Paramedic Update Part 3

1. TOPIC
56
NNeeoonnaattoollooggyy

2. Objectives
• Identify incidence and
morbidity/mortality in neonatal
complications.
• Review leading causes of death in the
<1 year bracket.
• Discuss the assessment format and
interventions for a newborn child.
• Review a mnemonic to assist the
paramedic in remembering steps and
interventions on a neonate.

3. Introduction
• In utero, the fetus is totally
dependent on the mother for
survival.
• Once born, the neonate now needs
to rely on his own body processes for
survival.
• Many times, there are congenital or
acquired anomalies that disturb the
body's processes.

4. Epidemiology
• 2 percent to 5 percent of all live
births have some type of congenital
anomalies.
• 20 percent to 30 percent of perinatal
deaths are the result of congenital
anomalies.

5. Epidemiology
• 10 percent of births will need some
medical help at birth to begin life.
• 1 percent will need aggressive
resuscitation to survive the neonatal
period.

6. Terminology
• Review of terminology related to
newborns
– Fetal or in utero
– Gestational period
– Premature
– Term
– Late term
– Perinatal
– Infancy

7. Transitioning
• Review the anatomic and physiologic
changes from in utero to the
extrauterine environment.
• The lungs must open and allow gas
to be exchanged for the first time.
• Discuss how meconium aspiration,
structural defects, and infection can
affect the neonate.

8. AABBCCss ““IInn TThhaatt OOrrddeerr,, EEvveerryy
TTiimmee””
• Airway
– Anatomical differences make positive
pressure ventilation challenging.
– Do not place pressure on the trachea.
– The insertion of an oropharyngeal
airway or a nasopharyngeal airway may
help control the airway.
– The use of a bag-valve-mask does not
require much force or strength.

9. To provide positive pressure ventilation, use a bag-valve
mask. Maintain a good mask seal. Ventilate
with just enough force to raise the infant’s chest.
Ventilate at a rate of 40–60 per minute for 30
seconds, then reassess

10. Pathophysiology
• Breathing
– Rate of 40–60 per minute.
• 30–40 for older neonate.

11. Pathophysiology
• Breathing
– Tidal volumes
• 15–25 mL for a newborn.
• 25–50 for a neonate up to 1 month of age.
• “Just enough to move the chest.”
– Use a manometer to keep airway
pressure <30 cmH2O.

12. Pathophysiology
• Breathing
– If adequate:
• Rapid improvement in color and perfusion
will occur.
• Heart rate will normalize.
• Spontaneous respirations may return.
• Use a blended mix of oxygen to achieve a
desired pulse oximetry level.

13. Pathophysiology
• Careful and efficient basic airway
management is preferred over
advanced techniques.
• Meconium aspiration should only be
performed to distressed babies.
• Review the 2010 AHA Guidelines for
achieving the desired SpO2 levels.

14. Pathophysiology
• Circulation
– If persistently bradycardic (<60 bpm),
signs of poor perfusion after 1 minute of
BVM with oxygen, start compressions.
– “Thumb technique” is recommended.
– Compression: Breath ratio 3:1

15. To provide chest compressions, circle the torso with the fingers and
place both thumbs on the lower third of the infant’s sternum. If the
infant is very small, you may need to overlap the thumbs. If the
infant is very large, compress the sternum with the ring and middle
fingers placed one finger’s depth below the nipple line. In the
newborn, compress the chest one-third the depth of the chest at the
rate of 120 per minute and a ratio of 3:1 compressions to
ventilations.

16. Pathophysiology
• Circulation
• Obtain intravenous access
– Can be challenging.
– Use intraosseous if needed.
• Consider 1:10,000 epinephrine if
heart rate does not increase.
• Determination of poor perfusion

17. WWhhaatt iiss aafftteerr AABBCC?? DDEEFFGG
““DDoonn''tt EEvveerr FFoorrggeett GGlluuccoossee””
• Fuel stores in infants are quickly
exhausted.
– Coordinating feeding and breathing is
exercise enough for a sick infant.
– Ascertain feeding and sleeping patterns.
– Always access a blood glucose level.
– Glucose (D10W) administration in the
neonate.
– 5-10ml/kg iv over 20 min.

18. H is for Hypothermia
• Hypothermia
– Environmental temperature is important
– The best resuscitation efforts will fail on
a cold neonate.
– If the temperature in the back of the
ambulance is comfortable for you, then
it is too cold for the neonate.

19. I is for Infection
• Infection
– Major killer of neonates
– ANY of the following requires physician
evaluation:
• ANY history of fever, cyanosis, apnea, rapid
or shallow breathing.
• ANY history of poor feeding, decreased urine
output, or vomiting.
• ANY blood in stool, urine, or emesis.
• ANY rash beyond “baby acne.”

20. Safe Transport of the Infant
• Transport in parent's arms is not
acceptable.
• Transporting the neonate in an
isolette is ideal.
• Use a commercially available age-appropriate
car seat, or an
integrated car seat.

21. Case Study
• You are called to care for a 3-week-old
baby who has “stopped
breathing.” Upon your arrival, you
are met at the door by a frantic
young mother holding a limp baby.
The mother is crying and, through
her sobs, you can barely understand
her saying something about
“sleeping,” “blue,” and “not
breathing.”

22. Case Study (cont'd)
• What kinds of problems could this
neonate have?
• What are your priorities?

23. Case Study (cont'd)
• Scene Size-Up
– Standard Precautions taken.
– Scene is safe, no entry or egress
problems.
– 3-week-old male, about 6 or 7 pounds.
– Patient found in mother's arms, limp.

24. Case Study (cont'd)
• Scene Size-Up
– Mechanism of illness/nature of injury is
unresponsiveness.
– First child, no prenatal care, minimal
hospital stay at birth.

25. Case Study (cont'd)
• Primary Assessment Findings
– Patient unresponsive.
– Airway looks clear with manual
technique.
– Breathing slow and irregular.
– Carotid pulse 98/min, peripheral pulse
absent.
– Peripheral skin cool and blue.
– Poor muscle tone, neonate is very limp.

26. Case Study (cont'd)
• Is this patient a high or low priority?
Why?
• What are the patient's life threats, if
any?
• What care should be administered
immediately?
• Should endotracheal intubation be
initiated immediately?

27. Case Study (cont'd)
• Medical History
– Born 1 week early, recent diagnosis of
upper respiratory infection.
• Medications
– Nebulized med for upper respiratory
infection.
• Allergies
– Mother does not think infant has any.

28. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils sluggish to respond to light.
– Airway patent, patient being ventilated
at 30/min.
– Central pulse present now only
60/minute.

29. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Skin is still cool, cyanosis has resolved
some.
– Pulse oximetry only 90 percent with PPV
and supplemental oxygen.
– Patient still limp, no response to
interventions.

30. Case Study (cont'd)
• Is the infant improving or
deteriorating?
• Is there any additional treatment or
change in treatment required?
• What is the likely underlying cause
for the emergency?

31. Case Study (cont'd)
• Care provided:
– Patient positioned supine, secured for
transport.
– Ongoing PPV with oxygen.
– Compressions administered when heart
rate dropped below 60/min with poor
perfusion.

32. Case Study (cont'd)
• Care provided:
– Temperature maintained with
ambulance heater and warm blankets.
– Rapid transport with paramedic
intercept.

33. Case Study (cont'd)
• What signs and symptoms would
indicate that the patient’s condition
is still deteriorating?.
• What additional interventions will
you provide?

34. Case Study (cont'd)
• Additional care provided:
– Peripheral IV access or IO access.
• Fluid administration with use of buretrol.
– Administration of epinephrine.
– Reassess and monitor the patient.

35. Summary
• Neonatal emergencies are stressful
for the parent as well as EMS
providers.
• Remember the mnemonics for
assessing and managing neonates:
– ABCs “In that order every time”
– DEFG “Don't ever forget glucose”
– H is for hypothermia
– I is for infection

36. Summary
• Also ensure proper and secure
transport to hospital in ambulance.
• Paramedics must remember that
good basic interventions are
preferred when managing for this
age group, but they must be
competent in providing advanced
interventions when needed.

37. 55
TOPIC
OObbsstteettrriiccss ((AAnntteeppaarrttuumm
CCoommpplliiccaattiioonnss))

38. Objectives
• Review rates for complications seen
during pregnancy.
• Discuss specific pathology related to
obstetric emergencies.
• Review specific questions to ask
when obtaining an obstetric history.
• Review assessment parameters and
current treatment standards for a
patient with antepartum
complications.

39. Introduction
• Antepartum refers to the period of
pregnancy prior to the onset of labor.
• Emergencies that occur during this
time may be benign or even life
threatening.
• The goal of the paramedic is to
differentiate between these and
provide safe, and occasionally
lifesaving, treatment to these
patients.

40. Epidemiology
• 4 percent of all pregnancies develop
third trimester complications.
– 22 percent are placenta previa cases.
– 31 percent are abruptio placentae cases.

41. Pathophysiology
• Placenta Previa
– Placenta implants over the internal
cervical os.
– Types include complete, marginal, and
partial.
– Cervical effacement can lead to
hemorrhage at the implantation site.

42. Placenta previa.

43. Pathophysiology
• Abruptio Placentae
– Placental lining separates from the
uterus.
– The expanding collection of blood
continues to force the placenta away,
which increases bleeding.
– Complete and partial abruption occurs.

44. Abruptio placentae.

45. Pathophysiology
• Ectopic Pregnancy
– Pregnancy in which the ovum implants
outside the uterine cavity.
– Still the leading cause of pregnancy-related
deaths in the first trimester.
– Almost 100 percent result in fetal death.

46. Ectopic pregnancy.

47. Pathophysiology
• Preeclampsia and Eclampsia
– Preeclampsia has hypertension, edema, protein
in the urine, visual disturbances, and
headaches.
– Eclampsia is all the above, but in addition the
patient has now developed generalized tonic-clonic
seizures.
– Preeclampsia is the third leading cause of
pregnancy-related death.
• New hypertension >140/90 mmHg
• Previous history of hypertension > 30/15 mmHg
above norm

48. Pathophysiology
• Spontaneous Abortion
– Loss of pregnancy before the age of
viability.
– Spontaneous means abortion was
unintentional, involuntary, and due to
some natural cause.
– Patient will commonly have abdominal
cramping, discharge, and expulsion of
tissues of conception.

49. Types of Abortion

50. Assessment
• Physical exam should follow the
standard primary and secondary
assessments.
• Assessment techniques should be the
same as those for a non-pregnant
patient.

51. Assessment
• Patient interview should include a
focus on:
– When was last menstrual period?
– Have you been pregnant before?
– Are you experiencing any pain or
discomfort?
– Are you having any vaginal discharge?
– Any prenatal care?
– When is your due date?

52. Antepartum Complications and
Associated Signs and Symptoms

53. Emergency Medical Care
• Consider spinal immobilization.
• Assess and maintain the airway.
• Determine breathing adequacy.
– Provide oxygen if adequately breathing.
– Provide high-flow oxygen via positive
pressure ventilation if inadequately
breathing.

54. Emergency Medical Care
• Assess circulatory components.
– Check pulse, skin characteristics.
– Control major bleeds.
– Suspect internal hemorrhage

55. Emergency Medical Care
• Position patient left lateral
recumbent tilted to the left side.
• Provide aggressive care for seizures.
– Magnesium sulfate
– Benozdiazapines
• Initiate IV access and administer
fluids based on presentation.
• Expedite transport to facility.
• Reassess and reassure while en
route.

56. Case Study
• At about 0230 hours, your EMS unit
is dispatched to a local battered
women's shelter in the downtown
area. Upon your arrival, you find a
19-year-old female, 8½ months
pregnant. She has bruises and cuts
on her face, and dried blood on her
shirt. She states her boyfriend beat
her up and kicked her in the
stomach. She now has abdominal
pain and bleeding.

57. Case Study (cont'd)
• What kinds of injuries could this
patient have?

58. Case Study (cont'd)
• Scene Size-Up
– Standard Precautions taken.
– Scene is safe, no entry or egress
problems.
– 19-year-old pregnant female, 160
pounds.

59. Case Study (cont'd)
• Scene Size-Up
– Patient found in sitting position.
– Mechanism of injury is physical
altercation.
– The police have been summoned but not
on scene yet.
– First pregnancy with no prenatal care.

60. Case Study (cont'd)
• Primary Assessment Findings
– Patient responsive.
– Airway appears open.
– Breathing fast but adequate.
– Carotid and radial pulses present.
– Peripheral skin cool and slightly
diaphoretic.
– Pants soaked with blood from vaginal
bleeding.

61. Case Study (cont'd)
• Is this patient a high or low priority?
Why?
• What are the patient's life threats, if
any?

62. Case Study (cont'd)
• Medical History
– None other than pregnancy.
• Medications
– She takes OTC multivitamin.
• Allergies
– Patient denies any.

63. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils reactive to light bilaterally.
– Airway patent, patient’s breathing is
rapid.
– Central and peripheral pulses present.
– Pulse oximeter reading 99 percent on
oxygen.
– Soft tissue injuries to face are minor.

64. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– BP 100/60, heart rate 122, respirations
22.
– Painful dark red blood escaping from the
vagina.
– Abdomen is tense to the touch, tender
also.

65. Case Study (cont'd)
• What is the patient's para and
gravida status?
• What do you think is the patient's
primary problem?
• Why is the abdomen tense?
• What complications could the patient
have as a result of this condition?
• What care will you provide?

66. Summary
• Antepartum emergencies can be the
reason for the EMS call, or a
consequence of some other trauma
or medical problem.
• In many instances, there are two
lives at stake—the mother and the
unborn child.
• The paramedic must properly assess,
treat, and transport these patients.

67. 51
TOPIC
TTrraauummaa iinn SSppeecciiaall
PPooppuullaattiioonnss:: GGeerriiaattrriiccss

68. Objectives
• Discuss statistical rates pertinent to
the aging population.
• Discuss incidence rates for geriatric
trauma and death.
• Identify pathophysiologic changes
that accompany injuries in geriatrics.

69. Objectives
• Differentiate early from late
assessment findings.
• Review current treatment strategies
for the geriatric patient suffering
from trauma.

70. Introduction
• In trauma, age is one of the most
important determinants.
• Elderly patients do not survive
trauma, and concurrent chronic
diseases make survival even more
unlikely.
• It is important to reconsider the
assessment and management of the
geriatric trauma patient

71. Epidemiology
• Over 40 million geriatric people in
the United States
• Geriatric patients use a
disproportionate amount of EMS and
health care services.
• Geriatric patients account for 75
percent of fall-related deaths.

72. Epidemiology
• The elderly drive fewer miles, but
have a three times higher death rate
in motor vehicle crashes.

73. Pathophysiology
• Head and Brain Trauma
– Brain atrophy increases injury.
– Higher risks of blood occupying lesions.
• Findings may be delayed.
– Patient or family may not remember
injury.
– Pupillary findings may not be reliable.

74. Pathophysiology
• Neck Trauma
– Perception of pain is diminished.
– C1 and C2 fractures common with
minimal traumatic mechanisms.
– Immobilization concerns

75. Pathophysiology
• Spinal Trauma
– Degenerative bone disorders are more
common.
– Presence of kyphosis or scoliosis
increases injury risks.
– Anterior cord syndrome is almost
exclusively a geriatric emergency.

76. Neck injuries are common in patients
with a history of either head or chest
wall trauma.

77. Pathophysiology
• Thoracic Trauma
– Ribs become brittle.
– Disease states of lung tissue decrease
function.
– Compensatory mechanisms are unable
to recover when a thoracic injury
occurs.

78. Pathophysiology
• Abdominal Trauma
– Liver and spleen are more exposed to
injury.
– Internal bleeding can be masked by
what is thought to be a “normal” systolic
pressure.

79. Pathophysiology
• Musculoskeletal Trauma
– Bones are more at risk of injury due to
decrease adipose tissue, weakening
cartilaginous support, and underlying
disease.
– Osteoporosis contributes to bone
weakness and fractures.
– Isolated fractures can become life
threatening.

80. Pathophysiology
• Burn Trauma
– Fourth leading cause of death in
geriatrics.
– Changes in the skin make burns more
severe.
– Burn shock occurs more readily as does
airway occlusion due to burns.
– Linear increase in mortality of a burn
injury based on age alone.

81. Common Manifestations of Trauma
in Geriatric Patients

82. Common Manifestations of Trauma
in Geriatric Patients

83. Common Manifestations of Trauma
in Geriatric Patients

84. Emergency Medical Care
• Spinal immobilization considerations
– Allow for cervical/spinal curvature.
• Assess and maintain the airway.
• Assess and manage circulatory
components.

85. Emergency Medical Care
• Determine breathing adequacy.
– Apply high-flow oxygen via
nonrebreather to maintain a normal
oxygen saturation with adequate
breathing.
– Provide positive pressure with high-flow
oxygen if inadequately breathing.

86. Emergency Medical Care
• Provide full immobilization.
• Initiate transport to an appropriate
trauma facility.
• Consider establishing IV access to
keep systolic blood pressure >90
mmHg.
• Treat any minor injuries, time
allowing.
• Frequently reassess for rapid
deterioration.

87. Case Study
• You are called to a residential
address where an elderly male was
trying to retrieve Christmas
ornaments from his attic, when he
slipped and fell down the attic steps.
Upon your arrival, the patient is at
the bottom of the steps, moaning,
with blood coming from a temporal
laceration. His right ankle looks
angulated.

88. Case Study (cont'd)
• Scene Size-Up
– Standard Precautions taken.
– Scene is safe, no entry or egress
problems.
– 82-year-old male, 160 lbs.
– Patient found in lateral fetal position.
– Mechanism of injury is fall down 10–12
wooden steps.
– No additional resources needed at this
time.

89. Case Study (cont'd)
• What kinds of injuries could this
patient have?
• What will be your assessment
approach to him?
• What is your first priority?

90. Case Study (cont'd)
• Primary Assessment Findings
– Patient moaning, but responsive to
yes/no questions only.
– Airway open, breathing adequate, rate
fast.
– Carotid and radial pulses present,
tachycardic.

91. Case Study (cont'd)
• Primary Assessment Findings
– Peripheral skin cool and slightly
diaphoretic.
– Bleed to right temporal region.
– No other major bleeding noted.

92. Case Study (cont'd)
• Is this patient a high or low priority?
Why?
• What interventions should be
provided at this time?

93. Case Study (cont'd)
• Medical History
– Hypertension, myocardial infarction,
COPD, constipation, hemorrhoids
• Medications
– Coumadin, Nitro PRN, Proventil, Colace,
Preparation H
• Allergies
– Morphine

94. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils equal and reactive, membranes
hydrated.
– Airway patent, minute volume
adequate, breath sounds diminished.
– Central and peripheral pulses present.
– Pulse oximeter reading 94 percent on
ambient air.

95. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Patient is becoming more unresponsive.
– BP 180/90, heart rate 108, respirations
28.
– Right ankle angulated with swelling,
pain, and tenderness noted.

96. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Physical assessment reveals no other
skeletal trauma.
– No other findings are contributory to
this report.

97. Case Study (cont'd)
• Provide two different explanations for
his change in mental status.
• What else about this patient's
medical history could make
managing him more difficult?

98. Case Study (cont'd)
• Will his age or his medical history
make you alter your treatment any?
• If the patient starts to improve, what
would be the expected findings for:
– Mental status
– Heart rate
– Muscle tone

99. Case Study (cont'd)
• Care provided:
– Patient cervical spine manually
immobilized.
– High-flow oxygen via mask initially, PPV
with supplemental oxygen after patient
is in respiratory failure.
– Patient carefully immobilized to supine.
– Patient loaded and transported to
appropriate trauma center.

100. Case Study (cont'd)
• Care provided:
– Intravenous access should be
established and fluids should be
administered only to maintain SBP of 90
mmHg.
– Patient reassessed and reassured during
transport without change in condition.
– Treat laceration and ankle en route if
possible.

101. Summary
• Although they are adults,
approaching a geriatric patient
should be given the same
consideration as approaching the
pediatric patient.
• Many times the paramedic will need
to anticipate deterioration, modify
treatment to fit the patient, and not
expect all care to have the same
effect as it would on a younger
patient.

102. 49
TOPIC
CCoommpplleettee aanndd IInnccoommpplleettee
SSppiinnee aanndd SSppiinnaall CCoorrdd IInnjjuurriieess

103. Objectives
• Discuss the predisposition, incidence,
and mechanism of spinal cord
injuries.
• Review normal spinal cord anatomy.
• Discuss the pathophysiology of spinal
cord injuries.
• Review motor and sensory findings
for incomplete spinal cord injuries.

104. Objectives
• Review assessment tests that
ascertain spinal cord involvement.
• Review current treatment standards
for cord injuries.

105. Introduction
• Cord injuries in the traumatized
patient may be subtle or obvious.
• The paramedic must keep a high
index of suspicion for possible spinal
cord damage.
• Failure to manage, or the
mismanagement of, a cord injury can
have permanent, if not fatal,
outcomes.

106. Epidemiology
• 11,000 new cases of spinal cord
injury per year in the United States
• About 80 percent occur to men,
average age 38 years.
• Incidence of elderly spinal cord injury
is on the rise.

107. Illustration of the spinal nerves (a)
laterally and (b) posteriorly. The
ganglia are detailed as well.

108. Cross section of spinal cord showing
corticospinal, spinothalamic, and
posterior columns.

109. Ligaments and intervertebral disks of the
spine. Lateral view of the spinal column
(anterior to the right). The lower vertebrae
have been cut sagittally to reveal the spinal
canal and some of the ligaments.

110. Pathophysiology
• Injury to the spinal cord
– Flexion, rotation, compression,
hyperextension, lateral bending,
distraction, penetration
– Primary cord injury (structural damage)
– Secondary cord injury (ongoing damage
from swelling or ischemia/necrosis)

111. Pathophysiology
• Complete spinal cord injury
– Total loss of motor and sensory
function.
– Fairly easy to detect.
– Can be mimicked by spinal shock.
– Management still remains the same.

112. Pathophysiology
• Incomplete spinal cord injury
– A portion of the spinal cord is injured
– Partial neurologic function
– Requires immobilization
– Specific presentations of incomplete
spinal injury include:
• Central cord syndrome
• Brown-Séquard syndrome
• Anterior cord syndrome

113. Cross sections of the spinal cord, showing the H-shaped
gray matter surrounded by white matter.
Illustrated here are the three most common types
of incomplete spinal cord injury (the areas of the
injury are highlighted in red): (a) Central cord
syndrome results from injury to the central cord.
(b) Brown-Séquard syndrome results from injury to
the right or left half of the cord. (c) Anterior cord
syndrome results from injury to the anterior cord.

114. Incomplete Spinal Cord Injury
Syndrome Assessment Findings

115. Pathophysiology
• Spinal shock
– Loss of neurologic function and
autonomic tone distal to injury site.
– Neurogenic hypotension, hypothermia,
bradycardia may result.

116. Differential Assessment Findings:
Hypovolemic Shock Versus Neurogenic
Shock

117. Assessment Findings
• Dispatch information may provide a
clue.
• Assess spinal tracts by testing for
pain, light touch, and motor function.
• Goal is to assess the cord at multiple
levels to ensure presence/absence of
injury.

118. Spinal Cord Motor Assessment and
Level of Loss of Function

119. Level of Spinal Cord Injury
Correlated to Loss of Sensory
Function

120. Emergency Medical Care
• The following patients should always
be immobilized
– Significant mechanism of injury.
– Patient has an altered mental status.
– Patient has pain or tenderness to
vertebral column.
– Patient is unreliable.
– Any sensory or motor dysfunction is
found.

121. Emergency Medical Care
• Manual cervical spine considerations
• Assess and maintain the airway.
• Determine breathing adequacy.
– Administer oxygen to maintain SpO2
above 94 percent
– Provide positive pressure ventilation
with high flow oxygen if inadequate

122. Emergency Medical Care
• Assess circulatory components.
– Check pulse, skin characteristics.
– Control major bleeds.
• Initiate transport to an appropriate
facility and reassess patient’s ABC’s
and neurologic function en route.

123. Emergency Medical Care
• Initiate intravenous access with a
large-bore catheter.
– Administer IV fluids to keep systolic
blood pressure >90 mmHg.
– If hypoglycemic (blood glucose level
<60 mg/dL), administer 25 g of 50%
dextrose in water.
– Consider vasoactive agents in severe
cases of spinal shock.

124. Case Study
• You have a 31-year-old construction
worker who fell from a scaffolding
onto a pile of waste material from
about 20 feet. Bystanders state he
landed on his back and was
unresponsive for about 15 seconds.
Upon your arrival, the patient can
speak to you, but is not sure what
happened.

125. Case Study (cont'd)
• Scene Size-Up
– Standard Precautions taken.
– Scene is safe, workers have cleared
area of debris.
– 31-year-old male patient, 180 lbs.
– Mechanism of injury appears to be a fall
– Additional resources are not requested
at this time

126. Case Study (cont'd)
• Scene Size-Up
– Patient found supine, no gross
hemorrhages.
– Patient entry made, egress not
problematic.
– No additional resources needed at this
time.

127. Case Study (cont'd)
• Primary Assessment Findings
– Patient responsive, but amnestic to fall.
– Airway open, breathing adequate, no
dyspnea.
– Carotid and radial pulses present,
normal rate.

128. Case Study (cont'd)
• Primary Assessment Findings
– Peripheral skin warm and slightly
diaphoretic.
– No major bleeds noted to body.
– Patient keeps telling you that he cannot
move his arms.

129. Case Study (cont'd)
• Is this patient a high or low priority?
Why?
• What interventions should be
provided at this time?

130. Case Study (cont'd)
• Medical History
– Asthma
• Medications
– Proventil inhaler PRN
• Allergies
– No drug allergies

131. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils equal and reactive, membranes
hydrated.
– Airway patent, good minute ventilation.
– Central and peripheral pulse and
perfusion good.

132. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pulse oximeter reading 98 percent on
ambient air.
– Patient has normal lower extremity
motor tone; however, he cannot move
his arms.

133. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– He can feel light touch in all extremities,
but not painful stimuli to arms.
– Deformity and abrasion to base of neck
noted.
– B/P 104/80, heart rate 70, respirations
12.
– BGL is 120 mg/dL

134. Case Study (cont'd)
• Do you suspect a spinal cord injury?
If so, what type?
• Explain the reason for the conflicting
assessment findings.
• What spinal nerve tract is injured on
this patient?
• What treatments would you provide
to this patient?

135. Case Study (cont'd)
• Care provided:
– Patient’s cervical spine manually
immobilized.
– Administer oxygen to maintain SpO2
above 94 percent.
– Patient carefully immobilized.
– Transported to an appropriate facility.
– Initiated intravenous access and provide
fluids to maintain SBP >90 mmHg.

136. Summary
• As mentioned, the traditional method
for assessing motor, sensory, and
perfusion is not sufficient for
incomplete spinal injuries.
• Incomplete SCI need immobilization
as well to prevent the incomplete
from progressing to complete.

137. TOPIC
48
TTrraauummaattiicc BBrraaiinn IInnjjuurryy

138. Objectives
• Discuss the predisposition, incidence,
and death rates for brain injuries.
• Review the pathophysiology behind
the types of brain injuries.
• Define assessment considerations
and findings for patients with brain
injuries.
• Review current treatment
parameters for patients with
herniating and non-herniating brain
injuries.

139. Introduction
• Brain injuries may manifest
themselves now, or weeks later.
• The physiology of the brain and
surrounding structures leaves itself
open to certain types of brain
injuries.
• Understanding the pathophysiology
of brain injuries will allow the
paramedic to provide optimal
treatment.

140. Epidemiology
• 1.5 million head injuries occur per
year in the United States
• It is the leading cause of death in
accident victims younger than 45.
• 50,000 people die each year from
brain injury.

141. Pathophysiology
• Intracerebral hemorrhage
– Extraaxial hemorrhage
• Epidural, subdural, subarachnoid
– Intraaxial hemorrhage
• Occurs within brain tissue itself
• Intracerebral hemorrhage
– Intraparenchymal hemorrhage
– Intraventricular hemorrhage

142. Pathophysiology
• Diffuse axonal injury (DAI)
– Most devastating of traumatic brain
injuries
– Acceleration-deceleration mechanism
– Frequent outcome is coma
– Stretching and swelling of axons

143. Pathophysiology
• Diffuse axonal injury
– Concussion
• Mild DAI
• GCS 13-15
– Epidural hematoma
• Serious complication of head injury
• Bleeding between dura and skull

144. Pathophysiology
• The rise in ICP causes a cascade of signs
and symptoms, including:
• Decreased mental status
• Severe headache
• Fixed and dilated pupils
• Vomiting
• Altered or absent breathing
• Posturing
• Systolic hypertension with associated
bradycardia (Cushing reflex, a late finding)

145. Figure 48–1 Epidural hematoma.
Pt. will suffer a loss of consciousness and then a period of
responsiveness.
Shortly thereafter, his level of consciousness will deteriorate rapidly.
Result from low velocity impact skull Fx is common occurring in 90% of pt.

146. Pathophysiology
• Diffuse axonal injury
– Subdural hematoma
• Bleeding between arachnoid and dura
• Low-pressure bleed
• Phases include acute, subacute, and chronic

147. Pathophysiology
• Acute phase—Signs and symptoms begin
immediately
• Subacute phase—begins three to seven days
after the injury
• Chronic phase—begins two to three weeks later
• Subdural hematoma is seen in child abuse cases
and incidents involving shaken baby syndrome.
• typical mortality rate around 60 percent.

148. Pathophysiology
• Signs and symptoms of acute subdural
hematoma include:
• Declining level of consciousness
• Abnormal or absent respirations
• Dilation of one pupil
• Weakness or paralysis to one side of the body
• Vomiting
• Seizures
• Increasing systolic blood pressure
• Decreasing heart rate

149. Figure 48–2 Subdural hematoma.

150. Pathophysiology
• Diffuse axonal injury
– Subarachnoid hemorrhage
• Brain tissue becomes ischemic
• Severe headache common
• May rapidly progress to seizures and cardiac
arrest

151. Assessment Findings
• Dispatch information
– Seizures, headache, trauma, etc.
• Soft tissue injuries to skull
• Closed or open skull injuries
• Alteration in mental status
• Possible loss of airway patency
• Breathing may be irregular and slow
• Changes to vitals (Cushing response)

152. Assessment Findings
• Response to painful stimuli
– Purposeful vs. nonpurposeful
– Decorticate vs. decerebrate
• Assess and reassess mental status.
– Compute Glasgow Coma Score, look for
trends.
• Assess vital signs
– Trends of vitals may also help identify
brain injury.

153. Nonpurposeful responses to painful stimuli include
(a) flexion (decorticate) posturing and (b)extension
(decerebrate) posturing.

154. Glasgow Coma Scale

155. Implications of Changes in Vital
Signs with Head Injuries

156. Emergency Medical Care
• Manual cervical spine considerations
• Assess and maintain the airway.
• Determine breathing adequacy.
– Administer oxygen to maintain SpO2
above 94 percent.
– Positive pressure ventilation with high
flow oxygen if inadequate.
– Consider hyperventilation (at no more
than 20/min) with brain herniation.

157. Emergency Medical Care
• Assess circulatory components.
– Check pulse, skin characteristics.
– Control major bleeds.
• Transport immediately to an
appropriate medical facility.

158. Emergency Medical Care
• Initiate a large-bore intravenous
catheter.
– Administer fluids to keep systolic blood
pressure >90 mmHg.
– Do not cause hypertension with IV
fluids.

159. Emergency Medical Care
• Be prepared to manage seizure
activity.
• Constantly monitor airway,
breathing, and circulation.
• Mental status changes are key to
determining improvement or
deterioration.

160. Case Study
• You are called to a motorcycle
accident where a rider who was not
wearing a helmet lost control of his
cycle on a turn and hit a tree. When
you arrive, the patient is lying
supine, blood covering his face and
shirt, and the patient is actively
seizing. The police are already on
scene and you can hear the wail of
the fire department sirens
approaching.

161. Case Study (cont'd)
• Scene Size-Up
– Standard precautions taken.
– Scene is safe, police stopped traffic
– 43-year-old male patient, 200 lbs.
– Patient supine, blood on face and shirt.
– MOI- motorcycle accident
– Entry made, egress not problematic.
– PD on scene, FD pulling up.
– Additional resources requested

162. Case Study (cont'd)
• Based on the information provided
and the scene size-up, what
differential diagnosis might you
suspect?
• What types of additional resources
may you consider requesting?
• What are your priorities at this time?
• Would you consider this a high-priority
patient? Why?

163. Case Study (cont'd)
• Primary Assessment Findings
– Patient unresponsive, active tonic-clonic
seizures.
– Mouth clenched shut, blood on face,
sonorous breath sounds with gurgling.
– Breathing is ineffective due to seizure
activity.

164. Case Study (cont'd)
• Primary Assessment Findings
– Carotid and radial pulses present.
– Peripheral skin warm and sweaty.
– No major bleeds noted to body.

165. Case Study (cont'd)
• What interventions should be
provided at this time?
• How would you manage the airway
of this patient?
• What could be the cause of his
seizure activity?

166. Case Study (cont'd)
• Medical History
– Unknown
• Medications
– Unknown
• Allergies
– Unknown

167. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils unequal, sluggish to light.
– Airway patent, spontaneous breathing
still ineffective.
– Patient is still unresponsive and seizing.
– Pulse oximeter reading 82 percent
initially with attempts at PPV. 93
percent on high-flow oxygen.

168. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– B/P 198/90, heart rate 56, spontaneous
respirations 4 and irregular.
– Crepitus noted to posterior vertebrae.
– Depressed right frontal skull fracture
noted.
– Sinus bradycardia on monitor
– Blood glucose level 65 mg/dL

169. Case Study (cont'd)
• What type of brain injury would you
suspect?
• Is this patient displaying any
indications of herniation? Why?
• What interventions might you
provide at this time?

170. Case Study (cont'd)
• Care provided:
– Stabilize cervical spine
– Considering hyperventilation based on
protocol
– Maintain airway, oxygenation, and
ventilation

171. Case Study (cont'd)
• Care provided:
– IV initiation and fluid therapy
– Stop seizures (based on protocol)
– Full spinal immobilization
– Rapid transport to appropriate facility

172. Summary
• Brain injuries are a common cause of
death and disability following
traumatic events.
• Prehospital recognition and proper
management can help reduce the
long-term effects of brain injuries.
• As with any trauma, focus first on
supporting lost function.

173. 45
TOPIC
SSoofftt TTiissssuuee IInnjjuurriieess:: CCrruusshh IInnjjuurryy
aanndd CCoommppaarrttmmeenntt SSyynnddrroommee

174. Objectives
• Review the occurrences and
mechanisms of soft tissue trauma.
• Discuss pathophysiological changes
at the cellular level of crush and
compartment syndrome injuries.
• Review assessment findings and
current treatment interventions for
these types of injuries.

175. Introduction
• Crush injury is a mechanism of blunt
trauma, whereas compartment
syndrome is an injury pattern.
• Crush injuries are caused by
excessive compressive forces on the
body.
• Can occur to small localized areas
(thumb), or to large regions
(thorax).

176. Epidemiology
• A broad definition of soft tissue
injury accounts for the vast majority
of traumatic injuries.
• Crush injuries are a small portion of
this category.
• Crush injuries result from a wide
range of mechanisms.

177. Mechanism
• Direct force
– Tissue destruction from compressive
forces
• Entrapment/Weight-based
compression
– Compression caused by patient's
position
• Internal compression
– Internal swelling causing compartment
syndrome

178. Direct force can cause crush injuries,
some resulting in open wounds.

179. A stroke patient who has fallen and
trapped her right leg beneath her body
weight.

180. Pathophysiology
• Direct compression destroys tissue
cells.
• Pressure can also inhibit normal
blood flow to tissues, worsening
tissue damage.
• Compression > four hours may result
in muscle breakdown with toxin
release.
– Can have devastating systemic effects.

181. Pathophysiology
• Compartment syndrome
– Compression from the opposite
direction.
– Swelling or bleeding in muscle occurs.
– Fascia enveloping muscle is
nondistensible.
– Pressure builds, causing changes to
blood flow.

182. Assessment Findings
• Common findings
– Pain to traumatized area
– Possible entrapment of extremity
– Bruising, tenderness, ecchymosis
– Deformity, loss of function
– Diminished or absent distal circulation,
motor, or sensory findings
– Internal hemorrhage, shock

183. Assessment Findings
• Specific compartment syndrome
findings
– Pain, discomfort, burning sensation
– Pain that continues after immobilization
– Tenderness, unusual firmness at injury
site
– Altered CMS distal to the injury
– Weakness or paralysis of muscle

184. Assess circulation in an extremity
following a crush injury.

185. Emergency Medical Care
• Spinal immobilization considerations
• Assess and maintain the airway.
• Determine breathing adequacy.
– Maintain adequate oxygenation.
– Positive pressure ventilation with high
flow oxygen if inadequate.
• Assess circulatory components.
– Check pulse, skin characteristics.
– Control major bleeds.

186. Emergency Medical Care
• Relieve any compression pressure if
possible.
– Cellular waste products may be released
into the blood stream.
– May result in massive internal bleeding.
• Initiate intravenous therapy.
• Consider the administration of
medications.

187. Emergency Medical Care
• Prepare for cardiac arrest.
• Treat any minor injuries, time
allowing.
• Consider full spinal immobilization.
• Transport to appropriate facility.

188. Emergency Medical Care
• Preventing and treating
compartment syndrome.
– Elevate extremities.
– Beware of constricting immobilization.
– Apply cold.
– Monitor distal CMS.

189. Case Study
• You are called to a remote area of
your response district where a man
was injured while cutting down trees.
The man was reportedly trapped by
a fallen tree for hours prior to being
found missing by his family. When
you arrive, the patient's abdomen
and legs are still entrapped, and the
fire department is extricating him.
The patient is able to respond to you.

190. Case Study (cont'd)
• Scene Size-Up
– Standard Precautions taken.
– Scene is safe, no further fear of pinning.
– Adult male, 40 years old, 230 lbs.
– Patient found supine, large tree stump
across his abdomen and legs.

191. Case Study (cont'd)
• Scene Size-Up
– Patient entry made, egress problematic
due to woods and distance to carry.
– Additional resources of FD on scene
already.

192. Case Study (cont'd)
• Primary Assessment Findings
– Patient responsive, seems lethargic
though.
– Airway open and maintained by self.
– Breathing is rapid, alveolar sounds
present.

193. Case Study (cont'd)
• Primary Assessment Findings
– Carotid and radial pulses present,
cannot assess lower extremities.
– Peripheral skin cool, pale, sweaty.
– You see some evidence of bleeding from
legs, but nothing current.

194. Case Study (cont'd)
• Is this patient a high or low priority?
Why?
• What interventions should be
provided at this time?
• What type of injuries do you expect
from this mechanism?
• Describe how this mechanism could
cause compartment syndrome.

195. Case Study (cont'd)
• Medical History
– High cholesterol.
• Medications
– Patient denies any, watches his diet.
• Allergies
– “Some antibiotics,” he states.

196. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils dilated but reactive, membranes
pale.
– Airway patent, breathing tachypneic.
– Peripheral perfusion diminishing to
arms.
– Breath sounds present bilaterally.

197. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Patient's mental status still continuing to
deteriorate.
– Pulse oximeter reading 98 percent on
high flow.
– BP 100/82, heart rate 114, respirations
20.
– Unable to assess lower extremities or
abdomen.

198. Case Study (cont'd)
• The fire department reports that it
will take them at least 10 minutes to
lift the tree stump off of the patient.
• They ask you if you need anything
else ready or set up. What would be
your response?
• What additional emergency medical
care might you consider while
waiting for extrication?

199. Case Study (cont'd)
• After lifting the tree from the patient,
he arrests about 30 seconds later.
Explain why this may have
happened.
• What emergency care will you
provide?

200. Case Study (cont'd)
• Care provided:
– Patient immobilized.
– Open and maintain airway.
– PPV with oxygen due to apnea.
– Cardiopulmonary resuscitation initiated
upon arrest.

201. Case Study (cont'd)
• Care provided:
– Advanced cardiovascular life support
provided accordingly.
– All lower extremity fractures managed
by immobilization to backboard.
– Rapid transport.

202. Summary
• Crush injuries are a rare, but
potentially fatal mechanism for soft
tissue trauma, since the injury
pattern could be so widely dispersed.
• The paramedic should indentify and
treat life threats before managing
the soft tissue trauma and
compartment syndrome issues.

203. TOPIC
43
CChheesstt TTrraauummaa

204. Objectives
• Review annual injury and death rates
for chest trauma victims.
• Understand pathophysiologic
changes that occur with chest
trauma.
• Discuss common clinical findings of
chest trauma.
• Identify the importance of
mechanism of injury in determining
presence of chest trauma.

205. Introduction
• Chest injuries can be obvious and
dramatic, or small and easy to miss.
• The assessment of the chest must be
comprehensive in order to find all
injuries.
• The paramedic must understand the
physiology of the chest wall and its
response to trauma.

206. Epidemiology
• 20 percent to 25 percent of trauma
deaths each year are due to thoracic
trauma.
• The most common mechanism is
motor vehicle collision.

207. Epidemiology
• Immediate deaths are due to
myocardial or aorta rupture.
• Early deaths are due to tension and
open pneumothorax, tamponade,
flail segments, and hemothorax.

208. Pathophysiology
• Chest trauma distorts the normal
thoracic anatomy.
• Distortion injures body system and
causes a change in physiology.
• V/Q ratio disturbances, hypoxemia,
and hypercapnea ensue.
• Ultimately, cellular death occurs.

209. Pathophysiology
• Tension pneumothorax
– Disruption of visceral pleura
– Accumulation of intrathoracic air
– Collapse of lung tissue
– Shifting of mediastinum
– Changes in hemodynamics
– Assessment
• Early findings
• Late findings

210. In a tension pneumothorax, air continuously fills the
pleural space, the lung collapses, pressure rises, and
the trapped air compresses the heart and the other
lung.

211. Pathophysiology
• Open pneumothorax
– Disruption of parietal pleura from hole in
chest
– Accumulation of intrathoracic air
– Collapse of lung tissue
– Injury may turn into tension
pneumothorax
– Assessment findings

212. In an open pneumothorax, air enters the chest
cavity through an open chest wound or leaks from a
lacerated lung. The lung then cannot expand.

213. Pathophysiology
• Flail chest
– Fractured ribs (2 or more in 2 places)
– Creates “free floating” segment of chest
– Paradoxical motion inhibits adequate
ventilation
– Resulting pulmonary contusion
– Assessment findings

214. Flail chest occurs when blunt trauma causes the
fracture of two or more ribs, each in two or more
places.

215. With a flail chest, (a) the flail segment is drawn
inward as the rest of the lung expands with
inhalation; (b) the flail segment is pushed outward
as the rest of the lung contracts with exhalation.

216. Pathophysiology
• Hemothorax
– Similar to pneumothorax
– Pleural cavity fills with blood (chest
trauma)
– Collapse of lung tissue creates
hypoventilation
– May also cause hypovolemia
– Assessment findings

217. In a hemothorax, blood leaks into the chest cavity
from lacerated vessels or the lung itself,
and the lung compresses.

218. Pathophysiology
• Acute pericardial tamponade
– Injury to heart causes blood to collect in
pericardial sac
– Pericardial sac nondistendable
– Collapsed ventricles, poor stroke volume
– Assessment findings

219. In pericardial tamponade, accumulating
blood compresses the heart inward.

220. Assessment Findings
• Inspection
– Any open chest injuries
– Any structural abnormalities
• Auscultation
– Type, quality, location of breath sounds
• Palpation
– Structural abnormalities
– Subcutaneous emphysema

221. Differential Field Diagnosis of
Chest Injury

222. Emergency Medical Care
• Spinal immobilization considerations
• Assess and maintain the airway.
• Determine breathing adequacy.
– Provide positive pressure ventilation
with high-flow oxygen @ 10-12/min if
inadequately breathing.
– Occlude any punctures to chest wall.
– Decompress a tension pneumothorax.

223. Emergency Medical Care
• Assess circulatory components
– Check pulse, skin characteristics
– Control major bleeds
• Provide full immobilization
• Initiate safe and expeditious
transport
• Establish a large bore IV en route.
– Avoid aggressive fluid administration
• Consider pain medication

224. Case Study
• Your EMS unit is summoned for a
patient who was injured while
hunting. Upon your arrival, you find
a male patient holding his hand over
his right thorax. Some blood is
seeping past his fingers, and the
breathing looks labored. Friends
report he was accidently shot with an
arrow.

225. Case Study (cont'd)
• Scene Size-Up
– Standard Precautions taken.
– Scene is safe, no sign of struggle.
– Young male, 18 years old.
– Patient found sitting along edge of road.
– No patient entry nor egress problems.
– No additional resources needed
presently.

226. Case Study (cont'd)
• Primary Assessment Findings
– Patient responsive.
– Airway open and maintained by self.
– Breathing is rapid, patient is dyspneic.
– Breath sounds diminished on the right.
– Carotid and radial pulses present but
radial gets weaker with inhalation.
– Peripheral skin cool, pale, sweaty.
– No other major bleeds or concerns.

227. Case Study (cont'd)
• Is this patient a high or low priority?
Why?
• What interventions should be
provided at this time?

228. Case Study (cont'd)
• What are your differentials thus far
that the patient could be suffering
from?
• Do you think that this patient will
have a problem with the ventilation
or perfusion side of the V/Q ratio?
Why?

229. Case Study (cont'd)
• Medical History
– Patient states he has attention deficit
hyperactivity disorder and Tourette
syndrome
• Medications
– Patient states he takes Vyvance, Tenex,
and Albilify
• Allergies
– Patient states he is allergic to penicillin

230. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Pupils dilated but reactive, membranes
pale.
– Airway patent, breathing tachypneic.
– Peripheral perfusion diminishing.
– Absent breath sounds to right thorax.
– Patient's mental status still continuing to
deteriorate.

231. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– No jugular venous distention noted
– No tracheal deviation noted
– Penetration injury fourth intercostal
space, right anterior chest.
– Pulse oximeter reading 98 percent with
supplemental O2.

232. Case Study (cont'd)
• Pertinent Secondary Assessment
Findings
– Occlusive dressing “burped.”
– B/P 82/palp, heart rate 114,
respirations 20.
– Pulsus paradoxus noted

233. Case Study (cont'd)
• What would be key clinical
indications the patient is
deteriorating despite treatment?
• What advantage does “burping” the
occlusive dressing have?
• Why would PPV possibly be
detrimental to the patient?

234. Case Study (cont'd)
• Based on the assessment findings,
what is your differential diagnosis?
• What additional treatments would
you perform?
• How would the patient benefit from
your interventions?

235. Case Study (cont'd)
• Care provided:
– Patient immobilized.
– High-flow oxygen via nonrebreather
mask, switched to PPV due to failing
ventilations.
– Occlusive dressing to chest injury which
is burped.

236. Case Study (cont'd)
• Care provided:
– Needle decompression.
– Transport to trauma hospital initiated.
– Established intravenous access to
maintain systolic BP of 90 mmHg.

237. Summary
• Chest wall injuries can result in
significant disturbances to the V/Q
ratio.
• Although these injury typically
require surgery, the paramedic can
provide treatments that will support
lost function.