Patients With Traumatic Injuries

1
Patients With Traumatic Injuries

• Condell Medical Center
• EMS System
• ECRN Packet
• CE Module II 2008

Prepared by Sharon Hopkins, RN, BSN, EMT-P
2
Viewing Packets on the Website

• To see the packet in larger print or to review
  the packet and you no longer have a paper copy,
  go to the Condell website
• www.condell.org/emergency/
• On right side of page choose ECRN CE
• This will take you immediately to the CE page and
  then choose your year and module.
• Contact your EMS office for a copy of the quiz.
• You must complete 4 modules per year to maintain
  current ECRN licensure

3
Objectives

• Upon successful completion of this module, the
  ECRN should be able to
• Identify the differences between a Category I, II
  and III trauma patient
• State EMS pre-hospital transport decisions for
  trauma patients based on Region X guidelines
• Understand what the mechanism of injury is and
  the information it provides
• Understand the difference between the index of
  suspicion and the general impression

4
Objectives contd

• Describe assessment and field treatment
  appropriate for the patient with traumatic insult
  based on Region X SOPs
• Burns, tension pneumothorax, sucking chest wound,
  flail chest, pericardial tamponade, eviscerated
  organs
• Understand where the landmark for chest needle
  decompression
• Review trauma scenarios
• Successfully calculate the GCS and RTS given the
  patients parameters
• Identify and appropriately state interventions
  for a variety of EKG rhythms
• Identify ST elevation on a 12 lead EKG
• Successfully complete the quiz with a score of
  80 or better

5
Leading Causes of Death

• In the age groups from 1 to 44, unintentional
  injury is the leading cause of death
• 45 and over, the leading causes of death are
  disease
• cardiovascular disease and cancers
• These statistics point to a financial burden
  placed on the patient as well as society for
  unintentional injuries
• Source National Vital Statistics System,
  National Center for Health Statistics, CDC

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Level I Trauma Centers

• Prepared and committed to handle all types of
  specialty trauma 24/7
• Provides leadership and resources to other levels
  of trauma care in the Region
• Participates in data collection, research,
  continuing education, and public education
  programs
• Level I Region X Evanston Hospital, St. Francis
  in Evanston
• Level I non-Region X Advocate Lutheran General,
  Froedtert (Wisconsin)

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Level II Trauma Centers

• Increased commitment to trauma care for the most
  common trauma emergencies with surgical
  capability available 24/7
• Participates in data collection, continuing
  education, and public education programs
• Level II in Region X Condell, Glenbrook,
  Highland Park, Lake Forest, Rush North Shore,
  Vista Medical Center East (VMH)

8
Additional Level II Trauma Centers -
Not Geographically In Region X

• Centegra McHenry, Illinois
• Good Shepherd Hospital (GSH) Barrington,
  Illinois
• Northwest Community Hospital (NWCH) Arlington
  Heights

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Region X SOP -Trauma Transport

• Systolic B/P lt 90 on 2 consecutive readings (or
  peds lt 80)
• Transport to the highest level Trauma Center
  within 25 minutes
• 25 minute clock starts from the time of injury

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Region X SOP Trauma Transport

• Traumatic arrest, isolated burns gt20
• Transport to the closest Trauma Center
• No airway
• Transport to the closest Emergency Department

11
Hospital on By-pass

• The closest appropriate hospital must still
  accept any patient in a life-threatening
  condition even if they are on by-pass

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Region X SOP Trauma Transport

• Category I Trauma Patient
• Unstable vital signs
• Based on anatomy of the injury
• Transport to the highest level Trauma Center
  within 25 minutes
• 25 minute clock starts from the time of injury

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Region X SOP Trauma Transport

• Category II Trauma Patient
• Based on mechanism of injury
• High potential for injury but patient is stable
  for now
• Based on existence of co-morbid factors that
  increase the risk of complications to recovery
• Transport to the closest Trauma Center

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Region X SOP Trauma Transport

• Category III Trauma Patient
• All other traumatic injuries and where routine
  care is being provided
• Isolated traumatic injury (generally GCS gt10)
• Isolated fractures
• Minor burns
• Lacerations
• Transport the patient to the closest Trauma Center

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Transport Decisions

• When possible, EMS and Medical Control are to
  honor the patients request for hospital
  destination

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Mechanism of Injury

• The process and forces that cause trauma
• Mentally recreate the incident from the evidence
  noted
• Identify strength of forces involved
• Identify direction forces came from
• Identify areas of the patients body most likely
  affected by the forces
• Start to identify the mechanism of injury during
  the scene size-up

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Accepting The Radio Report

• Start forming a mental picture as you receive
  report
• You are mentally forming an opinion based on
  mechanism of injury
• Youll think differently for the patient who fell
  5 feet versus 30 feet
• Form a general impression based on the paramedic
  report of mechanism of injury with their field
  assessment

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Injury Patterns Pedestrians

• Adults
• Generally turn away present lateral surfaces
• Anatomically, impact is low on the body
• Injuries to tibia, fibula, femur, knee, lateral
  chest, upper extremity, then head neck
• Pediatrics
• Generally turn and face the vehicle
• Injuries anatomically higher on the body than
  adults
• Injuries to femur, pelvis and then those
  sustained when run over or pushed aside by the
  vehicle

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Injury Patterns Motor Vehicle

• Rotational (38 of MVC)
• Injuries similar to frontal lateral
• Deceleration is usually more gradual injuries
  less serious although the vehicles look worse
• Frontal (32 of MVC)
• Up and over the steering wheel pathway
• Femur fractures
• Blunt abdominal injury via compression
• Lower chest injuries after steering wheel impact
• Head neck injuries with windshield impact

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Injury Patterns Motor Vehicle

• Down and under the dashboard pathway
• Lower leg injuries from sliding under the dash
• Chest injuries with steering wheel impact
• Collapsed lungs from breath holding at time of
  impact
• Ejection
• 27 of fatalities
• 2 impacts with interior vehicle then the
  objects outside the car (ground, trees, fences,
  etc)

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Injury Patterns Motor Vehicle

• Lateral impact T-bone (15 of MVC 22 of all
  MVC fatalities)
• Much less structural steel for protection between
  victim and impact site
• Vehicle damage may not look severe but internal
  injury potential is high
• Upper lower extremity fractures on impact side
• Lateral compression with a large amount of
  internal injury to chest abdominal organs
• Unrestrained passengers are missiles and add to
  injuries other passengers already sustained

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Injury Patterns Motor Vehicle

• Rear end (9 of MVC)
• Head rotates backward and then snaps forward
• Less neck injury if the head rest is properly
  positioned
• Rollover (6 of MVC)
• Occupant experiences impact every time vehicle
  impacts a point on the ground
• Vehicle sides and roof provide less crumple zones
  for absorbing impact forces
• Ejection is common in unrestrained persons

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Index of Suspicion

• Your anticipation of injury to a body, region,
  organ, or structure based on identification of
  the mechanism of injury
• Your index of suspicion is honed from experience
  and time on the job

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General impression

• Formed from mechanism of injury and index of
  suspicion
• Will guide the EMS provider regarding a direction
  on how to proceed in caring for this patient

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Putting It All Together Sample

• Report
• The mechanism of injury is a frontal MVC
• ?The steering wheel is broken, chest wall is
  bruised, breath sounds decreased on the right
• Your index of suspicion is chest injury
• Your general impression is pneumothorax

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Documentation of The Complaint To Include

• O - onset
• P provocation/palliation
• Q - quality
• R - radiation
• S severity (0 10)
• T timing when did it start

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Documentation

• Provide answers to
• Who (the patient youre caring for)
• What (happened)
• When (did it happen)
• Where (which body part)
• How (did it occur)

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EMS Trauma Care Amputated Parts

• Routine trauma care
• To remove gross contamination, gently rinse with
  normal saline
• DO NOT use distilled water to irrigate open
  wounds
• Normal saline is isotonic and less harmful to
  tissue
• Cover stump with damp (normal saline) sterile
  dressing and ace wrap
• Ace provides uniform pressure to stump
• Cover wounds with sterile dressing

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EMS Care of Amputated Parts

• Place part in a plastic zip lock bag
• Place bag in larger bag or container over ice and
  water
• Do not ice the part alone

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EMS Pain Management Including for Adult Burns

• Morphine for pain control
• 2 mg slow IVP over 2 minutes
• May repeat every 2 minutes as needed to a maximum
  of 10 mg
• Watch for respiratory depression
• Monitor for a drop in blood pressure due to
  vasodilation from the medication

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Adult Burns - Electrical

• Immobilize the patient
• High potential for traumatic injury
• Muscle spasms during contact with source
• Thrown when power source cut
• Assess for dysrhythmia place on cardiac monitor
• Assess distal neurovascular status of affected
  part
• Cover wounds with dry sterile dressings

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Adult Burns - Inhalation

• High risk for airway compromise
• Note presence of wheezing, hoarseness, stridor,
  carbonaceous sputum, singed nasal hair
• High flow oxygen via non-rebreather mask
• Monitor for need of advanced airway device
• ETT consider using ETT one size smaller than
  normal due to potential swelling of the airway

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Adult Burns - Chemical

• HAZ-MAT team may be involved in the field
• If powdered chemical, first brush away excess dry
  material
• Clothing removed if possible
• Area flushed with sterile saline
• If eye involvement, remove contact lenses and
  flush continuously with sterile saline
• Avoid contamination of noninvolved areas

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EMS Care for Adult Burns - Thermal

• Superficial 1st degree
• Area cooled with sterile saline
• lt20 BSA involved, apply sterile saline soaked
  dressings for transport
• gt20 BSA, apply dry sterile dressing for
  transport
• Do not overcool major burns or apply ice directly
  to burned areas

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Adult Burns - Thermal

• Partial or full thickness (2nd or 3rd degree)
• Wear sterile gloves and mask while burn areas are
  exposed
• Decreases additional risk of wound contamination
• Cover burn wound with dry sterile dressings
• Preventing air flow over exposed burn areas
  reduces pain levels
• EMS will place a clean sheet over the patient
• Protect the patient from hypothermia

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Infant differences back 13, each buttocks
2.5, each entire leg 14
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Case Study 1

• Adult patient reached over a charcoal grill just
  as the match was thrown onto the soaked coals
• Injury is restricted to the right forearm
• What type of burn is this?
• Using the Rule of Nines, what is the TSBA burned?
• What type of care is appropriate?
• How can the pain be managed?
• What does the documentation look like?

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Case Study 1 Patient with Burns
Skin is reddened and some blistering is present
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Case Study 1 Category III

• Combination of superficial and partial thickness
  burns approx 4.5 TSBA (circumferential around
  forearm)
• Evidence of redness with a blistered area
  although blister is broken
• Appropriate care includes cooling burn, applying
  sterile saline soaked dressing (lt20 TBSA)
• Additional helpful care
• Elevation of arm, removal of ring before fingers
  swell
• For pain control
• Morphine 2 mg slow IVP can repeat 2 mg in 2
  minutes up to 10 mg

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Chest Injuries Traumatic Arrest Category I
Trauma

• Begin CPR
• Transport to closest Trauma Center
• A hospital on by-pass must take a patient in life
  threatening condition if they are the closest
  appropriate hospital
• EMS to perform bilateral chest decompression
• Use common sense does the scene size up,
  evaluation of mechanism of injury and general
  impression indicate a potential chest wall injury?

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Chest Injuries Tension Pneumothorax Category
I Trauma

• History of injury to the chest wall
• On rare occasions can be spontaneous
• Diminished breath sounds
• Hyperresonance if percussion done
• Severe dyspnea
• Hyperinflation of chest
• Jugular vein distention
• Tachycardia
• Hypotension

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In-field Needle Decompression

• Landmarks anterior approach
• 2nd intercostal space in the midline of the
  clavicles
• Place prepared flutter valve needle over the top
  of the rib
• Avoids potential injury to vessels and nerves
  that run along the bottom of the rib

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Quick Way to Find 2nd ICS

• Feel for the top of the sternum
• Roll your finger tip to the anterior surface at
  the top of the sternum
• Feel the little bump near the top of the sternum
• This bump is the Angle of Louis
• From the Angle of Louis slide your fingers angled
  slightly downward toward the affected side
  following the rib space
• You are automatically in the 2nd ICS
• Identify the midline of the clavicle
• The midline is more lateral than persons realize
  and usually runs in line with the nipple

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Alternate Method to Find 2nd Intercostal Space

• Palpate the clavicle and find the midline
• The midline is farther out (more lateral) from
  the sternum than most persons realize
• Move your finger tips under the clavicle into the
  1st intercostal space
• 1st rib is under the clavicle and is not palpated
• Spaces identified for the numbered rib above the
  space
• Feel for the firm 2nd rib and palpate the soft
  space below the rib
• This is the 2nd ICS

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Field Equipment

• Long needle (preferably 2-3 inch) and large bore
  needle (preferably 12-14G)
• Flutter valve finger cut from a glove
• Cleanser to prepare skin overlying the site
• Method to secure needle in place
• Skin will most likely be diaphoretic
• Tape may not stick
• May need to maintain manual control of needle

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Skin Preparation
Midline of clavicle
2nd ICS
Angle of Louis
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Inserting the Needle

• Remove proximal end cap
  from needle if present
• Will be able to hear trapped air escaping
• Needle inserted over top of rib
• Once hiss of air heard continue to advance
  catheter while withdrawing stylet
• Stabilize catheter as best as possible
• Patient should symptomatically improve
• Do not expect to hear improved breath sounds
  takes time for the lung to reexpand

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Case Study 2

• EMS is called to the scene for a 52 year-old male
  with c/o sudden onset dyspnea with pain between
  his shoulder blades while watching TV at home.
  The patient is agitated, short of breath, with
  increased respiratory rate and SaO2 of 89.
• Further assessment reveals decreased breath
  sounds on the right and clear on the left
• Vital signs 98/62 HR 118 RR 32 and shallow
• Your impression intervention plan?

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Case Study 2

• Spontaneous tension pneumothorax
• They dont all develop from trauma
• Supplemental oxygen support via non-rebreather,
  cardiac monitor, preparation for IV
• BUT
• This patient needs needle decompression while the
  above are being prepared
• Patients with a tension pneumothorax cant wait
  and will deteriorate without needle decompression

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Sucking Chest Wound Category I Trauma

• Most common with penetrating wounds
• Free passage of air between the atmosphere and
  pleural space if the open wound is at least 2/3rd
  the size of the diameter of the trachea
• Size of trachea about the size of pts 5th finger
• Air is drawn into the chest cavity, not into the
  lungs
• Air replaces lung tissue
• Lung collapses

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Sucking Chest Wound

• Severe dyspnea
• Open chest wound
• Check anterior, posterior, axilla areas
• Frothy blood at wound opening
• Sucking sound as air moves in and out
• Tachycardia with hypovolemia

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Treatment Sucking Chest Wound

• Immediate treatment is to seal the opening
• May start by placing a gloved hand over the wound
• When able, place an occlusive dressing, taped on
  3 sides, over the wound
• Wound now converted to a closed pneumothorax
• Monitor for signs of tension pneumothorax
• May need to lift a corner of the dressing to
  release trapped air via burping dressing

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Flail Chest Category I Trauma

• 3 or more adjacent ribs broken in 2 or more
  places
• Segment becomes free with pardoxical chest wall
  motion during respirations
• Paradoxical movement more evident after the
  muscles splinting the flail segment fatigue
• Usually takes a tremendous amount of blunt trauma
  to cause a flail chest
• Associated severe underlying injury (ie
  pulmonary contusion) will often be present
• Respiratory volume reduced and respiratory effort
  increased

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Treatment Flail Chest

• Place patient on the injured side (may not be
  possible to do this in the field based on
  mechanism of injury)
• High flow oxygen non-rebreather mask
• Monitor for need to assist ventilations via BVM
  to deliver positive pressure ventilations
• Evidence of underlying pulmonary injury
• Effort and fatigue
• Pulse oximetry
• EKG monitoring
• Tremendous amount of force is delivered to the
  chest wall and cardiac injury is highly likely as
  a result

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Pericardial Tamponade Category I Trauma

• Blood or other fluid fills the pericardial sac
  restricting cardiac filling contractility
• Most often related to penetrating trauma
• Venous return to the heart is restricted
• Decreased cardiac output
• Pressure on the coronary arteries restricts blood
  flow to the myocardium

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Pericardial Tamponade Signs Symptoms

• Usually history of penetrating trauma
• Agitated patient
• Diminished strength of pulses (weak and thready)
  with tachycardia
• Narrowing pulse pressure
• Diastolic systolic numbers moving closer
  together
• Distended neck veins (JVD)
• Diaphoretic and pale
• Muffled, distant heart tones
• Hypotension

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Treatment Pericardial Tamponade

• Treatment in the field is limited to being
  supportive
• Patient requires high index of suspicion and/or
  rapid identification with rapid transport
• In ED will perform needle thoracentesis and then
  transfer the patient to the OR for open heart
  surgery

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General Assessment Pearls

• Restlessness and agitation
• You must consider ?hypoxia, ?shock, ?influence of
  alcohol and/or drugs
• This is one time you need to assess for all
  reasons of restlessness and not just stop when
  you discovered one cause there may be more than
  one pathology going on at a time

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Evaluation Pearls Low SaO2

• SaO2 reading may be inaccurate in the presence
  of
• Hemorrhagic shock with delayed capillary refill
• Hypothermia
• Lung damage
• Evaluate all parameters together to get the best
  overall picture in ventilated patient
• What does the ETCO2 indicate?
• Are you able to ventilate the patient?
• Are there extenuating circumstances where the
  circulation is affected and would affect the
  pulse ox reading like those listed above?

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More Case Studies
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Case Study 3

• Your 34 year-old patient received a GSW to the
  right upper abdomen.
• They are conscious and alert B/P 90/62 HR 120
  RR 28 bleeding is minimal
• Category trauma?
• What interventions are appropriate in field?

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Case Study 3 Category I Trauma

• Consider need for spinal immobilization
• During assessment of wound, consider thoracic
  injury in addition to abdominal injury depending
  on the angle of the GSW.
• Examine for an exit wound
• Check the back and the axilla
• Prepare for the worst assume the patient will
  deteriorate before ED arrival
• Repeat VS B/P 80/ HR 140 RR 32, remains
  conscious and in pain
• Category I is transported to the highest level
  Trauma Center within 25 minutes

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Case Study 3 - Treatment

• Routine trauma care
• Question is this an isolated abdominal wound or
  is it a combination abdominal/ chest wound?
• Need to treat patient for potential injuries of
  both body cavities
• EMS cannot determine in the field the angle of
  the trajectory
• Cover the wound and watch for evisceration
• Fluid resuscitation keep B/P at low levels the
  higher the B/P the faster the patient bleeds out

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Case Study 4

• A 10 year-old patient has a
  penetrating injury to
  the right leg near the knee
  while playing in his backyard
• Initial VS B/P 90/70 HR
  130 RR 32 no active
  bleeding
• Category trauma? Field interventions?

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Case Study 4 Category III

• Next VS B/P 92/64 HR 110 RR 20.
• Stabilize foreign body in place (gauze, trauma
  dressing)
• Obtain distal neurovascular status
• Distal pulses
• Movement can you wiggle your toes?
• Sensation close your eyes and tell me which
  toe I am touching
• Document distal neurovascular status and describe
  how the foreign object is stabilized in place

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Case Study 5

• Your 62 year-old patient had abdominal surgery 1
  week ago. Today at home he sneezed hard and felt
  a tearing
  sensation in his
  abdomen and
  called EMS.
• VS B/P 100/60
  HR 110 RR 24
• No active
  bleeding
• What
  interventions
  are appropriate
  in
  the field?

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Case Study 5 - Interventions

• Immediately cover the wound
• Need to minimize contamination
• Need to prevent more organs from protruding
• Need to prevent loss of fluids
• Place a saline moistened dressing over the
  exposed tissue
• Place dry gauze over the saline dressings
• Can place light manual control over the organs to
  prevent further evisceration especially during
  movement, coughing, sneezing, deep breaths

69
Case Study 6

• Your 45 year-old patient is a construction worker
  who was accidentally shot in the head with a nail
  gun
• Upon EMS arrival, the patient is awake, alert,
  talking (GCS 15)
• VS B/P 132/78 HR 96 RR 20 complains of a
  minor headache minimal bleeding at a few
  puncture wounds noted on the occipital area of
  the scalp (patient has thick hair).

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X-ray from EDNo deficitsnoted
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Case Study 6 - Treatment

• Consider any injury above the level of the
  clavicles to include a c-spine injury until
  proven otherwise and immobilize the patient
• Control bleeding
• The face and scalp have such a rich blood supply
  small wounds tend to bleed heavily
• Protect from further contamination
• The open wound may be in direct contact with the
  brain
• Document neurological evaluation to establish
  baseline for comparison (AVPU, GCS, movement)

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Case Study 7

• EMS was called to the scene for a 10 year-old
  female who has been run over by a bus
• As patient exited bus, she bent down to tie her
  shoe and was caught under the wheels of the bus
• EMS noted a large amount of avulsed tissue with
  bleeding from the left hip, left buttock, and
  left upper thigh area
• The patient is screaming in pain
• VS B/P 110/70 HR 110 RR 26 GCS 15
• What is your impression?
• What is your treatment plan?

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10 y/o run over by bus
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Case Study 7 Category I or II?

• General impression
• Category II minimally pedestrian run-over
• Category I trauma if unstable pelvis or 2 or
  more long bones (proximal bones) fractured or
  unstable vital signs
• Potential problems to consider address
• Massive hemorrhage control of hemorrhage
• Spinal injury
• Additional injuries
• Airway control
• Equipment to fit a 10 year-old
• Further wound contamination

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1 year F/U with skin grafts
76
Glasgow Coma Scale GSCReview and Practice

• Tool used to evaluate and monitor a patients
  condition
• Evaluates
• Best eye opening
• Best verbal response
• Best motor response
• Serves as an indicator/predictor of survival
• To be obtained on all EMS patients

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GCS

• Possible total score 3 (lowest) 15 (highest)
• Minor head injury patient scores 13 15
• Moderate head injury patient scores 9 12
• Severe head injury patient scores lt8
• Significant mortality risk

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GCS Pearls

• The change in the GCS is more important than the
  absolute score
• Check for associated injuries
• Manage a head injury as a multiple injured
  patient until other injuries ruled out
• Stabilize the neck for any head injury
• Dont assume the level of consciousness is
  altered just because of ETOH and/or drugs
• Is there an occult (hidden) injury present?
• Provide accurate, clear, detailed documentation

79
GCS Eye Opening 1-4 Points

• Spontaneous (4) eyes open may or may not focus
  
• To voice (3) prior to touching the patient,
  eyes will open to sounds around them
  calling/yelling to them to open eyes
• Often difficult to accurately assess due to EMS
  gaining immediate c-spine control so difficult at
  times to determine if patient responded to voice
  or touch (pain). Eyelid flutter to voice is 3
  points
• To pain (2) doesnt necessarily imply you must
  apply painful stimulus, could be just to touch
• Flutter of eyelids when touched is scored as 2
• None (1) eyes remain closed with no eyelid
  flutter or other eye movement eyes do not open

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Whats the Eye Opening Score?

• When the patient is asked to open their eyes,
  they refuse and actually close them tighter
• What is their eye opening?
• The score is 3 (dont open their eyes but there
  is eyelid movement to voice command)
• Later, if the patient is more cooperative and
  then open their eyes, their GCS will improve
• MAKE SENSE?

81
GCS Verbal Response 1-5 Points

• Oriented (5)
• Confused (4)
• Words may be appropriate to situation but pt does
  not respond to questions
• Inappropriate words (3)
• Words are spoken and understood but nonsensical
  to the situation (over there)
• Incomprehensible words (2)
• Includes mumbling, unintelligible speech,
  moaning, groaning
• None (1)

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Whats the Verbal Response Score?

• You have touched the patients injured arm and
  the patient yells stop, ow, dont youre hurting
  me
• The patient does not carry on any other
  conversation with you
• The comments were appropriate for the situation
  but the patient is not oriented nor are the words
  inappropriate.
• So by default this patient is scored a 4 for
  confused

83
GCS Motor Response 1-6 Points

• Obeys command (6)
• Localizes pain (5)
• Patient who pulls equipment off pushes your
  hands away purposeful movement
• This patient knows where the obnoxious stimuli is
  contacting his body
• Withdraws to pain (4)
• Pt cannot isolate where they feel the noxious
  stimuli so just pulls back/withdraws
• Flexion (3) arms bent towards midline when
  stimulated (decorticate)
• Extension (2) arms extended when stimulated
  (decerebrate)
• None (1) remains flaccid

84
Whats the Motor Response Score?

• This patient is constantly trying to pull off the
  cervical collar, take off the B/P cuff, and pull
  out the IV (you call this uncooperative)
• This patient is aware of what part of the body is
  feeling some noxious stimuli so they are trying
  to get rid of it/escape from it
• This is purposeful movement (the patient
  localizes the annoyance) and is scored 5

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GCS Pearls

• Give the patient the best score possible
• If the patient moves the right side of their body
  but no movement on their left, score them for the
  movement they currently exhibit on the right
• If patient deteriorates, easier to see the drop
  or change in the GCS score
• When testing for responses, watch even for
  minimal activity like eyelid flutter or a grimace

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GCS Pearls

• Acceptable noxious stimuli
• Armpit pinch or nailbed pressure
• Sternal rub, pinching web space between fingers,
  pinching shoulder muscle (trapezius)
• Earlobe pinch is out of favor
• Can cause movement of head neck in response to
  the pain

87
GCS and RTS Tools

• See end of document for full size print of the
  GCS and RTS forms
• This information is also on the radio run report
• The ECRN is to fill out a GCS score on every EMS
  call
• The ECRN calculates the RTS on every trauma
  patient

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RTS Scoring 0 12 points
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Practice GCS and RTS

• Calculate the scores for the next 6 cases
• Assign GCS (3 15 points)
• RTS
• Convert the raw GCS number to its respective
  score 0 4
• Add the converted GCS number to the points (0
  4) for the respiratory rate and systolic B/P
• Determine the RTS (0 12 points)

91
GCS RTS Practice 1

• Patient eyes are open and they watch you during
  the examination
• The patient is confused they dont remember how
  they got hurt and cant remember the day of the
  week
• When you ask the patient to show me 2 fingers,
  they respond but are slow to do so
• VS B/P 120/70 HR 88 RR 18
• Total GCS?
• Total RTS?

92
Practice 1

• Total GCS 14
• Eye opening 4 (spontaneous)
• Verbal response 4 (confused)
• Motor response 6 (follows commands)
• Converted GCS 4
• Respiratory rate 4
• Systolic B/P 4
• Total RTS - 12

93
GCS RTS Practice 2

• The patient does not open their eyes
• The patient groans when pinched or an injured
  body part is touched
• The patient does not follow commands and will
  push your hands away when you touch them
• VS B/P 96/68 HR 102 RR 22
• Total GCS?
• Total RTS?

94
Practice 2

• Total GCS - 8
• Eye opening 1 (none)
• Verbal response - 2 (groans)
• Motor response 5 (pushes you away)
• Converted GCS - 2
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 10

95
GCS RTS Practice 3

• The patients eyes are open
• When asked what month is this?, the patient
  responds, he, umm, hemy jacket. I dont ..
• If touched or pinched, the patient pulls away
  from the contact
• VS B/P 132/72 HR 96 RR 16
• Total GCS?
• Total RTS?

96
Practice 3

• Total GCS 11
• Eye opening 4 (spontaneous)
• Verbal response 3 (inappropriate words)
• Motor response 4 (pulls away/withdraws)
• Converted GCS -3
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 11

97
GCS RTS Practice 4

• Your patients eyes are closed but they open wide
  if the patients injury is touched
• The patient yells dont or stop when there
  are pinched but does not answer questions or
  speak in sentences
• The patient will push your hands away when you
  touch them or try to put on equipment
• VS B/P 108/64 HR 102 RR 18
• Total GCS?
• Total RTS?

98
Practice 4

• Total GCS - 11
• Eye opening 2 (opens when touched pain)
• Verbal response 4 (appropriate to being touched
  but doesnt carry on a conversation marked
  confusion)
• Motor response 5 (pushes you away)
• Converted GCS -3
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 11

99
GCS RTS Practice 5

• The patients eyes are closed but the eyelids
  flutter when you loudly call out their name
• The patient does not answer questions but will
  groan when touched but not say recognizable words
• The patient does not follow commands but will
  push away your hands when touched
• VS B/P 80/52 HR 112 RR 12
• Total GCS?
• Total RTS?

100
Practice 5

• Total GCS - 10
• Eye opening 3 (eyelids flutter to voice)
• Verbal response 2 (groans)
• Motor response 5 (pushes you away purposeful
  movement)
• Converted GCS - 3
• Respiratory rate - 4
• Systolic B/P - 3
• Total RTS - 10

101
GSC RTS Practice 6

• The patients eyes are closed but will open when
  the patient is touched
• The patient says leave me alone and what are
  you doing? and goes back to sleep. When eyes are
  open they respond I dont know to questions
• They do not follow command and will push your
  hands away when touched
• VS B/P 110/68 HR 88 RR 20
• Total GCS?
• Total RTS?

102
Practice 6

• Total GCS - 11
• Eye opening 2 (opens to touch pain)
• Verbal response 4 (appropriate to the situation
  but not oriented marked confusion)
• Motor response 5 (pushes you away)
• Converted GCS - 3
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 11

103
Practice Rhythm Strip Identification and ID of ST
elevation on 12 Lead

• Identify the lead II strip and think over the SOP
  treatment appropriate if the patient is
  symptomatic
• Identify the leads/location of the ST elevation
• At CMC check the bulletin board outside the EMS
  office for Cardiac Alert write-ups and more
  examples of ST elevation

104
Identify Rhythm Strip 1
105
Strip 1

• Second degree Type I Wenckebach
• PR interval gets longer, longer, longer and then
  there is a dropped QRS
• The PR interval resets and the cycle starts again
• Type I drops one
• Wenckebach winks at you
• Notice grouped beating (group and a space, group
  and a space)
• Patient usually not symptomatic

106
Treatment IF Symptomatic Bradycardia

• Bradycardia or Type I Wenckebach
• Atropine 0.5 mg rapid IVP (when theyre alive
  give 0.5)
• May repeat every 3-5 minutes to total of 3mg
• If ineffective, begin pacing
• Type II or 3rd degree heart block
• Begin TCP
• Valium 2 mg slow IVP for discomfort
• May repeat 2 mg IVP every 2 minutes to max 10 mg
• TCP set at rate 80/minute and start at lowest mA
• Watch for capture
• If TCP not effective, give Atropine 0.5 mg rapid
  IVP
• May repeat Atropine 0.5 mg every 3-5 minutes max
  3mg

107
Identify Rhythm Strip 2 6
second strip
108
Strip 2 - Sinus Rhythm

• No treatment necessary for this rhythm
• Treat the patients complaint
• IF ACS complaint, then ACS SOP
• Aspirin 324 mg chewed (faster absorption)
• Nitroglycerin 0.4 mg sl
• May repeat in 5 minutes watch B/P
• Screen for recent Viagra type drug usage
• Morphine if 2nd NTG dose not effective
• 2 mg slow IVP
• May repeat every 2 minutes to max 10 mg

109
Identify Rhythm Strip 3 6 second
strip
110
Strip 3 Atrial fibrillation

• A risk associated with atrial fibrillation is
  stroke
• Clots form and are stagnant in the atria
• Clots can break off and migrate into the
  circulation
• Important with new onset atrial fibrillation to
  determine how long they have been in it to guide
  therapies
• gt48 hours higher risk of throwing a clot if
  rhythm converted to sinus rhythm

111
EMS Treatment Rapid Atrial Fibrillation

• Symptoms most likely dependent on the heart rate
• The faster the heart rate, the less tolerable the
  rhythm is especially for elderly patients
• Stable patient with B/P gt100 mmHg
• Verapamil 5mg SLOW IVP over 2 minutes
• If no response in 15 minutes B/P stable, repeat
  5mg SLOW IVP over 2 minutes
• Unstable patient with B/P lt100 mmHg
• Contact Medical Control for direction

112
1 Identify ST Elevation
113
2 Identify ST elevation
114
3 Identify ST Elevation
115
ST Elevation Answer Key Evaluate the 3 12 Lead
EKG Examples at the end of the packet

• EKG 1 Leads V 1 - 4
• EKG 2 Leads V 2 - 5
• EKG 3 Leads II, III, aVF

116
Bibliography

• Bledsoe, B., Porter, R., Cherry, R. Paramedic
• Care Principles Practices 2nd Edition
  Brady.
• 2006.
• ITLS Bulletin. Case Study ITLS Patient ETCO2.
• June 2008.
• Region X SOPs Eff date March 1, 2007 Revised
  January
• 2008.
• www.chems.alaska.gov/ems/document/GCS
• www.merck.com
• www.swsahs.nsw.gov.au/