1. Prehospital Trauma Life Support PHTLS Refresher Program

3. Prehospital Trauma Life Support Managing the Multisystem Trauma Patient Part I

5. Predicting Injury In a 50 mph (80 km/h) MVC, what types of injuries would occur if the patient were to strike the windshield?

6. What type of injury patterns might you see in a frontal impact? Frontal Impact

7. What types of injuries would you expect? Rear Impact

8. What types of injuries would you expect? Lateral Impact

9. What types of injuries would you expect? Rotational Impact

10. What injury patterns might you see following this crash? Rollover

18. Gunshot Wounds How do the injuries differ when created by medium- or high-velocity weapons?

20. To what is cavitation related? Gunshot Wounds: Cavitation

21. Entrance and exit wounds Gunshot Wounds

22. The ultimate in fragmentation is created by shotgun wounds Shotgun Wounds

25. It’s mid-January and you have been dispatched to a multivehicle crash on the interstate. Initial reports indicate there are multiple patients and a fuel tanker is involved. When does your scene assessment begin? Scenario

26. What are the components of scene assessment?

32. Glasgow Coma Scale Eye Opening Spontaneous 4 To Voice 3 To Pain 2 None 1 Verbal Response Oriented 5 Confused 4 Inappropriate Words 3 Incomprehensible Words 2 None 1 Motor Response Obeys Command 6 Localizes Pain 5 Withdraws (pain) 4 Flexion (pain) 3 Extension (pain) 2 None 1

34. Simultaneous Assessment Breathing Airway Kinematics Circulation Disability Expose/ Environment

35. Decision Making Trauma-related incident Scene assessment Primary survey Life -threatening or multisystem injuries No Yes Initiate rapid transport Reassess Secondary survey Secondary survey Reassess Manage injuries as appropriate Initiate transport

36. A 16-year-old loses control of his bicycle on gravel. Your patient is found on the side of the road holding his right wrist. Multiple abrasions are noted on his face and upper extremities. The scene is safe. Scenario

37. Primary Survey A: Patent B: Normal; BS clear C: Minor bleeding from chin laceration; radial pulse normal; skin warm, pink, and dry D: GCS score 15 E: Deformity noted to right wrist How do you proceed?

44. You are dispatched to a motorcycle and vehicle collision. Bystanders report that the motorcycle was traveling at about 40 mph (65 km/h) when a car pulled in front of the motorcycle. You find the patient lying on the pavement 30 ft (9 m) away from the crash. His helmet is heavily damaged and has been removed by a bystander. Scenario

46. You arrive on the scene of a single vehicle MVC. Your patient is a 25-year-old female who is trapped upright in the driver’s seat. Her VR is 36 and she is cyanotic. Gurgling sounds do not improve with suctioning or manual maneuvers. The fire department estimates that it will be 10 minutes before she is extricated. How would you manage her airway at this point? Scenario

48. Your patient is a 35-year-old construction worker who fell 25 ft (7.6 m) and landed on his head. His GCS score is 3. He is apneic and is being ventilated with a BVM. Three attempts at orotracheal intubation are unsuccessful. What are the airway management options at this point? Scenario

50. At a college baseball game a 22-year-old third baseman is struck in the head by a line drive. Upon your arrival his GCS score is 7 (E-1, V-1, M-5). His teeth are clenched and he is vomiting. How would you manage his airway? Scenario

52. Shock “ The patient is in shock! ” What does this term mean?

53. Staged Death Hypoperfusion Cellular hypoxia Anaerobic metabolism Cell death Organ failure Patient death

54. What conditions can interfere with each component of the Fick principle? Alveolus Capillaries Red blood cells Capillaries Kidney O 2 O 2

55. Your patient is a 30-year-old woman who lost control of her vehicle, which then struck a light pole. The patient was unrestrained. There is significant damage to the vehicle. You find the patient slumped over in the driver’s seat. You see that the steering wheel is bent. The scene is safe. Scenario

56. Primary Survey A: Patent B: Fast; BS clear C: No external hemorrhage; weak and rapid radial pulse; cool and diaphoretic skin D: GCS score 14 (E-4, V-4, M-6); anxious E: Bruising across abdomen and right thigh deformity Vitals: VR, 24; pulse, 118; BP, 112/82 Is this patient in shock? Why?

57. What is the most likely cause of the patient’s shock? Why is the patient’s BP normal? Primary Survey

58. Estimated Blood Loss Approximate internal Bone blood loss (mL) Rib 125 Radius or ulna 250–500 Humerus 500–750 Tibia or fibula 500–1000 Femur 1000–2000 Pelvis 1000–massive

59. Hemorrhagic Shock

60. Your patient is a 27-year-old male who was working in a grain silo. His left leg became entrapped in an auger. After a 45-minute extrication process, the fire department manages to release his mangled leg. Scenario

61. Primary Survey A: Patent B: Marked tachypnea C: Moderate hemorrhage from extensive soft tissue injury to lower left leg; no radial pulse; very fast, weak carotid pulse; pale, cool, diaphoretic skin D: GCS score 12 (E-3, V-3, M-6) Vitals: VR, 38; pulse, 140; BP, 74/50 What stage of shock is the patient in?

62. A 27-year-old male dock worker was pinned between a fork lift and a loading dock. Upon your arrival, the patient is lying supine on the ground complaining of severe lower abdominal pain. The ambient temperature is 35° F (1° C). You are 25 minutes from the trauma center. Scenario

63. Primary Survey A: Patent B: VR fast C: No external hemorrhage; rapid and weak radial pulse; pale, cool, moist skin D: GCS score 15 E: Significant pain on palpation of lower abdomen and pelvis What are the principles of shock management?

66. Prehospital Trauma Life Support Managing the Multisystem Trauma Patient Part II

68. Responding to a call at a police station, you encounter a 19-year-old male complaining of chest pain and dyspnea. You learn that your patient was kicked in the chest during a fight. What injuries could occur with this mechanism? Scenario

69. Primary Survey A: Patent B: Left chest pain during inspiration; BS equal, VR fast C: No external bleeding, normal pulse rate D: GCS score 15 What injuries can you rule out? How should this patient be managed?

70. Your patient sustained a close-range shotgun blast to the abdomen. A segment of bowel is eviscerated. How are eviscerations managed? Scenario

71. A 24-year-old female fell down a flight of stairs. She is 36 weeks pregnant. She is complaining of severe back pain. What physiologic changes occur during pregnancy? What are the common causes of injury in the pregnant patient? Scenario

72. Primary Survey A: Patent B: Normal C: Pulse rapid; skin warm and dry D: Anxious E: No obvious injury noted Vitals: pulse, 114; VR, 20; BP, 92/56 Are these findings due to trauma or pregnancy?

73. After immobilization to a long backboard, reassessment shows her radial pulse to be 140 and weak. Her BP is 80/60. What could explain these findings? How would you manage this patient? Scenario

74. Long Backboard

77. Anatomy Skull Periosteum Dura mater } One functional layer Arachnoid membrane Pia mater (directly attached to brain surface and not removable Vessels in subarachnoid space Epidural space Subdural space Subarachnoid space

78. The Brain

81. Primary Survey Bystanders report a 5-minute loss of consciousness. The child is now awake and complaining of a headache and has vomited once. A: Intact B: Normal C: Normal D: GCS score 14 (E-4, V-4, M-6), PERL What is a concussion?

82. You are called to a local bar where a 22-year-old male has been in a fight. Bystanders state that your patient was beaten with a pool cue. The scene is safe. Scenario

83. Primary Survey A: Snoring noises B: VR slow and shallow; BS equal C: No external hemorrhage, radial pulse fast D: GCS score 6 (E-1, V-1, M-4); pupils R>L, sluggish E: Multiple hematomas on scalp and face Vitals: VR, 8; pulse, 110; BP, 150/90 What injuries do these findings suggest?

84. You are called to the scene of a rollover MVC where a 16-year-old female was ejected from the vehicle. You see the patient lying supine on the ground. Her breathing is noisy and rapid. She has a large scalp laceration. You identify no hazards. Scenario

85. Primary Survey A: Snoring, gurgling noises B: VR rapid and shallow; BS decreased bilaterally C: Moderate bleeding from scalp; rapid, bounding carotid pulse D: GCS score 5 (E-1, V-1, M-3) Vitals: VR, 38; pulse, 124; BP, 80/P

86. What life-threatening conditions do you identify? What could be causing her shock? Primary Survey

87. Management Goals for the TBI patient include preventing and reversing causes of secondary brain injury

90. You are called to a public pool for a 16-year-old male who sustained an injury while diving. Upon your arrival he has been removed from the pool. Scenario

91. Primary Survey A: Patent B: Rapid and shallow C: Slow heart rate; weak radial pulse; warm extremities D: GCS score 15, loss of motor and sensory function in extremities E: No other obvious injuries What is the life-threatening problem?

93. How would you manage this patient? Scenario

94. A 28-year-old male has been shot in the neck by his girlfriend. Scenario

95. Primary Survey A: Patent B: Fast; BS equal C: Copious external hemorrhage from neck wound, radial pulse fast and weak D: GCS score 15; no neurological deficits in extremities E: Expanding hematoma to left side of neck When is spinal immobilization indicated for penetrating trauma?

97. You are called to a nightclub where a 35-year-old female has fallen down a flight of stairs. Your patient denies neck and back pain but complains of severe left ankle pain. You smell alcohol on her breath. Scenario

98. Primary Survey A: Patent B: Normal; BS clear C: Minor bleeding from small scalp laceration; normal radial pulse D: Slurred speech; GCS score 15 E: Grossly deformed left ankle When is spinal immobilization indicated for blunt trauma?

99. Blunt Trauma Altered level of consciousness (GCS less than 15) No Yes IMMOBILIZE Rapid transport Spinal pain or tenderness? or Neurological deficit or complaint? or Anatomic deformity of spine? No Yes IMMOBILIZE Rapid transport Concerning mechanism of injury?

103. Presence of: Evidence of alcohol/drugs or Distracting injury or Inability to communicate When in doubt, immobilize! Concerning Mechanism of Injury No Yes IMMOBILIZE IMMOBILIZATION NOT INDICATED Rapid transport Transport No Yes IMMOBILIZATION NOT INDICATED Transport

104. You are called to the scene of a multivehicle crash on a highway. After your patient’s vehicle was rear-ended, it was propelled into the vehicle in front of it. The vehicle has moderate damage. The driver was unrestrained and the windshield is spider-webbed. On the basis of kinematics, why should spinal injury be suspected? Scenario

105. Primary Survey A: Patent B: Normal; BS clear C: Normal radial pulse D: GCS score 15 E: Abrasion on forehead What are the indications for rapid extrication?

106. The patient is complaining of neck pain. What role does a cervical collar play in spinal immobilization? How is spinal immobilization performed? Primary Survey

107. Prehospital Trauma Life Support Managing the Multisystem Trauma Patient Part III

109. You are called to the scene where an intoxicated male has stumbled and put his hand through a window. On your arrival you see a large amount of blood and broken glass by the front door. The police direct you to a 40-year-old male sitting in a chair, bleeding heavily from the upper arm. On examination you see a laceration to the antecubital fossa with copious, bright-red bleeding. Scenario

110. What, if any, life-threatening injuries are present? What are some examples of life-threatening musculoskeletal injuries? What ways exist to control the bleeding? Does this injury require rapid packaging and transport? Scenario

111. A 28-year-old female fell while skiing. Ski patrol has brought her to the lodge. She complains of severe right thigh pain. Scenario

112. Primary Survey A: Patent B: Normal C: No external hemorrhage; normal pulse rate; skin warm and dry D: GCS score 15 What are your conclusions based on these findings?

113. Secondary Survey You find a swollen angulated right thigh. How much blood could a patient lose from this type of injury? Is this enough to cause shock? How would you manage this injury?

114. Your patient is a 45-year-old male pedestrian who was struck by an SUV. He smells of alcohol. Scenario

115. Primary Survey A: Patent B: VR rapid and shallow; clear BS C: Blood oozing from multiple soft tissue injuries; weak and rapid radial pulse D: GCS score 13 (E-3, V-4, M-5) When you gently stress his pelvis, crepitus is noted and the patient screams in pain.

116. What are your conclusions based on the primary survey? What are your management priorities for this patient? Primary Survey

118. Secondary Survey VR, 24; pulse, 122; BP, 104/72 There is no abdominal or pelvic tenderness. How do you explain these findings?

119. Table of Estimated Blood Loss Approximate internal Bone blood loss (mL) Rib 125 Radius or ulna 250–500 Humerus 500–750 Tibia or fibula 500–1000 Femur 1000–2000 Pelvis 1000–massive

120. A 70-year-old woman slipped on some ice and fallen down a staircase. On your arrival she is complaining of pain in her left wrist and left ankle. On examination, deformities are found in both extremities. Scenario

121. Primary Survey A: Patent B: VR slightly fast C: Moderate hemorrhage from oozing and open ankle; irregular pulse D: GCS score 15 VR, 22; pulse, 105; BP, 110/70 Complains of pain at fracture sites

122. Are life-threatening injuries present? How are you going to manage this patient? Primary Survey

124. You are called to care for a patient who has been burned while fueling his lawn mower. As you approach, you see a 65-year-old male with burns to his right arm and anterior chest. The fire is now extinguished. Scenario

125. Primary Survey A: Patent B: Normal; clear BS C: No external bleeding; normal pulse rate DL GCS score 15 E: Bright-red skin with blisters on chest and entire right arm What are the key issues in assessing thermal burns?

126. Rule of Nines What percent of BSA is burned? 9% 18% 9% 9% 18% 18% 18% 1% 18% 18% 9% 9% 18% 1% 13.5% 13.5%

127. What are other factors in assessing patients with thermal burns? How are you going to treat this patient? When is pain management indicated? Primary Survey

131. You respond to a structure fire/explosion. On your arrival you see a 40-year-old male who has just been removed from the building and appears unresponsive. What are your first priorities? Scenario

132. Primary Survey A: Stridor noted; oral mucosa appears red B: Rapid; BS equal; rhonchi in all fields C: No external bleeding; weak and rapid pulse D: GCS score 3 (E-1, V-1, M-1) E: Partial-thickness burns of upper chest (9% BSA) What are your immediate concerns? Why is he showing signs and symptoms of shock?

138. Environmental Injuries

139. You are doing race coverage for a 10-km (6-mile) race. The temperature is 90° F (32° C) with 90% humidity. On finishing the race, a 55-year-old male collapsed. On your arrival you find the patient confused. What places this patient at high risk for a heat emergency? How would you treat him? Scenario

142. You respond to the scene where a 34-year-old male has slipped in mud and fallen into a sewer. You are on the scene when, after 10 minutes, the rescue team brings up a limp body. Scenario

143. Primary Survey A: Water in oropharynx B: Apneic C: No active hemorrhage; very slow and weak carotid pulse D: Unresponsive; GCS score 3 (E-1, V-1, M-1) E: Clothing is wet How are you going to manage this patient?

147. Pediatric Vital Signs Age 0-2 months 3 months 6 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years Mean Weight (kg) 3.0 6.0 8.0 10.0 12.5 14.5 17.0 18.5 21.0 23.0 25.0 28.0 Pulse Range 100-170 100-170 100-170 90-170 90-170 70-130 70-130 70-130 60-110 60-110 60-110 60-110 Hypotensive Systolic Blood Pressure 60 60 60 70 70 70 70 80 80 80 80 80 Ventilatory Range 30-60 30-60 30-60 30-60 30-60 20-40 20-40 20-40 15-30 15-30 15-30 15-30

148. Primary Survey A: Snoring noises B: Rapid and shallow ventilations C: No obvious bleeding; weak and rapid pulse D: GCS score 10 (E-2, V-3, M-5); contusion to forehead E: Air is 50° F (10° C) and damp How would you manage this patient?

150. You are on the scene with an 85-year-old woman who slipped and fell in her home. How does the assessment of the elderly patient differ from the younger adult? Scenario

151. Primary Survey A: Open B: VR rapid with slight wheeze C: No obvious bleeding; normal and regular pulse D: Unable to move legs due to pain; GCS score 12 (E-3, V-4, M-5) E: No obvious external trauma How are you going to manage this patient?

153. You are dispatched to the scene of a pedestrian struck by a vehicle. Law enforcement and the fire department are en route. It is an overcast spring day with a temperature of 50° F (10° C). Scenario

154. What are your initial concerns as you arrive on the scene?

155. Ensure the safety of the prehospital care providers and the patient. What are the safety concerns with this scene? Overview

156. Assess the scene situation to determine the need for additional resources. What additional resources may be needed? Overview

157. Recognize the kinematics that produced the injuries. What are the factors relating to kinematics implied here? Overview

158. Use the primary survey approach to identify life-threatening conditions. What are the key concepts of the primary survey? Overview Breathing Airway Kinematics Circulation Disability Expose/ Environment

159. Provide appropriate management while maintaining cervical spine stabilization. The patient has noisy ventilations and blood is draining from the oropharynx. What should be considered when managing this airway? Overview

160. The patient’s ventilatory rate is 6 and is shallow. Cyanosis is visible on the patient’s face and fingers. There is bruising across the chest and decreased breath sounds are heard on the left. GCS score is 7 (E-2, V-1, M-4). Support ventilation and deliver oxygen to maintain SpO 2 at 95% or more. How can this be accomplished? Overview

161. Control any significant external hemorrhage. Overview

162. Direct pressure controls the external hemorrhage from the right arm. The radial pulse is weak and rapid at about 140 beats/min. The patient is pale, cold, and clammy. There is crepitus and tenderness on palpation of the pelvis and a left thigh deformity consistent with a left midshaft femur fracture. How would you manage these findings? Overview

163. Provide basic shock therapy, including restoring and maintaining normal body temperature and appropriately splinting musculoskeletal injuries. Consider the use of the PASG for patients with decompensated shock (SBP less than 90 mm Hg) and suspected pelvic, intraperitoneal, or retroperitoneal hemorrhage; and in patients with profound hypotension (SBP less than 60 mm Hg). Overview

164. Maintain manual spinal stabilization until the patient is immobilized onto a long backboard . When is spinal immobilization indicated? Overview

165. For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival on scene. Platinum 10 minutes Golden Period Overview 10

166. Initiate warmed intravenous fluid replacement en route to the receiving facility. What are the considerations with prehospital fluid therapy? Overview

167. Ascertain the patient’s medical history and perform a secondary survey when life-threatening problems have been satisfactorily managed or have been ruled out. Overview

168. Above all, do no further harm.

170. PHTLS Works!

171. QUESTIONS?