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MIVT Mechanism of Injury Injuries sustained Vital signs Treatment Victims of Violence Interview in safe private environment away from family or others who may have accompanied patient to ED. Interview in private, no family, quiet and safe environment Rapid intubation LOAD Lidocaine - reduce risk of inc ICP Opioids Atropine Defasciculating Agents Airway and Ventilation Factors contributing to ineffective airway AMS LOC Protect C-Spine while assess / treat
MIVT Mechanism of Injury Injuries sustained Vital signs Treatment Victims of Violence Interview in safe private environment away from family or others who may have accompanied patient to ED. Interview in private, no family, quiet and safe environment Rapid intubation LOAD Lidocaine - reduce risk of inc ICP Opioids Atropine Defasciculating Agents Airway and Ventilation Factors contributing to ineffective airway AMS LOC Protect C-Spine while assess / treat
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MIVT Mechanism of Injury Injuries sustained Vital signs Treatment Victims of Violence Interview in safe private environment away from family or others who may have accompanied patient to ED. Interview in private, no family, quiet and safe environment Rapid intubation LOAD Lidocaine - reduce risk of inc ICP Opioids Atropine Defasciculating Agents Airway and Ventilation Factors contributing to ineffective airway AMS LOC Protect C-Spine while assess / treat
Drepturi de autor:
Attribution Non-Commercial (BY-NC)
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Descărcați ca PDF, TXT sau citiți online pe Scribd
Mechanism of Injury Interview in safe private environment Place evidence in separate paper bags Injuries sustained away from family or others who may Sealing bag with label with name, date, time, location where Vital signs have accompanied patient to ED evidence was collected Treatment Ask if know assailant Name and signature of person collecting In a relationship where they have been hurt before Maintain chain of custody Is patient pregnant Give to appropriate authorities Was victim forced to have intercourse Can pt explain injuries he/she has sustained History from victim of Violence - in private, no family, quiet and safe environment
Airway and Ventilation Rapid intubation
Factors contributing to ineffective airway LOAD AMS Lidocaine - reduce risk of inc ICP LOC Protect C-Spine while assess/treat airway problems Opioids Neurologic injury Atropine ETT most definitive airway in unconscious patient Spinal cord injury Defasciculating Agents Head injury Rib fractures, chest wall instability Steps - Table 4-2 - Seven P's Protection and positioning Pain from chest/abdominal injuries Preparation Placement with proof Preexisting respiratory disease Preoxygenation - 100% oxygen Most effective assessment tube placement Increased age Pretreatment visualize tube through cords Atropine for peds Inflate cuff Shock - inadequate perfusion of tissues Lidocaine in head injury or inc ICP ETCO2 Decrease in supply of oxygen and nutrients required to maintain metabolic needs of body Defasciculating dose Epigastric ausculation Sedation Bilateral Breath sounds Effects of Sympathetic Nervous System Stimulation Benzodiazepines Postintubation management Increase force of contraction (Positive inotropy) Opioids Secure ETT Increase heart rate (positive chronotropy) Anesthesia/Induction Vent Settings Vasoconstriction Etomidate, Thiopental sodium Chest X-ray Dilation of pupils Propofol, Methohexital Pulse ox Increased sweating (cholinergic) Paralysis with induction Medicate Adrenals - increased cortical and medullary secretion Succinylcholine Signs of airway failure Dilation of bronchials Depolarizing restless Renin secretion increased, vasoconstriction, retain water, sodium retention Pancuronium, Vecuronium, Rocuronium agitation Glycogenolysis (breakdown of stored glycogen) Prolonged hyperventilation causes vasoconstriction in head injury pts - therefore bag with appropriate rate for pt Hypovolemia - hemorrhage/burns Obstructive Blood loss - tachycardia early sign 2 large bore IV's Cardiac Tamponade S Plasma loss Rapid infusion of Crystalloids Compression of heart with obs. to atrial filling H Monitor Urinary output for response to fluid resuscitation Tension Pneumothorax O Monitor temp - use warmed fluids Mediastinal shift with obs to atrial filling C Affects tissue extraction of oxygen 1st labs type and cross and H&H Tension Hemothorax K Impaired cardiac contractility Combination of Pneumothorax and Hemothorax Coagulopathies - due to cellular disruption ( also in hypothermic trauma pts) S Control bleeding - elevation and direct pressure Distributive Shock T Cardiogenic Neurogenic shock A MI Base Deficit and Lactate Levels may need vasopressors for hypotension not responsive to IV boluses T Arrythmias Resuscitation endpoints for Septic Shock E Blunt Injury determining the degree of oxygen Anaphylactic Shock S Decrease contractility debt (lack of oxygenation over Shunting microcirculation - decrease venous resistance Decrease cardiac output resuscitation time) for shock Venous pooling -maldistribution of blood volume Loss contractility Poor distribution of blood flow TNCC Summary 6th Edition EdComp, Inc. Scalp - five layers Meninges - 3 layers - PAD Cerebral perfusion pressure = Mean arterial pressure (MAP) - Intracranial pressure (ICP) Skin Pia Mater Reflects brain, cerebrospinal fluid, blood in the fixed space vault Connective Tissues Arachnoid Adequate perfusion of oxygen and nutrients to the brain is dependent on this pressure Aponeurotic galea Dura mater Primary determinant of cerebral blood flow Loose areolar tissue Should be maintained at 60 mm Hg in absence of ischemia Pericranium Augmented systolic BP may be necessary to increase CPP Less than 70 can cause increased risk of ischemia Less than 60 associated with poor outcomes Early signs of Increased ICP Late Signs on increased ICP CUSHING's Reflex (Phenomemon) or Response - sign of ischemia Headache Dilated nonreactive pupil Increase in systolic BP Nausea/vomiting Unresponsive to verbal/painful stimuli Widening Pulse Pressure Amnesia Abnormal Posturing Reflex Bradycardia Altered level of consciousness Elevated Systolic Blood Pressure Diminished Respitory Effort Restlessness Widening pulse pressure Drowsiness Decreased pulse rate Skull Fracture - linear and nondisplaced Depressed Skull Fracture Changes in speech Changes in respiratory rate and pattern Headache Headache Loss of Judgement Osmotic diuretic reduces ICP - Possible decreased LOC Possible decreased LOC assessed benefit - resolution symptoms Open Fracture Possible Hypotension and hypoxia Concussion - diffuse brain injury Palpable depression Less than 90 mm Hg Transient Loss of consciousness Apnea/cyanosis Headache Basilar Skull Fracture Mandible Fracture PaO2 less than 60 mm Hg Confusion/Disorientation Headache No Nasal Intubation Malocclusion Dizziness Decreased LOC Trismus - can't open mouth Herniation of brainstem Nausea/vomiting Raccoon's eyes Pain/movement Unilateral or bilateral pupillary dilation Loss of Memory Battle's signs Facial asymmetry Asymmetric pupilary reactivity Difficulty with Concentration Hemotympanium Step off deformity Abnormal posturing Irritability Facial nerve palsy Edema, hematoma Fatigue CSF rhinorrhea, otorrhea Hemotympanium Anesthesia lower lip Supratentorial herniation Post Concussive Syndrome Facial Trauma Uncal most - posterior Persistant headache Central or transtentorial herniation Dizziness Lefort I Lefort II - Dicephalon and midbrain Nausea Separate teeth from rest of maxilla Fracture nasal, orbits, medial pyramid Memory impairment slight swelling Massive edema CSF leakage Attention Deficit Lip lac/fractured teeth nasal swelling Rhinorrhea - nose Irritability independently move maxilla Malocclusion Otorrhea - ear Insomnia mal occlusion CSF Rhinorrhea High potential for infections Loss of libido Anxiety Lefort III - complete break maxilla, Orbital Fracture Depression zygoma, orbits, bones Diplopia Early sign of changes in neuro Massive edema Loss of vision Diffuse Axonal Injury Altered level of consciousness Mobility zygoma bones Altered EOMs Acceleration/Deceleration Immediate coma - few weeks to 3 mos Ecchymosis Enopthalmos Diffuse, microscopic, Hemorragic lesions Hypertension Anesthesia cheek Subconjunctval Hemorrhage Brain Stem, Reticular Activation System Elevated Temp Diplopia Infra orbital pain or loss sensation Prolonged coma Excessive sweating autonomic dysfunction Open bite, malocclusion Orbital bony deformity Shaken baby this kind of injury Abnormal Posturing CSF Rhinorrhea Tapping of muscle/nerve Elevated ICP Mild to severe memory impairment, cognitive Do Not intubate Nasally with Facial Trauma behavioral, and intellectual deficits Aggressive airway management of secretions/ intubation is indicated Focal Brain Injury Raising Head of Bed - head higher than feet Neuro assessment Contusion - Intracranial hemorrhage - 48 hours to 2 weeks Decreases ICP C-5 - Top of shoulder Altered level of consciousness Decreases Intraocular pressures T-4 - Nipple line Unusual behavior May improve breathing in a COPD trauma patient T-10 - Umbilicus Abnormal Posturing (flexion, extension, or flaccidity) Simple, doesn't require much effort or equipment L-4 - Great toe Signs of increasing ICP May be lifesaving. TNCC Summary 6th Edition EdComp, Inc. Epidural Hematoma - Arterial Facts about the eye Initial decreased LOC - Lucid period - rapid deterioration Pupil dilation occurs with sympathetic stimulation Penetrating Trauma Persistant decreased LOC Severe Headache Intraocular pressures keep the globe rounded Visual impairment Hemiparesis/Hemiplegia, opposite side - posturing Sleepiness Normal Intraocular pressures - 15 mm Hg Contents leaking out Unilateral fixed and dilated pupil same side Dizziness range 10-20 Odd shaped globe Nausea, vomiting greater than 30 may have glaucoma hyphema Subdural Hematoma - venous - more in elderly, those on anticoagulants, and etoh abuse low may have penetration of globe decreased IOP More lethal Signs increased ICP restricted extraocular movements Steady decline in LOC Ataxia Hyphema Hemiparesis or hemiplegia opposite side Incontinence blood in the anterior chamber - direct impact to eye Unilateral fixed and dilated pupil same side Seizures deep, aching pain mild to severe decrease in visual acuity Intercranial Hematomas increased intraocular pressure Progressive and often rapid decline in LOC Pupil abnormalities restricted EOMs Headache Contralateral hemiplegia Signs of increased ICP Neck Injuries Dyspnea, tachypnea Hematoma Flail Chest Hemoptysis Loss of layrngeal prominence Free floating sternum Sub Q Emphysema Bruits Decreased to absent breath sounds Active bleeding Pneumothorax Penetrating trauma Cranial nerve, facial sensory or motor nerve deficits Air in pleural space with loss of negative intrapleural pressure Hoarseness Difficulty swallowing Dyspnea Tachycardia Blunt Trauma may cause Hemothorax - 1500 or more - mediastinal shift, low venous return, low BP Hyperresonnance injured side Increased intrathoracic pressure Dyspnea, Tachypnea Decreased or absent BS injured side Respiratory distress Chest pain Associated Injuries Chest Pain Hypotension Signs shock Sternal Fractures Possible open pneumo sucking wound on insp. Unilateral absent breath sounds Tracheal Deviation - in Tension Hemothorax Blunt Cardiac injury Assess for chest tube insertion Decreased Breath sounds on injured side First and second rib fracture Tension pneumothorax Assess for needle thoracentesis Dullness to percussion on injured side. Great Vessel injuries Life threatening - needle decompression immediately Brachial plexus injuries Severe respiratory distress Chest tube troubleshooting Ruptured Diaphragm head and spinal cord injuries Absent sounds on injured side F fluctuation in water seal Dyspnea/orthopnea Rib fractures and flail chest Hypotension O output Dysphagia Pulmonary contusions Low BP C color of drainage Abdominal pain Pneumothorax Distended Neck veins - head and upper extremities A air leak Sharp epigastric or chest pain radiating Hemothorax Trachael deviation Left shoulder - (KEHR's Sign) Fractures of lower ribs (7th-12th) Cyanosis - late sign 2nd ICS mid clavicular line - needle decomp. Bowel sounds in lower to middle chest Liver and spleen injuries Decreased Breath sounds injured side. Pulmonary Contusion Tracheobronchial injury Type of impact and thoracic injuries Dyspnea, tachypnea Dyspnea, tachypnea Pericardial Tamponade Frontal Impact Ineffective cough Hemoptysis Beck's Triad Anterior flail chest Hemoptysis Potential airway obstruction Distended neck veins Blunt cardiac injury - tamponade Hypoxia Sub Q emphysema neck, face, suprasternal Low blood pressure Pneumothorax Chest Pain Decreased or absent breath sounds Muffled heart sounds Transection of aorta Chest wall contusion or abrasions EKG abnormalities - tachycardia, PEA Side impact Chest drainage systems Dyspnea Lateral flail chest Blunt Cardiac Injury Tape down and secure to prevent dislodging Cyanosis Pneumothorax EKG abnormalities - tach, PVC, AV blocks Maintain chest system below level of chest Traumatic aortic rupture Chest Pain Keep water seal chambers upright Diaphragmatic rupture Chest wall ecchymosis No dependent loops to kinks Motor vehicle vs pedestrian Never clamp Transection of aorta Notify MD if output greater than 1000 or Abdominal visceral injuries 200ml/hr for 3-4 hours' TNCC Summary 6th Edition EdComp, Inc. Hepatic Injuries Splenic Injuries Hollow Organ Injuries - lap belt injuries - suspect with bruising of abdomen RUQ pain Kehr's sign - left shoulder referred pain Small bowel most common Abdominal rigidity, spasm, guarding Tender LUQ Peritoneal irritation muscle rigidity, spasm, guarding Rebound tenderness Signs hemorrhagic shock Eviseration of small bowel or stomach - cover with moist gauze Decreased or absent Bowel Sounds Abdominal rigidity, spasm, guarding CT/DPL - bile, feces, food fibers Signs hemorrhage or hypovolemic shock DOPA - ETT troubleshooting Burns Rate of infusion - crystalloids Renal Injuries Dislodgement Zone of Coagulation - tissue not viable Age Deceleration forces - vascular damage Obstruction Zone of Stasis - capillary occlusion, Burn size, depth Ecchymosis ove flank Pneumothorax decreased perfusion and edema Intravascular pressures Flank tenerness ilicitied during palpation Equipment Zone of hyperemia - increased blood flow Time elapsed since the burn Hematuria CT best diagnostic FOCA - chest drainage troubleshooting Plasma loss and other vascular responses % burn*kg*rate = amount in 24 hours Fluctuation Loss of permeability of the capillary 1/2 in the first 8 hours Urethral Trauma Output Electrical burns 1/2 over next 16 hours Female - almost always with pelvic fractures Color Myoglobinuria - flush kidneys well Male - straddle trauma Air leak 1st intervention - STOP the BURN Inhalation burn - listen for hoarseness Supra Pubic pain Provide airway support Urge but can't pee Suspecting Compartment Syndrome Helmeted Riders Hematuria Elevate only to level of the heart, NOT above Must remove helmet to adequately assess airway and protect C-Spine Blood at meatus Reassess Neurovascular status often See Helmet removal and traction section in the back of the book. Rebound tenderness Pulses Rigidity, spasm, guarding Sensation A. Airway 1st five A-E in order Displaced prostate Edema B. Breathing If you stop at one point, fix it before going on C. Circulation You will be tested on this material Urinary output Assessing Pelvis - DO NOT Rock D. Disability TNP stations, look at expectations in the back of infants - 2 ml/kg/hr Apply gentle pressure to bilateral iliac crests E. Exposure book. Children - 1 ml/kg/hr toward the midline to test for instability F. Five Adjuncts, Family, Five Vital signs Adults - 0.5 ml/kg/hr Greatest risk, large vessels in pelvis may bleed G. Give Comfort Zones of Decontamination H. History, MIVT, Pt information Hot zone Cold Zone I. Inspect Posterior Highest contamination Safe and free from contamination Minimal medical care Full Medical Treatment Basic airway Pregnant Women Hemorrhage control Hypervolemic and hyperdynamic state Antidotes Normal fetal tones 120-160 Take to warm zone Always protect yourself and team first ABC's always first can't help others is you are incapacitated Turning to left lateral position when if unstable, Warm Zone removes pressure from Vena Cava Position uphill and upwind of Hot zone Mother's life is critical to fetus life, protect fetus, but treat the mother Some contamination, but less than Hot Limited Medical Care Pediatric Trauma Stabilize Order of frequent injury Blood volume dependent on size of pt Decontaminate Head Infant approx 90 ml/kg Move to cold zone Musculoskeletal Child approx 80 ml/kg Abdomen Can compensate 25% blood loss by inc. HR and Inc PVR Chemical agents Table 14-2 page 253 Vesicants Thorax Heart Rate categorized by physiological effects Exposure Tachycardia first sign of shock Chemical makeup Inhalation Bradycardia ominous sign No antidotes Topical IV Bolus 20ml/kg Skin Decontamination Most common Blood Admin 10 ml/kg Cap refill > 3 seconds best indicator for poor perfusion Nerve Agents mustard Pallor/mottled skin Sarin most well known lewisite Spinal Immobilization Cyanosis late sign V-Series Treatment Make sure pad shoulders for Hypotension - late sign of shock G-Series airway management children - large heads Urine output for peds Exposure oxygen Keep spine neutral position Infants - 2 ml/kg/hr Dermal remove clothing Child - 1 ml/kg/hr Inhalation Decontaminate Action - inhibit acetylcholinesterase Soap and water and 10% SLUDGE/BBB and DUMBELS bleach TNCC Summary 6th Edition EdComp, Inc. Nerve Agents (con't) S Salivation D Diaphoresis and Diarrhea SCIWORA L Lacrimation U Urinary incontinence Suspected spinal cord injury without radiographic abnormality U Urination M Myosis D Diarrhea B Bradycardia, Bronchorrhea, Bronchospasm Peds G Gastrointestinal Distress E Emesis 22 gauge catheter E Emesis L Lacrimation 20 ml/kg bolus for pediatrics - consider blood after 2 bolus B Bronchorrhea S Salivation and Secretion PRBC - rate of infusion 10mlkg B Bronchospasm If no peripheral access after 90 seconds - intraossesous B Bradycardia 16 - 18 gauge bone marrow Antidotes Aspirate bone marrow Atropine pralindoxime - minutes to few hours to administer
Blood Administration in Trauma - untyped and crossed Pulmonary Agents Anthrax
O-Negative - childbearing females - due to Rh compatiblility issues Chlorine and Phosgene Woolsorter's disease Causes pulmonary edema similar to inhalation burn Black Bane Transporting patients - Stabilize, Transfer - Transport Treatment Fifth Plague Table 16-2 on page 288 - Criteria for transfer Move to fresh air, higher ground Modes Must have accepting MD Possible Mechanical ventilation cutaneous Must have available resources - increased level of care - and the appropriate hospital Oxygen inhalational Risks do not outweigh benefits of transfer Antibiotics for pneumonia gastrointestinal MD of transferring hospital initiates transfer Type of transfer must be appropriate - critical care transport, ALS - minimum RN and Paramedic usu. Blood Agents Ricin - Castor Beans Type of Transport - ground, helicopter, fixed wing Carbon Monoxide and Cyanide ( bitter almonds) Ingested - NVD, dehydration, GI hemorrhage What to send Hallmark of Cyanide toxicity is Metabolic Acidosis Inhaled - pulmonary and systemic MIVT report Cells in anaerobic metabolism fever, tachypnea, tachycardia, hypotension Patient assessments Alert to key things hepatitis, pancreatitis, myocardial damage Diagnostic procedure results Bitter almond smell bone marrow suppression Vital Signs Surroundings 8-24 hours after exposure Planned interventions and procedures Dead animals death in several days Copies of all medical records/xrays etc. Multiple casualities Family Time, route and nature of exposure Allow family to see patient prior to transport Suggest stay at sending hospital until pt leaves Biological Agents Clues to exposure Provide written directions, maps to receiveing hospital Bacterial A number of patients present with Reinforce - not to follow too closely, open laws Viral same signs and symptoms Provide psychological support - have someone stay with family until leaves Toxins Unusual age distribution for a common If death occurs, have someone else on your team with you to help support family Types A,B,C disease Virulence Whenever you move a patient - reassess ETT Ability to spread from person to person Transporting patient - may dislodge and airway not effective Availability Whenever you treat a person, reassess neurovascular status i.e. splinting Small Pox Plague Viral Prodrome Unmanaged Pain Gram negative Bacillus Yersinia pestis Malaise, fever, cephalgia, Increased heart rate Bubonic - most common Gastrointestinal upset Peripheral vasocontriction and pallor septicemic, pneumonic Red Rash - 2-3 days after exposed Tachypnea Patient to patient common and highly fatal progress to vesicles and pustules Muscle tension leading to guarding or splinting as a reflex to reduce pain Contact and Droplet Precautions begins on face, to extremities and Loss of parasympathetic tone - anorexia, nausea/vomiting then to torso Release of catecholamines resulting in increase BP, Cardiac afterload, and myocardial oxygen Contact and airborne precautions consumption Assess Botulinum Radiation Subjective - pain is what is it to the patient, you can't assess level most lethal substance known Survival probable - Less and 100 rads Objective signs - see above poorly canned or preserved food Survival possible - dose 200-800 rads Side effects from medication - re - assessment critical for pt safety and pain control Hallmark symptoms - descending flaccid paralysis Survival Improbable - more than 800 rads Resp depression facial nerved, chewing muscles, swallowing, resp. Treatment Hypotension Action - prevents release of acetylcholine Stabilization, assessment, ABCs N/V prohibits muscle contraction Decontamination Bradycardia Dirty and clean areas Hallucinations See Zones above TNCC Summary 6th Edition EdComp, Inc. Wound management CISM - why Primary intention prepare staff to manage their job-related stress Sutures, staples, skin tape, glue Provide assistance for staff members who are experiencing the negative effects of stress 6-8 hours after injury provide education and prevention programs well approximated and noncontaminated injuries Interventions Delayed primary intention Irrigation essential to infection prevention promote ventilation of feelings Bite wounds and lacerations provide support and reassurance cleansing, irrigation, debridement and antibiotic administration mobilize resources for additional support to promote wound preparation for 3-5 days before primary closure do not criticize anyone's performance Secondary Intention - dirty wounds Conduct the debriefing with specially trained facilitators not closed and allowed to heal gradually by granulation and re-epithelialization See table 15-1 for symptoms of Stress in critical incidents - pg 280 ulcerations, human bites, full or partial thickness abrasions, punctures Disaster Management grossly contaminated wounds D - detect Triage - utilitarian approach to provide the greatest good to the Older Adults differences I - Incident command greatest number Aging related changes can increase comorbities and modify response to meds S - Scene security and safety Limited ability to respond to stress of injury - decreased physiological reserves A - Assess hazards Decreased cerebral blood flow S - Support required loss of pulmonary reserve T - Triage and Treatment loss of pulmonary muscle tone E - Evacuation reduced cough reflex R - Recovery hypoxia from pre-existing conditions Family intervention Atherosclerosis Be truthful, don't give false hope cardiac output and stoke volume decrease with age If a death occurs, have another team member go with you to help support family medications impair myocardial response to shock - may not increase heart rate preexisting anemia preexisting malnutrition - decreased peristalsis, and gastric mobility decreased fat stores, slowed metabolic rate This material is copyrighted by EdComp, Inc. Any reproduction or use without impaired ability to concentrate urine written consent is prohibited. urine output not best indication of hydration status loss of ability to buffer acids and bases, reduced glomerular filtration rate may need to reduce doses of medication many take anticoagulants - increasing risk to bleed have thinner vessel walls as well.