Trauma Patient Assessment Intubation Review Needle Decompression Condell

Trauma Patient Assessment Intubation Review Needle Decompression Condell Medical Center EMS System October, 2007 CE Site Code #10 -7200 E 1207 Prepared by: Sharon Hopkins RN, BSN, EMT-P

Objectives Upon successful completion of this module, the EMS provider should be able to: • identify life threatening trauma to the adult population • describe the Region X interventions that apply to traumatically injured patients • actively participate in return demonstration of the use of the BVM

• actively participate in return demonstration in use of emergency equipment to secure an airway via intubation including in-line technique • actively participate in return demonstration of needle decompression • review a variety of EKG rhythms • successfully complete the quiz with a score of 80% or better

7 Ways to Die in Trauma • • Hypovolemia Hypoxia Acidosis Obstructed airway Flail chest Cardiac tamponade Tension pneumothorax

Perfusion • Circulation is the movement of blood through the heart and blood vessels • Adequate circulation dependent on: – functioning pump – intact blood vessels – adequate volume of blood • Adequate perfusion – enough blood with an adequate supply of oxygen & nutrients delivered to organs & tissues and the removal of waste products

Hypoperfusion • Inadequate perfusion also known as shock • Shock - a life threatening condition of inadequate blood flow to body cells that could result in death of cells

Normal Blood Volumes • • Neonate 85 ml/kg Infant 80 ml/kg Adult men 75 ml/kg Adult women 65 ml/kg

Typical Total Blood Volumes • • • Neonate (7#) - 3 kg x 85 ml = 255 ml 1 y/o infant (24#) - 11 kg x 80 ml = 880 ml Adult man (180#) - 82 kg x 75 ml = 6150 ml (200#) - 91 kg x 75 ml = 6825 ml Adult woman (150#) - 68 kg x 65 ml=4420 ml

Stages of Blood Loss • Stage 1 - compensated – blood loss up to 15% of circulating blood vol – 154# person (70 kg) is 500 -750 ml loss • at a typical blood drive you donate 500 ml and over a period of 15 -20 minutes – early compensation • nervousness • slight paleness • slightly cool skin • slight elevation of pulse rate

• Stage 2 blood loss - compensated – blood loss at 15 - 25% of circulating volume – 750 - 1250 ml of blood volume is lost – Additional compensatory measures in place ( in catecholamine release) • tachycardia definitely noted with normal blood pressure • pulse strength lessened • pulse pressure narrowed (diastolic & systolic values closer together) • peripheral vasoconstriction noted as cool, clammy skin • patient is anxious & thirsty

• Stage 3 blood loss - decompensated – 25 - 35% loss of circulating blood volume – 1250 - 1750 ml of blood is lost – compensatory mechanisms failing – classic signs of shock evident • rapid tachycardia with falling blood pressure • narrowed pulse pressure with barely palpable pulse • tachypnea, air hunger • anxious, restless, severe thirst • decreased level of consciousness • pale, cool, diaphoretic

• Stage 4 blood loss – Blood loss greater than 35% total circulating blood volume – patient very lethargic, confused, or unconscious – barely palpable central pulses – rapid, shallow, ineffective breathing – skin very cool, clammy, extremely pale • High mortality rate – even with aggressive identification and intervention

Categories of Shock or Shock Syndromes ¬Low-volume shock - absolute hypovolemia • Number one cause of preventable deaths • Absolute loss of circulating blood volume – trauma – dehydration • diarrhea • vomiting • poor intake • fever

Distributive shock – vascular space too large for the amount of blood circulating – problem distributing the blood volume to all the body’s cells • sepsis • drug overdoses - including alcohol and anything that dilates blood vessels (ie: nitroglycerin, calcium channel blockers) • neurogenic shock (spinal shock) - injury to the spinal cord • anaphylactic shock

®Mechanical (obstructive) shock – anything that slows or prevents the venous return of blood or obstructs the flow of blood to or through the heart can lower cardiac output and cause shock – tension pneumothorax – cardiac tamponade – myocardial contusion

Case Scenario #1 • Your adult patient has fallen 30 feet off a ladder • They are confused • The abdomen is tender and rigid • The left femur is deformed and the thigh is increasing in diameter • The patient is pale, cool, and clammy. The pulse is tachycardic and the patient is tachypnic. B/P remains 88/60. • What is your impression?

Case Scenario #1 • The patient is in hypovolemic shock • The patient meets criteria for a Category I trauma patient • The patient requires transportation to the highest level Trauma Center within 25 minutes • Does this patient require a blood glucose level in addition to all the trauma care they are receiving? – Yes - they are confused!

Hypoxia • Hypoxemia – decreased oxygen content of the arterial blood • Hypoxia – decreased oxygen content to the body’s cells and at the tissue level

Causes of Hypoxia 3 Reduction of oxygen in the system 3 Inadequate oxygen transport 3 Inability of tissues to use the oxygen delivered

Conditions That Can Affect Blood Oxygenation 3 Depressed respiratory drive – head injury – central nervous system depressants • narcotics, sedatives 3 Paralysis of respiratory muscles – spinal injury – inhalation injury – neuromuscular diseases (ie: ALS, muscular dystrophy, polio)

3 Increased resistance in the airways – asthma – chronic bronchitis, emphysema – congestion 3 Decreased compliance of lungs and thoracic wall – interstitial lung disease from inhaling toxic material – infection – lung cancer – connective tissue diseases – chronic pulmonary hypertension

3 Chest wall abnormalities – flail chest – scoliosis – full thickness burns with contractions 3 Increased thickness of the respiratory membrane – pulmonary edema – interstitial fibrosis

3 Decreased surface area for gas exchange – emphysema – tuberculosis – pneumonia – pulmonary edema – atelectasis 3 Reduced capacity of blood to transport oxygen – anemias – hemoglobin abnormalities – carbon monoxide poisoning – methahemoglobinemia

3 Ventilation and perfusion mismatching (ventilated alveoli are not perfused or perfused alveoli are not ventilated) – asthma – pneumonia – pulmonary embolus – pulmonary edema – myocardial infarction – respiratory distress syndrome – shock

Respiratory Acidosis • Primarily a problem with inadequate elimination of carbon dioxide (CO 2) from the lungs (or increased CO 2 retention) – respiratory depression or arrest – neuromuscular impairment (ie: ALS, muscular dystrophy, polio) – sedative, hypnotic medications – chest wall injury • flail chest, pneumothorax – pulmonary disorders • airway obstruction, COPD, pulmonary edema

Acidosis • When a patient is not ventilating/breathing effectively, they will develop respiratory acidosis. This is often followed by the development of metabolic acidosis • Many medications administered in critical situations are not effective when given in an acidotic environment

Hypoxia and Acidosis • If the patient needs or you suspect that they need O 2, you must supply the patient with supplemental oxygen • Do not withhold oxygen therapy to the patient with COPD • Adequately ventilating and oxygenating the patient will prevent/treat/reverse hypoxia and/or acidosis

Oxygenation & Ventilation • Oxygen therapy for patients in the field – nasal cannula at 2 - 6 l/min • delivers 24% - 44% O 2 – non-rebreather oxygen mask at enough flow to keep the reservoir inflated during inhalation (typically 12 -15 l/min) • delivers 90% plus O 2 • Ventilation rates – patient with a heart rate buts needs ventilation support - ventilate 1 breath every 5 - 6 seconds – once intubated, ventilate 1 breath every 6 -8 seconds

Case Scenario #2 • Your 56 year-old patient has been involved in a head-on crash into a tree. Upon your arrival, you note a dusky, cyanotic appearing patient with a rapid respiratory rate who is struggling to breathe. The patient is so anxious they are uncooperative. • Breath sounds indicate bilateral wheezing with very diminished breath sounds. • What is your first impression?

Case Scenario #2 • This patient was on their way to the ED for treatment of an asthma attack • While trying to reach for their inhaler, they lost control of the vehicle and struck the tree • EMS approach is to treat them as a trauma patient with a medical emergency – this patient requires trauma care while an albuterol nebulizer treatment is simultaneously started

Obstructed Airway • Foreign bodies – food, foreign material, blood – swollen tissues • Patient is unable to speak, cough, or cough is weak & highpitched • Patient is becoming dusky or cyanotic • Totally obstructed airways will cut off oxygen supply • You have 4 -6 minutes to reopen an airway to minimize negative consequences

Adult Airway Obstruction • Conscious patient who is unable to speak – continuous abdominal thrusts • chest compressions for pregnant or obese patients • Unconscious patient – open airway & attempt to ventilate – reposition head and repeat attempt once – perform direct visualization of the airway and attempt removal with the magill forceps – if obstruction unrelieved, begin CPR steps – during ventilation steps, attempt ventilations twice, reposition between the 2 attempts – consider cricothyrotomy

Magill Forceps

Needle Cricothyrotomy • While patient supine, locate the cricothyroid membrane – soft membrane between thyroid cartilage (Adam’s apple) and cricoid cartilage • Stabilize larynx with thumb & middle finger of one hand • Prep the area of the cricothyroid membrane • Insert 14 G or larger angiocath, with syringe attached, into trachea at 450 angle • Aspirate air with the syringe

Thyroid cartilage Cricothyroid membrane Cricoid cartilage Thyroid gland Thyroid cartilage (Adam’s apple) Cricothyroid membrane Cricoid cartilage

• Air should return easily if in the trachea • Advance the catheter while withdrawing the stylet (like starting an IV) • Attach a 3. 0 mm ETT adapter (the colored proximal tip of the ETT the BVM attaches to) to the needle hub • Ventilate assessing for breath sounds • Secure the angiocath • Continue to ventilate • May need to allow for longer exhalation time than inhalation time

Needle Cric Step #1 - needle advanced, confirmation by air being aspirated with the syringe Step #2 - catheter advanced while the stylet is removed

Step #3 - the 3. 0 mm adapter removed from the proximal end of a 3. 0 mm ETT Step #4 - the 3. 0 mm ETT adapter will be attached to the needle hub of the IV catheter when the stylet is removed Step #5 - patient can be ventilated; assess for breath sounds, allowing adequate time for exhalation

Cricothyrotomy • Indications – contraindication for placement of an endotracheal tube – endotracheal tube placement not possible – attempt to place an endotracheal tube fails – to relieve upper airway obstruction – emergency access with severe facial trauma

Melker Cric Kit • Department personnel recommended to review the CD from Cook Medical to review using the Melker Emergency Cricothyrotomy Catheter Set

Case Scenario #3 • This patient has been impaled by a foreign object • Do they need spinal immobilization for this injury? • No

Flail Chest • Fracture of 3 or more adjacent ribs in 2 or more locations • Chest wall segment becomes unstable • Mortality rate is 20 - 40% due to associated injuries • Secondary lung contusion is often associated with flail chest • Development of hypoxia is common

Flail Chest On Right Side

Signs & Symptoms Flail Chest • History of chest wall injury • Tenderness & bony crepitus on palpation • Tachypnea ( respiratory rate) • Tachycardia • Decreased pulse oximetry • Late sign is paradoxical motion – muscle spasms may hide the paradoxical motion for the first few hours

Field Interventions For Flail Chest • Supportive oxygenation – non-rebreather oxygen mask – possibly BVM if ventilations need to be supported (1 breath every 5 -6 seconds) – intubation (probably in-line technique) if necessary • Fluid replacement for co-existing injuries • Do not “tape” chest wall for support

Cardiac Tamponade • Tears in the heart chamber walls with blood entering the pericardial space • Occurs in <2% of patients with chest trauma • A result of penetrating trauma, blunt trauma, and occasionally, spontaneous • Increase in pericardial pressure • Heart is prevented from expanding and refilling with blood • Stroke volume and cardiac output decreases

Cardiac Tamponade

Signs & Symptoms of Cardiac Tamponade • Peripheral vasoconstriction (cool & clammy) • Tachycardia • Narrowed pulse pressure (diastolic blood pressure rises more than systolic blood pressure) • Beck’s Triad 3 JVD (early sign) 3 muffled heart tones 3 hypotension (late sign)

Is It Tamponade or Hypovolemic Shock? • JVD is present in cardiac tamponade – compression of the heart chambers causing a decrease in filling which creates a backup of fluid noted as JVD • JVD is not present in hemorrhagic shock – there is a total decrease in blood volume throughout the entire circulatory system so there is nothing to be backing up

Field Interventions For Cardiac Tamponade • Cardiac monitoring • Oxygen support • IV fluid replacement if shock present – 20 ml/kg – reevaluate every 200 ml • Rapid transport with high index of suspicion • Removal of blood from the pericardial sac will be performed at the hospital

Tension Pneumothorax • Trapping of air in the pleural space • Increase in pleural pressure producing a shift in the mediastinum • Compression of: – the lung on the unaffected side – vena cava reducing blood flow return to the heart with a decrease in cardiac output

Tension pneumothorax on the right side with shifting to the left

Signs & Symptoms of Tension Pneumothorax • • • Anxiety Cyanosis Increasing dyspnea Tachycardia Hypotension or unexplained signs of shock Diminished or absent breath sounds on affected side with profound hypoventilation • Distended neck veins (JVD) • Subcutaneous emphysema

Field Interventions For Tension Pneumothorax • A true emergency requiring immediate identification and intervention • Goal: reduce the pressure in the pleural space – emergency needle decompression

Needle Decompression • Prepare equipment – 2 -3” long catheter 12 - 14 G – skin surface prep material(ie: alcohol prep pad) – flutter valve attached to IV catheter • Identify landmarks – 2 nd intercostal space, mid-clavicular line • Clean site • Insert needle, bevel up, over the top of the 3 rd rib (into the 2 nd intercostal space)

Landmarks For Needle Decompression Rib #1 Rib #2 2 nd intercostal space mid-clavicular line Rib #3

Placement of Needle Flutter valve attached 3 rd rib 2 nd rib

Placement of Needle

• As air is released, clinically the patient should show improvement – less distress; less anxiety – greater ease in breathing/ventilating – rise in pulse ox saturation level • Secure angiocath and flutter valve – place opened, loosened 4 x 4’s around base of the angiocath • Monitor patient status watching for deterioration

Case Scenario #4 • Your patient was a pedestrian struck by a vehicle at a high rate of speed. Upon your arrival you initially felt a faint pulse but now there is none. The patient is not breathing and bagging is difficult due to the resistance felt. • What is this rhythm and how is it treated? 6 second strip - there is no pulse

Case Scenario #4 • The rhythm is PEA (with a rapid rate) • The patient is treated as an arrested trauma with suspicions of chest injuries (difficulty bagging) – Any airway maneuvers need to provide immobilization of the airway • opening airway using jaw thrust maneuver • intubation would be the in-line technique

Case Scenario #4 • Patient interventions – Full spinal immobilization – CPR - IV - O 2 support - monitor – Consider the 6 H’s and 5 T’s as causes – Perform bilateral chest decompressions – Fluid challenges reevaluating every 200 ml – Drugs - Epinephrine 1 mg every 3 -5 minutes • Rate is >60 so Atropine not indicated • Transport destination – Traumatic arrest - to closest Trauma Center

Intubation • Preferred advanced airway for controlling the airway in patients who are unable to maintain an open airway • Indications – unable to ventilate an unconscious patient – patient cannot protect their own airway – prolonged ventilation is required

Intubation • Advantages – airway is isolated preventing aspiration – ventilation (breathing) and oxygenation is easier to accomplish – suctioning of the trachea is easier – gastric insufflation of air during inhalation is prevented

Intubation • Disadvantages – inadvertent placement in the esophagus with lack of recognition of improper placement – ineffective ventilation volumes • use enough volume to gently make the chest rise – inappropriate ventilation rate • patient with a pulse, breath once every 5 -6 seconds • during CPR with intubated patient, ventilate once every 6 -8 seconds while chest compressions continue uninterrupted

Intubation Equipment • BVM connected to oxygen source • Handle and blade – bulb bright and tight – straight blade lifts epiglottis up • preferred for infant intubations – curved blade fits into the vallecular space • ETT (generally size 7 -8 for men and size 7 for women; no cuff under age 8)

• Stylet – does not protrude beyond distal end of ETT – reform tube into curved position after straight stylet passed into position • Syringe – do not leave attached to cuff once ETT is in place; air will be pulled out of the cuff • Tape or commercial tube holder to secure tube • Cervical collar – tube positions are better maintained when head movement is minimized

Patient Preparation • Pre-oxygenate the patient with 100% O 2 for 15 - 30 seconds before the intubation attempt • Consider medications for conscious sedation – Lidocaine 1. 5 mg /kg, if head insult is present, to eliminate the cough reflex – Versed 5 mg initially; 2 mg every minute until sedated; 1 mg every 5 minutes to maintain sedation post intubation – Morphine 2 mg every 3 minutes to relieve pain, reduce anxiety, potentiate the effects of Versed – Benzocaine 2 second spray to eliminate the gag reflex, if present

Patient Positioning - Non-Trauma • Non-trauma patient - sniffing position – neck is flexed allowing the best alignment of anatomical landmarks – place a few towels under the patient’s head

Influence of Positioning Landmarks not in alignment; intubation more difficult for the practitioner and with increased risk of injury to patient Anatomical landmarks lined up; intubation is easier on the medical personnel and the patient

Difficult Intubations Neck and chest tissue fall over the airway making intubation difficult Better patient positioning allows for improved chance of success in intubation

Orotracheal Intubation

Cricoid Pressure Sellick’s Maneuver • Helps prevent gastric distention when bagging the patient using the mouth-to-mask technique • Helps prevent passive regurgitation with aspiration while bagging the patient or attempting intubation • With pressure applied over the cricoid cartilage, the esophagus becomes occluded • Can improve the view of the vocal cords for the intubator • Can help stabilize the trachea

Lateral View of ETT Placement Curved blade in vallecula

In-line Intubation Techniques • Indication – when spinal precautions need to be observed • Equipment – identical to normal intubation procedures • Manual cervical spine control – stabilization must be constantly maintained in a neutral position during the procedure – head is securely controlled post-procedure

Opening Airway with Cervical Trauma - Jaw Thrust

In-Line Intubation • Intubator positioning ¬ Intubator may sit at the patient’s head and their legs straddle the patient’s shoulders and arms; patient’s head is gripped with the intubator’s thighs Intubator may lie on their stomach facing the patient’s head • A second rescuer stabilizes the patient’s head by gripping the head from the side and grasping along the jaw and lower face, spreading their fingers near the temple (ear) area

In-Line Intubation • Patient being stabilized • Equipment being prepared • Cricoid pressure being held

Orotracheal Intubation • Face-to-face procedure to intubate a patient when the provider cannot take a position above the patient’s head (ie: patient in the sitting position) • Manual stabilization must be maintained by a second rescuer at all times (often from behind if there is room for the provider behind the patient)

Orotracheal Intubation Procedure • Primary rescuer takes a position facing the patient • Open the mouth with the left hand • Hold the laryngoscope in the right hand • Insert the blade into the patient’s mouth • Follow the normal curvature of the tongue • Visualize the vocal cords from above the patient’s mouth

• With the left hand, pass the ETT between the cords • Remove the stylet, if used • Begin to ventilate the patient with the BVM • Inflate the cuff and remove the syringe • Confirm proper ETT placement

Confirming Placement and Securing ETT ¬Direct visualization – cricoid pressure can be helpful • stabilizes the trachea • may “drop” the trachea into view • with enough pressure, can stop vomitus coming back up – once cricoid pressure is applied for blocking vomitus, pressure is maintained until the cuff is inflated

Cricoid Pressure

Bilateral & equal rise and fall of the chest ® 5 point auscultation – listen over the epigastrium (expect to hear nothing) – listen 4 points over the lungs • listen anteriorly just under the clavicles on either side of the sternum • listen in the axillary line approximately 5 th intercostal space ¯ETCO 2 detector – after 6 breaths should see & maintain the yellow color to indicate exhaled CO 2 being detected

• EDD bulb – back-up tool to the ETCO 2 detector – need to interrupt ventilation to use – when bulb is depressed and placed on the end of the ETT tube, will reinflate rapidly if ETT is placed in the trachea

Case Scenario #5 • What airway significance could there be in this case and what needs to be monitored?

Case Scenario #5 - End Results

Region X SOP’s • Field Triage Criteria For Assessing Trauma Patients • In-Field Spinal Clearance • Routine Trauma Care • Revised Trauma Score

Field Triage Criteria • Transport to highest level Trauma Center within 25 minutes if: – systolic blood pressure < 90 x 2 (peds < 80 x 2)

Field Triage Criteria • Transport to highest level Trauma Center within 25 minutes if patient is a Category I – Vital signs unstable • Glasgow Coma Scale <10 or deteriorating mental status • respiratory rate <10 or >29 • Revised Trauma Score <11

Field Triage Criteria • Transport to highest level Trauma Center within 25 minutes if patient is a Category I – Based on anatomy of injury • • • Penetrating injuries to head, neck, torso, groin Combination trauma with burns >20% Two or more proximal long bone fractures Unstable pelvis Flail chest Limb paralysis and/or sensory deficits above the wrist or ankle • Open and depressed skull fractures • Amputation proximal to wrist or ankle

Field Triage Criteria • Transport to closest Trauma Center if the patient is a Category II trauma patient – Mechanism of injury • Ejection from automobile • Death in same passenger compartment • Motorcycle crash >20 mph or with separation of rider from bike • Rollover (unrestrained) • Falls >20 feet (peds falls >3 x body length) • Pedestrian thrown or runover

– Mechanism of injury (continued) • Auto vs pedestrian/bicyclist with >5 mph impact • Extrication > 20 minutes • High speed MVC – Speed > 40 mph – Intrusion > 12 inches – Major deformity > 20 inches – Co-morbid factors • Age < 5 without car/booster seat • Bleeding disorders or on anticoagulants • Pregnancy > 24 weeks

Field Triage Criteria • If patient is not a Category I trauma patient (based on unstable vital signs or anatomy of the injury) and • patient is not a Category II trauma patient (based on mechanism of injury or co-morbid factors) then • provide routine trauma care and transport to the closest Trauma Center

Field Triage Criteria • Transport to the closest Trauma Center if: ütraumatic arrest üisolated burns > 20% BSA • Transport to closest Emergency Department if: üno airway can be established

Region X SOP’s Routine Trauma Care • Scene size-up • Initial assessment – Airway / spinal precaution – Breathing – Circulation – Disability - AVPU and GCS • (alert; responds to verbal; responds to pain; unresponsive) – General impression

Routine Trauma Care • Identify priority of transport ¬Begin rapid transport (treatment enroute) • Based on mechanism of injury or patient complaint Begin treatment and initiate transport • Treatment – Airway control - oxygen support – IV (200 ml if fluid challenge required) • Detailed exam as time permits • Ongoing assessment - on all patients – Every 5 minutes if patient is a rapid transport

Case Scenario #6 • Your patient is a 63 year-old male involved in a head-on MVC on a road with posted speed of 55 mph • Scene size-up – head-on car vs truck – restrained driver – heavy front-end damage – airbag deployed – back of seat broken

Case Scenario #6 - Assessment – By-standers state patient was initially unresponsive – Upon your arrival the patient is awake, alert, and cooperative – GCS 15 – 136/88; P - 68; R - 20; Sa. O 2 98%; NSR; breath sounds clear bilaterally – Complaints: soreness over multiple abrasions of chest, abdomen, and extremities; blood in the nostrils; tenderness with mild rigidity over the left abdominal wall where abrasions are noted

Case Scenario #6 ¬What initial care is to be established? What Category Trauma does this patient meet for transport decisions? ®What are the potential injuries you need to consider this patient receiving?

Case Scenario #6 • Patient meets criteria for a Category II Trauma – Stable vital signs – No anatomical injuries meeting criteria – High speed MVC with major deformity • Vitals & condition on arrival to ED – 104/82; P - 64; R - 18; Sa. O 2 - 100%; NSR – Patient now cool, pale, diaphoretic, clear breath sounds; capillary refill < 2 seconds; abdomen flat, non-tender; pain over lower right chest

Case Scenario #6 • Follow-up – Patient became hypotensive in the ED (B/P - 65/34; P-50; R - 18) – The patient went to OR and was found to have 2 liver lacerations and multiple liters of free blood in the abdominal cavity – The patient went to ICCU after OR • Why would this patient’s pulse rate not be higher if he lost so much blood? – The patient was taking beta blockers for hypertension control

In-Field Spinal Clearance SOP • A reliable patient without signs or symptoms of neck or spine injury and a negative mechanism of injury does not require full spinal immobilization • When in doubt, fully immobilize patient

In-Field Spinal Clearance SOP ü Mechanism of injury – High velocity MVC > 40 mph – Unrestrained occupant in MVC – Passenger compartment intrusion > 12 inches – Ejection from vehicle – Rollover MVC – Motorcycle collision > 20 mph – Death in same vehicle – Pedestrian struck by vehicle – Falls > 2 time patient height – Diving injury

In-Field Spinal Clearance SOP ü Signs and symptoms – Pain in neck or spine – Tenderness/deformity of neck or spine upon palpation – Paralysis or abnormal motor exam – Paresthesia in extremities – Abnormal response to painful stimuli

In-Field Spinal Clearance SOP ü Patient reliability – Signs of intoxication – Abnormal mental status – Communication difficulty – Abnormal stress reaction

In-Field Spinal Clearance SOP • If the patient meets the criteria of need for spinal immobilization based on mechanism of injury, and/or signs & symptoms, and/or reliability, then patient intervention includes: 3 routine trauma care 3 full spinal immobilization 3 transport

Revised Trauma Score - RTS • Points scored are based on: – Respiratory rate – Systolic blood pressure – Glasgow Coma Scale (scale 3 -15 and points converted for RTS) • eye opening • verbal response • motor response • Revised Trauma Score scale is 0 - 12 • Provide the ECRN with the components and they can score pt

Bibliography • Bledsoe, B. , Porter, R. , Cherry, R. Essential of Paramedic Care. 2 nd Edition. Brady. 2007. • Campbell, J. Basic Trauma Life support 5 th Edition. Brady. 2004. • Caroline, N. Emergency Care In The Streets. 6 th Edition. AAOS. 2008. • Limmer, D. , O’Keefe, M. Emergency Care 10 th Edition. Brady. 2005.

• Region X Standard Operating Procedures. March 1, 2007. • Sanders, M. Mosby’s Paramedic Textbook. Elsevier. 2007.

Name That Rhythm SVT

Name That Rhythm Second Degree Type II - Classical

Name That Rhythm Atrial Fibrillation

Identify ST Elevation ST elevation V 1 - V 4