260 (PHTLS) A-E

How many ribs form the chest wall?

12

Describe the degrees of frostbite.

1st degree - involving the epidermis and looks white or yellowish. Can heal over time. 2nd degree - involves the epidermis and some of the dermis. It looks similar to 1st degree but involves deeper tissues and while healing can have blisters. 3rd degree - involves the epidermis and the whole dermis. Initially skin is stiff and may have blood-filled blisters and significant swelling during healing which is lengthy 4th degree - involves the layers all the way to the muscle and bone. There are not usually blisters or swelling with this type and necrosis of the tissues is usually fairly rapid.

Define "flail segment"

2 or more ribs broken in 2 or more places.

What is the typical fluid volume needed to resuscitate a burn patient?

2-4ml x kg x percentage of TBSA burned (only second and third degree burned areas). This is usually given over the first 24 hours. That is a large amount of fluid and while we should waste time doing complicated fluid calculations we should realize that a large pt with a large burn will need large fluid.

What are signs that a simple pneumothorax has become a tension pneumothorax?

A simple pneumothorax may cause loss of lung sounds but hemodynamic compromise is the clue that it is now a tension pneumothorax. Loss of a radial pulse is the quickest way to identify this during reassessment.

List the signs of Hypovolemic shock

AMS, tachycardia, tachypnea, pale/cool/clammy skin, and a LATE sign - hypotension

What assessment findings would cause you to be suspicious of hypovolemic shock in your trauma patient?

AMS, tachycardia, tachypnea, skin condition and mechanism consistent with possibility of blood loss or obvious blood loss

What assessment findings should lead you to immediately consider needle chest decompression?

Absent lung sounds and loss of radial pulses (hemodynamic compromise)

List some risks factors for heat illness

Age, medical problems, exposure to high temps, dehydration, etc.

What is the purpose of the pleura?

Aid in the expansion of the lungs by adhering to each other

Define subcutaneous emphysema and how you would assess for it.

Air trapped in the subcutaneous tissue, palpation of the chest and neck.

.What is a contraindication for use of a traction splint?

Any injury to any other part of the leg including possible injuries to the pelvis.

Describe arterial, venous and capillary bleeding in terms of color and flow.

Arterial spurts and is brighter red, venous flows and is darker red, capillary oozes and is dark red

How do you assess for neurogenic shock?

Assess for all the signs of shock and also assess for difference in skin signs above and below the possible injury sign.

What is the recommended treatment for pulmonary contusion?

Assess for and treat ventilation and oxygenation issues

In order to limit damage to the involved extremity, when should the tourniquet be removed?

At the hospital under normal circumstances

Why might LR be preferred in a burn patient over NS?

Because NS contains a much larger percentage of chloride, LR would be preferred to prevent hyperchloremic acidosis.

What is the purpose of the intercostal muscles and where are they located?

Between the ribs, give structure and assist in breathing

What impact would a blood thinner have on a fall patient?

Bleeding doesn't stop as it should (consider internal bleeding)

What is the BEST volume replacement for a patient in hypovolemic shock?

Blood

What types of medications could complicate a fall victim problems?

Blood thinners, beta blockers

What is the BEST treatment for hypovolemic shock due to blood loss?

Blood!

Define the term Commotio Cordis

Blow to the anterior chest causing sudden cardiac arrest.

Describe "cardiac contusion" and what assessment findings might lead you to suspect as a injury?

Bruising, associated injuries (steering wheel impact, etc.)

.What is the treatment for hypovolemic shock?

Control the bleeding, O2, supine, keep them warm, rapid transport, replace fluids

You respond for a patient who has been stabbed. The scene is secure at this time and patient is found lying on the ground, breathing is shallow, radial pulse is not present but carotid is palpable. You note an open wound to the left side of the chest with some blood and bubbles coming from the wound. What is your plan of treatment in order of importance. (i.e. 1st, 2nd, etc.)

Cover the open wound with a gloved hand until an occlusive dressing can be placed. Listen to lung sounds and note if absent on the left side. If absent on the left side prep equipment for NCD - if enough help is present, Oxygen or assisting ventilations should also be done. Perform NCD. Re-assess lung sounds and radial pulse. Transport rapidly for definitive treatment.

Define a tension pneumothorax

increased intrathoracic pressure causing pressure on the heart and vena cava, resulting in decreased cardiac output.

Describe Full-Thickness burns

involve the full thickness of the skin and underlying tissue. It can appear charred, leathery, and dry.

Define hypovolemic shock

loss of circulating volume and oxygen-carrying cells causing shock

What type of shock is neurogenic shock?

Distributive

Name the three membranes that cover the brain and define their purpose.

Dura mater - lining the inside of the skull. Pia Mater - adhered to the brain Arachnoid Membrane loosely covers the brain and blood vessels.

What is the treatment for cardiac tamponade and how does that affect your treatment of a suspected cardiac tamponade in the field?

Empty the pericardial sac, so rapid transport to a trauma center is the most important part of field care.

What options are there for pain control for a fall victim/broken hip patient and how would you administer those options? (include dosage)

Fentanyl 1-2mcg/kg IVP. (other options you haven't studied yet...Morphine, Ketamine)

What is the most common field treatment for hypovolemic shock?

Fluid bolus using NS or LR, 20cc/kg up to 2L and then consult med control.

What is the large opening at the base of the skull called and what is its purpose?

Foramen magnum, the brainstem exits here.

How would you assess for the more devastating causes of falls?

Good assessment looking for possibility of stroke or cardiac cause.

What impact would a beta blocker have on a fall patient?

Heart rate may not be able to compensate for the injuries sustained.

How should you treat an open wound to the chest wall?

Immediately cover with a gloved hand, followed by an occlusive dressing, and assess/reassess continually for development of a tension pneumothorax.

Why does the blood pressure increase in patients with increased intracranial pressure?

Increased MAP is needed to maintain CPP against the increased intracranial pressure.

What are warning signs of possible increased ICP and herniation?

Increased blood pressure, decreased heart rate and irregular or slow respirations.

Describe heat exhaustion

Insufficient cardiac output to meet the demands of cooling the body.

Describe Partial-thickness burns

Involve the epidermis and some of the dermis underneath. These involve varying degrees of blisters and also appear wet or glistening.

Describe the steps for a needle chest decompression including the two recommended placement sites.

Landmarks are: 2nd or 3rd intercostal space, mid-clavicular. 4th or 5th intercostal space anterior midaxillary. Determine that a tension pneumothorax is present, locate landmark and location of NCD, clean site, place needle and catheter, remove needle, secure in place and cover

How should a burn be "dressed"?

Large burns should be dressed with dry sterile dressings. Small burns can be cooled with water but we should be cautious of the possibility of heat loss/hypothermia.

What area of the brain controls breathing and heart rate?

Medulla

Why would vasodilation occur in neurogenic shock?

Messages to vasoconstrict aren't getting through to part of the body due to an interruption in the spinal cord.

What are the two recommended locations for needle chest decompression of a tension pneumothorax?

Mid-clavicular and mid-axillary

What is meant by "controlled hyperventilation"?

Mild hyperventilation to an ETCO2 0f 30-35

Is blood pressure a good predictor of whether or not your patient is in shock?

No

Is blood pressure a reliable gauge of the severity of hypovolemic shock?

No.

What is the benefit of splinting a fractured extremity?

Pain control and may help with bleeding control

What should be considered prior to moving a hip fracture patient?

Pain control and stabilization if possible.

What causes the erratic or irregular ventilation patterns seen in patients with increased intracranial pressure?

Pressure on the brain stem due to increased pressure within the skull

What is the difference between primary brain injury and secondary brain injury?

Primary - caused by direct trauma to the brain. Secondary - injury processes that are ongoing after the initial injury.

What is the purpose of the ribs?

Provide structure and protection, assist with breathing

What is the place of waveform capnography in the assessment of a trauma patient?

Real-time assessment of ventilation and circulation status

You have decompressed your patient's tension pneumothorax but a short time later on re-assessment of the patient you note increased work of breathing, decreased lung sounds on the affected side and loss of a radial pulse again. What is your next step?

Repeat the NCD and reassess.

What are the signs and symptoms of neurogenic shock?

Same as other types of shock above the injury but below the injury may be warm/dry.

Define traumatic Aortic Disruption and what assessment and treatment these patients need in the field

Significant force causing acceleration or deceleration injury to the aorta. Ascending is more mobile than the descending portion. Assessment involves index of suspicion. Pulses may differ between sides or between proximal and distal. Treatment is supportive and rapid transport.

What is the difference between a simple pneumothorax and a tension pneumothorax?

Simple - air in the pleural space. Tension - air causing increased thoracic pressure and collapse of the vena cava

What are dermatomes and why should we have a basic understanding of how dermatomes work?

Skin areas that indicate what

How do the signs and symptoms of neurogenic shock different from the signs and symptoms of hypovolemic shock?

Skin condition below the spinal injury would be opposite of expected signs of shock. (i.e. warm)

How is the diameter of peripheral vessels controlled?

Smooth muscle within the walls of the vessels which receive messages from the brain.

Why type of dressing should you use?

Something that will not allow air to enter the chest wound and the chest. Plastic packaging would work, there are commercial devices, or even taping a glove over it would work. Gauze, kerlex and other cloth will not work.

What assessment findings might lead you to consider smoke inhalation in your burn patient.

Soot around the nose and mouth, redness or swelling to mouth, nose or airway, stridor, wheezing, or difficulty breathing.

What is the initial step in the care of burn patients?

Stop the burn

Which causes of falls could be more devastating to the patient than the fall itself?

Stroke, Cardiac event

What is a hemostatic agent?

Substance that promotes clotting and is typically impregnated into gauze for use in packing a wound

Is elevation of the bleeding extremity still allowed?

Sure—just don't count on it to help and don't let it distract you from moving to adding a tourniquet to your direct pressure.

What are causes of secondary brain injuries?

Swelling and increased ICP, Hypoxia, Hypotension or inadequate cerebral blood flow, anemia, high or low CO2, High or low glucose.

What does SVR mean?

Systemic Vascular Resistance

What is Cushing's phenomenon?

The combination of increased arterial blood pressure and the resultant bradycardia that can occur with increased intracranial pressure, along with irregular breathing.

What is the difference between a three sided occlusive dressing or "vented" chest seal and a four sided occlusive dressing or non-vented chest seal?

The three sided dressing may allow of air to exit the wound without allowing air to enter the wound.

Describe heat stroke

This involves a failure of the body's thermoregulatory system to regulate body temperature. Usually involving a body temperature of 104* or more and central nervous system dysfunction

Describe the Rule of Nines for adults, pediatrics and infants.

This method divides the adult body into "nines" and aids in calculating an approximate burn percentage. It is then adjusted for the differences in children and infants.

Describe the Rule of Palms

This method uses the patient's hand (palm and fingers) as an estimation of 1% of their body surface area

How tight should you make the tourniquet?

To STOP THE PULSE

Why does the heart rate decrease on patients with increased intracranial pressure?

To compensate for the increase blood pressure. The body recognizes it does not need that high of blood pressure so drops the heart rate as compensation.

What is a junctional tourniquet?

Tourniquet style device that works at the junction of an extremity and the trunk where standard tourniquets are not able to be used.

What organs are contained in the mediastinum?

Trachea, main bronchi heart, major arteries and veins, esophagus.

How is a traumatic brain injury different than neurogenic shock?

Traumatic brain injury will cause swelling within the skull. This can cause increased ICP even to the point of herniation. Neurogenic shock is caused by an interruption in the spinal cord.

What is the treatment for distributive shock patients?

Treat life threats, O2, supine, keep warm, rapid transport, fluids to fill the container that is too large, consider vasopressors

What is the treatment for neurogenic shock patients?

Treat life threats, stop the bleeding if there is any, O2, supine (spinal precautions for this patient), keep warm, rapid transport, fluids to fill the container that is too large and consider vasopressors if needed.

What are possible causes of a fall?

Trip, pushed, dizzy, syncope, cardiac event, stroke, etc

Why do we no longer just hyperventilate patients who might have increased ICP?

Uncontrolled hyperventilation can lead to vasoconstriction which can cause hypoxia in the brain. Very bad.

What is the recommended treatment for a flail segment?

Ventilatory support, monitor for deterioration, pain relief can be considered.

What is the prehospital method of volume replacement?

Volume replacement with NS or LR in boluses (20cc/kg or 2L and then contact medical control)

Define a hemothorax

blood in the pleural space

Describe what injuries could cause a pulmonary contusion and how to assess for pulmonary contusions

blunt trauma is common cause, may or may not have obvious outward signs, lung sounds, suspicion of injury

Define atelectasis

collapse of alveoli

Describe decorticate and decerebrate posturing

decorticate - extension of legs and neck with arms flexed in toward the body. Decerebrate - extension of legs and neck with arms also extended.

Describe the three layers of the skin and their purposes

epidermis-outer layer, dermis and subcutaneous.

Define cardiac tamponade

fluid or blood filling the pericardial sac.

Is the use of pressure points to control bleeding an appropriate practice?

same answer as elevation---its NOT wrong—just don't waste any time waiting for it to maybe work

Describe superficial burns

similar to sunburn, redness, painful.

Define cerebral perfusion pressure

the pressure needed to perfuse the tissues of the brain

Define minute volume

total volume of air moved in and out of the lungs in a minute

Define the two types of Pleura and their locations

visceral, parietal, lining the chest wall and the outside of the lungs

When would you use controlled hyperventilation?

asymmetric or dilated and non-reactive pupils, extensor posturing, Decrease in GCS, Cushing's phenomenon.

PHTLS details several specific dermatomes you should remember. What are the anatomical locations of those dermatomes and the spinal location they represent?

"Nipple line" - T4, Umbilicus - T10, "C 3, 4, 5, keep the diaphragm alive."

Define pulmonary contusion

"bruise" to the lung tissue, causing blood in the alveoli

What is the recommended treatment for rib fractures?

Constant assessment of ventilatory status, supportive care. No taping, or restricting of chest wall due to secondary complications of pneumonia and alveolar collapse.

Why does cerebral perfusion pressure matter and how does it interact with intracranial pressure?

CPP is needed to supply oxygen and glucose to brain cells. CPP = MAP-ICP

What are the components of blood pressure?

Cardiac output (stroke volume + Heart rate) + systemic Vascular resistance

Why can a tension pneumothorax be considered both cardiogenic and obstructive shock depending on resource?

Cardiogenic due to causing decreased cardiac output, obstructive because it is causing restriction on the blood return to the heart.

What are the three main regions of the brain?

Cerebrum, cerebellum and brainstem

What are immediate assessment items that need to be considered when approaching a trauma patient?

Circulation status, Ventilation and Airway status.

Describe the care and treatment of the trauma patient who is also hypothermic.

While assessing for an caring for the trauma injuries, attempt to keep them warm and covered. Move to the heated ambulance as soon as possible and crank up the heat. Warm fluids only.

Can you have more than one type of shock at the same time?

Yes