Burn Care in the Field

Julia Sandoval, RN, BSN, CCRN, CFRN

9/14/2019

1. Discuss skin anatomy.

2. Types of burns.

3. Identify assessment and staging of burns.

4. Discuss medical management of the burn patient.

Objectives

Skin Anatomy

• Epidermis

– Protective layer

• Dermis

– Connective tissue, vascular, temp regulation

• Hypodermis

– insulation

Types of burns

• Most common-

– Thermal for adults

– Scald for children

• Thermal

• Hot surface

• Scald

• Frost bite

• Chemical

• Electric

• Radiation

http://understandingburncare.org/burn-severity.html

Staging of burns

• No longer described as 1st, 2nd or 3rd degree burns

• Superficial

• Superficial partial thickness

• Deep partial thickness

• Full thickness

• Unstagable

Staging of burns

• Superficial burns

– Epidermis layer

– No blisters

– Red colored

– Pain lasts 2-3 days

– Sloughing occurs after a few days

– “look like sunburns”

– Not included in estimation of Total body surface area burned

Staging of burns

• Superficial Partial thickness

– Involves dermis layer

– Red with blisters, weeping and painful

– Up to 21 day healing period

– Minimal scarring

• Deep Partial thickness

– Deeper dermis layer

– Painful

– Yellow or white, Blisters “wet” or “waxy” look

– 3-8 weeks healing

– Scarring present

http://img.medscape.com/pi/emed/ckb/clinical_procedures/1271089-1277234-1277360-1686489tn.jpg

Staging of burns

• Full-thickness burns

– Extends to subcutaneous structures

– White or brown in appearance

– “leathery” and “dry” with no blanching

– Minimal or no pain

– Greater than 8 weeks healing

– Skin graft

– Severe scarring

https://musculoskeletalkey.com/wp-content/uploads/2016/07/C137-FF2.gif

Assessment of Burn Patient

• Include partial and full thickness burns

• Estimation of Total Body Surface Area (TBSA) Burned

– Rule of nines

– Palmar method

– Lund-browder chart (US Army)

https://hospitals.jefferson.edu/depart

ments-and-services/burn-

center.html10

https://hospitals.jefferson.edu/departments-and-

services/burn-center.html10

1st on scene

• Scene safety

• Stop the burning process!

• Remove all clothing and jewelry/watches

Medical Management of Burn Patient

• A, B, C’s

• Airway

– Carbonaceous sputum

– Hoarseness or harsh cough

– Singes nose hairs/burned facial hair

– Difficulty breathing

– stridor

– Enclosed space, think inhalation injury

https://app.figure1.com/rd/images/54eff248a467d204024b5b29

Medical Management of Burn Patient

• A, B, C’s

• Breathing

– Rate

– Depth

– Perceived exertion

https://anesthesiology.pubs.asahq.org/data/Journals/JASA/930983/m_36FF01.jpeg

Medical Management of Burn Patient

• A, B, C’s

• Circulation

– Capillary refill

– Edema

– Distal pulses (*extremities and circumferential)

– Elevate extremities

– Explosion think multisystem trauma

https://i.pinimg.com/736x/d8/64/9b/d8649b514d5731b925d2a1a0ab932fbf.jpg

Fluid Resuscitation

• Plasma lost into tissue= hypovolemia

• >20% TBSA burn = fluid resuscitation indicated

• How much fluid?

• American Burn Association= 2-4 mg/kg/%TBSA

• Parkland Formula=

Dressings

• <10% TBSA

– Wet dressing

• >10% TBSA

– dry and non adherent dressing

https://signs-seeds.com/sign.php?id=13912

Exposure

• Prevent hypothermia

– Sterile burn sheet

– Heat on!

https://gtislington.com/intel/warmth-winter-fund/

Transport to burn center?

• >10% TBSA of >partial thickness

• Burns including: face, hands, feet, genitalia, perineum, joint or circumferential

• Full thickness burns

• Electrical or chemical burns

• Inhalation injuries

Thermal

• ¾ of all burns

• Heat produces tissue damage

• Separate fingers and toes with dry gauze

https://www.todayswoundclinic.com/articles/helping-thermal-burns-heal-

nutrient-rich-skin-care

Chemical

• Decontaminate as soon as possible

• Brush powders off

• Rinse with water (mineral oil for metal compounds)

• Alkaline (lye, plaster, cement) penetrates deeper and more serious

https://www.sciencedirect.com/topics/medicine-

and-dentistry/chemical-burn

Eyes

• Flush with water

https://images.emedicinehealth.com/images/4453/4453-4474-4849-12808.jpg

Electric

• Origin has been eradicated

• Be alert for cardiac (arrhythmias) and neurological (seizures) issues

• Locate entrance and exit

• Hard to determine extent of burns

https://twistedsifter.com/2012/03/licht

enberg-figures-lightning-strike-scars/

Frost bite

• Remove from elements

• Rewarm slowly

• Don’t rub the area

• Most common on hands and feet

https://www.mayoclinic.org/diseases-conditions/frostbite/multimedia/img-

20114490

http://safetytoolboxtopics.com/Weather/frostbite-prevention.html

Radiation Burns

• UV light is most common

– sunburns

• Radiation treatment

– Radiation dermatitis (chronic or acute)

• Nuclear

– Instant death from thermal energy if close

– Subsequent cancers and deformities if further form site

• Moisturize

• Warm water

• Pat dry to prevent tearing of skin

Nonaccidental Trauma

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwjH3YW

K_cfkAhUGuZ4KHdG-AysQjRx6BAgBEAQ&

https://plasticsurgerykey.com/154-non-accidental-injury-physical-abuse/

Take Away

• Stop the burning process

• Keep the patient warm

• Consider burn center early

• Pain control!

• Cover the burned area

References

• https://www.ncbi.nlm.nih.gov/books/NBK539773/

• https://coastalvalleysems.org/images/documents/Policy_Manual/Treatment_Guidelines/9000_ALS_Guidelines/9700_Pediatric/9713%20Pediatric%20Burns.pdf

• https://www.cdc.gov/safechild/child_injury_data.html

• https://coastalvalleysems.org/images/documents/Policy_Manual/Treatment_Guidelines/8000-ALS-BLS-Pediatric%20Guidelines/8009%20Burns.pdf

• https://www.healthlinkbc.ca/health-topics/not38390

• file:///C:/Users/sando/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/JA10CEArticle%20(1).pdf

• https://plasticsurgerykey.com/154-non-accidental-injury-physical-abuse/

Questions?

CHILDBIRTH AND OBSTETRIC COMPLICATIONS

2018

This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the pregnant patient,

delivery, delivery complications and post-delivery care for maternal and newborn patients.

Follow designated county protocols, policies and guidelines for actual care of obstetric and newborn patients.

Objectives

• Review basic anatomy and physiology of pregnancy

• Review basic field assessment of pregnant patients

• Review stages of labor

• Review basic delivery concepts, complications and immediate post-delivery care of maternal & newborn patients

• Review postpartum hemorrhage and interventions

Anatomy of Pregnancy

• Fetus– Position?

• Uterus– Fundus

– Cervix

• Amniotic Sac– Amniotic Fluid

• Placenta– Umbilical Cord

Source: http://anatomyorgan.com/diagram-pregnant-woman/

Pregnancy Stages & Changes• Full Term: 40 weeks

• Antepartum: Pre-delivery– 3 Trimesters

• Intrapartum: During labor– Stages of Labor

• Postpartum: After delivery of baby – Greatest risk for hemorrhage

• Physiologic Changes of Pregnancy: – Increase blood volume, CO, heart rate & oxygen demand– Elevated diaphragm, SOB, decreased GI motility, aspiration risk

Source: High Risk & Critical Care: Intrapartum Nursing, Association of Women’s Health, Obstetric and Neonatal Nurses, AWHONN, 2nd Edition.

Antepartum: Pre-DeliveryCare & Assessment

OB Field Assessment Includes…

• Primary Impression?

• Prenatal care & history?– Gravida # of pregnancies, Para # of deliveries, Term, Preterm?

– Previous pregnancy complications?

– Due Date: based on ultrasound or LMP?

– Vaginal discharge: blood, amniotic fluid leaking, color?

– Pain: location, continuous or rhythmic?

• Contractions—is she in labor??– Frequency & Intensity

– Urge To Push, Bearing Down, or Pressure?

– Does she feel fetal movement?

Source: ASTNA, Patient Transport: Principles & Practice. 4th Edition

OB Care Priorities In The Field

• Ensure ABCs

• Lateral positioning

– Improves fetal perfusion

• Vascular Access & Fluid Bolus: – If indicated and able

– LR or NS

• Treat mom to treat fetus!!

• Frequent maternal vital sign & fetal heart rate (if able)

• Rapid transport-if indicated

Source: Trauma in the Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-

Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018.

Supine Hypotension Syndrome – Compression of Inferior Vena Cava

– Decreased venous return to heart

– Decreased blood pressure

– Decreased perfusion to fetus

• Position OB patients laterally to prevent aortocaval compression!

Source: Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-

analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.

OB Bleeding Risks: Placenta Previa, Abruption & Trauma

• High risk for maternal fetal hemorrhage

• Physiologic changes of pregnancy can mask s/s of shock

• OB Trauma:– MVC, abuse, and falls: risk for abdominal trauma & placental bleeding

• Ensure ABC’s, vascular access & lateral positioning.

• Rapid transport!!

Source: Placenta Previa-Obstetric Risk Factors & Pregnancy Outcome. https://www.ncbi.nlm.nih.gov/pubmed/11798453. Accessed March 2018

Trauma In The Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-

Bedside-Tool/. Accessed March 2018

Intrapartum: LaborCare, Assessment & Complications

3 Stages of LaborStage 1

Thinning & dilation of cervix

Cervical dilation to 10cm

Decent of the fetus

Stage 2

Delivery of baby

Stage 3

Delivery of placenta

Source: Stages Of Labor. http://pennmedicine.adam.com/content.aspx?productId=14&pid=14&gid=000126. Accessed March 2018

Assessment of Labor In The Field …Do We Stay or Go???

• If head is NOT visible--- consider rapid transport!

• If head IS visible—delivery is likely imminent. – Prepare for delivery!

• Contractions?– Frequency

– Intensity

• Is delivery imminent?– Crowning

– Urge to push/have BM

Source: Coastal Valleys EMS Agency. Routine Obstetric Delivery.

https://www.coastalvalleysems.org/images/documents/Policy_Manual/Treatment_Guidelines/8000_BLS_Guidelines/8011%20Routine%20Obstetric%20Delivery.pdf

Preparation for Delivery: Here We Go!!• Stay Calm!!!

• Delivery Supplies: OB kit

• Prepare for newborn care:

– Newborn equipment

– BVM with small mask

– Clear Airway-Position-Stimulate

– Warmth: skin to skin with MOB if vigorous & stable

– Umbilical Cord Clamping: Immediate vs. Delayed • Nonvigorous vs. Vigorous Newborn Considerations

Source:

1. Routine Obstetric Delivery.

https://www.coastalvalleysems.org/images/documents/Policy_Manual/Treatment_Guidelines/8000_BLS_Guidelines/8011%20Routine%20Obstetric%

20Delivery.pdf. Accessed March 2018.

2. Neonatal Resuscitation Program. AAP. 7th Edition

Delivery In The Field: Now What??• Place infant on mothers abdomen after birth

• Clamp cord 8-10 inches from baby

– Use 2 clamps several inches apart: cut between clamps

– Delayed Cord Clamping X 30-60 seconds IF VIGOROUS

– Immediate Cord Clamping IF NONVIGOROUS

• Provide basic newborn care

– Clear Airway: with cloth or bulb as needed

– Optimal Open Airway Positioning

– Dry thoroughly & Provide Warmth

– Ongoing continuous assessment of ABC’s

Source: Neonatal Resuscitation Program. AAP. 7th Edition

Delivery of Placenta: Now What?

• Expect within a few minutes of delivery

• Do not pull on cord

• Transport while waiting for delivery of placenta

• Normal blood loss ~ 500ml

• Provide vigorous fundal massage!!

– Support lower uterine segment

– Ensure uterus stays contracted-firm

– Pitocin: as needed and if able

Source: ACOG Guidelines For Management Of Hemorrage. https://www.aafp.org/afp/2007/0401/p1101.html. Accessed 3/2018.

Postpartum Hemorrhage: >500ml blood loss

• #1: Provide Vigorous Continuous Fundal Massage:

– Goal: Uterine muscle contracted & firm

– Leading cause of hemorrhage is uterine atony after birth!

• Obtain Vascular Access

• Pitocin—if able

• After Fundal Massage & Pitocin

– Consider TXA—if available

• Expedite Transport!!

Source: OB Hemorrhage V2 Toolkithttps://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. CMQCC. California Maternal Quality Care Collaborative.

Accessed 3/20/2018

Image Source: dailymom.com

Preterm Labor & Delivery: Tiny Ones• Labor before 37th week

• Fetus viable after 23 weeks

– Some centers use 22 weeks as point of viability

– High mortality & morbidity < 25 weeks

• Expect baby to be underdeveloped

– Neurodevelopment

– Glycemic Control

– Respiratory Status

– Temperature Control

• Resuscitation considerations for tiny babies– Gentle handling & care is vital!!

– Follow Newborn Care Resuscitation Guidelines Source:

1. Preterm Labor and Birth. November 2016 American College of Obstetricians and Gynecologists.

2. Neonatal Resuscitation Program 7th Edition.

3. NICHD. Extreme Premature Birth Outcome Data. https://www.nichd.nih.gov/about/org/der/branches/ppb/programs/epbo/dataShow.

Prolapsed Umbilical Cord: Oh No!!• Optimal Maternal Position:

– Knees to chest, hips elevated lateral trendelenburg

• Maternal high flow oxygen delivery

• Consider manually elevating presenting fetal body part off of umbilical cord to improve fetal perfusion—if able

• Do not put pressure on the cord

• Expedite Transport!!

Source: Prolapse of The Umbilical Cord. Gynecol Obstet. 1987. Mar;82 (3): 163-7.

Nuchal Cord: Around The Neck!!• Umbilical cord around newborn neck during delivery

– Single loop, multiple loops, loose or tight?

• Consider gently slipping finger under cord and lift over head—if able

• Consider clamping and cutting cord—only IF necessary for delivery

• Expect newborn to:

– Be pale

– Appear hypovolemic

– Need resuscitation

Source: Obstetrics & Gynecology: November 1999 - Volume 94 - Issue 5

https://journals.lww.com/greenjournal/Citation/1999/11001/Tight_Nuchal_Cord_and_Shoulder_Dystocia__A.31.aspx. Accessed March 2018

Image Source: birthwithoutfearblog.com

Meconium Delivery: It’s Green!!• 1st in-utero newborn bowel movement-green stained

• Associated with:

– Fetal Distress

– Post-dates > 40 weeks

• Provide Basic Newborn Care:

– ABC’s

– Clear the airway: if needed

– Optimal airway positioning

– BVM/PPV: if needed

– Warmth

– Ongoing assessment of ABC’s & vital signsSource: Neonatal Resuscitation Program. AAP. 7th Edition

Breech Delivery: Wrong Way!!

• Rapid Transport !!!

• Allow delivery of body to occur passively:

– Support newborn body during descent

– Do not pull on body parts

– Do not hyperflex the head

• If head will not deliver:

– Consider use of gloved fingers to

create space for newborn air passage

Source: Imminent Breech Delivery

https://www.coastalvalleysems.org/images/documents/Policy_Manual/Treatment_Guidelines/9000_ALS

_Guidelines/9400_OB_GYN_Emergencies/9404%20Imminent%20Delivery.pdf. Accessed March 2018

Image Source: newhealthadvisor.com

Image Source: intranet.tdmu.edu.

Shoulder Dystocia: Stuck!!

• Anterior shoulder get stuck behind pelvic bone

• McRoberts Maneuver

– Knee-chest position for mom

• Suprapubic Pressure

– To dislodge shoulder from pelvic bone

• Complications

– Fetal hypoxia, newborn birth trauma, maternal injury

– Prepare for newborn resuscitation

Image Source: shoulderdystociainfo.com

Image Source: dailylifeld.blogspot.com

Sources:

1. ACOG Simulations Shoulder Dystocia. https://www.acog.org/-/media/Departments/Simulations-Consortium/Learning-Objectives/Shoulder-Dystocia.pdf>. Accessed March 2018

2. Management Of Shoulder Dystocia.

http://www.mc.vanderbilt.edu/dept/obgyn/High_Risk_Conference/2013/Mgmt%20of%20shoulder%20dystocia-D.%20ACKER.pdf. Accessed March 2018

Newborn Delivery CareAssessment, Care & Resuscitation

Reminder: Assign APGAR Score at 1minute and 5 minutes

Normal Delivery: Newborn Care

• Delayed Cord Clamping IF vigorous: X 30-60 seconds

• Dry, warm, stimulate, position

• Suction: mouth before nose—IF needed

• Blanket and hat—cover the head

• Skin to skin with mom---IF vigorous & stable

• Promote breastfeeding:

– IF baby is stable & vigorous

– Promotes uterine contractions

• Assign APGAR

• Ongoing assessment ABC’s

Source: Neonatal Resuscitation Program, 7th Edition Image Source: getdirect.com.au

Newborn Resuscitation: NRP• Term? Tone? How many babies? Breathing? Crying?• Warm, dry, stimulate, position and clear airway

• Supplemental O2: only as needed– If Cyanotic and/or HR < 60

• BVM-PPV, if:– Apneic, gasping or HR < 100– BVM rate 40-60/minute– 1 breath every 1- 1.5 seconds

• Check pulse: brachial or umbilical – Pulse < 60 start CPR Compressions– 3:1 Compression/Ventilation Ratio– Compress 1/3 depth of chest– 2 thumb method preferred

Source: Neonatal Resuscitation Program, 7th Edition

Image Source: slideshare.net

OB & Neonatal Clinicial Scenarios Simulated Training (optional-as able)

• OB Sim: Term delivery vertex including postpartum bleeding

• OB Sim: 28 week breech preterm delivery

• Neonatal Sim: 28 week NRP preterm delivery resuscitation

• Neonatal Sim: Term NRP delivery resuscitation

Questions & Thank You!

For additional information contact:

Yvette Gonzalez, RN, MS, C-NPT, C-EFM, High Risk OB & Neonatal Clinical Manager @

Yvette.Gonzalez@REACHAir.org

Additional References • Coastal Valleys EMS Agency. (2015). Obstetric Emergencies. Retrieved from

https://www.coastalvalleysems.org/policies-plans/treatment-guidelines.html

• Coastal Valleys EMS Agency. (2015). Trauma Management. Retrieved from https://www.coastalvalleysems.org/policies-plans/treatment-guidelines.html

• DynaMed Plus. (2016). Cardiac arrest in pregnancy. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T909456/Cardiac-arrest-in-pregnancy

• DynaMed Plus. (2017). Trauma in pregnancy. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T910335/Trauma-in-pregnancy-emergency-managementcoas

• EMS World. (n.d.) Beyond the basics: trauma during pregnancy. Retrieved from emsworld.com/node/173870

• Avery, D. M. (2009). Obstetric Emergencies. American Journal of Clinical Medicine. 6(2). Retrieved from http://www.aapsus.org/articles/16.pdf

• Forray, A. (2016). Substance use during pregnancy. F1000 Research. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870985/Trau

• Murphy, N. J. & Quinlan, J. D. (2014). Trauma in pregnancy: assessment, management, and prevention. American Family Physician. 90(10). Retrieved from http://www.aafp.org/afp/2014/1115/p717.html

• Jeejeebhoy, F. M. & Morrison, L. J. (2013). Maternal cardiac arrest: a practical and comprehensive review. Emergency Medicine International. Volume 2013. Retrieved from https://www.hindawi.com/journals/emi/2013/274814/

• ACOG. (2012). Intimate Partner Violence. Retrieved from https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Intimate-Partner-Violence

Maintaining The Airway

Zachary Whiting, BSN, RN

Flight Nurse, CALSTAR 12

How long is this?

• Why the airway?

• Anatomy

• Adult vs Pediatrics

• Equipment and Techniques

• Scenarios

Can long can you last?

• Without food – 3 weeks

• Without water – 3 days

Without OXYGEN

Cells on Cells on Cells

• No oxygen to airway = No oxygen to lungs

• No oxygen to lungs = No oxygen to blood

• No oxygen to blood = No oxygen to cells

• No oxygen to cells + not getting rid of CO2 + time =

What’s that red thing do?

• Teeth

• Mouth

• Throat

Why do I have to know that?

• Teeth

• Break and fall into airway and lungs

• Mouth

• Fill with saliva, vomit, blood

• Tongue can be a block

• Throat

• Source of the vomit, blood

• Target for oxygen arrival

• So you know where you are going!

Run! Its pediatrics!

• Many differences between adults and peds airways

• Top Three:

• Tongue is bigger

• Airway is short and narrow

• They have a big head

Again with the airway?

• Roadway for oxygen to get to the lungs

• Pathway for CO2 to get out of the body

Spicy Air

• Carbon Dioxide is the result of normal cell activity

• ACID

• Too much = BAD

• Denature the things with the things

Open and Honest

• Not just about keeping the airway clear and open, but air moving in and out

Airway Breathing

Do the MATH

You about to catch these hands!

• Your hands

• Position the head

• Straighten the road

• Sit them up, let gravity help

• Jaw thrust

• Get the tongue out of the way

• Sweep the mouth, Johnny!

• Clear out any big items you can see

Keep your head up, kid

• Positioning is the key

• Large head that kinks their airway

• Use a towel roll

Anti-Emesis Platform

• Give an anti-emetic

• Patients in C-Spine precautions on back board have no where to go

• It is hard to roll on a backboard

• Airway trumps Spine

• But be nice to it

Sponsored by Dyson

• Suction

• Remove any spit, dirt, blood, vomit, food

• Cheek to the middle

• The Vagus Nerve gets mad when you wake it

Do you play the trumpet?

• Oropharyngeal Airway

• Placed in the mouth

• Gets the tongue out of the way

• Keeps the mouth open

• Nasopharyngeal Airway

• “Nasal Trumpet”

• Placed in the nose

• Bypass the tongue, mouth

Let’s tube em’

• Intubation

• Placing a endotracheal tube into the throat, past vocal chords, into the trachea

• “Definitive”

• Advanced skill set• Last resort

• Be “bougie”

Sharpen the blades

• Cricothyrotomy

• Cutting into the cricoid cartilage, opening the trachea, inserting a tube

• Sexy unicorn skill• Last, last resort

• Never happens

Get in the rhythm

• 1. Position

• 2. Clear

• 3. Add adjunct

• 4. Add oxygen

• 5. Assist ventilation

• 6. Advanced, definitive airway

Practice, Practice, Practice

• Skills require constant practice

• Stressful interventions during Stressful situations

• Zach, how much do you practice?

Nose goes

• Oxygenation

• Nasal Cannula

• Providing increased oxygen to air

• Increased FiO2

• Mouth breathers beware

• Oxygen mask

• Maximum oxygen delivery

• 100% FiO2

• Vomiters beware

Now the squeezy thing, right?

• Ventilation

• Use a bag valve mask (BVM/Ambu) to provide positive pressure breaths

• Negative vs Positive Ventilation

• Must ensure seal on nose, mouth, and jaw

• 1 man – EC Grip

• 2 man – double EC Grip

• Give a breath

• Easy chest rise

• Complete chest fall

PEEP, not PEEPS

• PEEP

• Positive End Expiratory Pressure

• Standard on hospital BVMs

• Pre-Attach a PEEP Valve

• Splint the alveoli

• More surface area

• Thinner membrane

• Easier diffusion

Questions?

Trauma in the Field

Treatment and Transport

September 14, 2019

Objectives• Discuss how to recognize signs and symptoms of many

different types of life threating injuries

• Discuss the assessment findings and appropriate interventions for those injuries

• Review kinetic energy and MOI

• Identify treatment priorities

• Discuss trauma transport

Trauma GOALS

• Prevent hypoxia

• Ensure adequate oxygenation/ventilation

• Ensure adequate hemodynamics

Assessment

Assessment

• Primary Assessment

– Identify life-threatening injuries to the airway, breathing, circulatory and neurologic systems

• Secondary Assessment

– Identify injuries to the remaining body systems.

Assessment

• Primary assessment

– Airway

• Patent? Protected?

– Breathing

• Rate, Effort

– Circulation

– Disability

• GCS, AVPU

– Exposure (as appropriate)

• Vital Signs – Report them(DynaMed Plus, 2016b)

Subjective Assessment

• Good history is key!

• May be difficult or impossible dependant on LOC

• SAMPLE

– Signs/symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading to present situation

• OLD CARTS

– Onset, Location, Duration, Character, Aggravating or Associated Symptoms, Reliving Factors, Timing, Severity

Objective Assessment

• Neurologic exam

– LOC

– Motor strength x 4 extremities

– Reflexes

– Priapism

• Respiratory exam

– Lung sounds, effort, rate, etc.

• Cardiac exam

• Other as appropriate

Assessment and Mechanism of Injury

• Special consideration should be given to the

mechanism of injury and kinematics of trauma

• The type and anatomical location of external/visible

trauma should be correlated with potential for intra-

thoracic damage

• High index of suspicion for serious injury until

otherwise proven

Rib and Sternal assessment

• Deformity

• + Seatbelt/Steering wheel sign

• Ecchymosis

• Dyspnea

• Tachypnea

• Pain to palpation

• Crepitus

Don’t Forget the Back…….• Visually inspect back

• Sweep for blood

• Palpate ribs, spine, sacrum for tenderness and irregularities

• Dress the wounds

-direct pressure

-hemostatic dressings

• Report findings forward

Generalized Assessment • Visually note wounds and abrasions

• Palpate abdomen for localized vs. diffuse tenderness

• Consider possible internal injuries

• Diffuse, severe tenderness

high index of suspicion

of internal bleeding

Mechanism and Nature

• By obtaining a complete and accurate account of the MOI, the health care provider (regardless of training) can ANTICIPATE the injuries before he/she even touches or sees the patient!!

• Early identification and thorough report to next level of care.

– GSW vs fall

Anatomy

Chest Wall

Bony and muscular structures covering the entire thoracic cavity; Protects the heart and lungs, esophagus and trachea, aorta and vena cava.

Thoracic Cavity

Hollow & Solid Organs• Cardiovascular

• Respiratory

• Digestive

• Endocrine

• Nervous

Abdominal Anatomy

• Peritoneal Cavity

• Retroperitoneal Cavity

• Pelvic Cavity

Abdominal Anatomy

Questions?

Kinematics of Trauma

Thoracic trauma is typically a result from any combination of three mechanisms

– direct transfer of energy

– rapid deceleration

– compression of the chest wall

Energy and Trauma

• Work

– Force acting over distance

• Kinetic energy

– Energy of a moving object

• Potential energy

– Product of weight, gravity and height

Newton and Trauma

• Basic Law of Motion

• “Energy cannot be created or destroyed, but it can change in form or be absorbed”

• “A body in motion, remains in motion unless acted upon by an outside force.”

Forces and MOI Blunt Trauma

• MVC

– Collision of car against another car or object

– Collision of passenger against interior of car

– Collision of passenger’s internal organs against the solid structures of the body

• Types of Collisions

– Frontal

– Lateral **

– Rear-end

– Rollovers

– Spins

Forces and MOI Blunt Trauma

• Falls

– Height of fall

– Surface or objects impacted

– First strike body part

• Auto vs. Pedestrian Collision

– Speed

– Struck and thrown or pulled under vehicle

Blast injuries• Primary Wave

– High Explosives

– Pressure wave

• Secondary Wave

– Projectiles

– Missiles

• Tertiary

– The body is thrown

• Quaternary – Burns

– Crushed from falling debris

Penetrating Trauma

• Medium or high velocity

– Usually caused by bullets

– Bullets can change shape and ricochet within the body

– Pressure waves cause cavitation

– IF possible, identify weapon caliber and shooting distance

Penetrating Trauma vs. Impalement

Special Considerations

• Stabilize

• Intervention

• Able to transport?

Impalement Injuries

• Location, location, location

• Velocity?

• Object?

https://metrouk2.files.wordpress.com/2016/09/ad_219592582.jpg

Impalement Injuries

Facial Injuries

• Circulation

• Airway

• Breathing

• Disability

Penetrating Eye Injury

• Immobilize

• Eye patch uninjured eye

Spinal Injuries• Spinal Motion Restriction LEMSA direction

• Assessment

Flail Chest: Pathophysiology

• Fractures of two or more ribs in two or more places

Flail Chest: Assessment

• Pain

• Dyspnea

• Hypoxia/cyanosis

• Grunting

• Accessory muscle use

• Paradoxical movement of the flail segment

– Foot of bed

Pneumothorax/Hemothorax: Pathophysiology

• Pneumothorax: Disruption in pleura displacing air into pleural space hence compressing lung and decreasing lung inflation during inspiration

• Hemothorax: Blood instead of air

• Most are subacute and do not require intervention, only monitoring

Pneumothorax/Hemothorax: Assessment

• Respiratory distress

• Decreased breath sounds

• Subcutaneous air

• Tachycardia

• Signs of hypoperfusion/shock

• Difficulty lying flat

• Anxiety

• Impending tension pneumo/hemo

Pneumothorax and Hemothorax

Pneumothorax/Hemothorax: Treatment

• Open: Apply 3 sided occlusive dressing or commercial device

• Monitor

• Manage pain and anxiety

• Chest tube

Tension Pneumothorax

Tension Pneumothorax: Pathophysiology

• Air or blood in the pleural space impeding cardiac output leading to decompensated shock and cardiovascular collapse

• Assessment:

–Worsening respiratory distress

– Absent or severely diminished breath sounds on affected side

– Hypotension

Pneumothorax/Hemothorax:Treatment

• When do you intervene?

– Failure to oxygenate

– Failure to ventilate

– Compromised hemodynamics

HYPOTENSION

• Chest Tube

Tension Pneumothorax: Treatment

• Needle Thoracostomy

• Second

• Fourth-Fifth

Pulmonary Contusion: Pathophysiology

• Pulmonary contusion is the most common potentially lethal chest injury

– Injury to the lung parenchyma causes interstitial hemorrhage and edema

– Hypoxia results from decreased lung compliance and ventilation/perfusion mismatch

Pulmonary Contusion: Assessment

• Signs of hypoxia – Dyspnea– Tachycardia, hypotension– Anxiety, ALOC

• Lung assessment may reveal wet sounds over injured areas.

• Hemoptysis

• Radiology studies may not reveal evidence of contusion within the first 24 hours

Pulmonary Contusion: Treatment

Cardiac Tamponade: Pathophysiology

• Blunt or penetrating

cardiac trauma

• Rapid blood

accumulation in the

pericardium can be

fatal with as little as

150ml

Aortic Rupture: Pathophysiology

• Usually abrupt blunt trauma

– death occurs immediately

in 90% of occurrences

– Patients that are

salvageable usually have

an incomplete laceration

near the ligamentum

arteriosum of the aorta

Diaphragmatic Rupture: Pathophysiology

• Herniation of the abdominal

contents into the thoracic

cavity

• Compression of the ipsilateral

lung and shift of the

mediastinal structures

– most commonly seen on the left

side

Diaphragmatic Rupture: Treatment

• Oxygenation/ventilation

• NG/OG

• Immediate surgical repair

Commotio Cordis

• Direct blow to the chest over the precordial region, in a small area of concentration, at a critical time during the cycle of a heart beat causing cardiac arrest. V-fib

• Extremely rare

• Mostly young boys and men (average age 15) at sporting events

• Treat cardiac rhythm

Commotio Cordis

Management of Evisceration• Sterile dressing to place protruding organs near the wound

(NOT into wound)

• Cover organs and wound

completely with sterile or clean

moist dressing

• Pain management

• Sedation

Crush Injury• Crush Injury

• Vascular/nerve system damage

• Recognition/extent/severity may be difficult to determine

• Cellular death continues after compression

Pediatrics• Larger body surface area, get cold faster, loose sugar

faster

• Precipitous decline, check blood glucose

• Anatomically different (airway)

• Pediatric assessment triangle– Appearance, work of breathing, circulation

• Parent usually present,

think two patients

Traumatic Shock

• IV fluids

• TXA

Transport

• Rapid transport to closest trauma center is crucial

• Avoid delays with iv starts, intubation (unless necessary).

• Watch your scene times!!!

SummaryBasics of treatment and transport in the trauma patient:

• Rapid evaluation and high index of suspicion

• Support of airway,

maximizing oxygenation and ventilation

• Manage life threatening injuries

• Treat pain and anxiety

• Rapid transport to appropriate facility

Reference

• Pediatric assessment

References• DynaMed Plus. (March 23, 2017a) Bladder trauma-emergency management. Retrieved from

http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T902791 • DynaMed Plus. (July 27, 2017b). Blunt abdominal trauma in adults-emergency management.

Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T902709/Blunt-abdominal-trauma-in-adults-emergency-management

• DynaMed Plus. (March 23, 2017c). Bowel injury-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T902783/Bowel-injury-emergency-management

• DynaMed Plus. (June 03, 2016). Pancreatic trauma-emergency management. Retrieved from http:///topics/dmp~AN~T906326/Pancreatic-trauma-emergency-management

• DynaMed Plus. (March 23, 2017d). Penetrating abdominal trauma-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T902786/Penetrating-abdominal-trauma-emergency-management

• DynaMed Plus. (April 27, 2017e). Penetrating back trauma-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T905757/Penetrating-back-trauma-emergency-management

• DynaMed Plus. (March 23, 2017f). Renal trauma-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T902800/Renal-trauma-emergency-management

• DynaMed Plus. (April 26, 2017g). Splenic trauma-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/topics/dmp~AN~T903977/Splenic-trauma-emergency-management

• Pediatric Trauma Lecture; Todd Pellitier• Trauma Mechanism of Injury and Shipping em out!!; Suz Rohl

References• DynaMed Plus. (April 25, 2017). Blunt aortic injury. Retrieved from

http://www.dynamed.com.frontier.idm.oclc.org/login.aspx? direct=true&site=DynaMed&id=902822

• DynaMed Plus. (April 26, 2017). Blunt cardiac injury. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx? direct=true&site=DynaMed&id=903738

• DynaMed Plus. (March 23, 2017). Blunt chest trauma. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=913033

• DynaMed Plus. (July 18, 2016). Cardiac contusion. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=905591

• DynaMed Plus. (April 26, 2017). Diaphragmatic injury. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=902797

• DynaMed Plus. (April 26, 2017). Hemothorax. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=902798

• DynaMed Plus. (May 2, 2017). Pneumothorax. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=902798

• DynaMed Plus. (June 8, 2016). Pulmonary contusion. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=902798

• DynaMed Plus. (April 26, 2017). Rib fracture-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=902798

• DynaMed Plus. (April 27, 2017). Traumatic pericardial tamponade-emergency management. Retrieved from http://www.dynamed.com.frontier.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=902798

END

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