Revised 8/4/2007. Trauma

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Britton Simmons
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1 Trauma 57

2 General Principles for Trauma Emergencies 1. Do NOT delay transport for treatment. Beyond rapid trauma assessment, establishing an airway (with basic or advanced techniques), spinal immobilization and control of life threatening hemorrhage, the priority in caring for the trauma patient is rapid evacuation of the patient with further care performed en route to the hospital. 2. As a first responder, the priority for Rice EMS is to manage the CABCs and package the patient for transport. Criteria: Any patient suffering from significant trauma, especially when alcohol is involved Scene safety CABC s (Cervical Safety) CPR if necessary V/S Dress open wounds that are bleeding profusely Splinting as appropriate only after life threats are stabilized If hypotensive (systolic BP less than 90 mm/hg), place in Trendelenburg position If open chest or abdominal wound, apply an occlusive dressing EMT-l: Control airway with endotracheal tube or alternative airway device as needed. IV: NS, largest bore possible 58

3 Amputation Criteria: Patient with a part that is pathologically or surgically totally separated (removed) from the rest of the body CABCs Glascow Coma Scale SpO 2 if available V/S Hemorrhage control EMT-I: IV: NS titrated to systolic BP of at least 100 mmhg in adult, largest bore possible. Intubate if necessary C-spine immobilization if needed Oxygen should be at L/min via NRB 100% oxygen IV must be NS titrated to a systolic of at least 100 mmhg in the adult. IV catheters should be the largest bore possible Splint associated fractures Amputated parts SHOULD be: o Rinsed with sterile normal saline o Placed in a plastic bag o Kept cool during transport to the hospital Amputated parts should NOT be: o Soaked or placed in water o Covered with soaked wet gauze or towels o Placed directly on ice or ice packs, as this can result in frostbite Amputations are disabling and sometimes are life-threatening injuries. They have the potential for massive hemorrhage, but most often, the bleeding will control itself with pressure applied to the stump. The stump should be covered with a damp sterile dressing and an elastic wrap that will apply uniform, reasonable pressure across the entire stump. If bleeding absolutely cannot be controlled with pressure and there is a prolonged delay of ambulance transport, a tourniquet may be used. In general, a tourniquet is to be avoided whenever possible. It should be applied as distally as possible. The patient should be transported directly to a facility capable of performing reattachments, if the part appears at all salvageable. 59

4 Bites and Stings Insects Criteria: Known or suspected envenomation by: Hymenoptera Ants Brown recluse spider Black widow spider Remove patient from environment as necessary o Scene safety o If suspect venomous animal bite/sting and animal is dead, place body in sealed container and take to ER for identification ONLY IF IT IS SAFE TO DO SO. CABCs SpO 2 if available V/S If there is an allergic reaction, refer to allergic reaction protocol Remove stinger or venom sacs if present Remove tight clothing and jewelry on affected extremity Apply cool compress for pain control If stinger, wash site with soap and water (if available) EMT-I: IV NS TKO Symptoms and findings of these envenomation include: Ants, Bees, and Wasps Symptoms: Immediate pain Signs: Vary from local reaction to anaphylaxis. Brown Recluse Symptoms: Localized immediate pain, nausea, vomiting, weakness, fever Signs: A blister forms at the bite, which develops into an ulcerative lesion. Cardiac dysrhythmia, hemolysis, renal failure, and shock Black Widow Symptoms: Immediate pain which may subside, muscle cramps and muscle pain which develop in 1/2 to 2 hours after bite, weakness, back pain, abdominal pain Signs: Muscle rigidity (tetany), convulsions, respiratory paralysis 60

5 Bites and Stings (continued) Insects (continued) Oxygen administration is optional in the asymptomatic or very mildly symptomatic patient. It should be by NRB at L/min in the moderately to severely ill patient. IV access is optional in the asymptomatic or very mildly symptomatic patient. It should be NS titrated to an adequate systolic in all other patients. 61

6 Bites and Stings (continued) Snake Bites Criteria: Known bite by a venomous snake Fang marks, swelling and pain at wound site CABC's V/S If coral snake bite, wash wound immediately with copious amounts of water Keep patient supine and treat symptoms Immobilize limb with splint at the level of the heart DO NOT APPLY ICE, COLD PACK OR ARTERIAL TOURNIQUET If possible, send dead snake to ER If bite is on upper extremity, remove all jewelry Mark edge of swelling and note time EMT-I: IV: NS, titrate to maintain an adequate systolic BP. TRANSPORT IMMEDIATELY Texas has four endogenous venomous snakes: rattlesnakes, water moccasins, copperheads, and coral snakes. Bites by the coral snake are very rare. Only about 50% of snake bites result in envenomation. However, EMS personnel should assume that if the patient has been bitten by a known venomous snake, or by any type of unknown snake, that he/she has been envenomed. The coral snake's venom is essentially a neurotoxin, resulting in altered mental status, seizures, peripheral motor difficulties, paresthesia, respiratory depression and paralysis. Though quite rare, significant envenomation by a coral snake carries a very high mortality rate. The venom of the other three snakes, all pit vipers, is primarily a hemotoxin with some neurotoxin components. With these bites, the patient may present with a wide range of symptoms and signs, varying from little or no local reaction to massive local tissue destruction, generalized hemolysis, shock, kidney failure, and widespread ischemia and infarcts. Factors which influence the patient s clinical status include: Whether or not the snake actually envenomated the victim The size of the snake in relation to the size of the victim: in general, the larger the snake and/or the smaller the victim the more severe the consequences of a bite The type of snake: copperhead bites are generally less toxic than water moccasin bites, which in turn are less toxic than rattlesnake bites. Coral snakes, although 62

7 Bites and Stings (continued) Snake Bites (continued) possessing more toxic venom, rarely inject an adequate volume to result in severe illness. Conversely, pit vipers generally inject a much greater volume. Movement expedites the spread of the venom. Therefore, the patient's physical activity MUST be kept to an absolute minimum. There are many debates concerning the usefulness of constricting bands. At this point, they cannot be clearly supported or eliminated from use. If a constricting band is used, be certain that the constricting band is obstructing venous flow only, and that the patient retains a good pulse distal to the band. 63

8 Burns Criteria: Patient sustaining tissue injury from any of the following types of burns: Thermal Chemical Electrical Lightning Remove patient from burn source CABCs Assess body surface area effected Airway management as necessary V/S with SpO2 if available C-spine immobilization if necessary If chemical, brush off and flush with water If <10% BSA, cool burns with sterile saline Dress with dry sterile burn sheet Remove jewelry and clothing from affected areas EMT-I: IV NS TKO, unless hypotensive (BP < 90 mmhg) then titrate to a SBP > 100 mmhg with 20 ml/kg bolus (Do not initiate in burned extremity if possible) Intubate if necessary The removal of victims from the heat source takes priority over all other treatments. Airway management including intubation should be considered. Oxygen must be via NRB at L/min. Ventilation injuries, if severe, should be treated with endotracheal intubation (the Nasotracheal route is preferred) and mechanical ventilation. Absolute indications for intubation: Rapid, shallow ventilation with tachypnea of breaths/min AND decreased mental status. Respiratory rate of less than 8-10 breaths/min Mechanical airway obstruction from trauma, edema, or laryngospasm Unconsciousness Relative indications for intubation: History of an enclosed space explosion or fire Singed nasal hairs or oral mucosa Erythema of the palate, soot in the mouth, larynx or sputum Edema associated with a burn of the face or neck Signs of respiratory distress such as nasal flaring, respiratory crowing or stridor, anxiety, agitation, or combativeness. 64

9 Burns (continued) Burns are classified by their depth: Superficial (First degree): Limited to the most superficial layers of the skin, producing redness and pain, as in mild or moderate sunburn. There are no blisters and the surface markedly and widely blanches to light pressure. Partial Thickness (Second degree): Penetrates the skin deeper, producing pain and blistering, as well as some subcutaneous edema Blisters may or may not form The base blisters may be erythematous or whitish with fibrinous exudate Full Thickness (Third degree): Involves damage to or destruction of the full thickness of the skin and can involve underlying muscle, bone, and other structures as well. Third degree burns may, but generally do not, present with blisters The surface may be white and pliable when pressure is applied or it may be black, charred, and leathery Third degree burns may be pale in color and mistaken for normal skin, but the subdermal vessels do not blanch to pressure Body temperature should be closely followed because hypothermia occurs frequently in the extensively burned patient. IV s must be NS and should be as large bore as possible. Acute hypotension is rarely found in the early stages of burns. If hypotension is present, consider other possible causes, i.e.; hypovolemia, hypoxia, or undetected underlying injuries. Parkland Burn Formula: (IV fluids for first 8 hours) (% Burn Area) x (Pt. Wt. in Kg) = cc/hr 4 NOTE: This formula does not apply to patients in shock. The patient in shock needs more aggressive IV fluid replacement and should be treated accordingly. Wound Care: The object of wound care in the burn patient is to prevent further damage and infection. Remove all clothing around the burn, but do not pull any clothing that is stuck to the wound. DO NOT apply ointment or solutions to the wound. Cooling, with sterile saline is appropriate for small (<10% BSA burns). Saline should not be used on larger burns; they should be covered with dry, sterile dressings. TIME IS OF THE ESSENCE! 65

Burns (continued) Burns requiring a burn facility are as follows: *See Rule of Nines in Reference Section Size: Second degree >30% BSA Third degree >10% BSA Burns with associated significant injuries

10 Burns (continued) Burns requiring a burn facility are as follows: *See Rule of Nines in Reference Section Size: Second degree >30% BSA Third degree >10% BSA Burns with associated significant injuries Burns with associated inhalation injury Involvement of face, hands, or genitalia Circumferential burns Chemical substances requiring special consideration: Dry Lime and soda ash should be brushed off because contact with water will form a corrosive substance. These areas should not be irrigated unless they are already wet. Large quantities of water should be used if the burning process has already begun. Phenol (carbolic acid) is not water-soluble and will not be removed well by water irrigation. It is alcohol-soluble, however, and the affected area should therefore be washed with any alcohol product (e.g. rubbing alcohol, gin, scotch) prior to prolonged flushing with water. Lithium and sodium metal produce considerable heat when mixed with water and may explode. Therefore any large chunks remaining in or around the burn must be placed in oil. After this is done the burn should be washed with copious amounts of water. 66

11 Burns (continued) Remember that chemical injuries are frequently deceiving in that initial skin changes may be minimal even when the injury is severe. Only steam inhalation causes actual thermal damage to the respiratory tract. Inhalation of hot gases can cause immediate upper airway obstruction; airway edema can produce a slower developing upper airway obstruction; and injury to the capillaries of the small airways and alveoli can cause delayed progressive respiratory failure. For all inhalation injuries determine: The nature of the inhalant Duration of exposure Whether the patient was in a closed environment Whether the patient experienced any loss of consciousness For Chemical burns of the eye, refer to the Eye Injury protocol. 67

12 Eye Injury Criteria: Patient who has sustained Injuries to the globe, open or closed, with or without loss of vision and finding of: Corneal abrasion Foreign body in eye Chemical burn Lacerated or avulsed globe Excessive tearing and burning of eyes Arc" burn of globe EMT-B/EMT-I: CABCs o C-spine immobilization if indicated Glascow Coma Scale V/S with SpO2 if available Bandage o If open injury to globe, shield both eyes If chemical burn, flush with sterile saline Chemical burns can cause catastrophic, rapid damage. Therefore, it is imperative to intervene and stop the reaction as soon as possible with by flushing the eye with sterile saline. Flushing of the eye may result in vagal stimulation, with transient hypotension, dizziness, and nausea. These symptoms will usually resolve when flushing is stopped. Flushing a non-intact (disrupted) globe may cause serious injury to the eye. The disrupted globe must be immobilized. The best way to immobilize the eye is to obstruct vision in both eyes by patching. When covering an eye, be sure that no pressure is exerted on the globe. An injury that does not involve or disrupt the globe, such as a simple corneal abrasion, requires the covering of only the affected eye. However, if you are not certain of the extent of the injury, cover both eyes. A foreign body that penetrates the globe should be left in place and supported if necessary, and both eyes should be covered. 68

13 Head Trauma Criteria: Patient sustaining an open or closed head injury with either: Substantial mechanism of injury Altered mental status Loss of consciousness Isolated or in the presence of other injuries, with the exception of patients meeting Multi-System Trauma criteria CABCs o C-spine immobilization Alternative airway device if necessary V/S with SpO2 if available Blood glucose analysis: if less than 80 mg/dl, refer to hypoglycemia protocol EMT-I: IV NS TKO unless hypotensive, BP < 90 mmhg, then titrate to a SBP of 100 mmhg with 20 ml/kg bolus Intubate if necessary Mental status is by far the single most important finding in determining the significance of a head injury. V/S may reflect increasing intracranial pressure or brain injury (Cushing's reflex: increased blood pressure, decreased pulse rate, and irregular respirations), but are far less reliable than mental status. This includes information about a loss of consciousness prior to your arrival. If the altered mental status is out of proportion for the apparent injury, consider the altered mental status protocol. Intubation should be utilized to secure the airway and permit hyperventilation (if the patient is exhibiting decerebrate posturing) in the patient whose mental status permits. Generally, any patient who has a Glasgow Coma score of 7 or less should be intubated. Oral intubation is preferred in the deeply comatose patient. Approximately 5-20% of head injury patients have cervical spine injury, so if oral intubation is to be used, extreme caution and modified technique must be employed. An additional person should provide manual cervical spine immobilization during intubation attempts. Seizures will markedly increase ICP. If the head-injured patient is wearing a helmet, such as for motorcycle riding, the prehospital personnel should remove the helmet prior to completing spinal immobilization. Helmets should be removed carefully, using two rescuers, so as not to cause movement of the cervical spine for three primary reasons: 1. The helmet will prevent a complete exam of the patient's head. 2. The helmet will interfere with airway and oxygenation management. 3. The helmet will put the patient's head in flexion, especially if the patient is young. Intravenous access should be large bore, and the fluid of choice is NS. Remember that head injuries rarely result in hypovolemia, so if hypotension is seen, reassess for other injuries. 69

14 Multi-System Trauma Criteria: Injury to the chest, abdomen, pelvis, or extremities with evidence of possibly significant injury Multiple soft-tissue or musculoskeletal injuries with evidence of compensated or uncompensated shock CABCs V/S EMT-I: IV: NS, largest bore possible; titrate systolic blood pressure to >90 mmhg with 20 ml/kg bolus Findings or complaints related to the chest, abdomen, or pelvis must elicit an aggressive response, as these injuries are associated with high morbidity. This is especially true in the elderly patient. Tachycardia in the normotensive trauma patient must be considered to represent compensated shock. Hypotension will not be seen until late in the shock cycle. Airway management and oxygenation must be aggressive. If the patient can be intubated, he should be. Always assist ventilations with the BVM unless the patient's respiratory rate and tidal volume are good, and then use high flow oxygen, via NRB mask. Continual reassessment of the airway and ventilatory status is imperative. TRANSPORT IS TREATMENT in the trauma patient, so REMS personnel should focus on preparing the patient for transport. Spinal precautions influence all aspects of treatment in the trauma patient. Always use airway, ventilation, intubation, assessment, and movement techniques that minimize or eliminate potential aggravation of spinal injury. Hallmark findings of a tension pneumothorax include: EARLY Unilateral decreased or absent breath sounds Continually increasing dyspnea and tachypnea Signs of acute, profound hypoxia LATE JVD Contra lateral tracheal deviation Cardiovascular collapse Tension pneumothorax should also be suspected in the unconscious trauma patient in whom there is unusually high resistance to BVM ventilation. 70

15 Near Drowning/Drowning Criteria: Water submersion WITH or WITHOUT cardiopulmonary arrest WITHOUT evidence of hypothermia Remove from water CABCs If apneic o Initiate and maintain mechanical ventilation with 100% oxygen If pulseless o Initiate CPR o AED C-Spine V/S including SpO 2 if available Blood glucose analysis: if less than 80 mg/dl, refer to hypoglycemia protocol If hypotensive, elevate legs EMT-I: IV: NS TKO (unless hypotensive, BP < 90 mmhg, then titrate to a systolic BP > 100 mmhg with 20 ml/kg bolus) If unconscious, endotracheal intubation or alternative airway device Quickly identify the need for rapid transport. If hypothermic, treat as per "Hypothermia" protocol. Ensure Dispatch advises HFD that an ALS unit is needed. 71

Chapter 29. Objectives. Objectives 01/09/2013. Burns

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