y occurs fro m cont am inated need le sticks o r th rough sexual contact. There is an estimated 6 to 30 percen t chance that health-ca re workers who arc exposed to a nccdlestick by HBV-co nt ami nated blood \vi ll develop hepatitis B infect io n if the}' have no t received their vacc ine or have not develo ped an appropriate imm une response to the vacci ne. Passage o f the Needlestick Safety and Prevention Act of 2000 by the U.S. Co ngress requires the use of needle-safe o r needleless devices. This legislat io n has cut the nu mber o f sharps injuries by mo re th.1Il half since 2003. Infectio n ca n also occu r by contacting infectious bloody secretio ns with open skin lesions o r mucosal surf.lees. Routine testing of donor blood for H BV makes transm ission from blood transfusion very rare. Although H BV infec tion is uncommon in th e general po pu lat ion. members o f certain groups arc considered much more likely to ha rbo r the virus. High-risk groups arc im mi grant s from areas where HBV is prevalent (Asia , Pacific Islands), incarcerated individuals, institutio nal ized patients. intravenous d rug lIsers. male homosexuals, hemophiliacs, household contacts of HBV patients, and hemod ialysis pa tients.
- - . --
PEARLS
An EMS Standard
AJ patieflts Me potential carriers of infectious disease. That is why standard p-ecautions ¥e the EMS standard /Of practice.
-----
PEARLS
I mmu 1I;zat;oll$
Be prepared! Stil)"Up to date on .a of )'011" immunizations.
318 •
CHAPTER 22 Standard Precautions in the Prehospital Setting
-. --.
PEARLS
OPIM The itbbre'o'iation 'OPIM" rm to other (than blood) pot~ infectious materials. Those materials ~,
• "'~ I\id (CSf) Synovial fluid
• Amniotic fluid • Pericard"W IIuid
Pleural fluid • Any fluid with gross .,;sible blood
In the United States. the Occupational Safety and Health Administ ration (OSHA) mandated in 1991 that all employers of health-care workers are required to offer HBY vaccine to any health-care worker who is at risk of occupational exposure to blood and OPI M. This must occur with in 10 days of being hired. This vaccine offers lifelong protection. Vaccines ava ilable today are recombinant; they contain no human components. A titer (blood test) is performed I to 2 months after completion of the vaccine series to document response to the vaccine. If positive, no further titer testing is needed or recommended. The vaccine is safe and produces immunity in over 90 percent of people vaccinated. Th e seco nd form of protection is hepatitis B imm unoglobulin (HBl G). This preparation contains antibod ies to HBV and prov ides temporary, passive pro tection against HBV. HBIG is only 70 percent effective and when effect ive, provides protection for only 6 months. HBI G is used o nly when th ere has been a significa nt exposure to HBY in an unimmunized person but is given in conj unction with vaccine to offer full coverage postexposure.
HEPATITIS C The hepatitis C virus (HCV) was identified in 1988-1989. This virus is thought to be respo nsible for the majo rity of what had been identified as non -A, non-B hepatitis infections. The incubation period is 6 to 7 weeks. Antibodies to the HCV have been used 10 identify pat ients with previous Hev infection. Those exposed to Hev are tesl-positive 5 to 6 weeks after exposure. Prior to 1992, HCV was the leading cause of hepatitis resulting from blood transfusions. In addition to being spread by blood transfusion, the virus also appears to be spread by sharing of intravenous needles. sexual contact. tattooing, and body piercing. much like HBY. Health -care workers can acquire infection through hollow-bore necd lesticks with contaminated needles. The likelihood of becoming infected wilh HCV after a single highrisk needlcstick is estimated at 1.8 percent. This risk is furth er reduced by the use of nccdJesafe devices. HCV infection tends to be less severe than HBV during the init ial infection. However, there appea rs to be a greater likelihood of becom ing a chronic ca rrier of Hey following infectio n. Liver failure and cirrhosis occu r in 10 to 20 percent of chronic HeV earners. There is cu rrently no vacci ne available to prolect against HeV infection. Evidencc suggests that there is no protective effect pro\' ided by administering immune globulin following exposure to HeV. Now, rapid HCV testing can be performed on the sou rce patient and if positive, the exposed provider can be offered a follow-up test (HCY-RNA) in 4 to 6 weeks post exposure. This latter test detects the virus itself. This reduces the concern about having acq uired the disease to 4 to 6 weeks instead of 6 illonths of follow-up. Treatment is available for people who acquire the disease. Current treat ment is with Pegasys, a combination of lo ng-acting interferon and another antiviral agent , ribavirin. Together, this treatment has resu lted in 56 percent of persons clearing their in fec tion.
HUMAN IMMUNODEFICIENCY VIRUS INFECTION HIV infect ion is caused by the human immunodeficiency virus (HI V). Patients with HIV infect ion develop a defect in their immune system. This predisposes the HIV-infected patient to a variety of unusual infections not genera lly seen in healthy patients of similar age. Patients infected with HI V ca n present w ith a wide spectrum of clinical man ifesla-
CHAPTER 22 Standard Precautions in the Prehospit al Setting lions. Many pat ients with H1 V infectio n arc asymptoma tic. However, any patient \vho carries HI V, wheth er he manifests sympto ms of AIDS or nOI , can transmit the virus. HI V patients being treated with curren! drugs may be virus neg:ltive and as such, pose a min ute risk. HIV appears to be transmitted in a manner similar to HBV. Although the virus has been cultured from a variety of body fl uids, o nly blood has been implicated in the transmission of the vi rus in the workplace. This is because o ther body fl uids do not ca rry enough virus particles to t ransmit the disease. Semen and vagi nal secretions have been shown to transm it the virus during sexual act ivity. but this sho uld be of no concern in the workplace. Th ere is no evidence to suggest that the HI V is transmitted by casual contact. Transmissio n 10 hea lth -care workers has been documented only after accidental pa renteral exposure (needlestick) or exposure of mucous membranes and opcn wounds to large amounl s of infected blood. Measurable risk dat'a for occupatio nal exposu re is 0.3 perce nt for needlcstick injuries and 0.09 percent for IllU CO US membrane exposure. There is o ne documented case of transmission fro m infected blood on nonintac! skin. Th is case was reported in 2002 and involved a health -care worker wilh extensive dermatitis who did not always use gloves approp ri ate when caring fo r a patient coi nfected with HI V and HCV. 1-1 IV appears to be different from the hepatit is B virus in two ways . • HIV does not survive outside the body. No special clean ing agents are requi red . • HI V is transmitted far less efficiently than HBV. Several groups have been iden tified as having a high risk of HI V in fec tion. These include male ho mosexuals or bisexuals, intravenous drug abusers. pati ent's who have received blood transfu sio ns o r pooled-plasma products (such as hemophiliacs). and heterosexual co ntacts of J-II V-positive people. However. because of the difficulty in identifying HI V-in fected patients. all contacts with blood and OPIM should be considered a potential HIV exposu re. Th is concept (all patients are potentially infective) is why standard preca uti ons are "universally" applied. There is currently no available vaccine to protect aga inst HIV in fection. Antiretrovi ral drug regimens, though not a cure, have been shown to prolong the li fe of 1-1 IV/AIDS patients. So me studies have suggested that antiretroviral agents may reduce the risk of HI V transmission in health -care workers if ad mini stered immedi ately fo llowi ng a significant exposure to HIV-i nfec ted blood and OP IM. The decisio n to administer such agents should be based o n the nature of the exposure, the likelihood that the patient is infected with HIV, and the du ration of time follow ing exposure (Figu re 22- 1). In general , hollow-needle exposures are more significant than solid instruments (such as a scalpel). If the exposure meets the CDC cri teria for offerin g drugs postexposu re to the healthcare worker, they can be admi nistered with in " hou rs but not days." Employees nccd to be counseled about the side effects and the unknown issues involving the usc of these d rugs befo re they arc started. Baseline lab work also needs to be drawn. This can all be avoided by performing rapid HIV testing on the source patient. This is the standard of care and prevents a health-ca re provider fro m being placed on these d rugs awaiting blood work o n the source. Remember, aU postex posure medical fo llow-up begins with tesli ng the sou rce, not the exposed employee.
TUBERCULOSIS From 1985 to 1993, the incidence of active tuberculosis increased significantly to over 25,000 cases in the United States. This was the result of an increase in cases among people infected with HIV and an increase in immigra tion of people from areas where tuberculosis in fection is endemic (Asia, L.1tin America. the Caribbean. Africa). Beca use of better
319
320 • CHAPTER 22 Standard Precautions in the Prehospital Setting
Highest Risk Recommend Antj-HIV therapy
End-stage HIV infection AND Deep injection with hollow needle
Increased Risk End·stage HIV infedion AND Superficial wound with hollow needle OR Solid needlestick OR Contaminated IV line OR Other sharp instrument or puncture OR Open skin or mucous membrane
Off., Anti· HIV therapy: possible benefit
Deep injection with hollow needle AND Known HIV carrier OR High-risk source (prisoner, IV drug user, homosexual or bisexual, hepatitis)
Low Risk
Superficial wound with hollow needle OR Solid needlestick OR Contaminated IV line OR Other sharp instrument or puncture OR Open skin or mucous membrane AND Known HIV carrier OR High-risk source (prisoner, IV drug user, homosexual or bisexual, hepatitis) OR Unknown source
1----l~~1
Offer Antj·HIV therapy; benefit unlikely
End-stage HIV infection AND Intact skin
No Risk Known HIV carrier or unknown source AND Intocl skin OR Urine OR Saliva
/-- - -;,..
No anti·HIV therapy
FIGURE 22· 1 Risk assessment for anti· lilV therapy following blood and body fluid exposure_
CHAPTER 22 Standard Precautions in the Prehospital Setting _ 321 public health measures, tuberculosis has been declining in the last several years. Cases decreased by 58.8 percent from 1997 to 2004 . In fact, the number of cases in 2004 was the lowest ever reported in the United States. Risk fa ctors for tuberculosis include homeless patients, certain immigra nt populations, patients at risk for HIV infectio n, and people who live in congregate settings (correction facilities, nursi ng ho mes, homeless shelters). On a global perspective, tuberculosis is still the deadliest infectious disease with 8 million new in fectio ns ann ually and 3 million deaths. Tuberculosis is caused by a bacteri um, Mycobacterillm fIIbercll/osis, which is spread fro m .111 in fected person to susceptible people through the air, especially by coughing or sneezing. This is 110/ a highly communicable disease. Con tract ing tuberculosis requires prolo nged direct contact, as in a family living situation. Only persons with active infection of the lung o r throat spread tuberculosis. II is esti mated that up to 5 percent of health-care workers wilJ test positive for tuberculosis when worki ng in high-prevalence envi ro nments. Cli nical manifes tations o f the disease become apparent only when the pa tient's immune system fa ils to keep t he bacteria in check. The bacteria then begins to infect the lungs and may spre90% in unconscious patient with closed head injury and clenched teeth • Severe flai l chest with respiratory failure and inabi lity to intubate d ue to gog reflex • Other conditi ons as determined by medi cal direction
Preparation : IV access, assess airway
for difficulty, assemble equipment Pre-oxygenate 3 min. with 100% oxygen
Atropine 0.01 mg/kg IV
0.3 0.1
IV or IV)
Apply cricoid pressure Attempt intubation
If unable 10 intubate
Confirm tube position with plus ETC02 assessment and
Continued paralysis; Vecuronium 0. 1 mg/kg IV
Continued sedation: Midazolan 0.1 IV
Monitor
Keep patient warm Paralyzed palient can't maintain FIGURE A·23 Steps in rapid sequence intubation.
Succinylcholine
1.0-1.5 mg/kg IV
Unsuccessful
1 . Attempt placement of BIAD 2. If unsuccessful perform
APPENDI X A Optional Skills •
At the time of public.1tio n. several studies have called into question the utility of this skill in the field setting. The decision to implement the useofRSI by an EMS system should be carefully reviewed, especially with respect to issues of skill retention, tra nsport times. and the availability of alternative airway methods. Any system using Rs l must have in place a strong educational and quality improvement program.
TECHNIQUE The ideal app roach uscs the six Ps: Preparatio n, Preoxygenation, Premedicate, Paral yze, Pass the tube, confirm Position.
t. Prep"mlioll. First. evaluate the difficulty you may experience when you try to in tubate. Do th is by using the Mallarnpati score (see Cha pter 4). If the patient appears to be particularly difficult to intubate. you would be better served using a DI AD o r BVM than st ruggling with a paralyzed, apneic, hypox.ic patient. If you decide to perform Rs l, you should have a plan fo r an escape airway sho uld inl'ubation be unsuccessful. All necessary equipment, including suction , should be readily ava ilable and checked. Proper positioning is an im portant part of preparation. Whi le the EMS environ ment often precludes placing the patient at a good height, on a stretcher, in the sniffing position, any steps we can take to better position ourselves so that we have the best view are helpful. Given that many of our patients arc in spinal motion restriction, o ne "positioning step" we can take, just prior to intubation, is to remove or looscn the cervical collar and apply in-line stabiliz.1tion. Th is will allow you to move the jaw forward and improve visuali7.ation of the cords. 2. Preoxygellarioll. Since the patient will be rendered apneic. hypoxia will rapidly follow. To extend the time for intubat ion, nitrogen in the lungs is "washed out" by having the patient breathe 100 percent oxygen for 2-3 mi nutes. Washout of the nitrogen allows the patien t to tolerate up to 5 minu tes of apnea (o nly 2- 3 minutes in children) during intu batio n without becom ing hypoxic. In patients with airway compromise o r other problems. ventilat ions can be assisted, though care should be made not to vent ilate wi th too much fo rce, thus reducing the risk of insumating air into the stomach and th us regurgitation of stomach contents leading to aspi rat io n. Applica tio n of cricoid pressure (Sellick's maneuver) will help red uce th is, as well as red uce risk of aspiration as the lower esophageal sphincter relaxes ;Ifter adm inist ration of paralytic. All patients sho uld be placed on a cardiac monilor, a pulse oximeter, and a cap no meter at th is time, if not previously done. 3. Premedicate. Both the act of intubatio n and some paralytics can raise in tracranial pressure. Though advocated in the past. use of IV lidoca ine prior to intubation has been fo und to be of no benefit in the field setting. Pediatric patients given succi nylcho line may develop bradyca rdia. Most experts feel that pediat ric pat ients and those adults receiving a repeat dose of succinylchol ine should receive 0. 1 mglkg of atropine. Remember also in the pL-diatric patient that the usc of a length-based system, such as the I3roselow tape o r similar, can decrease dosing errors. Depolarizi ng paralytic agents like succinylcholine can ca use fasiculations, which can cause a rise in bot h intracranial pressure and intraocular pressu re as well as be uncomfortable for the patient. A nondepolarizi ng blocki ng agent such as vccuronium at 0.01 mglkg can be given at 3 minutes prior to admi nistering the pa ralytic agent. Because it adds time to the process in what is often a time-critical situation, many fi eld providers om it th is step. The last premedication is the sedat ive. This ensu res that the patient is not awake while para lyzed. Benzodiazepines such as versed at 0. 1 mglkg can be used, tho ugh
353
354 • APPENDIX A O ptional Skills
• • • • • •
Histo ry of Malignant Hyperthe rmia Burns ove r 24 hours o ld Crush Injury over 48 hours o ld Stro ke. Co rd Injury> 7 days < 6 mo nths Sepsis ove r 7 days Myo pathies. De ne rvating Diseases
etomidate (0.3 mg/kg) is a more common sedative agent and has the advantages in that it has minimal effects on hemodynamics. Some trauma surgeons do not support use of etomidate due to reported ad renal suppression . with even a single dose.
4. Paralyze. Two types of paralytics are available. A depolarizing agent , such as succinylcholine is the preferred agent d ue to rapid o nset of action and rapid degradatio n. At a dose of I to 1.5 mg/kg (2 mg/kg in children), intubating conditions are achieved within 90 seconds of administration and is clea red within 5 minutes. Contraindications to use of depolariz.ing agents are listed in Table A-2 . Nondepolarizing agents have a longer onset and paralysis lasts longer. The fastest acting agent is rocu ro ni um (0.5 mglkg adult; 0.75 mglkg in children). Vecuronium 0. 1 mg/kg can be used to maintain paralysis after intubation is successfu l. 5. Pass the Tube. Once intubating conditions are achieved. pass the tube. Aids in the process include the use of a stylet. the gum clastic bougie, and external laryngeal manipulation . 6. Confirm Position. Use techniques described in Chapter 5. Use of capnography is mandatory so that inadvertent tube dislodgement can be detected. See ideal timeline for RSI in Table A-3.
- 7 minute s -5 minutes -3 minutes
o 3/4 to 1.5 minute s ' .5 to 2 minutes > 2 minute s
Identify need fo r intubat ion Brief history if possible to rule out co ntraindications Prepare equipment and patient Preoxygenate Pretre at and sedate Paralyze Pass the t ube Co nfirm positio n Post intubatio n care
APPENDIX A Optional Skills •
BIBLIOGRAPHY 1. Davis, D. P., D. Hoyt, M. Cehs, et al. 2003. The effect of paramedic rapid sequence intubation
o n o utcome in patients with s~vere traumatic brain injury. Journal o/Trauma 54 (3): 444-53. 2. Nowicki, T., S. London. 2005. Manag~m~nt of the diffiwlt airway. EM
3.
4.
5. 6.
7. 8. 9.
Reports.
Am~rican
Health Consultants 26: 208-22. Robinson, N., M. Clancy. 200 1. In patients with head injury undergoing rapid sequence intubatio n. does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. EmergellCY Medicille JournaI I8(6): 453-57. Sivestri, 5., G. Ralls, B. Krauss, et al. 2005. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monito ring on the rate of unrecognized misplaced intubatio n within a regional emergency medical services system. Anl/als 0/ EmergerlCY Medicine 45(5): 497-503. Stewart, C. 2002. Advanced airway mallagement. Upper Saddle River, NJ: Brady-Pearson Education. Walls, R., et al. 2004. Marlllal 0/ emergency airway management, 2nd cd. Philadelph ia: Lippincott Williams and Wilkins. Wang, H., et al. 2005. Procedural experience with out-of-hospital endotracheal intubation. Critical Care Medicine 33(8): 1718-2 1. Wang, H. E., p. Davis, R. O'Connor, R. Domeier. 2006. Drug assisted intubation in the prehospital setling. PreilOspital Emergel/CY Ctlre, 10(2): 261-71. Wang H. E., I. Li, B. Dannenberg. 2006. Managing the airway of the pediatric trauma patient: Meeting the challenge. Trauma Reports, American Health Consultants 7(2).
355
Communications with the Receiving Hospital Corey M. Siovis, MD, FACP, FACEP
Objectives Upon completion of this appendix. you sho uld be able to: 1. Discuss the four-phase commu nicatio ns poticy. 2. Discuss the 12 sleps that make lip those phases.
3. Provide accurate itnd succinct p
cardiac tamponade, l06- t07 cardiopulmonary arrest, 312 chemical bums, 249-251 chest drcomprcssio n, 115-117 diaph ragma tic rup ture, 109 ET lube position, capnography, 92-93 ET tube position, reronfirmation, 90 eviscerat ion, 208 external jugular can nulation, 137 tJaiJ chest, 101- 103 Hare traction splint, 231-234 head trauma, 155-157 hemo rrhage, 129- 132 [0 infusion (child), 138-139 Ke ndrick e:ttrication device, 188-189 laryngoscopic orotracheal intuba tion, 83,
,....,
length-based resusci tation tape (child's weight ),140 log-rolling prone patien t, 197 rog-rolling supine patient, 194-1% massive hemotho rax, 105 motorcycle helmct, 199-202
INDEX .
nasotracheal intubation, 87--88 NPA insertion, 79 ongoing exam.
y Yancey, Arthur H" II, 203
Z Zone of coagulation, 239 Zone or hyperemia. 239 Zone of stasis, 239
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