Chest Trauma Espanola Valley Emergency Medical Services Espanola, NM.
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Transcript of Chest Trauma Espanola Valley Emergency Medical Services Espanola, NM.
Chest Trauma
Espanola Valley Emergency Medical ServicesEspanola Valley Emergency Medical Services
Espanola, NMEspanola, NM
Factoids
25% of trauma deaths25% of trauma deaths10% require surgery10% require surgery
Classifications
By mechanismBy mechanismpenetratingpenetratingbluntblunt
By injuryBy injury
The chest - what’s in there?
Chest wallChest wallPleuraPleuraLungsLungsMediastinumMediastinumDiaphragmDiaphragm
Key Anatomy review
Define the limits of the chestDefine the limits of the chest Inspiration/expirationInspiration/expiration
Pleura/potential spacePleura/potential spaceNeurovascular bundleNeurovascular bundlePericardiumPericardium
What can go wrong
Chest wallChest wallRib fracturesRib fracturesFlail chestFlail chestSternal fractureSternal fracture
Why do we care?Why do we care?PainPainMarkers for underlying injuryMarkers for underlying injuryPain limited respirationPain limited respiration
What can go wrong
LungsLungsPneumothoraxPneumothorax
OpenOpenClosedClosedTensionTension
HemothoraxHemothoraxHemopneumothoraxHemopneumothoraxPulmonary contusionPulmonary contusionMichelin man syndromeMichelin man syndrome
What can go wrong
MediastinumMediastinumMyocardial contusionMyocardial contusionPericardial tamponadePericardial tamponadeAortic dissectionAortic dissectionMyocardial rupture/penetrationMyocardial rupture/penetrationEspophageal ruptureEspophageal rupture
Diaphragm Diaphragm RuptureRupture
Traumatic asphyxiaTraumatic asphyxia
Pearls
Tension presents like tamponadeTension presents like tamponadeBoth hypotension, neck vein distension and Both hypotension, neck vein distension and
narrow pulse pressurenarrow pulse pressure tension more commontension more common tamponade usually with penetrating traumatamponade usually with penetrating trauma tension usually with blunt traumatension usually with blunt trauma tamponade has normal lung soundstamponade has normal lung soundsyou can treat tensionyou can treat tension tamponade is going to the OR anywaytamponade is going to the OR anyway
Pearls
Flail segment may not be initially visibleFlail segment may not be initially visibleBeck’s triadBeck’s triadChildren more prone to contusions and Children more prone to contusions and
tension pneumothoraxtension pneumothoraxTracheal deviation with tension is rareTracheal deviation with tension is rareEach side of chest can hold 3 liters of Each side of chest can hold 3 liters of
blood in adultblood in adultNeed long needle for thoracostomyNeed long needle for thoracostomy
PPV Suspicions
Peak airway pressures > 50 cm HPeak airway pressures > 50 cm H22OO
PEEP > 15 cm HPEEP > 15 cm H22OO
ARDS, COPD, or asthmaARDS, COPD, or asthma
Use of tidal volumes > 12 mL/kgUse of tidal volumes > 12 mL/kg
Prehospital Treatment
Recognition: H and PRecognition: H and POxygenate: high flow O2, intubation, RSAOxygenate: high flow O2, intubation, RSA
But beware of positive pressureBut beware of positive pressureMaintain perfusion: crystalloids, bloodMaintain perfusion: crystalloids, blood
No M.A.S.T.No M.A.S.T.Release tension: needle decompressionRelease tension: needle decompressionRapid transport to hospitalRapid transport to hospital
Needle Decompression
PPEPPEAssess the needAssess the needClean and prep site ( 2Clean and prep site ( 2ndnd intercostal space intercostal space
midclavicular) midclavicular) Select appropiate size catheterSelect appropiate size catheter
12-14g 3 inch for adults, size appropiate for 12-14g 3 inch for adults, size appropiate for infants and childreninfants and children
Cook catheterCook catheter
Needle Decompression
Monitor for rush of air and may measure Monitor for rush of air and may measure with syringe.with syringe.
Reassess for hemodynamic and Reassess for hemodynamic and oxygenation improvement.oxygenation improvement.
DocumentationDocumentation Indications/Procedure Indications/Procedure Location Location Results Results
ED treatment
Recognition: expensive testsRecognition: expensive testsOxygenate: high flow O2, intubationOxygenate: high flow O2, intubationMaintain perfusion: crystalloids and bloodMaintain perfusion: crystalloids and bloodRelease tension: chest tubeRelease tension: chest tubeRapid transport to ORRapid transport to OR
RSA Case review
3 Cases3 Cases
RSA Case Review
Case #1Case #111/01/2009 121311/01/2009 1213hrs hrs
Dispatched to an unresponsive 54 y.o. Dispatched to an unresponsive 54 y.o. female.female.
12:15 12:15 Enroute to Camino Santa Cruz. Enroute to Camino Santa Cruz.12:26 12:26 Arrive on scene. Arrive on scene.12:3012:30 Initial physical exam and assessment Initial physical exam and assessment12:4212:42 Depart scene Depart scene
RSA Case Review
1250 hrs RSA Procedure1250 hrs RSA Procedure
1315 hrs Post sedation 1315 hrs Post sedation
1320 hrs Back in service1320 hrs Back in service
HPI
Family members found patient Family members found patient unresponsive sitting on the toilet. unresponsive sitting on the toilet.
Two hours prior she had suffered a fall at Two hours prior she had suffered a fall at home.home.
Earlier in the morning, prior to the fall, she Earlier in the morning, prior to the fall, she had no complaints according to the family.had no complaints according to the family.
PMHx
Traumatic brain injury 35 years ago.Traumatic brain injury 35 years ago.Breast cancerBreast cancerClosed head injury and left temporal scalp Closed head injury and left temporal scalp
laceration repair with sutures in place from laceration repair with sutures in place from a recent fall.a recent fall.
Meds/Allergies
Aromasin, Alendronate.Aromasin, Alendronate.NKDANKDA
Initial Assessment
HR: 72, RR: 22, BP: 125/72, O2 Sat: 96% RA, HR: 72, RR: 22, BP: 125/72, O2 Sat: 96% RA, NSR on cardiac monitor.NSR on cardiac monitor.
Not alert, not responsive.Not alert, not responsive. Pupils unequal.Pupils unequal. Skin pale.Skin pale. Skull intact on palpation.Skull intact on palpation. No obvious new trauma.No obvious new trauma. No respiratory distress, lungs clear to No respiratory distress, lungs clear to
auscultationauscultation
What Now??
BGL-148mg/dlBGL-148mg/dl
Narcan 2 mgNarcan 2 mg
Ponder? Ponder? Risk benefit analysisRisk benefit analysis IndicationsIndications
Treatment
IV, 20 gauge in the right hand.IV, 20 gauge in the right hand.Cardiac monitorCardiac monitorOxygen (not specified)Oxygen (not specified)Depart scene 1242 hrsDepart scene 1242 hrs
Where to transport? Where to transport? Definitive care vs closest facilityDefinitive care vs closest facility
Reassessment
Not alert, not responsiveNot alert, not responsiveHR: 78, RR: 20, BP: 104/50, O2 Sat: HR: 78, RR: 20, BP: 104/50, O2 Sat:
100% on 100% O2 via BVM, NSR on 100% on 100% O2 via BVM, NSR on cardiac monitor.cardiac monitor.
Discussion
BVMBVMNarcanNarcanNuerological assessmentNuerological assessment
GCSGCSReflexesReflexes
RSA Procedure
Etomidate 26 mg (route not specified).Etomidate 26 mg (route not specified).Rocuronium 65 mg (route not specified).Rocuronium 65 mg (route not specified).#4 LMA placed and confirmed breath #4 LMA placed and confirmed breath
sounds, gastric tube placed, tube (not sounds, gastric tube placed, tube (not specified) secured.specified) secured.
Reassessment
Not alert, not responsive.Not alert, not responsive.HR: 70, RR: 12, BP: 108/50, O2 Sat: HR: 70, RR: 12, BP: 108/50, O2 Sat:
100% on 100% O2 via BVM, NSR on 100% on 100% O2 via BVM, NSR on cardiac monitor, ETCO2: 35 to 40.cardiac monitor, ETCO2: 35 to 40.
Versed 5 mg (route not specified) @ 1315 Versed 5 mg (route not specified) @ 1315 hrs.hrs.
Fentanyl 100 mcg (route not specified).Fentanyl 100 mcg (route not specified).Patient care turned over to Care Flight 5 Patient care turned over to Care Flight 5
for transport to UNMH for “neuro”.for transport to UNMH for “neuro”.
Summary
AppropriateAppropriate Gastric tube placementGastric tube placement DocumentationDocumentation
ETCO2 WaveformETCO2 WaveformPost sedation time and dosage for increased Post sedation time and dosage for increased
ICP and MAPICP and MAPRoutes of administrationRoutes of administrationWeight Weight Confirm placement by receiving teamConfirm placement by receiving team
Case #2
12/02/2009 12:2112/02/2009 12:21hrs hrs Dispatched to a “man down”.Dispatched to a “man down”.12:2112:21hrs Enroute to Alcalde Quick-mart.hrs Enroute to Alcalde Quick-mart.12:27hrs12:27hrs Arrive on scene. Arrive on scene.12:3212:32hrs Initial physical exam and hrs Initial physical exam and
assessmentassessment12:3812:38, , 12:4312:43, , 12:4512:45hrs reassessmentshrs reassessments1245hrs RSA procedure with #4 LMA1245hrs RSA procedure with #4 LMA
1255hrs reassessment and LMA #4 1255hrs reassessment and LMA #4 removal.removal.
1258 hrs King LT #5 place and 1258 hrs King LT #5 place and reassessed, versed givenreassessed, versed given
1305hrs Depart scene1305hrs Depart scene1315hrs Arrive Espanola Hospital1315hrs Arrive Espanola Hospital1345hrs Back in service1345hrs Back in service
HPI
Found lying prone in a pool of vomit. Last Found lying prone in a pool of vomit. Last seen 10 minutes ago walking around the seen 10 minutes ago walking around the Quick-mart. Appeared disorientedQuick-mart. Appeared disoriented
PMHx
UnknownUnknownUnknown allergies and medicationsUnknown allergies and medications
Initial Assessment
HR: 108, RR: 4, BP: 116/66, O2 Sat: 78% RA, HR: 108, RR: 4, BP: 116/66, O2 Sat: 78% RA, RSR on cardiac monitorRSR on cardiac monitor
BGL: 76 BGL: 76 GCS: 4GCS: 4 Skin cyanotic.Skin cyanotic. No obvious trauma seen.No obvious trauma seen. No JVD.No JVD. Pupils equal, 2mm round, sluggish reaction to Pupils equal, 2mm round, sluggish reaction to
light.light.
What Next?
Ponder?Ponder?
Risk benefit analysisRisk benefit analysis
Treatment
Narcan 2 mg IM left deltoid.Narcan 2 mg IM left deltoid.O2 at 15 L/min via NRB.O2 at 15 L/min via NRB.
4 minutes later…
Re-assessmentRe-assessment::HR: 111, RR: 24, BP: 112/66, O2 Sat: HR: 111, RR: 24, BP: 112/66, O2 Sat:
82% 15L/min via NRB, RSR, tachycardia 82% 15L/min via NRB, RSR, tachycardia without ectopy on cardiac monitor.without ectopy on cardiac monitor.
GCS: 4GCS: 4Skin pink, warm, dry.Skin pink, warm, dry.Breath sounds shallow with crackles.Breath sounds shallow with crackles.Gag reflex is intact. Gag reflex is intact.
Continued
TreatmentTreatment:: IV, 18 gauge in left external jugular vein.IV, 18 gauge in left external jugular vein.Narcan 4 mg IV.Narcan 4 mg IV.
5 minutes later
HR: 107, RR: 24, BP: 103/62, O2 Sat: HR: 107, RR: 24, BP: 103/62, O2 Sat: 94% 100% via BVM, RSR on cardiac 94% 100% via BVM, RSR on cardiac monitor.monitor.
GCS: 3GCS: 3Skin pink, warm, dry.Skin pink, warm, dry.TreatmentTreatment::
Narcan 2 mgNarcan 2 mg
What now??
2 minutes from last assessement
Re-assessmentRe-assessment::HR: 107, RR: 20, BP: 99/80, O2 Sat: 94% HR: 107, RR: 20, BP: 99/80, O2 Sat: 94%
100% via BVM, ETCO2: 40, RSR on 100% via BVM, ETCO2: 40, RSR on cardiac monitor.cardiac monitor.
GCS: 3GCS: 3Skin pink, warm, dry.Skin pink, warm, dry.
Continued
TreatmentTreatment::Rocuronium 75 mg IVRocuronium 75 mg IVEtomidate 30 mg IVEtomidate 30 mg IVVersed 5 mg IVVersed 5 mg IVFor airway control #4 LMA inserted with For airway control #4 LMA inserted with
bilateral breath sounds and no epigastric bilateral breath sounds and no epigastric soundssounds
10 minutes later…
Re-assessmentRe-assessment::HR: 102, RR: 16, BP: 99/82, O2 Sat: 86% HR: 102, RR: 16, BP: 99/82, O2 Sat: 86%
100% via #4 LMA, ETCO2: no recording, 100% via #4 LMA, ETCO2: no recording, RSR on cardiac monitor.RSR on cardiac monitor.
GCS: 3GCS: 3Skin pink, warm, dry.Skin pink, warm, dry.Difficult to ventilate through the LMA, air Difficult to ventilate through the LMA, air
escaping from the mouthescaping from the mouth
TreatmentTreatment::Decision made to remove the LMA and Decision made to remove the LMA and
place #5 King LT.place #5 King LT.
3 minutes later…
HR: 101, RR: 16, BP: 102/81, O2 Sat: 98% HR: 101, RR: 16, BP: 102/81, O2 Sat: 98% 100% via #5 King LT, ETCO2: 38, RSR on 100% via #5 King LT, ETCO2: 38, RSR on cardiac monitor.cardiac monitor.
GCS: 3GCS: 3 Skin pink, warm, dry.Skin pink, warm, dry. Good air exchange with ventilations via the Good air exchange with ventilations via the
King LT, no epigastric sounds, equal chest King LT, no epigastric sounds, equal chest rise and bilateral lung sounds.rise and bilateral lung sounds.
5 mg versed5 mg versed
Summary
Appropriate Appropriate Narcan Narcan DocumentationDocumentation
Case #3
12/27/2009 1628hrs Dispatched to an MVC 12/27/2009 1628hrs Dispatched to an MVC with injurieswith injuries1629hrs En route1629hrs En route1634hrs On scene1634hrs On scene1635hrs rapid assessment1635hrs rapid assessment5-7 minute extrication5-7 minute extrication1650hrs RSA Procedure1650hrs RSA Procedure1655hrs reassessed 1655hrs reassessed 1700hrs spo2 <90%1700hrs spo2 <90%1720 spo2 100%1720 spo2 100%
HPI
Pt (33 y/o male) was unrestrained driver of Pt (33 y/o male) was unrestrained driver of an old-model pick up truck that was t-an old-model pick up truck that was t-boned on passenger side. ~1 ft intrusion. boned on passenger side. ~1 ft intrusion. Pt found face down on passenger side of Pt found face down on passenger side of truck .truck .
Significant damage description with no Significant damage description with no airbags. airbags.
Speed of other vehicle ~50mphSpeed of other vehicle ~50mph
PMHx
UnknownUnknown
Unknown medications and allergiesUnknown medications and allergies
Rapid assessment
GCS 7, pulse-130’s, Respirations-22 GCS 7, pulse-130’s, Respirations-22 snoring, BP->80, skin P/W/D with cool snoring, BP->80, skin P/W/D with cool extremities. extremities.
No signs of alcohol involvementNo signs of alcohol involvement~70kg~70kg
What next??
ResourcesResources
SafetySafety
Assessment
Pt responsive to Pt responsive to painfulpainful stimuli, GCS 7. stimuli, GCS 7. Decrease mobility to right extremities. Pupils Decrease mobility to right extremities. Pupils +right steady gaze non tracking+right steady gaze non tracking
Labored respirations, deformity to right upper Labored respirations, deformity to right upper chest with SQ air to Right pectoral region. chest with SQ air to Right pectoral region.
LS + BS to all lobes with crackles and grinds LS + BS to all lobes with crackles and grinds to right lobes.to right lobes.
ABD Soft no rigidity or guardingABD Soft no rigidity or guarding Pelvis intactPelvis intact
Assessment
Pulse 148, spo2 unreadable, respirations Pulse 148, spo2 unreadable, respirations 22 with BVM assist, BGL- 239 mg/dl. BP-22 with BVM assist, BGL- 239 mg/dl. BP-154/89.154/89.
Pt withdrawing from BVM assistance. Pt withdrawing from BVM assistance.
1650hrs SPO2-100-99%1650hrs SPO2-100-99%
What next??
Ponder?Ponder?
Risk benefit analysisRisk benefit analysis
Treatment
BVM with 100% O2, IV 18g LAC with BVM with 100% O2, IV 18g LAC with blood tubing, 70 mg Rocuronium, 28mg blood tubing, 70 mg Rocuronium, 28mg Etomidate, and 100 mcg Fentanyl, 5 mg Etomidate, and 100 mcg Fentanyl, 5 mg Versed. 1650hrsVersed. 1650hrs
Equipment prepared and lubed. #4 LMA Equipment prepared and lubed. #4 LMA with 14F G-tubewith 14F G-tube
Reassessment
1655 hrs- HR-146, Resp-10-12 BVM, BP-1655 hrs- HR-146, Resp-10-12 BVM, BP->80, SPO2-96 >80, SPO2-96 90%. 90%.
1700 hrs- HR 134, BP 96/48, SPO2 86 1700 hrs- HR 134, BP 96/48, SPO2 86 89%, ETCO2 35 mmHg89%, ETCO2 35 mmHg
1705 hrs- HR-144, Resp 10-12, BP > 80, 1705 hrs- HR-144, Resp 10-12, BP > 80, SpO2- 95 SpO2- 95 97%, ETCO2 33 mmHg 97%, ETCO2 33 mmHg
Size 4 LMA placed, 45 ml air inflation of Size 4 LMA placed, 45 ml air inflation of cuff. +BS, -epigastric sounds, +misting, + cuff. +BS, -epigastric sounds, +misting, + ETCO2 readingETCO2 reading
NG tube (G-Tube) advance after NG tube (G-Tube) advance after confirmation of LMA placement as above.confirmation of LMA placement as above.
Pt care to Careflight. Pt transported to St Pt care to Careflight. Pt transported to St Vincent’s Hospital.Vincent’s Hospital.
Thoughts?
Vitals?Vitals?Sympathetic drive?Sympathetic drive?
Hypoxia?Hypoxia?Complications, causesComplications, causes
Sedation?Sedation?Versed, FentanylVersed, Fentanyl
Documentation?Documentation?ETCO2 waveform, G- tube placement, etc.ETCO2 waveform, G- tube placement, etc.
Follow Up
Follow Up
G-tube in the left lungG-tube in the left lungChest tube placedChest tube placedPt with dissected aortaPt with dissected aorta
RepairedRepaired3-4 days later plan to extubate and plan to 3-4 days later plan to extubate and plan to
survive injuriessurvive injuries
Questions??Questions??
1. We need to remember to preload the 1. We need to remember to preload the NG tube in the LMA and finish placement NG tube in the LMA and finish placement and confirm it after the LMA is secured.and confirm it after the LMA is secured.Document epigastric sounds with air bolus Document epigastric sounds with air bolus of toomey syringe and/or description of of toomey syringe and/or description of gastric substance upon connection to gastric substance upon connection to suction.suction.
2. We MUST ensure that the Nonin 2. We MUST ensure that the Nonin continuous pulse ox is placed prior to continuous pulse ox is placed prior to beginning the procedure. We believe that beginning the procedure. We believe that previous issues have been corrected with previous issues have been corrected with the repair of our Nonin monitors and the repair of our Nonin monitors and purchase of sticky probes. We must ensure purchase of sticky probes. We must ensure we are monitoring patient appropriately prior we are monitoring patient appropriately prior to proceeding with procedure. to proceeding with procedure.
3. We MUST ensure that we have the ETCO2 3. We MUST ensure that we have the ETCO2 place on the airway before insertion of the place on the airway before insertion of the airway. This is to allow time-stamping of when airway. This is to allow time-stamping of when the airway was placed (with the presence of the airway was placed (with the presence of CO2) and therefore also rough drug CO2) and therefore also rough drug administration times. Documentation of administration times. Documentation of waveform is definitive for ventilation of any waveform is definitive for ventilation of any airway (i.e. good square waveform and plateau airway (i.e. good square waveform and plateau on breath to breath via vent or BVM).on breath to breath via vent or BVM).
4. We MUST provide Dr. Bajema and 4. We MUST provide Dr. Bajema and Mike with ALL data that is generated by Mike with ALL data that is generated by the Nonin monitors. When printing it out, the Nonin monitors. When printing it out, we can provide only the information we can provide only the information surrounding the airway insertion, but the surrounding the airway insertion, but the entire excel file needs to be emailed to entire excel file needs to be emailed to them as an attachment.them as an attachment.
5. We MUST use the checklists (the 10 5. We MUST use the checklists (the 10 P’s and procedure card) that are in the P’s and procedure card) that are in the RSA bags. Dr. Bajema stressed this RSA bags. Dr. Bajema stressed this repeatedly. repeatedly.
6. We MUST check and sign the 6. We MUST check and sign the accountability books in the RSA bags accountability books in the RSA bags EVERY shift.EVERY shift.
7. All documentation (not just RSA) 7. All documentation (not just RSA) should include pt. weight somewhere in should include pt. weight somewhere in the chart as some of our meds (all the the chart as some of our meds (all the RSA meds) are weight based.RSA meds) are weight based.
Dr. Bajema challenges us to strive for a perfect RSA with Dr. Bajema challenges us to strive for a perfect RSA with all the required documentation. Common omissions are:all the required documentation. Common omissions are: 100% Spo2100% Spo2 ETCO2ETCO2 Gastric tube placement Gastric tube placement Ventilator usage on all RSA patientsVentilator usage on all RSA patients
Dr Bajema also would like all providers on Dr Bajema also would like all providers on scene during the RSA to be informed and scene during the RSA to be informed and involved in patient care despite level of involved in patient care despite level of licensure or who is the primary provider. licensure or who is the primary provider.
““It was not my patient” It was not my patient” is not is not acceptable. acceptable.
Great Job!!! Great Job!!!