Paramedic Trauma Study Guide (ebook) (1).pdf

Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 1 Copyright 2021 - Pass with PASS, LLC1 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above s...

Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 1 Copyright 2021 - Pass with PASS, LLC1 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. About the Authors Adam Peddicord Co-Founder, Pass with PASS, LLC Adam has been a Paramedic since 1998 and started his fire service career in 1993. He is currently the EMS Coordinator and a Captain/Paramedic at Newport (KY) Fire/EMS Department where he also serves as the Medical Commander of the Newport Police Department SWAT Team. He holds multiples Associate’s Degrees along with a Bachelor’s and Master’s Degree in Nursing and is a board-certified Family Nurse Practitioner. As a Nurse Practitioner, Adam has experience in orthopedics and addiction medicine. Adam has over 20 years of experience in EMS education through the University of Cincinnati and Gateway Community and Technical College. Brandon Schoborg Co-Founder, Pass with PASS, LLC Brandon is currently the EMS Education Manager of a hospital and college based EMT/Paramedic Program in Kentucky. Previously, he was the EMS Education Manager for the Columbus (OH) Division of Fire, Director of EMS Education at Cleveland Clinic Akron General, Assistant Paramedic Program Coordinator at a community college in Kentucky and the Assistant EMS Coordinator, Engineer/Paramedic, and SWAT Paramedic with the Newport Fire/EMS Department in Kentucky for 8 years. He began his teaching career at the University of Cincinnati Clermont College. He completed his paramedic education at the University of Cincinnati in 2010. Brandon has an Associate’s Degree in EMS Paramedic, Bachelor’s Degree in Health Science, and a MBA in Healthcare Management. 2 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are Disclaimer copyrighted. All procedures listed in the study guide should only be performed by appropriately licensed/certified, authorized, and trained personnel as your local government, state, or country allow. Medication dosages may differ across the country, any medication dosages in the study guide are relatively standardized, however, we encourage you to check your local protocol and/or program’s preferred dosages. Copyright © 2021 by Pass with PASS, LLC. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Pass with PASS, LLC. Although we make every effort to ensure that the material contained within the study guide is current and accurate, we cannot guarantee accuracy. However, please know, that accurate and current study guides is extremely important to us and we continuously review our guides for quality assurance. Copyright 2021 - Pass with PASS, LLC 3 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are Table of Contents copyrighted. 1 Kinematics of Trauma & Mechanism of Injury Page 5 2 Burns Environmental Emergencies & SCUBA Diving 3 Soft Tissue Injuries & Fractures Review Questions 4 Head, Face, Neck & Spine Trauma Page 9 Page 13 Page 19 Page 29 Page 43 Page 5 48 Chest & Abdominal Trauma 6 Copyright 2021 - Pass with PASS, LLC 4 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 1 CHAPTER 1 Kinematics of Trauma & Mechanism of Injury 5Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 1: Kinematics of Trauma & Mechanism of Injury Trauma Kinematics of Trauma Motorcycle Crashes Head-On Impact: Over the handlebars → head and neck trauma, compression injuries to the chest and abdomen. If feet remain on footrests during impact → mid-shaft femur fracture(s), perineal injuries Angular Impact: Rider is often caught between motorcycle and second object (vehicle, barrier, etc.) Crush type injuries, open fractures to the femur, tibia, fibula Fracture/dislocation of malleolus Laying Motorcycle Down: Massive abrasions (road rash) → treat as you would a burn Fractures to the affected side Vehicle vs. Pedestrian Frontal impact → above knees/pelvis Pediatric Patients Initial impact → femur and pelvic injuries, internal hemorrhage Tend to face oncoming vehicle Secondary impact → thrown backwards, head and neck flexing forward Initial impact → bumper striking lower legs (lower leg fractures) Third impact → thrown to downward onto ground Vehicle vs. Pedestrian Secondary impact → hits hood/windshield, femur, pelvis, thorax, spine fractures Adult Patients Third impact → thrown to ground, hip and should injuries, deceleration injuries, fractures/hemorrhage Turn away from vehicle Lateral or posterior impacts 6 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 1: Kinematics of Trauma & Mechanism of Injury Types of Impact Car Crash: Frontal Impact (Head-On) Down and Under Pathway: Travels downward into the vehicle seat and forward into the dashboard or steering column Knees become leading part of body – upper legs absorb most of impact - knee dislocation, patellar fracture, femoral fracture, fracture or posterior dislocation of hip, fracture of acetabulum, vascular injury and hemorrhage Chest wall hits steering column or dashboard, head and torso absorb energy – tamponade, cardiac contusion, pneumothorax Up and Over Pathway: Body strikes the steering wheel – ribs and underlying structures absorb momentum – rib fractures, ruptured diaphragm, hemo/pneumothorax, pulmonary contusion, cardiac contusion, tamponade, myocardial rupture, aortic aneurysm. If head strikes windshield first → suspect cervical fracture (axial loading injury) Car Crash: Rotational Impact & Rollover Crashes Car Crash: Lateral Impact Vehicle is struck from the side (“T-bone collision”) Fracture of clavicle, ribs, or pelvis Rotational: produces same injuries as commonly found in head-on and lateral crashes Rollover: ejection, may have several types of injuries Pulmonary contusion Ruptured liver or spleen (depending on side involved) Head and neck injury Car Crash: Rear End Impact Vehicle struck from behind – back and neck injuries → hyperextension Copyright 2021 - Pass with PASS, LLC 7 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 1: Kinematics of Trauma & Mechanism of Injury Blast Injuries, Cavitation, & Ballistics Blast Injuries (Explosions/Bombs) Primary Blast: pressure wave → injuries to ears (eustachian tubes), lungs, CNS, eyes, GI tract Secondary Blast: flying debris – blunt, penetrating, and lacerating injuries Tertiary Blast: patient is thrown and injured by impact on ground or other objects Cavitation Opening produced by a force that pushes the body tissues laterally, away from the tract of the projectile. https://www.survivalistboards.com Ballistics The energy created and dissipated by the object into surrounding tissues, determines the effect of a projectile on the body. Kinetic Energy = .5mass X velocity2 Bullets → doubling the velocity quadruples the energy → Small caliber bullet traveling at a high speed can cause a more serious injury than a large caliber bullet traveling at a low speed Copyright 2021 - Pass with PASS, LLC 8 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 2 CHAPTER 2 Burns 9Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Burns Burns ~ 1.25 – 2 million burns occur annually ~ 45,000 of those require hospitalization 3 – 5% are considered life threatening nd 2 leading cause of death for children > 12 years of age Half of all tap water burns occur to children < 5 years of age Populations of Greatest Risk Very young and very old Firefighters Metal smelters → apply heat to extract base metal Chemical workers Pathophysiology of Burns Thermal Electrical Chemical Radiation Jackson’s Zones of Thermal Wounds Thermal Zone of Coagulation Heat changes the molecular structure of Cell membranes break, blood coagulates and tissue proteins denature Molecules begin to move faster, faster, and faster which causes the denaturing or proteins Zone of Stasis Adjacent to Zone of Coagulation; less damage, however, inflamed. Decreased blood flow. Extent of burn damage depends on: temperature of agent, concentration of heat, and duration of contact Zone of Hyperemia Erythema (redness) develops in some burns When you hear the term “denaturing of proteins” think about what happens when you fry an egg. The heat from the stove denatures the protein by disrupting its bonds that held the molecules into shape. 10 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Burns Burns First Degree (Superficial): Reddened skin, pain at burn site, involves only epidermis, no blistering. Heals spontaneously in 2 -3 days. Second Degree (Partial Thickness): Intense pain, white to red skin, blistering, moist-mottled skin, involves epidermis and dermis. Third Degree (Full Thickness): Dry, leathery skin (white, dark brown, or charred), painless, all dermal layers/tissues may be involved. Fourth Degree: Involvement of muscle and bone, charred appearance, painless Rule of 9s – Adult Parkland Formula: 4mL X kg X %TBSA burned = 24 hour infusion 1st half over first 8 hours, 2nd half over next 16 hours >20% TBSA, 2nd and 3rd degree burns only Response to Burns Emergent Phase (Stage 1) Pain response; catecholamine release Fluid Shift Phase (Stage 2) Found in those with 15 – 20% BSA burn Peaks in 6 – 8 hours, lasts 18 – 24 hours Damaged cells initiate inflammatory response; can cause massive edema due to leak capillaries c i r t a i d Hypermetabolic Phase (Stage 3) Lasts for days to weeks Increase in body’s need for nutrients e P – s Resolution Phase (Stage 4) Scar formation; general rehabilitation and progression to normal function 9 f o e l u 11 Copyright 2021 - Pass with PASS, LLC R Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Burns Burns Inhalation Injury Toxic inhalation: synthetic resin combustion → cyanide and hydrogen sulfide → systemic poisoning → more frequent than thermal inhalation burn Signs and Symptoms of Inhalational Injury Above Glottis The upper airway “normalizes” the temperature of the inspired air (which is great, because it protects our lower airway from these extreme temperatures), however, it sustains the impact of the superheated air. Facial burns, singed nasal or facial hair, “sooty” sputum, hypoxemia, stridor, red mucus membranes, grunting respirations. Signs and Symptoms of Inhalational Injury Below Glottis Steam inhalations more likely to reach lower airways – has 4,000 times the heat carrying capacity than dry air. Wheezes, crackles or rhonchi, productive cough, hypoxemia, bronchial spasm Carbon Monoxide Poisoning Affinity for hemoglobin is 250 times greater than oxygen → creates carboxyhemoglobin Odorless, tasteless gas Cherry red skin only presents at levels > 40% (late sign) “Multiple people feeling ill in same residence/building” → nausea/vomiting, headache, decreased LOC, weakness, tachypnea, tachycardia CO produces false pulse oximetry reading High flow, high concentration oxygen is best treatment for these patients Acid vs. Alkali Burns Acids → burning process lasts just 1 – 2 minutes → will cause coagulation Alkalis → burning process lasts minutes to hours → will cause liquefaction necrosis 12 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 3 CHAPTER 3 Soft Tissue Injuries & Fractures 13Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Soft Tissue Injuries & Fractures Soft Tissue Injuries Closed Wounds Contusion → blood vessel disruption below the epidermis; typically caused by blunt trauma; “ecchymosis” = bruising. Expose and clean wound, control bleeding, bandage wound. Hematoma Collection of blood beneath the skin; similar to a contusion; greater tissue damage; involves larger blood vessels; typically caused by blunt trauma. Expose and clean wound, control bleeding, bandage wound. Abrasion Partial thickness skin injury, caused by scraping or rubbing away of skin layer. Expose and clean wound, control bleeding, bandage wound. Laceration Results from tear, split, or incision of the skin; often caused by a knife or other sharp object; sizes and depths vary depending on injury sites and mechanism. Expose and clean wound, control bleeding, bandage wound. 14 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Soft Tissue Injuries & Fractures Soft Tissue Injuries Puncture/Pentrating Wound May result in significant damage dependent upon location. Check for exit wounds; objects may be embedded deeper than they appear; reassess frequently. Expose and clean wound, control bleeding, bandage wound. Avulsion Full-thickness skin loss, wound edges cannot be approximated; frequently involves ear lobes, nose tip, finger tips, and ring finger. Clean wound surface, fold skin back into normal position, control bleeding with bulky dressings. If avulsed parts are completely torn away, save in sterile dressing and keep moist with sterile saline. Amputations Complete or partial loss of a limb, caused by a mechanical force. Apply pressure dressing; use pressure points to control bleeding; use tourniquet as necessary. Wrap amputated part in sterile dressing and place in plastic bag; put bag in pan with water and cold packs. **Do not immerse amputated part directly in icy cold water** 15 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Soft Tissue Injuries & Fractures Soft Tissue Injuries Impaled Objects Do not remove the object as severe bleeding may occur. Expose the wound area; control any perfuse bleeding by direct pressure (not over impaled object), apply several layers of bulky dressings to splint object in place; secure dressings; treat for shock; reassess and transport. Imapled Object in Cheek Take care that object does not enter oral cavity, causing airway obstruction. If cheek wall is perforated, profuse bleeding into mouth and throat can cause nausea, vomiting, aspiration. External wound care will not stop the flow of blood into the mouth Examine the wound site, both inside and outside the mouth. If you find the perforation and can see both ends, remove the object. If object is impaled into another structure, stabilize in place. Position patient to allow for drainage; monitor patient’s airway; bandage outside of wound; provide blow by oxygen; provide care for shock. 16 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Soft Tissue Injuries & Fractures Fractures Types of Fractures Ligaments → connect bone to bone Tendons → connect muscle to bone Sprain → stretching and tearing of ligaments Strain → overstretching and/or overexertion of muscle Blood Loss Associated with Fractures Rib = 125mL Radius or Ulna = 250 – 500mL Humerus = 500 – 750mL Tibia or Fibula = 500 – 1,000mL Femur = 1,000 – 2,000mL Pelvis = 1,000mL + Greenstick → most common fracture in children Injury Presentations Hip Fracture Affected leg is shortened and externally rotated *Fractures closer to the head of the femur may present similarly to anterior hip dislocation → shortened leg and an internally rotated. Hip Dislocation Affected leg is shortened and internally rotated. Usually a posterior dislocation of the femoral head. Femur Fracture Affected leg is shortened and externally rotated with mid-thigh swelling (from hemorrhage) 17 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Soft Tissue Injuries & Fractures Crush Injuries & Compartment Syndrome Crush Syndrome Body is entrapped for > 4 hours Crushed muscle tissue becomes necrotic Traumatic rhabdomyolysis → skeletal muscle degradation; release of: myoglobin, phosphate, potassium; lactic acid; uric acid. When crushed tissue is released, toxins move RAPIDLY into systemic circulation → impacts cardiac function and kidney function Management IV access → 20mL/kg of NS (ideal body weight) Avoid LR or K based solutions After bolus, continuous infusion of 20mL/kg/hour Consider Sodium Bicarbonate → 1mEq/kg initial bolus; 0.25mEq/kg/hour infusion Consider Calcium Chloride → 500mg IVP; counteracts hyperkalemia Consider diuretics → Mannitol (Osmotrol), Furosemide (Lasix) Compartment Syndrome Likely 4 – 8 hours post injury 6 P’s → Pain → Paresthesia → Paresis → Pressure → Passive stretching pain → Pulselessness Goals of Treatment → care of underlying injury, splint and immobilize all suspected fractures, cold packs to severe contusions (reduces edema, prevents ischemia) 18 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 4 CHAPTER 4 Head, Face, Neck & Spine Trauma 19Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Skull & Spinal Cord Important Structures of the Skull Cranium → rigid and fixed in space Foramen Magnum → largest opening of the skull, spinal cord exits through this opening; this is site of brainstem herniation Cribriform Plate → inferior aspect of skull (“base”); rough surface, brain can easily be injured. T layer, directly on CNS Dura Mater: Outermost layer Meninges: Arachnoid Mater: middle (“durable”) Main job is to protect or “PAD” Pia Mater: innermost layer, web like (arachnoid = spider) Cervical Spine: 7 vertebrae Coccyx Spine: 4 vertebrae h Autoregulation: Changes in ICP result in compensation e s p in e Increased ICP = Increased BP This causes ICP to rise higher and the BP to rise h Thoracic Spine: 12 vertebrae a s 3 3 Monroe-Kellie Doctrine Expanding mass inside cranial vault; displaces CSF. t o t a l v If pressure increases, brain tissue is displaced Lumbar Spine: 5 vertebrae e r t e b r a e Sacral Spine: 5 vertebrae Copyright 2021 - Pass with PASS, LLC 20 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Brain Anatomy Cerebrum: The “actual” brain itself…when you think of “brain” you probably picture the cerebrum. Parietal Lobe Occipital Lobe Reticular Activating System: Responsible for maintaining consciousness and ability to respond to stimuli Frontal Lobe The brain receives ~ 20% of body’s total blood flow per minute Consumes 25% of body’s glucose Temporal Lobe Diencephalon (interbrain): Involuntary actions (temperature, sleep, water balance, stress, emotions) Mesencephalon (midbrain): Pons, Medulla Oblongata (Respirations, blood pressure, heart rate) “We live an die in the brainstem” Copyright 2021 - Pass with PASS, LLC 21 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Mental Status AEIOU TIPS: Mnemonic to rule in/rule out reasons for altered mental status and/or unconsciousness Alcohol Epilepsy Insulin Overdose Uremia Trauma Infection Psychogenic Stroke/Syncope Severity of AMS: DERM Depth of coma Eyes Respiratory pattern Motor function Babinski Reflex: dorsiflexion of the great toe and fanning of others – indicates dysfunction of the CNS Glasgow Coma Score: This is a must know! “Extra Value Meal $4.56” Decerebrate Posturing: Deep cerebral brainstem injury (more severe than decorticate) Decorticate Posturing: Deep cerebral brainstem injury – flexes towards the “cord” Copyright 2021 - Pass with PASS, LLC 22 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Head, Face, & Neck Trauma Le Fort Fractures https://www.aao.org/oculoplastics-center/le-fort-fractures Avoid Placing Facial Devices in LeFort Fracture Patients (nasopharyngeal airway, oropharyngeal airway, nasal endotracheal intubation, nasogastric tube, etc.) Types of Head Bleeds 23 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Head, Face, & Neck Trauma Increased Intracranial Pressure “Cushing’s Triad” = MUST KNOW Normal ICP range = 10 – 15mmHg or less Treatment: SPO2 > 94% Capnography monitoring of 35 – 40mmHg Treatment (Evidence of Herniation): Hyperventilation to yield ETCO2 of 30 – 35mmHg Evidence of Herniation: Cushing’s Triad OR unresponsive patient with bilateral, dilated pupils AND decerebrate posturing with no motor response to a painful stimuli Cushing’s Triad Systolic Blood Pressure 24 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Head, Face, & Neck Trauma Types of Amnesia: Retrograde Amnesia: no recall of events before the injury. Antegrade Amnesia: in ability to create new memories; exists after recovery of consciousness Basilar Skull Fracture Battle’s Signs “Retroauricular Ecchymosis” Associated with fracture of auditory canal and lower areas of skull Raccoon Eyes “Bilateral Periorbital Ecchymosis” Associated with orbital fractures Halo Sign → CSF drainage 25 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Spinal Cord Injuries Subluxation or Dislocation Fractures Spinous process and transverse process – stable Pedicle and laminae – unstable Vertebral body – unstable Common Sites of Injury C1/C2 → delicate vertebrae C7 → transition from flexible cervical spine to thorax T12/L1 → different flexibility between thoracic and lumbar regions Concussion Similar to cerebral concussion; temporary interference and transient disruption of cord function Contusion Bruising of the cord; tissue damage, vascular leakage and swelling Compression Secondary to displacement of vertebrae; herniation of intervertebral disc; displacement of vertebral bone fragment; swelling from adjacent tissue Laceration Caused by bony fragments driven into vertebral foramen; cord may be stretched to the point of tearing; penetrating injuries Hemorrhage Associated with contusion, laceration or stretching Spinal Shock Temporary insult to the cord; affects the body below the level of injury Affected area → loss of movement; loss of feeling; loss of bowel & bladder control; priapism; hypotension secondary to vasodilation Cannot distinguish between complete cord injury in the field Copyright 2021 - Pass with PASS, LLC 26 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Spinal Cord Injuries Axial Loading: Vertical compression of the spine results when direct forces are sent down the spinal column. Compression fracture or crushed vertebral bodies → T12 to L2 Central Cord Syndrome: Hyperextension cervical injuries → greater impairment of the upper extremities than of the lower extremities, paralysis of arms, sacral sparing (preservation of sensory or voluntary motor function of the perineum, buttocks, scrotum, or anus) Anterior Cord Syndrome: Usually seen in flexion injuries – decreased sensation of pain and temperature below level of lesion, intact light touch and position sensation, paralysis below the level of the lesion. Brown-Sequard Syndrome: Hemitransection of the spinal cord – weakness or paralysis of the extremities on the same side (ipsilateral) of the injury with loss of pain and temperature sensation on the opposite side (contralateral) Hemitransection, simply put, means “half” the cord has been transected. An easy way to remember this is the “-” between Brown & Sequard. Think of the hyphen as being a “half” transection. Neurogenic Shock Occurs when injury to the spinal cord disrupts the brain’s ability to control the body -Complete Cord Transection https://www.sciencedirect.com/topics/medicine-and-dentistry/dermatome Loss of sympathetic tone → vasodilation → reduced preload → reduction of cardiac contraction skin Below injury → warm, dry, flushed skin Above the injury → cool, moist, pale Copyright 2021 - Pass with PASS, LLC 27 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Head, Face, Neck & Spine Trauma Spinal Cord Injury Management Any patient movement must be coordinated, move patient as a unit NO LATERAL PUSHING – RESCUER AT THE HEAD CALLS ALL MOVES Steroids Reduce the body’s response to injury Reduce swelling & pressure on the cord Administered within 1st eight hours of injury Types of Medications Methylprednisolone (Solu-Medrol) Reduce capillary dilation and permeability Loading dose: 30 mg/kg over 15 minutes Maintenance: 5.4mg/kg/hour over 23 hours Dexamethasone (Decadron, Hexadrol) Reduce capillary dilation and permeability 5X more potent than Solu-Medrol 4 – 24mg (occasionally up to 100mg) Copyright 2021 - Pass with PASS, LLC 28 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 5 CHAPTER 5 Chest & Abdominal Trauma 29Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Chest & Abdominal Trauma Blunt Chest Trauma Very Low Velocity Rib Fractures Spine Injuries Low → High Velocity Rib fractures Spine injuries Hemo/pneumothora x Flail chest Pulmonary contusion Major vessel injury Cardiac contusion Cardiac tamponade Penetrating Chest Trauma Very Low Velocity Pneumothorax Hemothorax Major vessel injury Cardiac injury Possible abdominal injury Low → High Velocity Rib fractures Pneumothorax Hemothorax Major vessel injury Cardiac injury Cardiac tamponade Probably abdominal injuries Spine injuries 30 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Rib Fractures Occurs most often on lateral aspect of 3rd – 8th ribs (least protected by musculature) Higher incidence of fracture among adults → cartilage in pediatrics is more resilient, less calcified Caused by blunt or penetrating trauma May cause pain, difficulty breathing, crepitus Treatment Relieve pain, encourage patient to cough and breathe deeply Splint patient’s arm against chest Analgesics Look for other injuries 31 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Sternal Fracture & Pulmonary Contusion Sternal Fracture Direct blow to the chest → occurs in 2% of patients with blunt chest trauma (think steering column, dashboard, massive crush injury) History of significant anterior chest trauma, tenderness, abnormal motion or crepitation over sternum Treatment → analgesics, consider other more significant injuries (cardiac contusion, tamponade, pneumothorax, bilateral flail chest) Pulmonary Contusion Rapid deceleration injuries → MVC → injuries that cause flail chest >50% of blunt trauma patient have pulmonary contusion Signs and Symptoms Tachypnea Tachycardia Cough Hemoptysis Respiratory distress (coughing up blood) Crackles Cyanosis Treatment CPAP BiPAP BVM Intubation 32 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Pneumothorax Copyright 2021 - Pass with PASS, LLC 33 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Chest & Abdominal Trauma Hemothorax/Tension Pneumothorax Similarities: tachypnea, dyspnea, cyanosis, diminished or decreased breath sounds, tracheal deviation (late sign), asymmetrical chest rise Hemothorax/Tension Pneumothorax Differences: Hemothorax Accumulation of blood in the pleural space May be massive: 2 – 3L Dullness on percussion (hyporesonance) Narrow pulse pressure Hypotension/hypovolemia No JVD Tension Pneumothorax Accumulation of air in the pleural space JVD Hyperresonance on percussion Subcutaneous emphysema Patient’s will become hypotensive in late stages (obstructive shock) Needle Decompression: 10 – 16 gauge IV needed, at least 3.25” in length Insert needle above rib (to avoid nerves and vasculature that run under rib) Historically: 2nd intercostal space, mid clavicular Updated Evidence: 5th intercostal space, anterior axillary COVER ANY OPEN/SUCKING WOUNDS WITH AN OCCLUSIVE DRESSING 34 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Cardiac Tamponade A cardiac tamponade often occurs due to blunt trauma (think steering wheel to the chest). Tamponade carries a heavy mortality rate but before we jump into mortality, let’s review what happens in tamponade… The heart is surrounded by a sac, called the pericardial sac. This sac has three layers (or linings). The innermost lining is the visceral pericardium (visceral to the vasculature!), then the parietal pericardium, then the fibrous pericardium. In between the visceral pericardium and parietal pericardium is 25mL of pericardial fluid. Beck’s Triad When a tamponade occurs, there is an excess accumulation of fluid that builds up in the pericardial sac. Because the sac is tough (think leather) it does not expand well with this excess fluid – this excess fluid and lack of expansion puts more pressure on the heart which prevents it from filling and pumping like it needs to. This causes cardiogenic or obstructive shock Hypotension (EMS Standards recognize Tamponade as both forms of shock). Other Signs & Symptoms Tamponade can be caused by trauma, an Oxygen MI, pericarditis, or neoplasms. IV Access Fluid Bolus (20mL/kg) Vasopressor Management Chest Pain, Dyspnea, Orthopnea, ABCs Narrowing Pulse Pressure, Electrical Key Signs Alternans, Pulsus Paradoxus, Altered LOC & Symptoms 35 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Cardiogenic Shock Causes: Impaired myocardial contractility (MI) Impaired ventricular emptying (left-sided heart failure) Tension pneumothorax Cardiac tamponade Trauma (cardiac contusion) Signs and Symptoms: Systolic BP < 80mmHg Respiratory distress Chest pain Weakness Altered mental status Hypotension Tachycardia Management: Rapid transport Position of comfort Oxygen Identify and treat underlying problems IV access/fluid administration* Consider medications: positive inotropes/vasopressors Fluid Administration: Listen to lung sounds first! If dry: give fluids, 100 – 200mL boluses, (Starling’s Law) If wet: do not give fluids Copyright 2021 - Pass with PASS, LLC 36 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Dissecting Aortic Aneurysm Most common aortic catastrophe → affects three times as many people as “AAA” Signs and Symptoms: Syncope Absent or reduced pulses Unequal blood pressure readings (right side vs. left side) Unequal pulse strength (right side vs. left side) Heart failure “Tearing” sensation in chest or back (this is a big one!) Flank pain Scapular pain Pain radiating into legs Management: Rapid transport to hospital with emergency surgery capabilities Copyright 2021 - Pass with PASS, LLC 37 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Chest & Abdominal Trauma Flail Chest “Two or more adjacent ribs are fractured in two or more places” Signs and Symptoms Bruising Tenderness Crepitus Paradoxical motion with inspiration and expiration (late sign) Treatment SPO2 and ETCO2 monitoring Assist ventilations to achieve SPO2 > 94% Consider CPAP Consider intubation (as needed) Traumatic Asphyxia “Severe crushing injury to the chest and abdomen, results in increased intrathoracic pressure” Forces blood from the right side of the heart to the upper thorax, neck and face. Face will have a purple/red appearance Management ABC’s & hypovolemia/shock management https://intjem.biomedcentral.com/articles/10.1007/s12245-010-0204-x Commotio Cordis Leading cause of death in youth baseball in US (2 – 3 deaths per year) Blunt chest trauma, timed during upstroke of T wave (relative refractory period – “R on T phenomenon” Induces ventricular fibrillation Copyright 2021 - Pass with PASS, LLC 38 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Chest & Abdominal Trauma Diaphragmatic Rupture Sudden compression of abdomen results in increased intra-abdominal pressure Signs and Symptoms Abdominal pain, shortness of breath, decreased breath sounds, bowel sounds heard over thorax Management Oxygen/ventilatory support Fluids Rapid transport Solid Organ Injury Rapid and significant blood loss Solid organs most injured = liver and spleen Both can be life threatening Liver Largest organ in abdominal cavity Often injured by trauma to 8th – 12th ribs on right side Second most commonly injured intra abdominal organ Mortality rate = 54% Spleen Left upper quadrant 40% of patients have no symptoms…immediately Pain in left shoulder (Kehr’s Sign) Evisceration Protrusion of an internal organ(s) or the peritoneal contents through a wound Management Cover eviscerated contents with moist, sterile dressing Cover moist dressing with dry dress to conserve organ temp Never attempt to place organs back in cavity Hollow Organ Injury Sepsis, wound infection, abscess formation → spillage of their contents is primary concern Stomach → not often injured by blunt trauma Colon and small intestine → more likely to be injured by penetrating trauma than blunt trauma Abdominal Trauma Treatment Stabilize the patient & rapid transport Oxygen Permissive hypotension = 80 – 90mmHg Check for other injuries Reassess every 5 minutes 39 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Trauma in Pregnancy Trauma During Pregnancy ABCs first Aggressive resuscitation After first trimester, never transport pregnant patient flat on back (Supine Hypotensive Syndrome) Transport on left side → if spinally immobilized, “prop up” right side of backboard 6 – 12” to achieve a leftward lean Copyright 2021 - Pass with PASS, LLC 40 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Types of Shock Commonly Associated with Trauma 20mL/kg boluses, PRN 20mL/kg boluses, PRN 100 – 200mL boluses, PRN Stages of Shock 41 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 5: Chest & Abdominal Trauma Types of Shock Commonly Associated with Trauma Stage 1 Up to 15% loss in blood volume Pulse: Normal BP: Normal Stage 2 15 – 30% loss in blood volume Pulse: Mild tachycardia (100 – 120bpm) BP: Normal Stage 3 30 – 40% loss in blood volume Pulse: Moderate tachycardia (120 – 140bpm) BP: Decreased Stage 4 40% loss in blood volume Pulse: Severe Tachycardia (> 140bpm) BP: Decreased 42 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 6 CHAPTER 6 Environmental Emergencies & SCUBA Diving 43Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 6: Environmental Emergencies & SCUBA Diving Environmental Emergencies Hypothermia Core body temp (CBT) of less than 95 degrees → lose the ability to shiver Osborn wave (“J wave”) may be present at junction of the QRS and ST segment a i Mild hypothermia: 89.8 – 95 m r e h t Moderate hypothermia: 82.5 – 89.7 o p y h Severe hypothermia: < 82.4 / g 7 c 9 e 2 3 g / k s e e g e Increased risk of enter Ventricular Fibrillation a v a m i w / j m n o r c o . b d s e o m l p a c e i r n g i . l c w Management: y w g w o l / Handle with care / o : i s d r p t a t Move to warm environment and start rewarming process c h - Remove wet/cold clothing Heat Exhaustion CBT up to 103 Signs & Symptoms Severe cramps Dizziness Nausea Profuse sweating Headache Management: Move to cool environment Administer replacement fluids Cool patient with a cool water spray Signs & Symptoms Confusion/irrational behavior Coma Flushed skin Pulmonary edema Dysrhythmias GI bleeding Clotting disorders Reduced renal function Hepatic injury Electrolyte abnormalities **Sweating may be absent** Management: Move to cool environment Cool by fanning, keep the skin wet Administer fluids Administer benzodiazepines for seizures Heat Stroke CBT > 104 Copyright 2021 - Pass with PASS, LLC 44 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 6: Environmental Emergencies & SCUBA Diving SCUBA Diving Emergencies Diving Gas Laws: Boyle’s Law: if temperature remains constant, volume of a given mass of gas is inversely proportional to the absolute pressure. When pressure is doubled, the volume of gas in halved. Popping or squeezing sensation in ears. Dalton’s Law: pressure exerted by each gas in a mixture of gases is the same pressure that gas would exert if it alone occupied the same volume. Henry’s Law: at a constant temperature, the solubility of a gas in a liquid solution is proportionate to the partial pressure of gas. Descent Diving Injuries “The Squeeze” → Results from the compression of gas in an enclosed space as the ambient pressure increase with descent under water. Pain Sensation of “fullness” Headache Disorientation Vertigo Nausea Bleeding from nose or ears (think eustachian tubes) Copyright 2021 - Pass with PASS, LLC 45 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 6: Environmental Emergencies & SCUBA Diving SCUBA Diving Emergencies Ascent Injuries Air Embolism: most serious complication of pulmonary barotrauma → major cause of death and disability among divers. Occurs when ascending too quickly or holding breath while ascending to surface. Diver loses consciousness immediately after resurfacing. Signs and Symptoms: Difficulty breathing, stroke-like symptoms (vertigo, confusion, visual disturbances, focal neurologic deficits) Management: Oxygenation and airway protection Transport in left lateral recumbent position Hyperbaric oxygen therapy (“recompression”) Decompression Sickness (“the bends, diver’s paralysis, caisson disease, dysbarism”): Multisystem disorder that results when nitrogen in compressed air converts back from solution to gas → results in formation of bubbles in the tissues and blood. (Henry’s Law). Signs and Symptoms: Joint pain, rashes, itching, “bubbles under the skin”, chest pain, cough ,shortness of breath Management: Oxygenation and airway protection Transport in left lateral recumbent position Hyperbaric oxygen therapy (“recompression”) Nitrogen Narcosis (“rapture of the deep”): nitrogen becomes dissolved in the blood and crosses the blood-brain barrier. Causes CNS depression effects similar to alcohol which can seriously impair the diver’s thinking and lead to lethal errors. Usually becomes evident at depths of 75 – 100’. Copyright 2021 - Pass with PASS, LLC 46 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Want more Trauma review? Check out our Trauma Review Lectures for more in depth information! www.passwithpass.com 47 Copyright 2021 - Pass with PASS, LLC Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are Review Questions copyrighted. 1.) In a blast injury, the pressure wave occurs during which phase of the blast? _______________ 2.) If a patient’s head strikes the windshield, what type of spinal cord injury should be suspected? ______________________ 3.) This type of EKG finding is characteristic in the hypothermic patient. ____________________ 4.) When calculating the Parkland Formula, only ____ and ____ burns are calculated. 5.) After calculating the Parkland Formula, the first half of fluid should be given during the first _____ hours. 6.) Carbon monoxide has an affinity for hemoglobin that is _____ times greater than that of oxygen. 7.) _____________ skin is a late finding in high carbon monoxide levels. 8.) This type of inhalation burn has the greater likelihood of reaching the lower airways. _____________ 9.) This type of burn causes liquefaction necrosis. ________________ 10.) This type of burn causes coagulation. _______________ 11.) Bradycardia, irregular respirations, and an increasing blood pressure collectively form ___________ _______. 12.) This type of head bleed is arterial in nature and most commonly involves the middle meningeal artery. ______________ 13.) The inability to create new memories. ___________________ 14.) This type of head bleed is venous in nature and is more common than epidural bleeds. ___________ 15.) A hemitransection of the spinal cord is called _________- ________ __________. 16.) What is a major difference between a hemothorax and a tension pneumothorax? ____________ 17.) What is the preferred site of needle decompression? _______________________ 18.) Blunt chest trauma, timed during the upstroke of the T-wave that produces ventricular fibrillation. ___________________________________ 19.) The most common type of fracture in the pediatric patient. ___________________ 20.) Left untreated, a tension pneumothorax will develop into ______________ shock. Copyright 2021 - Pass with PASS, LLC 48 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Final Steps… As you finish this study guide, you are probably feeling on the top of your game! But, the journey isn’t over yet. You still have to conquer that exam, which you WILL do! Check out some of our tips before taking the exam! ➢ Do not pay attention to the timer – less than 1% of candidates fail because of time ➢ Do not pay attention to the question number, a percentage of students will get all 150 questions regardless of their performance – the question number doesn’t matter! ➢ Get a good night’s sleep and eat a good breakfast before the exam – do not underestimate this! ➢ Do not over study on exam day, “tying loose ends” is fine, but no heavy studying – stop reviewing several hours before the exam. Your brain needs rest too. ➢ Beat the test one question at a time, pause, relax, take a deep breath and pick the best answer. ➢ Read every question twice – a lot of students skip over key words and information – reading each question twice will help you pick up on information you didn’t catch the first time. Looking for a comprehensive review for the NREMT exam? Check out our Paramedic NREMT Study Guide! www.passwithpass.com 49 Copyright 2021 - Pass with PASS, LLC