TNP Teaching Station E Focus: Intubated Patient, Interpersonal Violence Objective Upon completion of this teaching station the learner will be able to: 1. demonstrate appropriate assessment for a hemodynamically unstable multiple trauma patient. 2. Identify assessment findings and interventions for the patient with an unstable pelvic fracture. Discussion Points Emphasize the sequence for assessing any definitive airway placed in the field After assessing alertness, the Endotracheal Tube (ETT) is the priority assessment Continue with the oropharynx assessment and proceed to the breathing assessment Compare to Intravenous (IV) placement in the field; the patency is assessed first before using the access Review and reinforce the use of balanced fluid resuscitation for uncontrolled hemorrhage Discuss the use of FOUR Score for the intubated patient Emphasize the need for a Computed Tomography (CT) scan when neurologic status is determined to be abnormal Discuss that urinary output of 0.5 ml/kg/hour is evidence of adequate fluid resuscitation in the average adult patient Emphasize that multiple trauma patients will have pain in spite of being intubated and paralyzed Emphasize the importance of the first reevaluation step in this scenario regarding suspected hemorrhage Review contraindications to urinary catheter insertion Review evidence collection procedures Review mandated reporting requirements Prehospital MIST Report An ambulance is en route with a 27-year-old female patient who was pushed out of a car traveling at approximately 45 mph (72 kph) She is intubated, and ventilations are being assisted with a bag-mask device Her blood pressure is 92/70 mm Hg, heart rate is 132 beats/min, respirations are assisted at 16 breaths/min, and SpO 2 is 95% She has one large-caliber IV line with isotonic crystalloid solution infusing at a rapid rate She is in full cervical spinal immobilization on a spine board There are deformities of the right forearm and bilateral lower extremities The patient is expected in five minutes. Please begin your initial assessment process. (note: If a model is used, for the sake of the model s comfort and safety, assume the model is in complete cervical spinal immobilization and that the team is adhering to standard precautions.) TNCC Seventh Edition 1
Preparation and Triage 1. States the need to activate the trauma team The trauma team is activated. Is there any specific equipment that you would prepare? 2. States need to prepare the trauma room. Ventilator respiratory therapy support Rapid infuser 3. States need to don personal protective equipment (PPE). Preparation is complete. PPE has been donned by the team. 4. Assesses for obvious uncontrolled external hemorrhage The patient has just arrived. Across-the-room Observation There is no uncontrolled external hemorrhage and no need to consider reprioritizing to <C>ABC. Primary Survey Airway and Alertness with Simultaneous Cervical Spinal Stabilization 5. Assess level of consciousness using AVPU 6. States the need to assess the placement of the ETT placed in the field (must identify ALL FIVE): Carbon dioxide (CO 2 ) detection device Observes for rise and fall of the chest with assisted ventilation and auscultates over the epigastrium Auscultates for bilateral breath sounds After 5 or 6 breaths, observes the CO 2 detector for evidence of CO 2 in exhaled air Assesses for improvement in patient s skin color The patient responds to verbal stimuli by appropriate withdrawal. Breathing and Ventilation CO 2 detector device is attached. Chest rises and falls with assisted ventilations and no gurgling is heard over the epigastrium. Breath sounds are equal bilaterally. After 5 to 6 breaths, there is positive evidence for CO 2 indicating the ETT is correctly placed in the trachea. Skin color is pale. NOTE: If the learner chooses a capnography sensor instead of the onetime-use detection device, give credit for this in Get Resuscitation Adjuncts. NOTE: If the learner chooses to insert a gastric tube, it can be done here without penalty for order. Give credit in Get Resuscitation Adjuncts. TNP Teaching Station E Focus: Intubated Patient, Interpersonal Violence 2
7. Assesses presence of secretions in the ETT There are no secretions noted in the ETT. 8. States the need to assess ETT position by noting the number at the lip AND secures the ETT; identifying the method used The ETT is secured and the number at the level of the lip is documented. 9. States the need to begin mechanical ventilation or continue assisted ventilations 10. States the need for a second person to provide manual cervical spinal stabilization AND demonstrates manual opening of the airway using the jaw-thrust maneuver 11. Assesses the airway, using inspection, auscultation, and palpation (identifies at least TWO): Are there any loose or missing teeth? Are there any foreign objects? Is there any blood, vomitus, or secretions? Is there any bony deformity? Ventilations continue. Manual cervical spinal immobilization is being provided. Please demonstrate your opening of the airway. There are no loose or missing teeth. foreign objects are noted. There are oral secretions; there is no blood or vomitus. bony deformity is noted. 12. States the need to suction the oropharynx The oropharynx is suctioned. 13. Reassesses the airway after suctioning the oropharynx The airway is now patent. TNCC Seventh Edition 3
14. Demonstrates and describes techniques to determine breathing effectiveness, using inspection, auscultation, and palpation (identifies at least FOUR): Is there spontaneous breathing? Is there symmetric chest rise and fall? What are the depth, pattern, and general rate of respirations? Is there increased work of breathing? What is the skin color? Are there open wounds or deformities? Are breath sounds present and equal? Is there subcutaneous emphysema? Is there any tracheal deviation or jugular venous distention? There is no spontaneous breathing. Chest rise and fall is symmetric. There is no spontaneous breathing. There is no spontaneous breathing. Skin color is pale. Multiple abrasions and contusions cover the anterior chest wall. There are no open wounds or deformities. Breath sounds are diminished. There is no subcutaneous emphysema. There is no tracheal deviation or jugular venous distention. Circulation and Control of Hemorrhage 15. Demonstrates and describes techniques for determining the adequacy of circulation, using inspection, auscultation, and palpation (must identify ALL THREE) Inspects for any uncontrolled external hemorrhage Palpates a central pulse Inspects and palpates the skin for color, temperature, and moisture There is no uncontrolled external hemorrhage. The central pulse is present, rapid, and weak. Skin is pale, cool, and moist. 16. Assesses the patency of prehospital IV line 17. States the need to place an additional large-caliber IV catheter The prehospital IV is patent. An additional IV catheter is placed. NOTE: If the learner elects to obtain blood samples for typing, credit is given in resuscitation adjuncts. TNP Teaching Station E Focus: Intubated Patient, Interpersonal Violence 4
18. States the need for administration of warmed, isotonic crystalloid solution with blood tubing AND administer a bolus The bolus of isotonic crystalloid solution has been administered. NOTE: If the learner asks about the volume of the bolus, respond that this may vary based on organizational protocol, provider preference, and patient status. 19. States the need to consider balanced resuscitation and administer blood products 20. Reassesses the adequacy of circulation after completion of the bolus (must identify BOTH) Palpates a central pulse Inspects and palpates the skin for color, temperature, and moisture Packed red blood cells, platelets, and plasma have been delivered and will be administrated as per protocol. The central pulse is stronger and slower. Skin color is improving, cool, and dry. NOTE: If the learner chooses to administer another bolus, state The team will continue to administer fluids and blood products per protocol. Proceed with your assessment. Disability (Neurologic Status) 21. Describes the assessment for the FOUR score What is the eye response? What is the motor response? What are the brainstem reflexes? What is the respiration status? Or the Glascow Coma Scale (GCS) What is the best eye opening? What is the best verbal response? What is the best motor response? Eyes remain closed to pain. (1) Localizes to pain. (3) Pupil and corneal reflexes are present. (4) Breathes at ventilator rate. (0) The total FOUR score is 8. There is no eye opening. (1) There is no verbal response. (1) The patient localizes to pain. (3) The total GCS score is 5. 22. Assesses pupils Pupils are equal, round, and reactive to light. TNCC Seventh Edition 5
23. States the need for CT of the head CT scan has been ordered, and radiology has been notified to expect the patient. Exposure and Environmental Control 24. States the need to remove all clothing AND inspect for uncontrolled hemorrhage or obvious injuries. Clothing is removed. Both lower extremities are shortened and externally rotated. There is no uncontrolled external hemorrhage. Bruises in different stages of healing are noted to arms and trunk. 25. States the need to preserve clothing in paper bags for law enforcement and maintain the chain of evidence. Clothing is placed in paper bags, labeled, and the chain of evidence is maintained. 26. States need to keep the patient warm by (identifies at least ONE): Blankets Warming lights Increased room temperature Warmed fluids Warmed oxygen 27. Obtains a full set of vital signs 28. States the need to facilitate family presence A warming method has been applied. Resuscitation Adjuncts Full Set of Vital Signs BP: 114/80 mm Hg HR: 100 beats/min RR: 12 breaths/min with mechanical ventilator T: 98 F (36.8 C) Facilitate Family Presence The family has arrived. There is tension and arguing. The husband is present. Other family members state he has been physically abusive and there is an active restraining order. TNP Teaching Station E Focus: Intubated Patient, Interpersonal Violence 6
29. States the need to alert hospital security and notify law enforcement Security is here. The family members have been given separate rooms and law enforcement has been notified. Get Resuscitation Adjuncts (LMNOP) 30. States the need for laboratory analysis (blood typing, blood gases, and lactate) 31. Attaches patient to cardiac monitor 32. States the need to consider insertion of a naso- or orogastric tube Blood samples are sent to the laboratory for blood typing, blood gases, and lactate. ECG shows sinus tachycardia with no ectopy. There are no contraindications. A gastric tube has been placed. 33. Attaches patient to pulse oximetry AND capnography 34. States the need to assess pain using an appropriate pain scale 35. Gives appropriate nonpharmacologic comfort measure (identifies at least ONE): Apply ice to swollen areas Repositioning Padding over bony prominences Verbal reassurance Other, as appropriate 36. States the need to consider obtaining order for analgesic medication SpO 2 : 95% Capnography value is within normal limits. The pain scale result is intermediated due to rapid sequence intubation (RSI). Assume pain is present based on mechanism of injury (MOI) and identified injuries. npharmacologic interventions have been instituted. An appropriate dose of analgesia has been ordered and administered. * Reevaluation for Transfer to Trauma Center At this time, based on your assessment so far, is there any sense of urgency to consider transfer to a trauma center or preparation for surgery? 37. States the need for a FAST exam and/ or radiologic imaging for suspected unstable pelvic fracture The FAST exam is negative for intraperitoneal blood. The pelvic radiographs are pending. TNCC Seventh Edition 7
38. States the need to prepare for surgery/angioembolization or transfer to a trauma center The surgical suite/angiography (or the trauma center) is notified and is being prepared. Please continue with your initial assessment. Secondary Survey History 39. States the pertinent history to be obtained (identifies at least ONE): MIST Past medical history (patient- or family-generated) Prehospital providers state witnesses saw the driver push her out of the moving vehicle. The patient s family states her husband has been abusive for years. She has no relevant past medical history. Head-to-toe Assessment NOTE: Learner describes and demonstrates the head-to-toe assessment by describing appropriate inspection techniques and demonstrating appropriate auscultation and palpation techniques. 40. Inspects AND palpates head AND face for injuries Multiple superficial abrasions and contusions are noted on the face. bony deformities are noted. 41. Inspects AND palpates neck for injuries; demonstrating removal AND replacement of cervical collar for assessment I will maintain cervical spinal stabilization while you perform your assessment. abnormalities are noted. 42. Inspects AND palpates chest for injuries 43. Auscultates breath sound AND heart sounds 44. Inspects the abdomen AND flanks for injuries There are multiple abrasions and contusions noted across the chest. other abnormalities are noted. Breath sounds are clear and equal bilaterally, and heart sounds are normal. There are multiple abrasions and contusions noted across the abdominal wall. A large ecchymosis is developing over both lower quadrants. The abdomen is flat. scars are noted. TNP Teaching Station E Focus: Intubated Patient, Interpersonal Violence 8
45. Auscultates bowel sounds Bowel sounds are hypoactive throughout. 46. Palpates all four quadrants of the abdomen for injuries 47. Inspects the pelvis AND perineum for injuries abnormalities are noted. Blood is noted at the urinary meatus. 48. States the need to assess for indications and contraindications for placement of a urinary catheter 49. Applies gentle pressure over iliac crest downward and medially Placement of a urinary catheter has been deferred due to blood at the meatus. There is crepitus with palpation. * 50. States the need to omit the assessment of the symphysis pubis based on previous findings 51. States the need for pelvic stabilization The pelvis is stabilized. 52. Inspects AND palpates all four extremities for neurovascular status and injuries Both lower extremities have obvious deformities, multiple abrasions, and contusions. There is one small laceration with controlled bleeding on the left calf. Both upper extremities have scattered abrasions, some quite deep, and contusions. The right upper extremity has a forearm deformity. The left has no bony injuries. Sensorimotor status cannot be assessed at this time because of responsiveness. Pulses are present in all four extremities and equal bilaterally. Skin is of normal color, warm, and dry after fluid resuscitation. 53. States the need to maintain manual cervical and spinal stabilization to turn patient for posterior assessment Inspects Posterior Surfaces The team maintains spinal stabilization for assessment of posterior surfaces. * 54. Inspects AND palpates posterior surfaces There are multiple abrasions and contusions across her back. Rectal tone is normal. other abnormalities are noted. TNCC Seventh Edition 9
55. States the need to consider removal of spine board The spine board has been removed. NOTE: Summarize injuries identified listed below throughout the scenario. If the learner has not already identified them all, ask for any additional noted at this time. 56. Identifies all simulated injuries Unstable pelvic fracture Deformity of left lower extremity with laceration Deformity of right lower extremity Deformity of right upper extremity Multiple abrasions and contusions of all four extremities Multiple abrasions of the chest wall Multiple abrasions of the back Possible urethral injury Suspected interpersonal violence/abuse Reevaluation Adjuncts * What reevaluaion adjuncts will you expect for this patient? 57. States need for reevaluation adjuncts (identifies at least three): Cervical spinal radiograph or CT scan Chest radiograph or CT scan Abdominal CT scan Cystogram or urethrogram Pelvic angiography Revised trauma score Clean and dress wounds Antibiotics Tetanus immunization Splinting, elevation, and ice Orthopedic consult Chain of custody handling of evidence Refer to social services for mandated reporting NOTE: The learner may wish to forgo all of these and send the patient to surgery immediately. That is acceptable. In that case, ask the learner to identify those adjuncts that may be indicated postoperatively. TNP Teaching Station E Focus: Intubated Patient, Interpersonal Violence 10
Reevaluation and Post-resuscitation Care What findings will you reevaluate? 58. States need to reevaluate primary assessment 59. States need to reevaluate vital signs 60. States need to reevaluate pain 61. States need to reevaluate all identified injuries and effectiveness of interventions 62. States the need for angioembolization, surgery, or transfer to a trauma center Definitive Care or Transport What is the definitive care for this patient? Is there anything you d like to add at this time? TNCC Seventh Edition 11