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7/29/2019 ECRN Mod II 2010 Penetrating Trauma
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Penetrating Trauma
ECRN Mod II 2010 CE
Condell Medical Center EMS System
IDPHSite code #107200E-1210
Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire District
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
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Objectives
Upon successful completion of this module, the ECRNwill be able:
Identify epidemiologic facts for firearm relatedinjuries
Identify relationship between kinetic energy andprediction of injury
Identify how energy is transmitted from apenetrating object to body tissue
Identify characteristics of handguns, shotguns andrifles
Identify organ injuries associated with gunshotinjuries
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Objectives contd
Identify management goals for a patient with gunshotwounds
Identify items that could cause stab/penetration
trauma Identify potential internal organ injuries dependant on
item causing stab/penetration injury
Identify management goals for a stab/penetrating
trauma patient
Identify adult fluid challenge issues
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Objectives contd
Identify adult fluid challenge dosages
Identify pediatric fluid challenge issues
Identify pediatric fluid challenge dosages
Identify indications for implementation ofintraosseous infusion
Calculate pediatric fluid challenge dosages
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Gunshots
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Gunshot Victims
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Firearm Related Injuries
Gunshot wounds are either penetrating or
perforating wounds
Technical terms:
Penetrating gunshots are when the bullet
enters, but does not come out of the body.
Perforating gunshots are when the bulletenters and exits the body
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Perforating Gunshots
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Penetrating gunshot
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Entrance wound
Surrounded by a
reddish-brown area
of abraded skin,
known as the
abrasion ring
Small amounts of
blood
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Mechanism of Energy Exchange
As bullet passes through tissue, it decelerates,
dissipating and transferring kinetic energy to
tissues
Cause of the injury is the kinetic energy
Velocity more important than mass in
determining how much damage is done
Small bullet at high speed will do more
damage than large bullet at slow speed
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Mechanism of Energy Exchange
High velocity High powered rifles; hunting rifles
Sniper rifles
Medium velocity Handguns, shotguns
Compound bows and arrows (higher energy released)
Low velocity Knives, arrows
Falling through plate glass window, stepping on
things, bits flung by lawnmower
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Medium & High Velocity
These items are usually propelled by
gunpowder or other explosive
Faster the object, the deeper the injury
Causes damage to the tissue it impacts
Creates a pressure wave which causes
damage frequently greater than the tissue
directly impacted
If bone is struck, bone shatters and multiple
bone fragments are dispersed
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Low velocity
Usually a result of items such as knives that
are propelled by a persons own power
Also includes objects inadvertently stepped on
Includes many objects a patient may be impaled
on
Damage usually limited to the area directly in
contact with the object
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Types of Firearms
Pistols
Revolver
Semi-Automatic
Shotguns Pump
Semi-Automatic
Rifles Bolt
Lever action
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Pistols Medium Velocity
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Shotguns Medium Velocity
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Rifles High Velocity
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Projectiles High Velocity
Rifle bullets are
designed to have
much greater
velocity thanshotgun bullets
Different size of
casing provides
more or lessgunpowder
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7 mm rifle shell High Velocity
Bonded design for deeppenetration and 90%+weight retention
Streamlined design
delivers ultra-flattrajectories
Devastating terminalperformance across awide velocity range
Unequaled accuracy andterminal performance forlong-range shots
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Projectiles Medium Velocity
Shotgun ammunitioncan be a variety of kinds
Slugs are one largebullet in the shell
Some shells containnumerous pellets ofvarious sizes
This can influencepatients injuries
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Shotgun Shell Medium Velocity
12 Gauge Shotgun Slug 12 Gauge Shotgun with #6 shot
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.38 caliber pistol ammunition
Controlled expansion to
1.5x its original
diameter over a wide
range of velocities Heavier jacket stands up
to the high pressures
and velocities of the
highest performancehandgun cartridges
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Compound Bows and Arrows
Medium Velocity
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Arrowhead Types Medium Velocity
Target tips Broadhead
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Arrow injuries
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Another ouch.
How would
you initiallystabilize
these
wounds?
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Principles of Wound Care
What are principles of wound care for the twoprevious wounds?
Scene safety even in the ED
Control bleeding
Usually little to no bleeding while object stillimpaled
Prevent further damage
Immobilize the object in placeGauze, tape, whatever it takes
Reduce infection
Prevent further contamination
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Different Types of Knives
Knives come in a wide
variety of shapes and
sizes
The type of knife caninfluence the injuries a
patient may have
Hilt/handle of knife
does not necessarily tell
how long the knife is
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Anticipation of Injury
Trajectory may or may not be straight
Knowing anatomy helps anticipate organinjury
Anticipating organ injury helps in knowingwhat signs and symptoms to watch for
Anticipation of injury = proactive care
Head wound = monitoring level of consciousness
Chest wound = assessing lung sounds
Abdominal wound = assessing internal blood loss
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Stabbings
15 year old stabbed in
the head at a London
bus stop
Cannot determine fromthe outer wound what
the damage is internally
Assume the worse
Stabilization of impaled
objects extremely
crucial
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Police Officer Stabbing
What injuries do you suspect?
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Organ Injury
Patient was shot
with a MAC-10
machine gun and
sustained a
liver injury
Lap sponge under fold of skin
Liver surface with injury noted to organ
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Scene Safety
Not exclusive to schools
Fort Hood, TX Shooting (2009)
Colorado Church Shootings (2007)
Queens, NY Wendys Shooting (2000)
Atlanta Day Trader Shooting (1999)
San Ysidro McDonalds Shooting (1984)
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Field Management Goals
Critical patients need rapid transport per SOP
Difficult to assess internal damage in the field
Stop any visible bleeding that could cause
hemorrhage hypovolemia
Address airway issues
Tension Pneumothoraxchest decompression
Suction to keep airway open
Intubate to secure the airway
Surgery is the answer to critical gunshots
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Field Management Goals
Focus on the basics
If there is a hole plug itIf there is bleeding stop it
If they cant breathe ventilate
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Region X
Field Triage Criteria For AssessingTrauma Patients
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Field Management Goals
Short on scene time! Under 10 minutes! Immediate life threatening issues addressed
Good BLS skills
ALS treatment while enroute to the hospital Report called as early as possible
Transport to Level 1 Hospital, if under 25
minutes Transport to closest hospital if Level I >25
minutes away
Helicopter considered in unique situations
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Patient Transport Decision From the
Field
Critical and Category I trauma patients
Transported to highest level Trauma Center
within 25 minutes
Aeromedical transport remains an optionespecially in lengthy extrication and
distance from the hospital
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Field Categorization of the Critical
Patient
Systolic B/P < 90 x2
Pediatric patient B/P < 80 x2
Blood pressure values taken at least twice and
5 minutes apart
These patients transported to highest level
Trauma Center within 25 minutes
Field Categorization of the Category I
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Field Categorization of the Category I
Trauma Patient Unstable vital signs
GCS < 10 or deteriorating mental status
Best eye opening 4 points max
Best verbal response 5 points max
Best motor response 6 points max
Respiratory rate 29
Revised trauma score < 11
Range 0-12
3 components added together
Converted GCS (3-15 score converted to 0-4 points)
0 - 4 points for respiratory rate
0 - 4 points for systolic blood pressure
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Field Categorization of the Category I
Trauma Patient
Anatomy of injury
Penetrating injuries to head, neck, torso, or groin
Combination trauma with burns > 20%
2 or more proximal long bone fractures Unstable pelvis
Flail chest
Limb paralysis &/or sensory deficits above wrist orankle
Open and depressed skull fractures
Amputation proximal to wrist or ankle
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Patient Transport Decision From the
Field Category II trauma patients
Transported to closest Trauma Center
These are stable patients with significant mechanism of injury
You know they are stable because of frequent reassessment
There is the potential for these patients to become unstable
Recognize that pediatric patients often pull you into false
sense of security (but so can adults)
Peds patients maintain homeostasis as long as possible
and when compensation fails, they deteriorate fast
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Field Categorization of the Category II
Trauma Patient
Mechanism of injury
Ejection from automobile
Death in same passenger compartment
Motorcycle crash >20 mph or with separation of
rider from bike
Rollover unrestrained
Falls > 20 feet Peds falls > 3x body length
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Category II Trauma Patient contd
Mechanism of injury contd
Pedestrian thrown or run over
Auto vs pedestrian / bicyclist with > 5 mph impact
Extrication > 20 minutes
High speed MVC
Speed > 40 mph
Intrusion > 12 inches Major deformity > 20 inches
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Category II Trauma Patient
Co-morbid factors
Age < 5 without car/booster seat
Bleeding disorders or on anticoagulants
Pregnancy > 24 weeks
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Category III Trauma Patient
All other patients presenting with traumatic injuries
Fractures
Sprains/strains
Burns Falls
Pain
Provide routine trauma care
Honor patients request for hospital choice asmuch as possible
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Field to Hospital Communication
EMS to call early; update as needed Gives time for hospital staff and resources to be
mobilized
The more critical the patient, most likely theshorter the report
Important details to be given
Head to toe picture needs to be painted Just as important to give tasks not completed
Intubation versus bagging
IV access obtained or not
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Abbreviated Radio Report
Department name, vehicle number and receivinghospital
EMS to state, this is an abbreviated report
Provide nature of situation and SOP being
followedAge and sex of patient
Chief complaint and brief history
Airway and vascular status
Current vital signs, GCS
Major interventions completed or beingattempted
ETA
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Fluid
Challenges
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Adult Fluid Challenge
Adult fluid replacement is in 200 ml
increments (replacement formula 20 ml/kg)
Storage issues
IV bags are usually in ambulance, in bays
Fluid eventually are at ambient temperatures
70 fluid into 98.60 body will cause core body
temperature to decrease
Hypothermia results
Cold patients become acidotic patients
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Adult Fluid Challenge
200 ml increments
Formula is 20 ml/kg
Example
200 # patient = 100 kg
100 kg x 20 ml/kg = 2000ml fluid challenge
Reassess your patient as you are passing the
200 ml mark Monitor breath sounds for fluid overload
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Adult Fluid Challenges
Vascular issues
Vessel damage results in extensive blood loss
EMS infuses Normal Saline
NS does not carry oxygen; NS solves volume issue
only
Volume deficit can be filled, but patient still in
distress due to lack of oxygen carrying capacity (ie:patient needs blood)
Goal should not be to get a 120/80 blood
pressure, rather to stabilize
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Adult Fluid Challenges
If your patients blood is becoming pink (ie:not red), they need more blood in the system!
EMS typically does not carry blood in the field
Important to accelerate transport to a facilitythat can add the blood and do the surgery torepair the underlying problem!!!
Good BLS skills are more important than ALSskills for these types of patients!
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Pediatric Fluid Challenges
Pediatric shock protocol EMS carries Normal Saline
Formula for fluid challenge is 20 ml per kg
Can be administered up to three times total or upto 60 ml per kg total
Smaller container (patient size) means less
fluid means less oxygen carrying capacity Example:
30# patient = 14 kg (30 2.2)
14 x 20ml/kg = 280 ml fluid challenge
Fl id Ch ll C l l ti P ti
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Fluid Challenge Calculation Practice
6 year old patient weighs 66 pounds 66 pounds = 30 kg
Fluid challenge of 30 kg x 20 ml = 600 ml each time
15 year old patient weighs 175 pounds
175 pounds = 80 kg
Fluid challenge of 80 x 20ml = 1600 ml fluid
25 year old patient weighs 120 pounds
Adult gets fluid challenge in 200 ml increments 75 year old patient weighs 180 pounds
Adult gets cautious fluid challenge in 200 ml increments
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Fluid Challenges
Precautions
All patients need to be monitored for potential
CHF
Even a previously healthy patient can be throwninto CHF
Too much fluid too fast
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Case Study #1
EMS dispatched for double shooting @ 0942
Ambulance enroute @ 0942
Ambulance staged @ 0947
Flight for Life notified @ 0952
Scene secured by police @ 1000
FFL in the air @ 1000 Patient contact made @1002
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Case Study #1
Ambulance enroute to landing zone @ 10:13
FFL on ground @ 10:15
FFL to Level I @ 10:23
.38 caliber revolver pistol used in the shooting
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Case Study #1
Patient #1
38 year-old female with multiple gun shot wounds
Found in the basement of the house
GSW to right hand (entry and exit)
GSW to right side of neck (entry) and lower right
ribcage (exit)
GSW to right forearm (entry and exit)
GSW to right humerus (entry and exit)
GSW to left hand (entry and exit)
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Case Study #1
Patient #1 contd
Approximately 2 liters of blood loss
Responding to verbal stimuli
Pupils: PERL
Lungs: left (clear), right (rhonchi), normal effort
Skin: Pale, dry, cool with delayed capillary refill
Past medical history, meds & allergies unknown
Unable to obtain B/P, femoral pulse @ 110
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Case Study #1
Respirations 22 with SPO2 of 94% on room air
SPO2 increased to 99% after oxygen @ 15 L via
NRB
ECG: Sinus tachycardia with rate of 110
Patient disoriented
GCS = 9; RTS = 10
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Case Study #1
Treatment plan:
Scene safety (field and in ED)
ABCs performed
Rapid transport with early communication to
receiving facility
Supplemental O2, IV enroute, monitor
Immobilization by c-collar, backboard & headimmobilizers
Patient needs to be exposed for evaluation of
multiple gunshot wounds
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Case Study #1
Bleeding controlled to entry & exit wounds
with trauma dressings
Oxygen administered at 15 L via NRB mask
IV of Normal Saline administered with 18 G in
left extremity, wide open rate
EMS crew monitored lung sounds and femoral
pulses throughout call
Patient transferred to FFL crew
CMC (as Medical Control) notified
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Case Study #1
Is this a Category I or II trauma patient and
why?
Systolic B/P below 90
GCS less than 10
RTS less than 11
Penetrating injuries to head, neck, torso or groin
Category I trauma patient
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EZ IO
Have you used one on a
patient or cared for a
patient with one?
High risk, low volumeprocedure
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EZ IO
Field indications
Must meet all indications
Shock, arrest, or impending
arrest
Unconscious/unresponsive
to verbal stimuli
2 unsuccessful IV attemptsor 90 seconds duration
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EZ IO Contraindications
Fracture of the tibia or femur
Infection at insertion site
Previous orthopedic procedure (knee
replacement, previous IO insertion within 480
) Pre-existing medical condition (tumor near site,
peripheral vascular disease)
Inability to locate landmarks (significant edema)
Excessive tissue at insertion site (morbid obesity)
Hold leg up off bed to allow excess tissue to falldependently
EZ IO Equipment
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EZ IO Equipment Lithium drill
Battery powered for 1000 insertions
Needle Blue needle 25 mm (1) 15 G for patients over 88 pounds
(40kg)
Pink needle 15 mm (5/8) 15G for patients between 7 and
88 pounds (3kg 40kg) EZ connect tubing
Syringe
Saline to prime EZ connect tubing
Primed IV bag Pressure bag/B/P cuff
Site prep material (ie: alcohol pad)
Equipment Case
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Equipment Case
Needle sizes used in Region X
EZ connect tubing
10 ml syringewith saline
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EZ IO Procedure
Prime EZ connect tubing with saline; leave syringeattached (for flushing)
Locate and cleanse site
Proximal medial tibia
Prepare driver and needle set; remove safety cap
Insert needle at 900 angle
Remove stylet
Attach primed EZ connect tubing Aspirate then flush line with remaining saline
Remove syringe only and connect primed IV set
Confirm needle placement
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Identifying
Site
Proximal medial tibia
2 finger breadths below patella (to tibial
tuberosity) and 1 finger breadth medially from
tibial tuberosity
May or may not be able to identify the tibial
tuberosity at 2 finger breadths below patella As patient is lying supine, legs tend to roll slightly
outward
This presents the flat surface of the tibia
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EZ IO Sites
Proximal medial tibia Site approved for Region X EMS personnel
FYI - Additional sites available
Humeral Ankle
Other EMS regions may use these additionalsites
These additional sites may be accessed by MDinserting IO needle
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Confirming EZ IO Placement
Sudden lack of resistancefelt
Needle stands up by self
Bone marrow may benoted on aspiration
No resistance to flushing
IV runs with pressureapplied to IV bag
No infiltration noted
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Documentation OF EZ IO Insertion
Document usual IV insertion information Time of insertion
Size IV bag used
Site, needle length, needle gauge
Amount of fluid infused in the field
Place fluorescent yellow arm band on patients wristto indicate insertion (or attempt) of IO
Recommended to place on same side as insertion
site Arm band used for successful and unsuccessful
insertions
Saline Lock/Extension Tubing
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Saline Lock/Extension Tubing
Field indication
To establish an extension line between the IV catheter and
the IV tubing
Allows hospital staff to change IV tubing with less disturbance to
the inserted IV catheter
To have access to circulation without the need for fluids
Equipment
IV start pak
IV catheter
Macrobore extension set (7.25 inches)
10 ml saline in syringe for priming tubing and flushing
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Routine medical care SOP states:
Establish 0.9 normal saline (NS) per IV/IO and
adjust flow as indicated by the patients condition
and age May use a saline lock cap on
IV catheter hub for stable
patients (not needing fluid
resuscitation)
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Region X SOP - Saline Lock
Saline Lock Procedure
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Saline Lock Procedure
Establish an IV following sterile technique
Remove stylet
Insert distal tip of primed extension tubing/ salinelock into IV catheter
If administering fluids, IV tubing should be alreadyattached to the extension tubing/saline lock
Adjust flow rate
If IV line is precautionary, flush extensiontubing/saline lock with 10 ml sterile normal saline
Remove syringe
Do not need IV tubing or IV bag
b / l k
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Extension Tubing/Saline Lock
Connecting to IV catheter Keep IV site as distal as possible
AC should not be your first choice
We are requesting to start getting into habit ofadding this extension tubing to all IV starts
IV Equipment for Saline Lock
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IV Equipment for Saline Lock
If patient needs fluid, attach primed IV tubing with bag to
proximal end of extension tubing/saline lock
Wipe off blue clave port with alcohol prep pad
Push in and twist primed IV tubing to connect
Adjust flow rate as indicated
Document time, type, and size IV solution hung
Distal tip of clave inserted into IV catheter
i bi / li k l
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Extension tubing/Saline Lock In Place
Extension tubing/saline lock properly secured
Insertion site not taped over
Clear view of insertion site through op-site/tegaderm
dressing Access to port available
Can easily attach primed
IV tubing if need to beginfluid therapy
I l S d IV Si
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Improperly Secured IV Site
Insertion site taped over
Gauze bandaging under tape
Increased risk of infection
IV site properly covered with see
through dressing
E i f M di i
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Extravasation of Medication
To use the extension tubing/saline lock forinfusion, must verify that the line is patent
Aspirate for blood return
Stop infusion if patient complains of pain/burning
Extravasation of IVPmedication resulting in
amputation of several fingers.Patient c/o pain during IVPand medication deliveringcontinued anyway.
C St d #2
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Case Study #2
25 year-old male shot in the chest
Police are on the scene
Patient sitting on ground, leaning against car
Several small casings on ground near victim
Patient bleeding from small chest wound left
anterior chest
Patient is anxious, pale, diaphoretic with
elevated respiratory rate
C St d #2
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Case Study #2
Patient alert and oriented x3
Complains of mild chest pain aggravated with
deep breathing
VS: 122/86, 90 20
Hole noted in the left anterior chest about the
3rd intercostal space
No air seems to be moving throughthe hole
C St d #2
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Case Study #2
Interventions required
Immediately seal the open wounds
Dressing secured on 3 sides
High flow oxygen administered via non-rebreather
IV access established
Contact Medical Control
What Category trauma is this patient?Category I penetration of torso
C St d #3
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Case Study #3
911 call to scene for a domestic incident Upon arrival, summoned to the back yard for a 23
year-old female patient lying on the groundconscious and awake
Patient states she was running out of the house andtripped down the stairs
Tree branch noted impaled through right flank atlevel of umbilicus
VS: 124/100; 120; 22; SpO2 98%; warm & dry
No active bleeding
C St d #3
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Case Study #3
What injuries do youanticipate knowing
entry point and angle
of impalement?
C St d #3
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Case Study #3
Initial assessmentperformedto identify life threats
Airway open
Breathing without distress although patientis upset
Circulation warm & dry; capillary refill 1 seconds; pulse steady and palpable at the
radial site
Disability & disrobe
AVPU awake, cooperative, anxious
C St d #3
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Case Study #3
Categorization?
Category I penetrating object to torso
Interventions
Secure impaled object, prevent further movement
Manual control initially
Gauze padding around entrance site
Assess for exit wound
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Case Study #3
What internal injury is anticipated? Abdominal
Solid organ bleeding
Hollow organ spilling contents causing
contamination Punctured vessels hemorrhage
Chest
Punctured diaphragm
Punctured lung
Punctured heart
Punctured vessels
Case Study #3 Follow up
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Case Study #3 Follow-up
Patient taken to OR
Stabilization maintained to prevent movement
of impaled object
Tree branch removed under direct
visualization
Abdominal cavity cleaned and flushed
Patient did well and was discharged 5 days
post-op
Case Study #4
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y
EMS responded to a call at a tavern for a personshot
Upon arrival, the patient lying on their right
side, blood noted under their head Patient is breathing, radial pulse is palpable
They do not open their eyes; the patient moans
when touched; the patient withdraws What is first things first?
SAFETY, SAFETY, SAFETY
Case Study #4
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Case Study #4
Need to log roll patientprotecting C-spine
Maintain clear airway
GCS Eye opening 1
Verbal response 2
Motor response 4
Total GCS - 7
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Case Study #4
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y
Report from EMS
Description of wound(s) noted including body
region
Type of weapon used if information is available
Distance from weapon if available
Closer the range, the more energy that is
behind the bullet/shot the greater the internal
damage
Note basic care provided (IV, O2, monitor)
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Case Study #5
A patient presents as a walk-in to your facility
Approximately 2 hours ago, he was involved in
a domestic disturbance
Patient states his girlfriend hit him in the
upper chest and he continues to have some
pain and is now worried regarding the injury
Awake and alert, vital signs stable
Dried blood noted on upper chest wall midline
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y You cant assess what you cant see remove
clothing
What injuries do you anticipate? Heart, lung, vessels
Trachea
Esophagus
Visible wound
Object viewed on x-ray
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Case Study #5 Operative View
Impaled object after removal
Was near pulmonary artery but no damage
Knife missed all vital structures
Case Closure
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Case Closure
What saves lives when impaled/penetratingobjects are involved?
Age and condition of patient
Younger patients and those in good health cantolerate the insult better
Rapid identification and transport from thefield
Proper stabilization of the object to preventfurther damage by movement
Rapid OR for direct visualization and repair
Bibliography
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Bibliography
Hoover, C. Fluid Resuscitation Controversies. EMSMagazine. March 2010.
Proehl, J. Emergency Nursing Procedures, 4th Edition.Saunders. 2009.
Region X SOP March 2007; amended January 1, 2008.
Smith, M. Lecture. Working Together EMS Conference2010.
Wauconda Fire Department call records
Olliver.family.gen.nz/launchpad/Head_wound.png
www.cabelas.com
www.jems.com
Bibliography contd
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Bibliography cont d
www.remington.com www.vidacare.com
www.Wikipedia.org
www.winchester.com
http://www.vidacare.com/http://www.vidacare.com/