Learning Station 3 Environmental Emergency 6 Driver of Car Gets Shot

1999 American Heart Association

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Acknowledgments
This teaching material was developed for the ACLS-EP Course by Paul Berlin, MS, EMT-P. He has generously donated much creative work to the AHA. B. Keith Chapman, EMT-P, of Temple Terrace, FL, also contributed to this material. Eric Fajardo, MD, Maj MC, Madigan Army Medical Center, contributed graphics and treatment recommendations.
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Learning Objectives
After completing this learning station you should be able to describe

Different BLS actions to take with trauma patients vs nontrauma Different ACLS actions to take with trauma patients vs nontrauma Where to modify the Primary and Secondary ABCD Surveys for trauma patients
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Case Management
55-year-old male with GSW to chest

You respond to scene of shooting plus MVA Victim struck in right chest in crossfire Car crashed into a pole Rescuer safety: police have scene secured; no threat posed by environment
Begin management now. What is the first BLS difference you note in out-of-hospital trauma care?
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Key Differences in BLS Actions: Scene Safety Assessment

Assess scene for Rescuer Safety! Get police to secure scenes of violence Ensure professional responders are safe from traffic Ensure professional responders are safe from scene hazards Cannot have rescuer become 2nd victim
What simple, rapid assessments can you make as you approach the victim?
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Initial Assessment at the Scene

Inspection: Unconscious, unresponsive Bleeding laceration: left eye Carotid = 148 bpm; no radial Respiratory rate = 38/min Skin pale and cool
What are your next actions?
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Primary ABCDD
Trauma vs Nontrauma A-B-C-D-D

Perform Primary ABCDD Survey Airway: for A do the following: Secure C-spine: until cleared later; high vigilance if any injury above clavicles Open airway: jaw thrust (no head tilt) Clear airway: foreign bodies, blood, teeth, debris

Primary ABCDD
Trauma vs Nontrauma A-B-C-D-D

Breathing: Oropharyngeal airway: keep the airway open Use BVM + jaw thrust no head tilt! Assess: must see bilateral chest rise No rise? Think pneumothorax/flail chest

Primary ABCDD
Trauma vs Nontrauma A-B-C-D-D

Circulation: Check: bleeding? external and internal? Control open hemorrhage PEA: in trauma patient major bleeding Check: neck for JVD?

Primary ABCDD
Trauma vs Nontrauma A-B-C-D-D

Defibrillation: Clinical evaluation strongly suggests rhythm is not VF (empty tank is cause of hypotension) Sudden VF unconscious MV accident = well-known sequence Disability: the 2nd D in trauma ABCDD Assess for neurologic Disability Glascow Coma Scale (GCS) is commonly used for trauma victims
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Continue In-Field Treatment

Rapid immobilization on spine board C-collar and head secured on board Rapid extrication from vehicle Oxygen by mask Low O2 saturation at 84% Rapid sinus tachycardia Unequal breath sounds Absent on right side

What is your assessment now? Getting worse? Getting better?

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Treatment During Transport

Rapid transport to definitive care The key factor in trauma care

Notify nearest appropriate level ED Airway and breathing? Endotracheal tube Circulation? IV rapidly infusing Differential diagnosis
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Secondary ABCDD
Differences in Trauma vs Nontrauma A-B-C-D-D
In trauma, providers struggle with this issue: Stay n Play Advanced treatment at scene? IV? ETT? Stabilize, then transport Versus Load n Go Advanced treatment with transport During transport: IV and ETT
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Load n Go vs Stay n Play

Current Practice by ACLS Providers: An Approach of Some of Both General: extricate stabilize resuscitate transport STAY actions: open airway ventilate endotracheal tube IV access + fluids GO actions: insert ET tube start IV give rhythm-based meds push significant amounts of fluids (first liters wide open)

See if you can provide a short report a summary of your assessment and treatment so far.
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ED Arrival
Short report Backboard/cervical collar BVET tube with 100% oxygen Ashen, sweaty, cap refill >2 seconds, cold GCS: eyes = 2, verbal = 3, motor = 3 1 IV of NS running HR = 140 bpm, BP = unable to obtain Extremities: floppy with no movement
Describe your initial assessment in the ED
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ED Assessment

2nd large-bore, pressure-bag IV Labs + type and cross NG, Foley catheter Cervical, thoracic spine x-rays Chest, belly, pelvis x-rays CT scan of head when stable Peritoneal lavage/ultrasound if belly suspect
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Managing Chest-Penetrating GSW

Entrance wound

Management depends on patients stability If agonal: Intubation Volume resuscitation ED thoracotomy

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Deadly Dozen

Lethal 6: you have <10 to 15 min to identify and treat Airway obstruction Tension pneumothorax Penetrating cardiac injury Open pneumothorax Massive hemothorax Flail chest

Hidden 6: not immediately lifethreatening; maximum time allowed <60 min Thoracic aortic disruption Tracheobronchial injury Myocardial contusion Diaphragmatic tear Esophageal injury Pulmonary contusion

Patient appears to have tension pneumothorax What are the most common causes? What are the most frequent clinical signs and symptoms?
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Tension Pneumothorax
Common Causes

Penetrating chest injury Blunt trauma + parenchymal lung injury Mechanical ventilation with positive pressure (PEEP) Spontaneous pneumothorax; blebs that failed to seal

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Tension Pneumothorax
Clinical Presentation

Respiratory distress Hypotension No or reduced breath sounds on one side Hyper-resonance to percussion Neck vein distention: absent with hypovolemia Tracheal deviation (late finding) Cyanosis
What do you think a chest x-ray would show in this patient?

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What would a CT scan of this patients chest look like?

Pleural margin; partial lung collapse

A: Air under tension in left thorax B: Collapsed right lung

Left

Right
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B: pressure of tension pneumothorax pushing midline

structures (heart, mediastinum) into patients left thoracic cavity

A: air, under tension, in thoracic cavity

A
Heart

Right

Left

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Tension Pneumothorax

Treatment Stat decompression: must convert tension pneumothorax into simple pneumothorax Use 12- to 14-g angiocath inserted into the 2nd intercostal space, midclavicular line, or 5th intercostal space, anterior axillary line Releases the air under tension Follow with chest tube
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Penetrating Cardiac Trauma

Pericardial Tamponade

Pathophysiology Fluid collects in pericardial sac Tension blocks venous return to heart May result from acute accumulation of as little as 75 to 100 mL of fluid

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Pericardial Tamponade

Chest x-ray Widened mediastinum Pneumothorax or hemothorax Electrical alternans

Note rounded bottle shape to left side of heart Compare with next 2 slides
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Pericardial Tamponade

Echocardiography

Pericardial fluid

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Pericardial Tamponade

Treatment: start Airway control Rapid, forced fluid resuscitation If unstable but with signs of life: Pericardiocentesis

Film taken after emergency pericardiocentesis Shows pericardial sac and space where fluid removed
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Summary
Caring for your patient

Tension pneumothorax Relieved: needle decompression Chest tube in; better ventilation Pericardial tamponade Relieved with pericardiocentesis Relief from only 20 to 30 mL Outcome To OR for GSW repair; stable condition
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