Prehospital Care of the Trauma Patient (Triage)

1. Prehospital Care of the Trauma Patient (Triage) Craig Cooley, M.D., MPH, EMT-P, FACEPAssociate EMS Fellowship Director Assistant Professor / Clinical Department of Surgery Division of Emergency Medicine University of Texas Health Science Center - San Antonio Associate Medical Director San Antonio Fire Department

2. S.T.A.R.T. • Simple • Triage • And • Rapid • Treatment

3. Initial AssessmentRPM • Respiration • Perfusion • Mental status

4. Treatment • Reposition airway • Stop major bleeding

6. No further treatment Admit to ECU

7. Life threatening injuries

8. Moderate injuries Can delay up to 1 hour

9. “Walking wounded” Can delay up to 3 hours (Send them to the waiting room)

11. Respiration • None -- Open airway • Still none → • Restored → • Present • Above 30/min → • Below 30/min → Check perfusion

12. Perfusion • Radial pulse • Absent → • Present → Check Mental status • Capillary refill • Greater than 2 seconds → • Less than 2 seconds → Check Mental status

13. Mental Status • Can NOT follow simple commands • Can follow simple commands

14. Scenario You are on your way home on the main highway when you see a large bus lose control and flip onto it’s side prior to being struck by the truck traveling behind it. You and a police officer passing by pull over. When he learns you are a doctor, he hands you a stack of triage tags from his trunk and says he will call for more help.

15. The first thing you see are several people wandering around the bus. Some have various lacerations, others appear to have broken arms. You instruct them to go over by the police car. Most do as they are told.

16. 40 year old male with bleeding from an abdominal wound. He is breathing 24 bpm, radial pulse of 120 and answers your questions appropriately.

17. 10 year old male who moans with any stimulus. RR 16/min, Pulse 90 bpm. He has no obvious injury.

18. 24 year old female. No respirations upon arrival. Repositioning airway does not help. Her left leg appears nearly amputated at the knee.

19. 50 year old female walking around calling for her dog. Respirations are 24/min. Pulse 84. She asks you to help her find her dog. She appears to have a broken right arm and a 7cm scalp laceration.

21. Acute Trauma Care

22. Nasopharyngeal Airway

23. Nasopharyngeal Airway What’s wrong with this NPA insertion?

24. Surgical Airway(Cricothyroidotomy)

25. Surface Landmarks for Cricothyrotomy Thyroid prominence – Adam’s apple usually visible only in males Top of thyroid cartilage Bottom of thyroid cartilage Cricothyroid membrane Cricoid cartilage

26. Beneath the Surface Landmarks Hyoid Bone Thyroid prominence (Adam’s apple ) - usually visible only in males Thyroid cartilage Cricothyroid membrane Cricoid cartilage Thyroid gland

27. Locating the Cric Incision Line Macdonald J C , Tien H C CMAJ 2008;178:1133-1135

28. Surgical Incision overCricothyroid Membrane

29. Incise through the epidermis & dermis Cricothyroid membrane Epidermis Dermis Surgical Airway

30. Surgical Airway Epidermis Cricothyroid membrane

31. Surgical Airway Single stabbing incision through cricothyroid membrane

32. Surgical Airway ***You do not slice, you stab, the membrane***

33. Surgical Airway Insert the scalpel handle and rotate 90 degrees

34. Surgical Airway Insert Mosquito hemostat into incision and dilate

35. Insert ET Tube Insert Endotracheal Tube – direct the tube into the trachea and towards the chest.

36. Check Placement Misting in tube

37. Secure the Tube At this point, the tube should be taped securely in place with surgical tape.

38. Pre-Hospital Care Guidelines Breathing a. In a victim with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25-inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart.

39. Pre-Hospital Care Guidelines Breathing b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the victim for the potential development of a subsequent tension pneumothorax.

40. Tension Pneumothorax • Tension pneumothorax is another common cause of preventable death encountered in the field. • Easy to treat. • Tension pneumo may occur with entry wounds in abdomen, shoulder, or neck. • Blunt (motor vehicle accident) or penetrating trauma (GSW) may also cause.

41. Pneumothorax A pneumothorax is a collection of air between the lung and chest wall due to an injury to the chest and/or lung. The lung then collapses as shown.

42. Tension Pneumothorax Side with penatrating wound A tension pneumothorax is worse. Injured lung tissue acts as a one-way valve, trapping more and more air between the lung and the chest wall. Pressure builds up and compresses both lungs and the heart.

43. Tension Pneumothorax • Both lung function and heart function are impaired with a tension pneumothorax, causing respiratory distress and shock. • Treatment is to let the trapped air under pressure escape. • Done by inserting a needle into the chest. • 14 gauge and 3.25 inches long is the recommended needle size.

44. Tension Pneumothorax • Question: “What if the victim does not have a tension pneumothorax when you do your needle decompression?” • Answer: • If he has penetrating trauma to that side of the chest, there is already a collapsed lung and blood in the chest cavity. • The needle won’t make it worse if there is no tension pneumothorax. • If he DOES have a tension pneumothorax, you will save his life.

45. Location for Needle Entry • 2nd intercostal space in the • midclavicular line • 2 to 3 finger widths below • the middle of the collar • bone This is a general location for needle insertion Picture of general location for needle insertion

46. Warning! • The heart and great vessels are nearby • Do not insert needle medial to the nipple line • or point it towards the heart.

47. Needle Decompression – EnterOver the Top of the Third Rib Rib Lung Chest wall Air collection Intercostal artery &vein Needle Catheter • This avoids the artery and vein on the bottom of the second rib.

48. Remember!!! • Tension pneumothorax is an easily treatable cause of preventable death in the field. • Diagnose and treat aggressively!

49. Sucking Chest Wound(Open Pneumothorax) Takes a hole in the chest the size of a nickel or bigger for this to occur.

50. Sucking Chest Wound • May result from large defects in the chest wall and may interfere with ventilation • Treat by applying an occlusive dressing completely over the defect during expiration. • Monitor for possible development of subsequent tension pneumothorax. • Allow the victim to adopt the sitting position if breathing is more comfortable.