Cleveland Clinic Prostate Cancer

[music playing] hi, my name kim krueger, andi'm a nurse and paramedic. and today i'm going to betalking about trauma and blood administration and burns. so why don't we get started? trauma poses a verysignificant threat to life. and it's important for us asproviders to identify injuries and transporting patientsto appropriate trauma centers for definitive care.

you can have minor injuries,you can have major injuries. we need to make theright decisions for that. and again, we have to identifythese life threatening illnesses andinjuries because it will improve patient outcomes. prehospital, we're talkingabout scene safety, rapid mobilizationand stabilization, and then transportingto the proper facility. and so we need to make thedetermination on scene,

is this an als transportor a bls transport? and if we were transferringpatients from another facility we have to make sure thatwe transport lab results, ct scans, x-rays, andpaperwork for the patient. when we talk aboutmorbidity and mortality, basically we're talkingabout disability and death. morbidity refers to nonfatalinjuries and disability, and mortality refers todeaths caused by injury and or disease.

for our pediatric population,the leading cause of death is in fact trauma. and also one of our rules istrying to prevent a trauma and providing qualitycare to our patients. and another importantthing we need to do is prevent anysecondary injuries so that the patientdoesn't have a bad outcome. we should all be familiar withthe different laws of newton. they give us some idea onwhat maybe the severe impact

is for the patients thatwe are dealing with, whether medical or trauma. different types oftrauma, we basically have the bluntinjuries and then we have the penetrating injuries. in some ways, blunt injuriesare more devastating or dangerous for thepatient than penetrating, because if somebody has a holein their chest, you can see it. it gets everybody's attention.

whereas blunt injuries tend bevery subtle and be very hidden, and we may not notice them ifwe're not paying attention. now we havedeceleration injuries. common cause of thisis automobile accidents and motorcycleaccidents or patients that have fallenfrom a great height. and things thathappen here is there are shearing injuries thattake place within the body. there's avulsinginjuries and then

there's rupturing injuries. the external forceinjuries, there's external forces that areviolating body tissues. and these are the gunshotwounds, stabbings, any type of projectiles,say, like in explosions. and the injuryand the severity's going to depend on whereexactly in the body the injury's taken place, themass behind the projectiles or the wounds, thebullets, and what's

the velocity ofthe foreign object. number of things that we needto look at determining who is going to require care ata level i or level ii trauma center, and theseare listed here. ejection from anautomobile is extremely dangerous for our patients. if we have a patient whois looking fairly good but somebody in the vehicle thatwas with them is dead we need to ask ourselves,why isn't this person

dead or also severely injured? then there are pedestrians. that's always a greatrisk because you have a lot of mass and forcethat is impacting these people. and anytime you haveintrusions into the compartment of the vehicle, that shouldbe a red flag for us, and if there's greatdeformity to the vehicle. rollovers areextremely dangerous because we have noidea what in fact has

gone on with thatpatient, as opposed to a patient that isrestrained in the vehicle. so triage, startedby a french person. i forget the name at this time. but basically you want to do thegreatest good for the greatest number of patients that we have. and there's a number ofdifferent triage systems out there. there's the salt triage,there's the start triage,

and some othersthat are out there. and we basicallyhave four categories. the immediate or red impactsthe airway, breathing, and circulation. head trauma, patientsthat are in shock. if we don't intervene, theymay in fact end up dying. then there's yellow. they're serious, butthey're stable at this time. often orthopedicand back injuries.

our minimal patientsare green patients or could be consideredthe walking wounded. and then expectant arethe black patients. they're the ones that aregoing to die no matter what we do based on theresources that we have. and so we need to havesome type of triage system so that we can providethe best care for the most amount of patients. we need to remember thatjust because a patient is

green or yellowinitially doesn't mean that they can'tchange to the red category. so the book that we're usingtalks about the start triage. and it's simple triage and rapidtransport, the acronym for it there. and we're looking at thewalking wounded again. we're looking at thenon walking patients. and then we go down to thehuman hemodynamic status of our patients.

and then we look atthe neuro status. and there's also ajumpstart triage, and this is for pediatricpatients or patients that are less than 100 pounds. and this is just a slide thatshows you the different steps in the triage system forthe start triage, the steps that we go through todetermine which category we're going to placeour patients in. and then this is just a slideshowing the jumpstart triage

for our pediatric patients andthe stages that they go through and what we're goingto do for them. this is generally used forpatients or children that are younger than eightyears and again, they weigh less than 100 pounds. and it's similar to thestart triage in many ways. difference is youinclude in this that there's an immediatepulse check of our nonbreathing patients, ourpediatric patients.

and these are labeled as blackif there's no pulse found. then you open the airwaywith manual maneuver for a patient that doesin fact have a pulse, but is not breathing. also looking at therate of respirations and then what the hemodynamicstatus of this patient is. there's trauma scoring systems,which are used both prehospital and in the hospital togive us some clue about how severely injured ourpatient might be.

there's a glasgow coma scalethat we are all familiar with. i like the acronymextra value meal, $4.65. that's a nice down anddirty way of remembering what exactly is in theglasgow coma scale. we're looking at thelevel of consciousness. we're going through the eyeopening, the verbal response and the motor response. and then we've got our score. highest is 15 andthe lowest is three.

and the old standardis, of less than eight, intubate, which is sometimestrue and sometimes not. we have to look at thepatient clinically. can also be usedto look at patients that have medicalconditions such as drug overdoses, metabolicdisorders, things like that. then the trauma score. that is basically apredictor of the likelihood of patient survival.

and this is the glasgowcoma scale again here. and that score ranges fromone to 16 with a score 16 being the best. and there you're lookingat the glasgow coma scale, the respiratory rate,the respiratory expansion, systolic blood pressure,and cap refill. what it doesn't do isit doesn't accurately predict survivability inpatients with severe head injuries, however.

so we need to remember that. so again, here's aglasgow coma scale and then here's atrauma scoring system. so a glasgow coma scaleis a little simpler. this trauma scoring system hereis a little more complicated. but they both have their placesin care of our trauma patients. then we have therevised trauma score, and this is used to determinethe severity of the injury. and what it's lookingat, it's looking

at the respiratory rate,the systolic blood pressure, and the glasgow coma scale. and the numbers areanywhere from 0 to 13. the worse off thepatient is, the lower the score they're going to have. and this is reallypretty impractical in the prehospital environments. it's used more efficientlyin the hospital. it doesn't readily identifythe small percentage

of severely injuredtrauma patients, however, who's vital signsat that time don't accurately reflect or representtheir actual condition. so we have to beworried about that. many times our patientshave compensatory mechanisms that are maintainingtheir vital signs, our patients that are inearly stages of shock. and so basically it comes downto our clinical assessment of the patient using our brainsand our assessment skills

that we've developedover the years. and then you've got theabbreviated injury scale. and this was designed to providea reasonably accurate means of ranking theseverity of injuries. and it looks at sixdifferent body regions and then it gives usan individual score to each of these injuries. and what they'relooking at is they're looking at the head, theneck, the thorax, the abdomen,

and the spine, andthe extremities. and that's got ascale of one to six. minor injuries wouldbe a number one, with injuries thatare unsurvivable have a score of six. and this looks onlyat a specific injury. it doesn't look atmultiple injuries or multi-system injuriesof our patients. and here's what therevised trauma score

would look like if youin fact would use that. again, this is morehelpful in the hospital. then we have the injury severityscore, another trauma scoring system. and this is ananatomic scoring system that provides sort of anoverall score for patients with multiple injuries. and it quantifies thesemultiple system injuries with the use of this score.

and the number for the scoreis anywhere from one to 75 with one is a minor injuryand 75 having a high mortality rate. again, not useful prehospital. patients with an injurysurvival severity score of greaterthan 15 are generally considered to havemajor trauma, and they require immediateattention and need to be transferred to alevel i trauma facility.

this is often used in the traumaregistry for data collection and research purposes. and then we have the traumainjury severity score, and this calculatessurvival probability of our criticallyinjured or ill patients. and this uses the issand revised trauma score, plus it looks atthe patient's age. and again, not really usedin the transport setting. generally when you'retalking about age

of the patients,generally the elderly, the older patientstend not to do as well with the same injuries thata younger patient might have. and this is what thetrauma scoring system would look like forthe iss, the things that they're goingto be looking at. so we have differentlevels of trauma care from level i to level iv. level i has thegreatest resources

and then it works its way down. so level is, they'reregional centers. a lot of times they'reuniversity settings. they're generallyin larger cities or heavily populated areas. and they have to becapable of providing every aspect of traumacare from prevention through rehabilitation. then you have levelii facilities,

generally less populated areas. they're expected to provideinitial definitive care regardless of injury's severity. so they have a lot of the sameresources that the level is do. they may be academicinstitutions or they could be public,private community facilities. their care is somewhatless comprehensive of level i trauma centers. level i trauma centersneed to do research,

whereas level iisdon't necessarily have to do research. moving down to level iii. these are basically for themost part community centers. and these are areas thatdon't have level i or level ii facilities. they assess a patient,they resuscitate them, provide emergencycare and stabilization until they can be transferredto a higher level of care.

then they haveprotocols in place that would helpthem to determine who needs to go toa higher facility. and then you have leveliv facilities generally found in more remoteareas, outlying areas where there's a higher level of care. and they provide advancedtrauma life support prior to transfer to thehigher level facility. this could be a clinic, urgentcare facility, or a smaller

hospital. initially all of these levels,no matter what they are, are expected to provide thesame high quality care initially for the patient. again, doesn't dependon their classification. and trauma centersare categorized as either adult trauma centersor pediatric trauma centers. they don't necessarilyhave to be both. pediatric traumacenters are less

common than the adult levels. and this is just a slide thatshows different levels of care that's provided inlevel ii trauma centers. and they go through thepatient characteristics or their conditions orinjuries that they have, what the mechanismof the injury is. and then from there theytake care of the patient or decide to transferthe patient out. and this is set up by theamerican college of surgeons.

so we have our general commonmanagement for patient. and we're speakingof patients that are very ill and inneed of close assessment or severely injured. and like any of ourseverely injured patients, we're focused on the airway,breathing, and circulation, our abcs. and any hospital thata patient would go to, the management is based on theadvanced trauma life support

guidelines through theamerican college of surgeons. again, immediate attentionis directed to the abcs because that's what is goingto kill a patient the quickest. and when we're talking aboutendotracheal tube placement airway management, whatare the best sounds? what are the end-title co2? we're looking at thecardiovascular status and trauma resuscitationfor the patient. we need to get as much medicalinformation, medical history

as you can from thepatient or the staff. and then we needto remember that we need to do repeated assessmentshead to toe, focused assessments based on whatour assessment shows us about the patient. because by repeatedassessments we can decrease the possibilityof missed injuries. and this is oftenvery important when we talk about ourmulti-system trauma

patients as opposed to apatient that has one injury. but one injury can have badconsequences for our patients. hypothermia is never goodfor our trauma patients. if you go on many of the traumacenters and their trauma room, it is a lot warmer than therest of the emergency department or trauma area. because again, like isaid, trauma patients don't do well ifthey're hypothermic. and we need toremember this when

we're talking about the patientsthat we find in a cold weather environment, when we exposethem when we're doing our exam. and so we need to bevery aware of that. also have to beaware of the injury in these cold environments andthe treatment that we provide. some of our patients need a lotof fluid for their crystalloids or blood, and we need toremember to try and provide them with warm fluids. because again,cold fluids can add

to the bad outcomesof our patients. by monitoring ourpatients we can reduce morbidity andmortality a lot of times. with hypothermia if we don'tmanage that as best we can, the mortality ratescan approach 100%. if we are transportingpatients from one facility to the next facility,it's really important that we bring any imagingwith us to the hospital that we're going tobe taking them to.

it helps, if you're goingto be on a transport, you need to havesome understanding of what we're looking for. with the standard x-rays,with the ct scans, it can help usmanage the patient. it can give us heads up onwhat we need to be looking for based on the x-raysand the ct scans, confirms placementof our et tube along with our end-title co2.

if there's any invasivelines that are put in we can see that. so our standard x-rays, that'susually what's done first. they provide limitedinformation for us, but it can be veryhelpful information. when we're lookingon the x-rays, we're looking for structureand landmark verification. you can see injuries likea tension pneumothorax, cardiac tamponade.

we can look at symmetryof these structures. we can find any foreign objectthat might be in the person. then there'scomputed tomography. cat scans can showus head bleeds, bleeding internally in the body. sometimes complexfactors which may not show up on a standardx-ray are going to show up on the ct scans. and typically these are usedfor scanning heads, the c-spine,

chest, abdominal-pelvic regions. then you have the mris. some hospitals havethis, some don't. what's nice now is a lot ofthese radiographic studies are now put on cds,so it's a lot easier to carry and transport. mris, generally limited usein our major trauma patients based on the time factorof doing these procedures. so it's more likely theyhave x-rays and ct scans.

there's a fast ultrasonography. it stands for focus assessmentwith sonography for trauma. and this is directedat identifying the presence of freeintraperitoneal or pericardial fluids. generally performed inthe emergency department or the trauma room. it many times has replaced thediagnostic peritoneal lavage, dpl, though that is still done.

it's decreased theneed for a laparotomy because it's going to give thema heads up about what is maybe going on with the patient,what they need to do. do we need to go to theoperating room right away, or can we just assessthis patient and we don't have to rush off tothe operating room? some prehospitalsystems have adopted this in theirsystems prehospital. and it's showingpromise identifying

early identification, again, ofabdominal bleeding and trauma, and looking at differentareas of the abdomen, also looking at differentareas of the chest. there's also intra-abdominalpressure monitoring, iap. the abdomen can haveintra-abdominal hypertension, which leads to abdominalcompartment syndrome. and normally when i thinkof compartment syndrome, i think of the extremities. but this can also takeplace in the abdomen.

and if this isn't takencare of, the person can die. acs can lead to end organdamage and multi-system organ failure during criticalillnesses and injuries that our patientsare undergoing. there's a variety of differentdevices that is used for this. these are the different typesof the abdominal compartment syndrome. you've got theprimary, and this is where you're going to needsurgical interventions

to manage this. secondary, thisis something that happens outside the abdomen. so say sepsis or burns canlead to abdominal problems. and then recurrent. this is abdominalcompartment syndrome that was initially successfullymanaged and then now develops. it's like a secondarytype of injury. and so by monitoring thisthey can prevent complications

from setting in a lot of times. and so i think it's reallyimportant for the cctps to maintain someproficiency in interpreting these images in collaborationwith the physicians that are going to be taking thereport from for transferring these patients. and we need to, again,remember that we need to ask for the copies ofall these imaging and results. all right.

let's start going downto specific injuries in the different body systems. so we're going tostart with the thorax. hundreds of thousands ofpeople are seen every year in the emergency departmentfor thoracic trauma and there's over18,000 deaths per year. studies have shown thatone in four trauma deaths are directly relatedto thoracic injuries. as we're aware of, and as youcan see in some of the organs

here in the chest, there'sa lot of important things that are locatedin their thorax. we've got the ribs that canget fractured and create underlying damage. the sternum can be injured. we've got the lungs,we've got the mediastinim. we've got our heart,we have subclavian. we have the aorta. there's a lot of thingsthat can be severely injured

based on what is goingon with our patient. we also have the diaphragm. the diaphragm can bedamaged and create problems both abdominally andin the thoracic cavity. and our big concern hereis our vascular system. again, the aorta,subclavian vessels. the heart can run into problemswith rupturing hole and holes. we also have to worry aboutthe oxygenation and ventilation that can be impacted by eitherblunt or penetrating trauma

in the thorax. majority of thechest, thoracic trauma involves the chest wall,chest injuries there. and we have to rememberthat the reason we're able to ventilate and breatheis because we have our pressure gradient. and if there's a tear in thechest cavity, the chest wall, that's going to impact that. the things that we'relooking for in the chest

and that can happento our patients is we can havesimple pneumothorax, we can have anopen pneumothorax. there's a tension pneumothorax. we can also have flail chest. hemothorax. we can havetrachiobronchial injuries, and we can also havepulmonary contusions. and so we need to be preparedfor that and assess it.

you have to be like detectives. so we'll start withthe open pneumothorax. in class they call ita sucking chest wound. you can sometimes heara sucking as a person is breathing in or out. and so again, we canhave open pneumothorax, we can have closed pneumothorax. then we have thesimple pneumothorax, and simple pneumothorax isoftentimes difficult to find,

especially prehospitalwhere it's noisy. you may not pick up that there'sa pneurmothorax because it's a simple one and it hasn'timpacted the patient yet. sometimes in the trauma center,the emergency department, it's not picked up until theyactually get a chest x-ray, depending on the size of it. a tension pneumothorax isgoing to kill fairly rapidly. it's basically pushingthe organs in the chest over to one side, andit needs to be treated

fairly rapidly ifwe want to have an improvement in our patient. it amazes me, allthe chest x-rays that you can find online thatshow a tension pneumothorax. a tension pneumothoraxshould hopefully be found on aclinical assessment. the big thing withpneumothorax, besides the cardiovascular effects,is that the patient's going to get hypoxic.

here's an open pneumothorax. the air is going in and out. and again, you've gotthat sucking wound. and the treatmentfor this is we're going to put anocclusive dressing on. initially we can use ourgloved hand to do that. and then as soon aswe have a chance, we can get our occlusivedressing and then tape on three sides.

so that prevents atension hopefully pneumothorax from developing. and it can also lift up thedressing to let air out. a big complaint on ourpatients for an isolated open pneumothorax is goingto be complaining of difficulty breathing. again, you've got thatsucking chest wound. you've got thatpenetrating trauma. they're going to be tachypneic.

we need to make surewith any patient that we maintain an openairway, high flow oxygen. and like i said, immediatelyput your gloved hand on there initially and then get thatocclusive dressing on there. and then by tapingon three sides, it works somewhat likea flutter veil, and then large [inaudible]ivs for this patient. oftentimes there's other seriousinjuries that take place along with the open pneumothorax.

and again, we're monitoringthe vital signs, the patient's mentation, their ecg andthe oxygen saturation. if they're intubatedwe're going to be monitoring their end-title co2. and we need to specificallyprepare and assess and watch for the development ofa tension pneumothorax, because they may needneedle decompression. chest tube may needto be inserted. and that's one ofthe things you need

to discuss with the physicianat the hospital that's sending the patient out if thisis a transfer, whether or not a chest tube should beput in before you actually transport the patient. and if a chest tubeis in place, you need to make sure that youmonitor if it's working and if there's any bloodthat's developing in there. so here they're oxygenatingthe patient, high flow oxygen. initially putting agloved hand on the chest,

and then getting the occlusivedressing and taping it on three sides. the open pneumothorax,again, you may need to needle the chest. but again, you're goingto need a large bore iv. i prefer having two in there. and then, like i mentioned,monitoring the vital signs, the o2 sat, cardiac monitor,and watching for development of a tensionpneumothorax, because that

will kill the patient. this is a simple pneumothorax. again, i've put arrows in there. if you look carefully on theright side, on the left chest, there's a definite line. again, if you're notpaying good attention when you're looking atthis, you could miss that. so you need to make sure thatyou look at it very carefully if they do have any x-rays,so you can see what's going on

in there and collaboratewith the physician who's going to be sendingthis patient out. again, depending onthe size, a patient may not have manysigns or symptoms, but it can develop intoa tension pneumothorax. this is often associatedwith our trauma patients with rib fractures because theyget driven into the lung, which creates thecollapsed lung there. may lead to spontaneous pneumo.

so here's ourtension pneumothorax. in this case it'son the left side. the lung is collapsed. and every time the patientbreaths in, some of that air's going to leak out intothe chest cavity creating more and more pressure, andeventually in this case, everything's goingto be pushed over to the right side of the chest. this is life threatening.

if we don't manage this witha chest tube or a needle decompression, theperson will die. and again, we need to rememberthat a simple pneumothorax could lead to atension pneumothorax, or if we have an openpneumothorax, the pressure can build up, can alsodevelop into a tension. so our patients goingto, if they're conscious, going to be very anxious. they'll be having dyspneayou'll be seeing jbd on patients

whether they'reconscious, unconscious. they're breathing fast. they will developtracheal deviation. and tracheal deviationis often hard to see. what is more helpful isif you take your fingers and start at thetop of the trachea and just follow the tracheadown with your fingers. you're more likely to feelthe trachea moving to one side because the upper tracheais pretty well anchored,

whereas the lower trachea isn't. and so you're not goingto necessarily see the lower trachea orits starting angle. so i found it helpfulto take my two fingers and just followthe trachea down. and we also see sometracheal tugging as a patient breathes in. if they're intubatedwho's ever ventilating them may notice you'regetting some resistance when

you squeeze that bag. and so there's more pressureto ventilate this person. or if they're on aventilator you're going to have high ventilator,high pressure alarms that are going off on the alarms. you'll have absent orgreatly diminished breath sounds in the affected sides. there's also somethingthat you may feel. it's called pulsus paradoxus.

when you take a pulseyou'll have a strong pulse, a weak pulse, a strongpulse, a weak pulse. it'll repeat itself. and if you look on theecg, what you might see is a tall qrs complex,a small qrs complex, a tall qrs complex alternating. also if they have acvp line in, you'll get an elevated centralvenous pressure. the equipment you need forthis is basically a 14 gauge iv

catheter. two and a half to threeinches-- not your standard one and a quarter-- isgenerally required. your body substance isolation,your gloves, a 10 ml syringe. and what you can dois you can put one to two mls of sterilesaline in the syringe. and that way when you stickthe needle through the chest and have your syringeon, you'll get air bubbles that come out there.

you need somethingto clean the chest. even if this is anemergency procedure, you still want to clean thechest, get the germs off there. and then once youget it in, you can put-- there's differentflutter valves. heimlich. you can use anonlubricated condom. or you can take agloved finger, depending what you've got there.

and then after you're done,just put a sterile dressing on. the only contraindicationto needling somebody's chest is if they don't need it. so here they've discoveredthe patient had a tension pneumothorax basedon your assessment. getting the equipmentready, you want to find the appropriate spot. it's in the secondintercostal space over the top of third rib.

and you want to go overthe top of the third rib because you havenerves and blood vessels underneath the ribs. and you want to dothe mid clavicular line when inserting that. you've got youraseptic technique and then you've got a fluttervalve, no matter what you use. that is optional. and then a 90 degreeangle, inserting the needle

over the top of the rib andthen down into the chest. take the needle outthere and you can, again, use a syringe withbubbles in there. you should be getting airbubbles in the syringe. you may hear a whooshof air, but again, it depends on how noisythe environment is. and then you wantto tape it in place. so hemothorax. so now instead of airin the chest cavity

we actually haveblood in the chest cavity from bloodvessels that are being ripped ortorn or lacerated. the patient with amassive hemothorax can go into hypovolemic shock. it's also harming the lung. and if it's amassive one, there's been as much as1500 mls the blood in the portal space there.

and there can be up to 3,000milliliters of blood in there, so you can see that thisperson's bleeding out there. this can happen fromboth penetrating trauma and blunt trauma. this could be from atumor in the chest that has eaten away throughthe blood vessel. and the things you're goingto see with these patients are a lot of thethings you're going to see with thetension pneumothorax.

they're going to be hypoxic. so they're going to be agitated. they're going to be hypotensivebecause of all the blood loss internally. heart rate's going to begoing fast, tachycardic. they're going to have tachypnea. if you listen forbreath sounds, they're going to be absent orgreatly diminished. if you would percuss a chest,which not many people do

and especially difficult inthe prehospital environment, it would be dull sound. whereas if it was atension pneumothorax it would be more of ahigher pitched sound. the patient might be havinghymoptysis, coughing up blood. and their shock isgoing to get worse. and if you do have a cvp line,that is going to be falling. a down and dirty wayto find out if this is a hemothorax versusa tension pneumothorax,

with a tension pneumothorax,you're going to be getting jbd. with a massive hemothorax,you won't get that jbd because all the bloodis in the chest cavity. so that's sort of adown and dirty way that i've used in the pastto make a determination prehospital as i say, tensionpneumothorax or hemothorax. but we do need to rememberthat the patient can have both a hemoand a pneumothorax. so management, we're managingthe airway, high flow oxygen.

this is a load and go situation. fluid, resuscitation with them. we'd like to get their bloodpressure to at least 90, if not a little bit higher. or a mean [inaudible]pressure of 65. you do need to be carefulthat if you give too much fluid, raise the bloodpressure too high, you can actually dislodgeclots that are formed and actually makethe bleeding worse.

they can also developa tension pneumothorax from the hemothorax. so this is the picturethat the collapsed lung, and then you look on theright lung on the left there. it's red. the pleural space isfilled with blood. and this would be amassive hemothorax. what these patients aregoing to need to have done is have a chest tube inserted.

so if it's at a hospitalthey should have done that. if it's not doneat that hospital and the patient doesn'tneed it at the time, they will put one in at thereceiving hospital there. so chest tubes canboth remove air or they can remove fluidfrom the pleural cavity. and so you may need to transporta patient that does in fact have a chest tube in them. and so you need to befamiliar with chest

tubes and their monitoringand how they work. the equipment that's goingto be needed for this is, again, your protectivegear, a scalpel, chest tubes. usually a minimum of 36french chest tube on adults is the minimum that you wantto have in this patient. you're going to need someclamps, sterile dressings, suture material, somethingto clean the skin. if the patient's awake theywill-- anesthetize the area, because it is extremely painful.

you have to make sure that youhave the patient's arm secured if they are conscious, becausethey're not going to like this. you're going to have tohave some type of collection chamber, the chest tubeitself, and mechanical suction needs to be available. but it's not alwaysused, depending on what the patient is doing. and so chest tubes are going tobe put in for pneumothoraxes, hemothoraxes or combinedhemo pneumothoraxes.

or sometimes there's pusin the pleural cavity and it can alsobe used for that. for the most part we'regoing to be seeing it for our trauma patients. look at this representation. and it shows a chesttube that's in place. and again, they're puttingit in fairly rapidly if the patient isin serious shape. or if the patientisn't crashing they

can take a little moretime to put it in. complications that can happenwith our patient and the chest tube is that they couldget more pneumothoraxes. they can actuallythen may come out. and that's reallyimportant when you're transporting the patient fromthe hospital bed to your cot and getting them to theambulance or the helicopter, that somebody needs tomonitor the pleurovac or whatever's being used andthe tubing itself so that it

doesn't come out. the chest tubes willbe sutured in place and there will bedressing over it, but they still can come out. chest tubes can also enterthe lung tissue itself. so they will always check beforeputting the chest tube in. oftentimes the physicianwill have a sterile glove and stick the finger, after theyget into the pleural cavity, stick his or her fingerin there to make sure

that they don't feelany lung tissue. can also lacerateintercostal blood vessels, could create ahemothorax or bleeding. and it could be misplacedand go below the diaphragm. and an infection can set in. again, that's whyyou need to make sure that the chest tube, the skinis properly prepped there. make it as clean,sterile as possible. before moving thepatient again make

sure that all the connectionsare taped or banded together, because we don't wantthem to come apart. make sure the dressingover the site is secured. some people take a permanentmarker and mark on a chest tube where in fact the chest tube iswhen you pick the patient up. and that way it allows youto see if the chest tube has come out or gonein deeper there. and then it willbe done, but you just want to make sure thatthe tube has been, in fact,

sutured into place and taped. and we don't want toassume that it can. you don't want tolift up the collection chamber above thelevel of the chest. you always want tomake sure that it's below the level of the chest. it does help, when you'retransporting the patient, to keep the tubing coiled. because you don'twant to get kinked,

because that will actas an obstruction. and just make sure thatyou assess and document any bubbling in the waterseal area of the chest tube, and how much blood is inthe collection chamber and what it's looking like. you do not want to clamp thetubes because that could lead to a tension pneumothorax,which you don't want to have. if there's continuousbubbling, which injury that thepatient may also have

is a trachealbronchial laceration. something to pay attention to. because of the chance for amassive amount of bleeding, these patients mayin fact need to also be getting bloodinfusions on there. and we'll be talking aboutblood administration later on. so there's a patient who'sgoing to need to a chest tube. and if it's apneumothorax, they will direct the chest tubesometimes more upward.

if it's a hemothorax,they'll direct the chest tube more downward. any way they're goingto find the site. and it's certainlyon the lateral side of where the injury is. this is a picture of acollection of devices, tubing that's going to beconnected to the chest tube. again, you want to make sureyou use good aseptic technique when they're doing this.

again, if thepatient is crashing, they may notanesthetize the area because they need to get in. but generally they're goingto anesthetize the area if they're got the time. again, they've markedthe tube for the desired length of insertion. you want to clamp the distal endof the tube with a large clamp, and also the proximal end.

that's going to helpget the chest tube in. you want to clamp the distal endbecause if it's a hemothorax, you don't want bloodpouring out of there. then you're goingto take the scalpel, make a transverse incision. generally it's over the fifthrib at the midaxillary line. and you're actually going totunnel over the fifth rib. again, they're goingover the top of the rib with their large clamp here.

they're going to push itthrough the pleural space and then spread the clamp andleave that clamp in place. and then they've got theirchest tube with a clamp on it, and they're going to again checkto make sure there's no lung tissue there and advance thechest tube with the clamp on it through the spacethat's been created. they will then removethe clamps and advance the tube where they want it,the depth that they want it in. they will connect thecollection device.

and it's going to havea one way valve that's like a heimlichvalve in this case. otherwise, they'll put it rightonto the pleurovac, the tubing from there. they'll take thedistal clamp off. they're going to besecuring the tube in place with suture material,and then close the wound. and then they're going toput some type of occlusive dressing over the wound.

because remember, again,this is an open wound into the chest cavity. and again, our role is tomake sure that we monitor the amount of fluid that'scoming out of the chest cavity, monitor the patientstatus, their mentation, their respiratory status,vital signs, a lot things that we would manageon our patients. we have the flail chest. and definition,fracture in two or more

places to two ormore adjacent ribs. many flail segments are fairlysubtle and easy to miss. so again, we need to dogood assessments on them. where some are quite obvious. so again, basedon the mechanism, what our patient'slooking like, we need to do a reallygood assessment, because it's easy to miss. it is often found in many ofthe serious chest injuries

and usually ourserious chest injuries have more than one injury. there have been caseswhere patients, they haven't found the flailsegment for up to six hours. one advantage of going to alevel i trauma center, a level ii trauma center,is they're used to dealing with lotsof trauma patients. and so they are more likelythan a system or a hospital that doesn't see a lot of traumapatients to pick this up.

but it does happen. you can also have what'scalled a central flail, and that's where the sternumis separated from the ribs. and there's a thing calledparadoxical respirations or movement, meaningwhen the patient inhales, the flail segmentactually sucks in. and when the patient exhales,that flail segment will go out. and what's actually happeningis that flail segment isn't moving.

it's the rest of thechest that's moving. besides a flail segment, theobvious injury that we can see, there's oftentimes bruisingto the underlying tissue. and so we have amild cardio contusion or a pulmonary contusion. and that's creating a bigproblem for our patients with those injuries, hypoxia,cardiovascular problems. but the patients, if again,if they're conscious, they're generally complainingof what we might see is they're

having dyspnea severepain because you've got fractured ribs. if you listen on theflail side there's going to be somediminished breath sounds. tenderness if youwould palpate it. you can oftentimesfeel [? prefedice ?]. and there's generallya bruise over the area. managing these patients,we want to maintain an airway again, high flowoxygen, assist ventilation.

many times these patientsneed to be intubated. way back when in the olddays when i started out, the treatment was puttingsandbags on the flail segment. which, if youthink about it now, it doesn't make much sense. but we've learned alot since those days. again, oftentimes best treatmentis intubating the patient. that's providingpositive pressure. and if they're not intubated,be prepared to intubate

you can put iv fluid, use tohelp stabilize the segment and take that down. this is a patient in the field. we need to get rapidly moving. and that's with anyof our trauma patients that are severely injured. and monitoring those thingsthat we're going to monitor. again, the o2 sat, the vitalsigns, their mentation, things like that.

these patients can alsodevelop a tension pneumothorax or a hemothorax. they can go into shock,respiratory failure because of pulmonary contusions. so we just need toprepare for that. pericardial tamponade. so there's blood that's leakedinto the pericardial space. and every time theheart beats, blood is forced into this opening.

and as you get more and morefluid in the pericardial space, it's sort of acting likea vice on the heart, so it can't expand to fill. and so the cardiac outputis going to be going down. it's generally morecommon in stab wounds than gunshot wounds, althoughgunshot wounds can cause it. generally it'scaused by penetrating trauma or blunttrauma to the chest. fractured ribscan also cause it.

and so there's either bloodin the pericardial space or there's fluid of some kind. patients thatreceive see radiation for cancer in the chest canhave a cardiac tamponade. pacemaker wires canalso cause that. so infections, pacemakerwires that have moved. again, our trauma. anytime there's surgery tothe chest this can happen. patients that havecancer in the chest.

the tumor again can erode intothe pericardial space there. big time mis,congestive heart failure can lead toperidcardial tamponade. renal failure because thatcan lead to infections. classic sign and symptomis again the beck's triad. and here you have[inaudible] pulse pressure where they're going to need[? hypotension, ?] hypotensive. there's jugular vein distensionbecause the blood basically can't go forward, soit's got to go somewhere.

so think of it assort of backing up. and the muffled heart tones. because you've got thisgreater distance now between the outside ofthe person and the heart, so the heart soundswill sound muffled, so we need to monitor that. may not have any pulseswith cpr if the person is in cardiac arrest. and again, you've gotthat paradoxical pulse

and electrical alternansthat you may see on that. again, hypotensionas this precedes. you can be cyanotic. again, dyspnea will kick in. they're going to tachycardic. classic rhythm that you willsee with pericardial tamponade is pulselesselectrical activity. the cvp is alsogoing to be going up if you are monitoring that.

and if they do a chest x-rayand you look on the chest x-ray, if you look at themediastinim, it's going to be wide,a wide mediastinim. it's going to be thenormal width apart. and again, that's whyit's important to have some familiaritywith our chest x-rays and what differentinjuries look like. so again, bsi to treat this. cardiac monitor and yourdefibrillator again.

there's differentpericardiocentesis kits. 50cc syringe or ml[inaudible] syringe. again, something toclean the skin with. appropriate medications, cardiacsedating, numbing medications. catheters to do that. you may use-- prehospital meansa spinal needle or your system may carry specificcatheters for this. drapes to drapeover the patient. again, 16, 18 gaugespinal needle,

three way stopcock,scalpels, alligator clips. again, depending on howyou're going to be doing it. it is nice if youhave ultrasound. that can help. we're not going tohave that prehospital, but they'll havethat in the hospital and that can help themto do that properly. so here's a pericardiocentesisthat they've done. so you've got the heart.

and you can see that you'vegot, in the pericardial space, you've got fluid of some kind. and you can see the needlethat's going in there. so indications for this wouldbe a patient with chest trauma that has the signs and symptomsof a cardiac tamponade. and they may be in pulselesselectrical activity again. the physician mayhave done a fast exam where they can actuallysee this on the ultrasound. contraindications, well,if they don't have it.

anything like that. we could give them arrhythmias. if you go into the ventricleit's going to get irritable. so actually you couldpuncture the ventricle. and you don't want to do that. again, creating problems. you can lacerate thecoronary arteries, you can lacerate the lung. you could give a tamponade.

if they don't have one, couldgive acute pulmonary edema from fluid there. if your angle is extremelyoff, you could actually puncture the liveror the stomach, so we just want tobe aware of that. and we could also givethem an infection, again, if we wouldn't do agood cleansing of the skin. so here this patienthas a cardiac tamponade and they've got their equipment.

they're cleansingthe area again. premedicate the patientif that is appropriate. again, you want tomake this as clean as possible and assterile as possible. again, prehospital it'sa little more difficult. but again, cleanit as best you can. so you want to, again,have the proper site. and that's going to be onthe left side of the chest, to the left of the zyphoid.

you're going to haveyour needle, whichever type of needle you'regoing to be using. in this casethey're infiltrating with some lidocaineto numb it up. oftentimes that's notdone prehospital there because we don't have the time. so there's your big needle,spinal needle, large syringe, 30 degree angle. and as you gothrough the skin you

want to start pullingback on the plunger. and as you can seeon the right here, there's blood in the syringe. and what you'regoing to be doing is you're going through theskin towards the ipsolateral shoulder-- that's a fancyname for the shoulder on the left side onthe same side there. so you want to be pullingback on the plunger. that way when you hitthe pericardial space

you should startgetting fluid, blood. and you know you'rein deep enough. and you want to stop going inany farther because you don't want to, again, you don'twant to go into the ventricle. and then what youwant to do is you're going to need to take theneedle out prehospital. in the hospitalthey may keep it in. again, it's going to dependon your protocols, what you're going to do.

but you want to save thatsyringe with the blood. theoretically if you'rein the pericardial space the blood is not going toclot because the clotting factors have been used up. if you go into the ventriclethe clot, blood in this syringe, will maybe clot. so that's why youwant to save it, because the physician maywant to know and will ask you, is the blood clotted or not?

again, there's somecontroversy on that, whether or not thatactually happens. but that's what you want to do. you want to savethat syringe so you can see if theblood clots or not. some patients have aorticdissection or transaction. the aorta can rupture. that's the mostdevastating thing that happens, because thepatient's going to bleed out.

and that's one of themost common causes of immediate death when you'retalking about motor people crashes, rapiddeceleration injuries. the aorta where itcomes off the heart moves fairly easilycompared to the rest of the aorta, which isanchored fairly well. and that can flap andtear fairly easily. it's injured at theligamentum arteriosum. and that's, again, dueto deceleration injuries,

whether motor people crashesor falls from great heights. if you get tearsthere and it ruptures, it's almost immediately fatal. patients that do have tearson the descending side have a 50% chanceof staying alive until they do reachthe operating room. and again, we need todo a good assessment. even in the hospital there'sa 30% mortality rate. prehospital it can bevery difficult to find

an aortic dissection. it's sometimes missedeven in hospitals there. so it comes with a goodassessment on our patients. if it's a thoracicdissection you can take pulses and bloodpressures in both arms. one arm will have a strong pulseand a higher blood pressure than the other arm, which willhave a weaker pulse and a lower blood pressure. that's a clue that they maybe having a dissection there.

they're going to behypotensive, decreased level of consciousness. our patients that have ahistory of hypertension often, again, they'll behypertensive in one arm and have a lower bloodpressure in the other arm. definitely be having chest painfor the thoracic dissection, may have some bruising. and again, if you look at thex-ray if it's in the hospital, you'll see a wide mediastinim.

if it's an abdominaltrauma and they've got an abdominal triple a,abdominal aortic aneurysm, you may feel a pulsatingmass and diminished or no pulses in the feet. you want to make sure thatyou don't palpate extremely hard on the abdomenarea because you don't want to causea rupture there. there may also befractures in the chest that you may feel when youpalpate the chest, especially

the first andsecond ribs up high. so again, managementis open airway, ventilation, oxygenation. you may need toventilate the patient. iv fluids. if they are nothypotensive you do not want to give a lot of ivfluids, because adding iv fluids to somebodywho's having a dissection can actually causeit to get bigger.

so if they are nothypotensive, you do not want to givea lot of iv fluids. you may want togive beta blockers. esmolol, metoprolol, again,to try and keep the blood pressure down. you like a mean bloodpressure of 65 to 70. you don't want to getthem any higher than that. and then rapid transportto the receiving hospital that you're going to.

and give them a heads upwhat you're bringing in. myocardial contusion. they're going to becomplaining of the same thing somebody that's had an mi isgoing to be complaining of. found in motor vehicle crashes. again, not wearing abelt, there's no air bag, and they run into somethingand their chest then goes into the steering wheel. and now they've got amyocardial contusion.

nothing that we're necessarilygoing to see on the patient. but again, they're going tobe complaining of chest pain, they might behaving palpitations, you might be seeing arrhythmiaslike pvcs, v tach, v fib. they could be having st segmentelevation or new bundle branch blocks, which we're generallynot going to know about that. if you listen apically youmight be hearing a murmur. you can also hear a pericardialfriction rub sometimes. and they may be tachycardic andthere's no explanation for it.

so that might be a clue. and then they can bein cardiogenic shock. so again, we're generallynot doing 12 leads on our trauma patients. but if your systemdoes do 12 leads and the patient issomewhat stable, and you think theymight have a mild cardio contusion like they'vegot blunt chest trauma, you may want to do a 12lead because it may give you

some important information. so oxygenation. you may need to usesome pharmacology if they're having arrhythmias. they could get ahemopericardium which can lead topericardial tamponade. if it's severe enough theycan have a myocardial rupture, a ventricular aneurysm. generally the myocardialcontusion patients

do fairly well, however. but again, we need to beprepared for the worst. diaphragmatic ruptureis pretty interesting. as it says here, bluntpenetrating trauma. basically what happens is thediaphragm gets torn and stomach contents, intestinescan actually go up into the chest cavity. usually it's duedo blunt trauma. but again, it can befrom penetrating trauma

if it penetrates the diaphragm. some people have weakenedareas in the diaphragm, and this can lead to, whenthey have some blunt trauma, cause that tearin the diaphragm. and so the abdominal organs willgo into the thoracic cavity. so they'll be complainingof abdominal pain, they're going to becomplaining of chest pain. they'll be in acuterespiratory distress because now you'vegot something that

doesn't belong in thechest cavity that's pushing things out of the way. you will be hearingdecreased breath sounds. and in the old classic they saythat you may hear bowel sounds or abdominal soundsin the chest cavity. this is fairly rare,but it is a possibility. they could havesubcutaneous emphysema because there might be airthat's leaked out there. you could have theobvious penetrating trauma

to the abdomen. and if you look at thepatient's abdomen, most of us, we have rounded abdomens. and if you look at yourpatient and they've had some blunt trauma and youlook and their abdomen has sunken in, that mightbe a clue that they may in fact have aruptured diaphragm. you may need to assist theventilation because they're obviously going to be havingsome respiratory distress

oxygenation, you may want toput in a nasal gastric tube, or an oral gastric tubeto decompress the stomach. there's somecontroversy about that. you want to be careful ifyou're ventilating the patient and they do have aruptured diaphragm. remember the stomach canbe in the chest cavity and you don't have agood seal, if you're using an ambu bagwith a mask and you don't have a good airwayopen, and you're getting air

into the stomach, well,that air in the stomach's going to expand the stomach andyou can make the patient worse. and you may want to intubatethese patients early on to prevent that from happening. the next things you'regoing to be talking about is the tracheobronchialdisruption. usually it's causedby penetrating trauma. that's the most common, thoughblunt trauma could cause it. generally it happens withinabout, oh, an inch and a half,

two inches at the carina, butcan actually occur anywhere along the tracheobronchial tree. these people are going to havesevere respiratory distress because it's part of the airway. they will be getting hypoxic. they're going to be tachycardic. they're going to beginsubq air because air's going to be leakingout into the tissues. they may be havinghemoptysis where

they're coughing up blood. you can see jugularvein distension if vessels get damaged there. and then again, you canhave tracheal deviation that's taking place. to manage this-- again,this is a big life threat-- administer oxygen, positivepressure ventilation. unless they startgetting worse and then you may need to intubate them.

though if it's a transsectionit's extremely difficult to intubate these patientsbecause the trachea is not lining up. may need to needledecompress the chest if they develop atension pneumothorax. a chest tube may be necessary. again, it all depends onhow serious this injury is, how much damage there is,and what the patient's doing. pulmonary contusions.

so now the lung is contused. and you can havealveoli torn, you can have blood vessels torn. so there can be bleedingthat goes along with this. you can have fluid leakingout from [inaudible] injured the tissue itself andinterstitial spaces around them. basically the lung gets hit fromthe inside of the chest wall. and what you have isthese shearing forces

that take place, which causesthe contusion to happen. this is subtle. generally prehospitalwe don't see that. it's more likely todevelop in the hospital. but again, if you'retransporting the patient from one hospitalto the next you may experience thison your patient there. so again, early on, probablynot going to see it again. it's very subtle.

often this may bemissed in the hospital because there's nosigns and symptoms. but what you'll noticeas this goes on, the patient's going toget more and more hypoxic, so they're going to getmore and more agitated. trouble breathing,tachycardic, tachypneic. if you look at a chest x-rayas this has been going on it'll be more opaque. it won't have a niceblack that you're

going to see inmost chest x-rays. if they did get a bloodgas because they're getting hypoxic, that'sgoing to be getting worse. what these peoplewill do, again, depending on how seriousthe contusion is, is they may need to be puton a ventilator and get anywhere from 10 to 15centimeters of water or cpap, again, 10 to 15centimeters of water. these patients need to havesome analgesia just like many

of our traumapatients if they're stable enough to have that. oxygen, iv, monitorvital signs, mentation. again, pulse ox, end-tidalif they're intubated. iv fluid resuscitationif need be. again, usually there's morethan one injury that goes on. a lot of these arenot isolated injuries. could tear the esophagus. and basically, thisis generally going

to be coming from sometype of penetrating injury. it can be a bullet,can be a knife, can be projectilesfrom an explosion. can also happen from somebodywho's drank alkali acids, there are some medical causes. if somebody's gotcancer in that area and you've got a tumor that,again, erodes the tissue. some people havegastroesophogeal reflux disease where the gas starts goingup into the esophagus.

that can cause erosions. and there's a conditioncalled mallory weiss tears. these are from patientswho have excessive vomiting with strong force. that can also causetears in the esophagus. they'll have a severeamount of pain in the area. they'll be running a feverbecause of [inaudible] tissue an infection can set in. they have dysphasia where theyhave trouble swallowing because

of the damage to the esophagus. they could have some subqair because it can also erode into the airway. and their pain issort of pleuritic, a sharp type of pain. they may, if youlook at the x-ray, they may have somemediastinal air or there's going to be somewidening on the imaging studies if, again, the airwaygets eroded along

with the esophagus. and you may evenhear-- it's described as sort of likea crunching sound if you listen inthat area there. need to manage the abcslike all of our patients. you have to bevery careful if you put a nasogastrictube in because it may go in the stomach,but it may also go into that openingin the esophagus.

and we do not wantto have that happen. so very, very careful if anng is going to be placed. traumatic asphyxia, theclassic that you see in books. some guy's by a loadingdock on the ground and he's standing nextto the loading dock, and the truck backs upand doesn't see him, and smashes him between theloading dock and the truck. so it happens fairly suddenly. and you've gotinjury to the chest

and could also be the abdomen. and basically what it does isit pushes or forces the blood backward out of theright side of the heart. and if you look atthis patient you'll see the jugular vein distension. you'll see veinsalso in the chest and the headengorged with blood. and this is deoxygenatedblood, and so the chest, neck, and head is going tolook blue or purple.

sort of like an extremecase of cyanosis. but this is not duereally asphyxia, what we think of asphyxia. but it's calledtraumatic asphyxia. by itself it's not fatal. these patientscan do quite well. it looks really bad, butit's not necessarily bad. so it may not be fatal,though it can be. signs and symptoms,again, you're

going to have this bluish,purplish discoloration of the chest, neck, and head. there can be associatedinjuries which you need to be concerned about. and a lot of that has to do withhow fast the truck was backing up and how much forcewas put on the person. again, jbd. you can even see, ifyou look in the eyes, you have conjunctival bleedingwhere blood vessels in the eyes

have burst. and a lot of times, once youget the truck away from them, you'll have this sharpline of demarcation that separates the [inaudible]area with the normal skin color below. management. ok, what's going onwith the patient? maybe you just need to providesupportive care for them because they really didn'tinjure anything too bad.

otherwise you need to treatthe associated injuries and monitor for them. again, anything in the chestcavity can get damaged. if they are entrapped because,say, something fell on them, say a large tree,again, manage them with oxygenation, ventilation,two large bore ivs if they look in serious shape. and then you needto develop a plan that, ok, whatare we going to do

if they have sudden hypotension? if they are entrapped fora prolonged period of time, the muscles will start releasingmyoglobin and potassium is collecting. and then when you get theperson out of the entrapment, whether the tree orthe vehicle-- again, it's been happening for awhile-- all this myoglobin gets released and thepotassium gets released, which adds its own problems.

myoglobin can lead to kidneyfailure down the road. high potassium can leadto cardiac problems. so we need to be preparedfor that, especially if you're transporting thepatient from the one hospital to the next and it'sa long transport time. you just need tobe aware of that. ear injuries is generallynot life threatening, so if it's an ear injury itself. but it's what's underneaththe ears that's our concern.

and so if you've gotfluid coming from the ears and or nose, you always wantto think of a basal skull fracture. and there's a thingcalled the halo test where if you drop fluidon like a four by four, the blood will separate outfrom the glucose and liquid. and it actually lookslike a little halo. and you can also doa glucose test on it because there is glucosein the cerebrospinal fluid.

and so again, the biggestthing isn't the life threats, but it's what's underneaththat can cause a life threat. so again, usually earinjuries are not too big of a thing for them. and when they have the neuroemergencies presentation they'll be talkingabout the halo test. concern for thepatient is they could a ruptured tempanic membrane. and the biggest complaintfor that for the patient

would be they've gotpain in the ears. they might have vertigobecause their balance is in that area in the lungs. you could alsohave some vomiting and some blood in the ear canal. so basically if thereis any bleeding, you could put someexternal dressings. don't pack the ear canal well. they may need anantiemetic like zofran

to prevent them from vomiting. and if there are injuries, ifyou are going to transport then by air you just haveto be aware of the fact that with pressure changes,that can cause pain in the patient's ears. so just be aware of that. eye injuries. again, an eye injury itselfis not life threatening. but again, if it's apenetrating trauma,

it's what's behind the eye. eyelid lacerations,again, nothing that's going to belife threatening. but you've got to becareful how much pressure you put on the globe of theeye, because they could have another eye injury a and theycould have a ruptured globe. and you don't wantto push on that and push out the vitreoushumor because that's going to cause permanentblindness in the patient.

so eyelid lacerations, put somelight direct pressure on there. put a dressing. but watch, again, howmuch you put on there. if there's anything implanted,a penetrating object in the eye, you want to make surethat you stabilize it. and also want to patchthe unaffected eye so that the eyes aren'tmoving, consensual movement. something that youcould see is a hyphema, and basically that's bloodin the anterior chamber

of the eye due to blunt trauma. again, not life threatening. these oftentimesheal up by themselves and blood gets reabsorbed. but these people shouldsee a ophthalmologist, and they will haveone at the hospital when you transfer them. again, a heads upletting them know that that's what they've got.

again, you want topatch both eyes. these eye injuries,if possible, you want to have them sittingas upright as possible to limit the amount ofpressure on the eye. and then they may needanalgesics for the pain because eye injuries canbe extremely painful. and you may need togive them something calm them down too, becausethey might be very anxious. so again, isolated eyeand ear injuries, again,

not life threatening. but very anxiousfor the patient. so here's that globe rupture. again, the thing thatgives your eyeball your globe, itssubstance and its shape is the vitreous humor. and if the globe ruptures,that leaks out and the body does not replace it. and they will beblind in that eye.

so we just want to, again,cover the eyes, both of them. you can put a rigid eyeshield or a cup over the eye. again, antiemeticsand pain medication. and you want to hopefullynot have them cough, because by them coughingthey can increase interocular their pressure. and so they may begiven antitussives to prevent any coughingfrom taking place. if there's an avulsion tothe eye or an eye [inaudible]

of the eyeball fromthe eye socket, they're going to be blind. again, it's not lifethreatening unless there's an underlying commonbehind the eye there. but again, we want to protectthe eye from further trauma. again, a protective cup orother rigid protective device and then gauze padding. i've seen thisonce in my career. it is pretty impressive looking.

retinal detachment, again,this can happen medically. people get thisas you get older, but it can also happen fromtrauma to the eye area. and basically partof the retina becomes separated from the wall. and these patients are goingto be complaining of sensations of flashing lights or they maybeseeing floaters in their eyes, and they may havesome vision loss. might also see someblack spots in the eye,

and usually theblack spots are found in the center ofthe visual field. and like the otherpatients, transport them sitting uprightif at all possible. and based on their injuries,don't put any pressure on the globe. and again, protect they eye withrigid eye shields if possible. we've got facial trauma. you can have mandibularfractures, maxillar fractures.

you can have dislocations. you know if somebody's gota dislocation of the jaw is they can't close their jaw. problem with that is, try andswallow with your jaw open up. it's pretty difficult to do. so you need tomake sure that you manage any secretionsthey have in there. they may have somecrepitus in the area. swelling, again, not beingable to close their jaw.

or they tell you that, youknow, when i close my jaw, my teeth don't go together. that's called a malocclusion. you could have apatient that has had a fracturedjaw or dislocation. they may have theirjaw wired shut. so you want to make sure thatyou've got wire cutters in case they would vomit because wedon't want them to aspirate, so you want to make sure thatyou've got suction equipment.

you may need to nasallyintubate these patients. you may need to do asurgical airway, again, depending on your protocols. usually there'sreally no treatment on scene for these patients. another big problem withfacial trauma and fractures are the le fortfractures, 1, 2, and 3. le fort 3 is you can basicallytake the front of the face and pull it away from the face.

and so there can be somemajor airway problems that you just haveto be aware of when we manage thesetypes of patients. again, sitting upright ifpossible, having suction. dental avulsions. again, it's more of acosmetic type thing. but if you do have thetooth, milk can be used. there's also somethingcalled hank's solution. saline, you reallydon't like to use,

but can be used ifit's less than an hour. so you can have injuriesto the larynx and trachea. fairly uncommon there. we have to rememberwith this type of injury that you have the airway,you've got [inaudible], you've also gotthis c-spine there. and so we may need to makesure that we immobilize these patients because of that. and then we need to,again, monitor the airway.

and they may behaving a hoarse voice, so that's somethingto pay attention to. if they are conscious,have them talk. it can be, again, lacerations,bruising, ecchymosis, tenderness in the area. they could have subqair because air's leaking out into the tissue. they can also have stridorwhich is a scary thing to hear in our patients.

this is fairly uncommon. if it does happen, it's usingin the cervical trachea area. usually blunt trauma'sthe most common injury. and this would besomebody that's gotten strangled,hanging, a clothes line injury like your snowmobilersthat go across country and get off the trail andgo on 60 miles an hour over an open field. and they come to a fencethat they don't see and get

a clothes line injury there. there again could bepenetrating injuries, but they're a minority of it. what you might see is you mightsee bubbling from a neck wound if there's penetrating air. again, subq air or emphysema. when they talk it'spainful, dysphonia. trouble breathing,again, the stridor. again, swelling.

and so you have to worry aboutairway management problems with that. you may need to intubatethem, but again it needs to be done verycarefully because of the trauma that's there. if there is an openwound, you want to make sure you put anocclusive dressing over it. again, spinal precautions,transport to the trauma center, and all the stuffthat we're going

to monitor on anyof our patients. some patients havethyroid injuries. again, fairly rare. big concern withthyroid injuries though is it's veryvascular and they can have hemotomas whichcan occlude the airway. can also do damage. they could go intothyrotoxicosis. fancy name for thyroid stormwhere they have excess thyroid

hormones that kickin following trauma. has about a 20% to30% mortality rate. and they get hypermetabolic. and they're goingto be tachycardic. oftentimes the heart rate'sgoing 140 beats a minute. they can become hyperthermic,temp 103, up to 104. they can be in a coma withagitation, nausea, vomiting. and they could haveelevated thyroid levels. they may need to begiven a beta blocker.

a esmolol drip can be common. they may need to besedated because they're getting so agitated. and we need to implementsome cooling measures because, again, theirtemperature is rising. again, they're not real common,but it is there as something to be aware of. big problem againwith neck injuries is you've got thejugular veins, you've

got the carotid arteriesthat are in that area. and so major traumato that area, they can bleed outfairly rapidly. they can also havehematomas which can impinge on the airway. you can get air embolism whichcreates its own set of problems and so direct pressure,occlusive dressing. some people advocate puttingthem in trendelenburg. if you set them uprightif air does get in there,

air rises, so it's goingto go into the brain. so trendelenburg might bea position to put them in. but we have to remember that byputting them in trendelenburg, especially larger patients, allthe abdominal cavity is going to be putting pressure onthe thoracic cavity, which can create respiratoryproblems for our patients. abdominal trauma, especiallyif it's blunt trauma, can be difficult to recognize. again, blunt can be moredangerous than penetrating

because there's nothing thereto get your attention initially. and the abdomen's afairly large area. even with some major bleedingit may not be noticeable, especially in our patientsthat have large abdomens. so again, need to do agood assessment on them. so you've got thespleen and the liver, two big organs which can havemass amounts of bleeding. you've got yourretroperitoneal area. you've got the kidneyswhich can run into problems.

we've got the aorta,that air going through the abdominal area. the bladder, which certainlyis not going to kill them, but you can get infectionsif the bladder ruptures. gall bladder, you've gotjuices that can do damage, cause peritonitis. we've got the small and largeintestines in the stomach. and the stomach has acids init which can leak out, again, leading to peritonitis.

you've got the smalland large intestines, which have e. coli andothers things in there, which can lead to peritonitis. the pancreas gets damaged. it's got the pancreaticjuices, which can do a number on theorgans in the abdomen. a lot of things that weneed to worry about there. it's not so much we're goingto do anything different based on what organ is injuredin the abdominal area,

retroperitoneal area. we just need tobe aware of that, yes in fact they do havesomething that is going on. so again, thebiggest thing that's going to causeproblems initially and life threateningfor our patients is a large amountof bleeding, again from the liver and the spleen. also again, you can havethe ruptured diaphragm

which can lead to thestomach intestines going up so we need to pay attentionto mechanism of injury. and again, they may not haveany initial signs and symptoms. and there may be somesigns that you might see. and again, initially,you're not going to see it prehospital,but again in patients that you're transferringto another hospital. you may see grey-turnersign, and that's bruising in the flanks.

so retroperitoneal kidneys. or cullen's sign, and that'sbruising around the umbilicus, the belly button. and we've got ourblunt trauma there. we've got ourpenetrating trauma. and again, we need todo a good assessment and monitor them until wedo get them to the hospital. and it's like anything can causeholes in the abdominal area. knives, guns, treelimbs, metal rods.

there's some cool pictures onthe internet with tree limbs and metal rods sticking inpeople in different areas. so again, we need tobe really suspicious of abdominal injuries,especially the blunt. and just be good cliniciansand do good assessments. and so we're inspectingand we're oscilltating and we're palpating. and again, primary assessmentif we're transporting. in all our patients that we'retransporting from a hospital,

we need to do ourprimary assessment at the bedside and maybeeven a secondary assessment and then continue to monitoron the way until we get there. these are the signs andsymptoms that we may see. we may not. again, it depends on theirinjuries and where they are and when we get to them. again, oxygen, iv fluidsif needed, at least two large bore ivs.

the patients may have a centralline in that the doctor put in before we got there. monitor theirvital signs, again. and we may need to dobolus with crystalloids and or blood depending on whattheir mean arterial pressure is or blood pressure in their cvp. and again, monitor the airway. they may have bladderinjuries, urethra injuries. and so they may havea foley catheter in.

if they have aurethra injury they're not going to puta foley catheter in because you have noidea where that foley catheter's going to go. so they'll look for blood at themeatus, the head of the penis. they'll also do acheck for the prostate. the prostate's aboutthe size of a walnut. it should be firm. and if they can't feelit, it feels boggy,

then they want to be realsuspicious that they've got a urethral injury there. like any of our trauma patients,you want to keep them warm. if they have anopen abdominal wound you make sure that it's coveredwith an occlusive dressing. a sterile dressingand an occlusive dressing over that toprevent loss of heat. if it's evisceration we wantto put a moist dressing over so it doesn'tstick to the organs

when they want to take it off. and i already talked aboutthe hollow and solid organs. so the solid organs are going tobe the ones that are bleeding. and then the holloworgans are the ones that have stuff that leaks out,which leads to peritonitis. but generally early on thehollow organs that are bleeding are going to be leadingour patients to shock. and so again for us,the biggest concern initially in the care of ourpatient of the liver, spleen,

because again, they'regoing to be bleeding out. kehr's sign is asign that's often found with a spleen injury. it's pain in the shoulder. it's a referred pain. and again, with the liveryou can also have that. again, our treatment ismonitor them to be aware that they do have anabdominal organ injury and just monitor for that.

many times they won't need totake the patients to surgery. they'll manage it medically. so rushing into surgeryisn't the first thing. but again, it depends on what'sgoing on with the patient. generally with a lot ofbleeding and farther down the road with peritonitis youwill get abdominal swelling. you're looking for distension,rigidity, tenderness. also want to remember that theymay have a tendency to vomit, so you may need toput an og or an ng in.

and the biggestthing, again, for us is a high index of suspicion. again, these are things that aregoing to be leaking stuff out. and again, shortterm, they're not going to see much from this. it's longer term whenthey're in the hospital. but again, if you'retransferring a patient from one hospitalto the next, you may be seeing the aftereffectsof these hollow organs

with the peritonitis. also have to rememberthat there's vascular injuries that take place. again, the aorta,inferior vena cava. our kidneys havemajor organs in there. there's mesentericarteries, iliac arteries. and it's just likeany vascular injury. i have to worry abouthypotension, bleeding out, hypovolemic shock.

and so standard stuff. we're going to bemonitoring them. airway, vital signs,things like that. we may need to manage theirairway with intubation and fluid resuscitation. monitor their blood pressure. 80, maybe 90 is good,permissive hypotension. crystalloids blood,if the crystalloids aren't managing it.

if they are bleedingout, they definitely do need to go to surgery. pelvis. a person can lose a lot ofblood from their pelvis, especially a thing calledan open book fracture. it's just like a bookif you open it up. that's kind of whatthe x-ray looks like. [? mbcs ?], falls, pedestriansstruck by a vehicle. if your pelvis is fracturedit's taken a lot of force,

and so you always want tolook for other injuries. the pelvis, again, hasa rich blood supply because of the arteriesthat go through there, and so they can lose alot of blood in there. so if you've gota pelvic fracture, anytime you palpate,you don't want to palpate real strongbecause you don't want to pick that bone, wherever itis, and lacerate a vessel that hasn't been laceratedyet so that we

can create a secondary injury. so gently palpate,gently rotate. look for uneven heightof the iliac crest. or maybe the legsaren't even in length. they will be having tendernessupon palpation, again, when you're doing it gently. crepitus. when you move them,you've got to be careful. you don't want to log rollthese patients because it's

going to, again, putpressure on the pelvis there. so you need to splint it. and depending onwhat's going on you can use the long backboardas a splint prehospital. there's also things like pelvicbinders that you can put on. if you don't havea pelvic binder you can usually a longsheet and wrap that around. it's again used forsplinting the patient. any of those things can work.

treat the patient for shock. if there's any soft tissuedamage, manage that. scoop stretcher is good forpicking these patients up. again, we don't want toroll them onto one side. extremity trauma. the life threatsfrom extremity trauma are generally the femers. generally mostextremity injuries are not lifethreatening, but they

do have morbidity where they canhave nerve and vessel damage, have amputations, butagain, not life threatening. so we've got sprains, strains,fractures, dislocations, contusions. big concern is compartmentand crushing syndromes, which we'll talk aboutin just a minute. so a big thing iscns assessment, splint properly,pain medication. and talks about the six ps.

that's what we're looking foran any extremity trauma or cms. if somebody's gotcompartment syndrome this is what we're assessing. pain, when you're talkingabout compartment syndrome is pain, when you look atit, it doesn't look bad. but it's pain that's horrible. touching or movingit's horrible. they're going to be pale. pulselessness isgenerally a late sign.

paresthesia, they've got afunny feeling in the extremity. that extremitymight be paralyzed. and they're complainingof pressure. so the big thing is, again,it's an extremity injury. splinting it properly. pain medications again,and managing and watching for the six ps. you have open fractures. you have closed fractures.

anytime you've got an openwound over an extremity, you want to becognizant of the fact that it could be afracture under there. fractures, you have to worryabout blood loss again. patients lose lots ofblood in the femers. these are the signsand symptoms that we're looking for or assessing. and these are how we're managingour patients that have the, in this case, the isolatedextremity fracture.

crepitus can also befound in these things. if they're bleeding outheavily from an amputation or major wound onthe extremities, tourniquets should be used. direct pressure as thefirst thing you want to do. but if that's not workingthen applied a tourniquet. tourniquets have been foundto be life threatening, which came out of theafghanistan and iraq war. any open wounds,you want to make

sure you've got steriledressings, iv fluids. again, the amount of fluidyou're going to be giving depends on whattheir vital signs are and their clinical situation. analgesics of some kind. extremity fractures. dislocations canbe very painful. splint them in the normalanatomical position. and you want to makesure that you do that.

check cms beforeyou do it and after. if they don't havea pulse after you splint it, you to reassessthat and resplint them. again, oxygenation,vital signs, monitor. if you've got femurfractures there's different types oftraction splints out there. the hare, sagerand kendrick which are used in ourfemur fracture here. it's a very large bone,[inaudible] of muscle spasm.

and it's amazing howmuch relief patients can get from putting them inone of these traction splints. contraindicationsthough, of course to them is if thepatient has a hip or a pelvic fracture, a kneeinjury or an ankle injury, dislocations or fractures. basically they're used formidline femur fractures there. and it can, again, make thepatient feel a lot better. when we think of aspine immobilization,

we all zero in onthe cervical spine. but we need toremember that any part of the spine from the sacralarea up to the c-spine can be damaged. usually the lumbarand the sacrum are not going to belife threatening. it's when you get higher up,and especially the c-spine. and we classify spinal injurieseither as stable or unstable. and it's basicallybased on the mechanism.

and you have flexion injuries,you've got flexion of rotation. you have extensioninjuries, you've got compression fractures. you have dislocations thatcan go along with this. and so you really need tobe looking at the mechanism can give us some idea of whatinjury that they may have. there's primaryinjuries, and that's the injury that happens inthe initial whatever happened. they run into a treeat 60 miles an hour,

they've fallen froma great distance, they dove into a swimmingpool with six inches of water. and so the mechanism isimportant in our assessment in deciding on possibleinjuries there. you can also havesecondary injuries. we can create it by notimmobilizing them properly, or it can come aboutbecause they're getting hypoxic becauseof damage to the vessels. and tissue aroundthe spine, there

can be swellingthat takes place. they can behypotensive, and that's going to impact the amount ofblood flow going to that area. they can have lacerations, soblood isn't going to that area also. hypothermia can create a problemfor [inaudible] fractures. and the biggest one, somethingthat we can do something about, is making sure weimmobilize them properly, that we don't mishandle them.

and then hypoxia,oxygenate them. if they're having problems withtheir blood pressure in that, make sure we've gotfluid that's going on there to maintaina blood pressure. so the mostdevastating fracture is going to be thecervical fracture. but any fracture can bedevastating for the patient itself. but cervical fractures earlyon can be life threatening.

the higher up, themore difficultly the patient's going to behaving farther down the road. the higher upfractures, they're going to be having problemswith breathing, so we need to make sure that wemonitor respiratory status, monitor theircardiovascular status. and somebody canhave a broken neck, but the fractureof the vertebrae hasn't impinged onthe cord itself.

and then weimmobilize improperly and we move them wrong, andnow that fractured vertebra has now entered the cordand damaged the cord. so we need to make very surethat we manage that properly. one of things you'llsee in somebody that's having respiratory compromisebecause of a cervical injury is they will havebelly breathing, diaphragmatic breathing wheretheir chest muscles aren't working real well andthey're using their diaphragm

to breathe. belly breathing'snormal on little kids. it's not normal on adults. that can again bea clue that they've got some cord injury there. thoracic fractures,again, can lead to problems with theintercostal muscles. also leading torespiratory difficulty. spinal shock is rarebut it does happen.

and so that's a patientwho is hypotensive and they also have a lownormal to a low pulse. and skin can be warm anddry, unlike other shocks where they're hypotensive,they're tachycardic. so spinal shock is, again,a low blood pressure with a low normalor a low pulse. 50s, 60s. so they are compensatingbecause their messages aren't able to get through to causevasoconstriction and cause

the heart rate to go up. these patients often do well. it's often a temporary thing. lumbar fractures. again, generally notlife threatening. common in somebody that'swearing a lap belt and not a shoulder strap and gets intoa rapid deceleration injury and they jackknife over. that's the most common thingyou're going to see that in.

again, immobilization. humerus. they can lose a prettygood amount of blood. again, generallynot life threatening unless it's an amputationor actively bleeding. and again, in any fractures, cmssensation, pulse, circulation, and movement. some people will use amarker to mark pulses because they canbe hard to find.

but immobilization on any ofthe extremity fractures and cms. rib fractures. usually one rib fracture'snot life threatening. sometimes not eventwo, and it depends on how bad the fractures are. but they can leadto flail segments, can lead to pneumothorax. there's also vessels inthere that can be torn, so they can have hemothoraxand significant bleeding

nasal fractures. biggest concern is itimpacting the airway. so we just needto amount for that and you may need to dosome suctioning in there. there can be dislocationsespecially in the joint area. it's not life threatening, butit can be limb threatening. so we need to monitor the cms. going to be having pain,there could be swelling. it's going to look abnormal.

and one way you cantell if it's abnormal a lot is look atthe other extremity. and that's with any fractures. they're not able tomove their extremity. we're going to be seeing that. so oxygen, airway, fluids. again, cms. splint it in theposition of comfort while maintaining circulation.

they may be able to manipulateit if there is no pulse there. and then just monitor thepulse motor and sensation on a regular basis. any of these fractures mayneed analgesic medication for pain relief or they may neediv fluids for blood pressure. these are justsome of the terms. subluxation's anotherterm for dislocation but can also go from a sprain. dislocation, there havebeen some subluxations where

it's pretty [inaudible],you look on the c-spine where it's an obviousdeformity where it doesn't go downnice and smooth. if you look at the x-rayit's pushed backwards. so different gradesof subluxation. and again, carefulc-spine immobilization on those patients. watch theirrespiratory status and their cardiovascular status.

amputations again canbe life threatening. direct pressure'sthe initial thing you're going to dowith these patients. if need be, and or atourniquet, depending on how bad the amputation is. some are life threatening,others are not. again, if it's an arm, leg,it can be life threatening. if it's a digit, it'sgenerally not life threatening. [inaudible] only wantto bring the part

with because they maybe able to reattach it. want to keep it cool. don't wet it downthough, because that will damage the tissue. ice, moist dressingsand the part. ziploc bag. if you've got those thatyou can put it in there and place it on ice. tourniquet, make sure youknow what time you put it on.

they're going to want toknow that in the hospital. so if there's adislocation, assume that there's afracture involved. and again, being ableto look at x-rays and understandingx-rays, that can help in the care of the patient. and an idea of whatmight be going on. so we definitely want to splint. a cast may have beenplaced, but generally

not if these patients were newto the emergency department. but they may be in the icuand have some casts on. you just need to make surethat they don't develop a compartment syndrome becausethere could be swelling underneath the cast, andthat's putting pressure on the compartmentsand the muscles. and so you need to makesure that you monitor cms below the injury. so here's compartment syndrome.

and these are the thingsthat can cause it. a lot of times it'smaybe in grandpa hasn't been heardfrom in a few days. somebody goes overand there's grandpa laying on his sideon his arm or leg, and the pressure from thatcauses compartment syndrome to take place. fluid is able toenter the compartments but it can't leave, and sopressure starts building up.

and then circulationgets impaired and function also gets impaired. and the extremity can be lost. so any extremity canhave this happen on, but the forearms and thelegs are the most common. and this takes a whilefor this to develop. it's not going tohappen rapidly. so again, we already mentionedpain out of proportion to what the injury looks like.

this is excruciating pain. just touching it, justmoving a little bit, the patient mightscream out in pain. again, pale, pulsenessness. again, that's a late sign. paresthesia's a funny feeling. paralysis of that limb. extreme amount of pressure. and there's a thing called[inaudible] thermia,

and that's the extremity mayalso be cold, because again, you're not getting thegood circulation there. so just again, monitorcms, airway, vital signs. elevate the extremityabove the heart if possible to limit the amount of fluidsthat are going to that area. in the hospital they'llhave the physician come in, and they can actuallymeasure the pressure in the compartments. and depending whatthe pressure is,

they will either observe them orthey will take them to surgery. you may need to removeany splinting material or loosen it. pain medication is realhelpful for these patients if their vital signswill handle it. you want to keep the kidneysworking, because they can have myoglobinthat's released. they go into rhabdomyolysisso the kidneys can shut down. potassium will get released.

and so they have hyperkalemiathat takes place. so again, these are thethings that might also be released is the calcium andsodium besides the potassium and the myoglobin. and this is known as asmiling death, quote unquote. this might bepatient, again, who's trapped for quite a while,is finally extricated, and they're happybecause they're out, and then all of thesudden the potassium gets

released because itdid not get released, and then they aren'tso happy anymore. and they're decompensatingand going downhill. so again, motorweakness, they're going to have some signsof trauma, compression. again, the sensory loss. if they've been trappedfor quite a while, dehydration fromthe rhabdomyolysis if you look at theirurine, it's going

to be dark or tea colored. and so they need tohave fluids going to basically flush the kidneys. and again, they're goingto have hyperkalemia. they're going to havehypercalcemia, again, from the electrolyte imbalancesthat are taking place. so they're going toneed a lot of fluids and there's formulas thatthe physicians will use. they may need sodium bicarbbecause of the waste products

the acid, they'regoing to be acidotic. you need to makesure you monitor their ecg, their heartmonitor, because they can have high potassium. and with high potassium wesee peaked p waves on the ecg, so they may need calcium. they're going to have a foleycatheter in because they want to monitortheir urine output. they want to have at least200, 100, 300 mls an hour.

normally we're happy with30 mls an hour in adults. they're going tobe given bicarb. they want to keep the phof the urine above 6.5. so they'll be havinga sodium bicarb drip. may be given mannitol,because again they want to have the fluid leaving,and so you want to make sure you monitor electrolytes. and again, theymay need analgesia for the pain and benzosto help relax the muscles,

because the musclescan go into spasm. it's all standardstuff for managing the extremity splinting. casting again. casts, they're notgoing to put on because they want theswelling to go down. but again, it might be apatient in the hospital that's been there for a while. just need to monitorthe cms there.

may need to reduceand realign, so that's traction splints,maybe femer fractures. or if there's dislocations,they may need to be doing that. we need to make sure that weknow what we're doing, do that. they may have externalfixaters on, internal fixaters. and you just need to be awareof those type of things, how to manage them. and basically you're notdoing anything for them just other than the factthat they do have the fixater

and you just want to be carefulwhen you're moving them. number of drugs thatthey might be given. so the anti-inflammatory drugsto control pain and reduce information. opiates, that's sort of themainstay of pain control. and again, we just need tomonitor respiratory depression, hypotension, andnausea and vomiting. if you give a narcoticopiate too fast, besides a respiratoryrate drop and then

them getting hypotensive,they can get real nausous and then vomit, and thenyou've got an airway problem that you're concerned about. so have the suction ready. [? petinols ?] a fairly commondrug given for trauma patients. unlike morphine,it has less effect on the respiratorydrive and hypotension, so it's safer to give. antibiotics may be givenwith major trauma patients

or if there's open wounds, openfractures, things like that. and they're started earlyon during the resuscitation phase in the hospital. and if they're onantibiotics, you just need to make surethat you monitor for any signs of anallergic reaction. they may be givenmuscle relaxants to release the spasms ifit's extremity fractures, because the muscleswill go into spasm.

a lot of our patientsare on anticoagulants. patients may be taking aspirinevery day on a regular basis, or they're on chromatin. and so that puts astress on their body that they may be bleeding orbe at risk for bleeding because of the anticoagulations there. and our traumapatients will have underlying medical problems. so maybe our patient hassome deep vein thrombosis.

so they're in thehospital getting heparin. and again, heparin willeffect clotting and whatnot. and so they may be atmore risk for bleeding. or the patients may be havingdic, disseminated intravascular coagulation. and they may be onanticoagulants for that. and then sedativehypnotics again, trying to relax our patient,make them less anxious, make them less agitated.

can have benzos,lorazepam, valium, ativan. can also have sedatives,propofol to keep them sedated. which is a nicething, especially when you're transportingthem to a hospital on a helicopter or an ambulance. a big thing to rememberwith older patients is that they generally haveunderlying medical problems. they're on medications thatcan affect their vital signs. so a lot of elderly peopleare on beta blockers.

keeps their heart rate low,keeps the blood pressure low. so that can havean impact on what we're going to seeunder vital signs. they could have pacemakers. kyphosis, their spinesare in strange shapes, so they don't lay on thebackboard like a younger person will with a normal spine. and so we've got tothink about padding. they may have dentures ordental devices in them,

so that could bean airway problem. they get nose bleeds easier,especially in the fall and winter when it'sdrier out, and plus they may be on some typeof blood thinner. again, with these underlyingmedical conditions, they're ok before the trauma,but now they've got the trauma. that's just one morebrick put on them that can put them overthe edge, so we just need to be aware of that.

they're at moreof a risk for not doing as well as ouryounger patients there. and they may take longer torespond to any of the things that we do for them. so we just needto be aware that. their temperatureregulating mechanism isn't as good, justlike real little kids. so maintain their temperatureas best as possible. splinting is reallyimportant, especially

in transports, longdistance transports. they get hypothermiceasier too because they don't have the subcutaneous fat. so again, the bigthing is just be aware of your elderlypatients, because they tend not to do as wellas the younger patients, and we need to be reallyastute clinicians. our pregnant patients. so you've gotactually two patients.

and the best thing we cando to take care of the baby is take care of the mother,because if the mother is in critical condition,if the mother is dying, the mother's going to takeeverything that she has and try to keep herself alive. and the child's goingto be put at risk. so again, two patientsthat were going on there. the mother has a largeblood volume in pregnancy, again because youhave the baby there.

and so they can lose a lotof their blood, up to 30%, before they're showingsigns of shock. so just be careful about that. mom's in the thirdtrimester, you do not like to havethem flat on their back because they can get supinehypotensive syndrome. and that's becauseyou've got this baby. think of it as a bowling ballpushing down on the vena cava, so they have less preloadcoming back to the heart.

they're going to gethypotensive and tachycardic. so you always want toput your pregnant females in their third trimestertilt to the left, so they can tilt thembackward to the left. the big thing that you cansee it our pregnant trauma patients, car crashes,falls as abruptio placenta where the placenta getstorn away from the uterus. and you can seehere a big mortality of this happens in our blunttrauma patients for the fetus.

so you may or maynot see bleeding. it's going to be a darker red. going to be havingabdominal pain. a lot of the times it'sa ripping, tearing pain. they'll be complainingof back pain. the uterus is tender. they can be showing signsof shock, hypotension, tachycardia. if you carry adoppler or they've

got a doppler inthe hospital they'll be listening forfetal heart tones. they may not have anyfetal heart tones. you can ask the mother, areyou feeling the baby move? if they do not feelthe baby moving, that's a concerning sign for us. and so again the big thing withthe, again, third trimester, make sure they're on theirleft side if at all possible. and two large boreivs, oxygenation,

doing a good assessment,and treating the injuries that you find. what's going on with the mom,what you find, you treat that. and that's the best thingyou can do for the baby. generally very severepatients-- and this has to do with distance. so it's not necessarilytrue that your severe trauma patients are all goingto be transported by air. if you're in a large urbanarea close to a major hospital,

you're going to go by ground. but more longerdistance, if it takes you longer to goto the hospital, you're going to go by air. and then the risk benefitratio, they should go by air. but it's going to take thehelicopter longer to get here and i can get them tothe hospital sooner. so that needs to comeinto your thought process. which way do we want to go onthe transfer of this patient?

helicopters can carrysome more advanced gear. they will carry bloodand things like that. so again, you're weighingthe cost-benefit ratio. so that is it for trauma.