PEC11 Chap 36 Multisystem Trauma.pdf

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Prehospital: Emergency Care

Eleventh Edition

Chapter 36

Multisystem Trauma and Trauma in Special Patient

Populations

Slides in this presentation contain

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Learning Readiness

• EMS Education Standards, text p. 1053.

• Chapter Objectives, text p. 1053.

• Key Terms, text p. 1053.

• Purpose of lecture presentation versus textbook reading

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Setting the Stage

• Overview of Lesson Topics

– Multisystem Trauma

– Trauma in Special Patient Populations

– Assessment-Based Approach: Multisystem Trauma

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Case Study Introduction

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Case Study

• How will Russ’s age affect the type and distribution of his

injuries?

• How might Russ’s injuries present differently from the

same injuries in an adult patient?

• What differences are required in the assessment and

(6)

Introduction

• The involvement of multiple body systems in trauma

makes management of the trauma patient more challenging.

• There are special considerations in assessment and

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Multisystem Trauma

(1 of 4)

• A patient is considered to have multisystem trauma when

more than one major system is involved.

• Significant forces increase the risk for injuries to multiple

systems.

• Morbidity and mortality are higher in patients with

multisystem trauma.

• The risk of developing shock is higher with multisystem

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Multisystem Trauma

(2 of 4)

• The care for multisystem trauma patients depends on the

systems involved.

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Multisystem Trauma

(3 of 4)

• Golden Principles of Prehospital Multisystem Trauma

Care

– Ensure safety of personnel and patient.

– Determine additional resources needed.

– Understand kinematics.

– Identify and manage life threats.

– Manage the airway while maintaining cervical spine

stabilization.

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Multisystem Trauma

(4 of 4)

• Golden Principles of Prehospital Multisystem Trauma

Care

– Control external hemorrhage and treat for shock.

– Perform a secondary assessment and obtain a

medical history.

– Splint skeletal injuries and maintain spine motion

restriction if needed.

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Trauma in Special Patient Populations

(1 of 25)

• Trauma in Pregnant Patients

– Anatomic and Physiologic Considerations in the

Pregnant Trauma Patient

▪ It is difficult to assess the fetus, so manage the

mother aggressively.

▪ The blood volume is increased by 50percent in late

pregnancy.

▪ The heart rate increases by 10 to 15 beatsperminute by the

third trimester.

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Trauma in Special Patient Populations

(2 of 25)

Pregnant Trauma Patient

▪ The diaphragm is elevated.

▪ Pain perception in the abdomen is altered.

▪ Decreased gastric motility and increased risk of

vomiting.

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Trauma in Special Patient Populations

(3 of 25)

– Assessment Considerations in the Pregnant Trauma

Patient

▪ The more severe the injury to the mother, the

greater the chances of fetal injury.

▪ Fetal death rates are nine times higher than

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Trauma in Special Patient Populations

(4 of 25)

Patient

▪ The most common problem caused by maternal

trauma is uterine contractions that may progress into labor.

▪ Abruptio placentae is premature separation of the

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Trauma in Special Patient Populations

(5 of 25)

Patient

▪ Fetal and maternal outcomes from motor vehicle

collisions are more favorable when the mother wears a seatbelt.

▪ Uterine rupture may occur as a result of motor

vehicle trauma.

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Trauma in Special Patient Populations

(6 of 25)

Patient

▪ Fetal distress can be caused by hypoxia or

hypovolemia, but signs of shock can be delayed or masked in pregnant patients.

▪ Attempt resuscitation of the pulseless pregnant

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Trauma in Special Patient Populations

(7 of 25)

– Management Considerations for the Pregnant

Trauma Patient

▪ When spine motion restriction is required, tilt the

spine board to the left to prevent supine hypotensive syndrome.

▪ Airway, ventilation, and oxygenation are critical to

the pregnant trauma patient. EMTs should

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Trauma in Special Patient Populations

(8 of 25)

Trauma Patient

▪ Airway and ventilation

– Assist inadequate ventilations.

– Administer oxygen and maintain as high an

SpO₂ as possible.

– The fetus can be severely hypoxic before the

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Trauma in Special Patient Populations

(9 of 25)

Trauma Patient

– Circulation

▪ Check for major bleeding.

▪ Absorb vaginal bleeding with a pad; do not pack

the vagina.

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Trauma in Special Patient Populations

(10 of 25)

Trauma Patient

▪ Consider ALS intercept or air medical transport for

major traumas involving pregnant patients.

▪ Anticipate the need for additional resources if

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Click on the Intervention That is Required to

Prevent Supine Hypotensive Syndrome When

Managing a Pregnant Trauma Patient

a. Fill all voids beneath the patient’s back with padding

when applying a long backboard.

b. Administer oxygen at 15 lpm by nonrebreather mask to

all pregnant trauma patients.

c. Tilt the long backboard to the patient’s left once straps

are applied.

d. Transport the patient in semi-Fowler’s position with the

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Trauma in Special Patient Populations

(11 of 25)

• Trauma in Pediatric Patients

– Mechanisms include drowning, burns, falls,

penetrating trauma, motor vehicle collisions, and pedestrian-vehicle collisions.

▪ Children are at risk of being abused by adults.

▪ Shaken baby syndrome is one of many causes of

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Trauma in Special Patient Populations

(12 of 25)

Pediatric Trauma Patient

▪ Traumatic forces are more widely distributed in

pediatric patients.

▪ Pediatric patients have heavy heads and weak

neck muscles.

▪ Infants and children have greater chest wall

(24)

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Trauma in Special Patient Populations

(13 of 25)

– Assessment Considerations in the Pediatric Trauma

Patient

▪ The Pediatric Assessment Triangle (PAT) helps

with formation of a general impression.

– PAT assesses appearance, work of breathing,

and circulation to the skin.

– PALS assesses consciousness, breathing, and

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Trauma in Special Patient Populations

(14 of 25)

– Assessment Considerations in the Pediatric Trauma

Patient

▪ Subtle changes in heart rate, blood pressure, and

skin perfusion may indicate cardiorespiratory failure.

▪ A slow heart rate may indicate hypoxia.

▪ Assess the brachial pulse.

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Trauma in Special Patient Populations

(15 of 25)

– Management Considerations for the Pediatric Trauma

Patient

▪ In spine motion restriction, pad beneath the child

who is younger than 8 years of age from the shoulders to the hips to prevent neck flexion.

▪ Open the airway and assess for any possible

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Trauma in Special Patient Populations

(16 of 25)

– Management Considerations for the Pediatric Trauma

Patient

▪ Assess circulation and control direct bleeding.

▪ Manage hypovolemia and shock.

▪ Prevent hypothermia.

▪ Transport to an appropriate facility.

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Trauma in Special Patient Populations

(17 of 25)

• Trauma in Geriatric Patients

– The risk of death and significant injury is greater than

for younger patients.

– A number of physiological changes predispose the

elderly to injuries.

– Falls are the most common cause of injury.

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Trauma in Special Patient Populations

(18 of 25)

Geriatric Trauma Patient

▪ Changes in the pulmonary, cardiovascular,

neurological, and musculoskeletal systems occur with aging.

▪ These changes make injury more likely and make

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Trauma in Special Patient Populations

(19 of 25)

– Assessment Considerations in the Geriatric Trauma

Patient

▪ Preexisting medical conditions and medications

affect the patient’s outcome.

▪ Altered mental status is a significant sign.

▪ Be alert to airway obstruction from dentures and

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Trauma in Special Patient Populations

(20 of 25)

– Management Considerations for the Geriatric Trauma

Patient

▪ Use padding when spine motion restriction is

necessary.

▪ Maintain a clear airway and be prepared to

suction.

▪ Support ventilation as needed to maintain an SpO₂

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Trauma in Special Patient Populations

(21 of 25)

• Trauma in Cognitively Impaired Patients

– Cognitively impaired patients are more prone to

trauma.

– Conditions include dementia, autism, brain injuries,

stroke, Alzheimer’s disease, and Down syndrome.

– Cognitive impairments can affect assessment and

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A Down Syndrome Patient May Have a

Mild-To-Moderate Developmental Impairment

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Trauma in Special Patient Populations

(22 of 25)

Cognitively Impaired Trauma Patient

▪ Physiological changes can accompany some

forms of cognitive impairment, depending on the underlying cause.

▪ Many patients have sensory loss related to aging

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Trauma in Special Patient Populations

(23 of 25)

– Assessment Considerations in the Cognitively

Impaired Trauma Patient

▪ History and consent may be difficult to obtain.

– First attempt to get information from the patient.

– Rely on others for information, if needed.

▪ Patients may be confused, upset, and

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Trauma in Special Patient Populations

(24 of 25)

– Assessment Considerations in the Cognitively

▪ Pain perception may be altered.

▪ Gain information through the trauma assessment;

reassess frequently.

▪ Maintain a high index of suspicion that impairment

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Trauma in Special Patient Populations

(25 of 25)

– Management Considerations for the Cognitively

▪ Involve the caregivers to increase cooperation.

▪ Err on the side of caution and treat as if the patient

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(1 of 9)

• Scene Size-Up

– Assess the mechanism of injury; suspect injury of

more than one body system.

– Identify whether the patient belongs to any special

patient populations.

– Do not assume altered mental status is due to a

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(2 of 9)

• Primary Assessment

– Suspect spinal injury, provide in-line stabilization.

– Assess the mental status.

– Establish an airway using a jaw-thrust maneuver.

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(3 of 9)

• Primary Assessment

– Provide oxygen for adequately breathing patients.

– Provide positive pressure ventilation if breathing is

inadequate.

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(4 of 9)

• Secondary Assessment

– Physical exam — Perform a rapid secondary

assessment.

– Anticipate altered reactions to pain among special

patient populations.

– Vital Signs — Obtain vital signs.

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(5 of 9)

– History

▪ When and how did the incident occur?

▪ What is the chief complaint?

▪ Are there any signs or symptoms associated with

the trauma?

▪ Is the patient pregnant? If so, how far along is

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(6 of 9)

– History

▪ How old is the patient?

▪ Does the patient take any medications?

▪ Is the patient allergic to anything?

▪ What is the patient’s medical history? Is there a

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(7 of 9)

• Emergency Medical Care

– Use Standard Precautions.

– Establish and maintain in-line spinal stabilization.

▪ For third-trimester pregnancy, tilt the backboard to

the left.

▪ For children younger than 8 years old, pad from

the shoulders to the hips.

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(8 of 9)

– Maintain a patient airway and adequate breathing and

oxygenation.

▪ Use a jaw-thrust maneuver.

▪ Be prepared to suction.

▪ Administer oxygen.

▪ Monitor the airway, breathing, pulse, and mental

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Assessment-Based Approach: Multisystem Trauma

and Trauma in Special Patient Populations

(9 of 9)

– Control bleeding.

– Treat for shock.

– Identify and treat other injuries.

– Transport immediately.

▪ Notify the receiving facility.

▪ Consider requesting ALS.

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Case Study Conclusion

(1 of 4)

EMTs arrive and, as they approach to apply in-line

stabilization to the spine and open the airway, they note a pale patient who appears unresponsive and who has

(49)

Case Study Conclusion

(2 of 4)

One EMT uses a jaw-thrust maneuver to open the airway,

as another completes the primary assessment. The EMTs

insert an oropharyngeal airway and begin assisting ventilations and administering supplemental oxygen.

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Case Study Conclusion

(3 of 4)

The EMTs perform a rapid secondary assessment, and

provide spine motion restriction, padding from the shoulders to the hips to maintain the neck in neutral alignment.

The EMTs are transporting within 6 minutes of arriving, and

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Case Study Conclusion

(4 of 4)

En route, they continue management of the airway and breathing, and keep Russ warm, as well as obtaining baseline vital signs.

Russ is stabilized at a Level III trauma center and then flown to a children’s hospital for further management.

Although he faces months of rehabilitation, the quick action

of the EMTs provided him with the best opportunity for a full

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Lesson Summary

(1 of 2)

• Suspect multisystem trauma in any patient who has been

subjected to a significant external force.

• Use the golden principles of trauma care to manage

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Lesson Summary

(2 of 2)

• Special populations of patients require additional

assessment and management considerations.

• The EMT must incorporate knowledge of the special

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Correct!

Supine hypotensive syndrome occurs when the pregnant uterus compresses the vena cava, reducing blood return to the heart. Tilting the long backboard to the left takes the

weight of the uterus off the vena cava.

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Incorrect

(1 of 3)

Filling the voids on a backboard is important for motion

restriction and patient comfort, but does not prevent supine hypotensive syndrome, which is caused by the weight of the uterus on the vena cava.

(56)

Incorrect

(2 of 3)

Administering oxygen to a pregnant trauma patient to

maintain an SpO₂ as close to 100% as possible is an

important part of management, but does not prevent supine hypotensive syndrome, which is caused by the weight of the uterus on the vena cava.

(57)

Incorrect

(3 of 3)

While semi-Fowler’s position can be helpful in a pregnant medical patient in preventing supine hypotensive

syndrome, it is contraindicated in a trauma patient.

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