Patients With Traumatic Injuries
Condell Medical Center
EMS System
ECRN Packet
CE Module II 2008
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Viewing Packets on the Website
• To see the packet in larger print or to review the
•
•
•
•
•
packet and you no longer have a paper copy, go
to the Condell website
www.condell.org/emergency/
On right side of page choose “ECRN CE”
This will take you immediately to the CE page
and then choose your year and module.
Contact your EMS office for a copy of the quiz.
You must complete 4 modules per year to
maintain current ECRN licensure
Objectives
• Upon successful completion of this
module, the ECRN should be able to:
– Identify the differences between a Category
I, II and III trauma patient
– State EMS pre-hospital transport decisions for
trauma patients based on Region X guidelines
– Understand what the mechanism of injury is
and the information it provides
– Understand the difference between the index
of suspicion and the general impression
Objectives cont’d
– Describe assessment and field treatment appropriate
for the patient with traumatic insult based on Region
X SOP’s
• Burns, tension pneumothorax, sucking chest
wound, flail chest, pericardial tamponade,
eviscerated organs
– Understand where the landmark for chest needle
decompression
– Review trauma scenarios
– Successfully calculate the GCS and RTS given the
patient’s parameters
– Identify and appropriately state interventions for a
variety of EKG rhythms
– Identify ST elevation on a 12 lead EKG
– Successfully complete the quiz with a score of 80% or
better
Leading Causes of Death
• In the age groups from 1 to 44, unintentional
•
•
injury is the leading cause of death
45 and over, the leading causes of death are
disease
– cardiovascular disease and cancers
These statistics point to a financial burden
placed on the patient as well as society for
unintentional injuries
• Source: National Vital Statistics System, National Center for Health
Statistics, CDC
Level I Trauma Centers
• Prepared and committed to handle all
types of specialty trauma 24/7
• Provides leadership and resources to other
levels of trauma care in the Region
• Participates in data collection, research,
continuing education, and public
education programs
• Level I Region X: Evanston Hospital, St.
Francis in Evanston
• Level I non-Region X: Advocate Lutheran
General, Froedtert (Wisconsin)
Level II Trauma Centers
• Increased commitment to trauma care for
the most common trauma emergencies
with surgical capability available 24/7
• Participates in data collection, continuing
education, and public education programs
• Level II in Region X: Condell, Glenbrook,
Highland Park, Lake Forest, Rush North
Shore, Vista Medical Center East (VMH)
Additional Level II Trauma Centers
- Not Geographically In Region X
• Centegra – McHenry, Illinois
• Good Shepherd Hospital (GSH) –
Barrington, Illinois
• Northwest Community Hospital (NWCH) –
Arlington Heights
Region X SOP -Trauma Transport
• Systolic B/P < 90 on 2
consecutive readings (or peds
< 80)
–Transport to the highest level
Trauma Center within 25 minutes
–25 minute clock starts from the
time of injury
Region X SOP Trauma Transport
• Traumatic arrest, isolated burns >20%
–Transport to the closest Trauma
Center
• No airway
–Transport to the closest
Emergency Department
Hospital on By-pass
The closest appropriate hospital
must still accept any patient in
a life-threatening condition
even if they are on by-pass
Region X SOP Trauma Transport
• Category I Trauma Patient
–Unstable vital signs
–Based on anatomy of the injury
–Transport to the highest level
Trauma Center within 25 minutes
–25 minute clock starts from the
time of injury
Region X SOP Trauma Transport
• Category II Trauma Patient
–Based on mechanism of injury
•High potential for injury but
patient is stable for now
–Based on existence of co-morbid
factors that increase the risk of
complications to recovery
–Transport to the closest Trauma
Center
Region X SOP Trauma Transport
• Category III Trauma Patient
– All other traumatic injuries and where
routine care is being provided
– Isolated traumatic injury (generally GCS
>10)
• Isolated fractures
• Minor burns
• Lacerations
– Transport the patient to the closest
Trauma Center
Transport Decisions
When possible, EMS and
Medical Control are to honor
the patient’s request for
hospital destination
Mechanism of Injury
• The process and forces that cause trauma
• Mentally recreate the incident from the
evidence noted
• Identify strength of forces involved
• Identify direction forces came from
• Identify areas of the patient’s body most
likely affected by the forces
• Start to identify the mechanism of injury
during the scene size-up
Accepting The Radio Report
• Start forming a mental picture as you
receive report
• You are mentally forming an opinion based
on mechanism of injury
• You’ll think differently for the patient who
fell 5 feet versus 30 feet
• Form a general impression based on the
paramedic report of mechanism of injury
with their field assessment
Injury Patterns – Pedestrians
• Adults
•
– Generally turn away & present lateral surfaces
– Anatomically, impact is low on the body
– Injuries to tibia, fibula, femur, knee, lateral
chest, upper extremity, then head & neck
Pediatrics
– Generally turn and face the vehicle
– Injuries anatomically higher on the body than
adults
– Injuries to femur, pelvis and then those
sustained when run over or pushed aside by the
vehicle
Injury Patterns – Motor Vehicle
• Rotational (38% of MVC)
•
– Injuries similar to frontal & lateral
– Deceleration is usually more gradual & injuries
less serious although the vehicles look worse
Frontal (32% of MVC)
– Up and over the steering wheel pathway
• Femur fractures
• Blunt abdominal injury via compression
• Lower chest injuries after steering wheel
impact
• Head & neck injuries with windshield
impact
Injury Patterns – Motor Vehicle
– Down and under the dashboard pathway
• Lower leg injuries from sliding under the dash
• Chest injuries with steering wheel impact
• Collapsed lungs from breath holding at time of
impact
– Ejection
• 27% of fatalities
• 2 impacts – with interior vehicle & then the
objects outside the car (ground, trees, fences,
etc)
Injury Patterns – Motor Vehicle
• Lateral impact – T-bone (15% of MVC; 22% of
all MVC fatalities)
– Much less structural steel for protection between
victim and impact site
– Vehicle damage may not look severe but internal
injury potential is high
– Upper & lower extremity fractures on impact side
– Lateral compression with a large amount of internal
injury to chest & abdominal organs
– Unrestrained passengers are missiles and add to
injuries other passengers already sustained
Injury Patterns – Motor Vehicle
• Rear end (9% of MVC)
– Head rotates backward and then snaps forward
– Less neck injury if the head rest is properly
positioned
• Rollover (6% of MVC)
– Occupant experiences impact every time vehicle
impacts a point on the ground
– Vehicle sides and roof provide less crumple
zones for absorbing impact forces
– Ejection is common in unrestrained persons
Index of Suspicion
• Your anticipation of injury to a body,
region, organ, or structure based on
identification of the mechanism of
injury
• Your index of suspicion is honed from
experience and time on the job
General impression
• Formed from mechanism of injury
and index of suspicion
• Will guide the EMS provider
regarding a direction on how to
proceed in caring for this patient
Putting It All Together Sample
Report:
• The mechanism of injury is a frontal
MVC
The steering wheel is broken, chest
wall is bruised, breath sounds
decreased on the right
• Your index of suspicion is chest injury
• Your general impression is
pneumothorax
Documentation of The Complaint
To Include:
• O - onset
• P – provocation/palliation
• Q - quality
• R - radiation
• S – severity (0 – 10)
• T – timing – when did it start
Documentation
• Provide answers to:
–Who (the patient you’re caring for)
–What (happened)
–When (did it happen)
–Where (which body part)
–How (did it occur)
EMS Trauma Care – Amputated
Parts
• Routine trauma care
• To remove gross contamination, gently rinse
•
•
with normal saline
– DO NOT use distilled water to irrigate open
wounds
– Normal saline is isotonic and less harmful to
tissue
Cover stump with damp (normal saline) sterile
dressing and ace wrap
– Ace provides uniform pressure to stump
Cover wounds with sterile dressing
EMS Care of Amputated Parts
• Place part in a plastic zip lock
bag
• Place bag in larger bag or
container over ice and water
• Do not ice the part alone
EMS Pain Management Including
for Adult Burns
• Morphine for pain control
–2 mg slow IVP over 2 minutes
–May repeat every 2 minutes as
needed to a maximum of 10 mg
–Watch for respiratory depression
–Monitor for a drop in blood pressure
due to vasodilation from the
medication
Adult Burns - Electrical
• Immobilize the patient
– High potential for traumatic injury
•Muscle spasms during contact with
source
•Thrown when power source cut
– Assess for dysrhythmia – place on
cardiac monitor
– Assess distal neurovascular status of
affected part
– Cover wounds with dry sterile dressings
Adult Burns - Inhalation
• High risk for airway compromise
• Note presence of wheezing, hoarseness,
stridor, carbonaceous sputum, singed
nasal hair
• High flow oxygen via non-rebreather mask
• Monitor for need of advanced airway
device
– ETT – consider using ETT one size
smaller than normal due to potential
swelling of the airway
Adult Burns - Chemical
• HAZ-MAT team may be involved in the field
• If powdered chemical, first brush away excess
•
•
•
•
dry material
Clothing removed if possible
Area flushed with sterile saline
If eye involvement, remove contact lenses and
flush continuously with sterile saline
Avoid contamination of noninvolved areas
EMS Care for Adult Burns - Thermal
• Superficial – 1st degree
– Area cooled with sterile saline
– <20% BSA involved, apply sterile saline
soaked dressings for transport
– >20% BSA, apply dry sterile dressing
for transport
• Do not overcool major burns or apply ice
directly to burned areas
Adult Burns - Thermal
• Partial or full thickness (2nd or 3rd degree)
– Wear sterile gloves and mask while burn
areas are exposed
Decreases additional risk of wound
contamination
– Cover burn wound with dry sterile dressings
Preventing air flow over exposed burn
areas reduces pain levels
– EMS will place a clean sheet over the patient
– Protect the patient from hypothermia
Infant differences:
back 13%,
each buttocks 2.5%,
each entire leg 14%
Case Study #1
• Adult patient reached over a charcoal grill just as
•
the match was thrown onto the soaked coals
Injury is restricted to the right forearm
•
•
•
•
•
What type of burn is this?
Using the Rule of Nines, what is the TSBA burned?
What type of care is appropriate?
How can the pain be managed?
What does the documentation look like?
Case Study #1 – Patient with Burns
Skin is reddened and some
blistering is present
Case Study #1 – Category III
• Combination of superficial and partial thickness
•
•
•
burns approx 4.5% TSBA (circumferential
around forearm)
– Evidence of redness with a blistered area
although blister is broken
Appropriate care includes cooling burn, applying
sterile saline soaked dressing (<20% TBSA)
Additional helpful care
– Elevation of arm, removal of ring before
fingers swell
For pain control
– Morphine 2 mg slow IVP; can repeat 2 mg in
2 minutes up to 10 mg
Chest Injuries – Traumatic Arrest –
Category I Trauma
• Begin CPR
• Transport to closest Trauma Center
•
– A hospital on by-pass must take a patient in
life threatening condition if they are the
closest appropriate hospital
EMS to perform bilateral chest decompression
– Use common sense – does the scene size –
up, evaluation of mechanism of injury and
general impression indicate a potential chest
wall injury?
Chest Injuries – Tension
Pneumothorax – Category I Trauma
• History of injury to the chest wall
•
•
•
•
•
•
•
– On rare occasions can be spontaneous
Diminished breath sounds
Hyperresonance if percussion done
Severe dyspnea
Hyperinflation of chest
Jugular vein distention
Tachycardia
Hypotension
In-field Needle Decompression
• Landmarks anterior approach
–2nd intercostal space in the midline
of the clavicles
–Place prepared flutter valve needle
over the top of the rib
•Avoids potential injury to vessels
and nerves that run along the
bottom of the rib
Quick Way to Find 2nd ICS
• Feel for the top of the sternum
• Roll your finger tip to the anterior surface at the
•
top of the sternum
Feel the little bump near the top of the sternum
– This bump is the Angle of Louis
• From the Angle of Louis slide your fingers angled
slightly downward toward the affected side
following the rib space
– You are automatically in the 2nd ICS
• Identify the midline of the clavicle
– The midline is more lateral than persons realize and
usually runs in line with the nipple
Alternate Method to Find 2nd
Intercostal Space
• Palpate the clavicle and find the midline
– The midline is farther out (more lateral) from the
sternum than most persons realize
• Move your finger tips under the clavicle into the
1st intercostal space
– 1st rib is under the clavicle and is not palpated
– Spaces identified for the numbered rib above the
space
• Feel for the firm 2nd rib and palpate the soft
space below the rib
– This is the 2nd ICS
Field
Equipment
• Long needle (preferably 2-3 inch) and large
bore needle (preferably 12-14G)
• Flutter valve – finger cut from a glove
• Cleanser to prepare skin overlying the site
• Method to secure needle in place
– Skin will most likely be diaphoretic
– Tape may not stick
– May need to maintain manual control of needle
Skin Preparation
Midline of
clavicle
2nd ICS
Angle of
Louis
Inserting the
Needle
• Remove proximal end cap
•
•
•
from needle if present
– Will be able to hear trapped air escaping
Needle inserted over top of rib
– Once hiss of air heard continue to advance
catheter while withdrawing stylet
Stabilize catheter as best as possible
Patient should symptomatically improve
– Do not expect to hear improved breath
sounds; takes time for the lung to reexpand
Case Study #2
• EMS is called to the scene for a 52 year-old male
•
•
•
with c/o sudden onset dyspnea with pain
between his shoulder blades while watching TV
at home. The patient is agitated, short of
breath, with increased respiratory rate and SaO2
of 89%.
Further assessment reveals decreased breath
sounds on the right and clear on the left
Vital signs: 98/62; HR 118; RR 32 and shallow
Your impression & intervention plan?
Case Study #2
• Spontaneous tension pneumothorax
– They don’t all develop from trauma
• Supplemental oxygen support via non•
rebreather, cardiac monitor, preparation for IV
BUT
This patient needs needle decompression while
the above are being prepared
– Patients with a tension pneumothorax can’t wait and
will deteriorate without needle decompression
Sucking Chest Wound – Category I
Trauma
• Most common with penetrating wounds
• Free passage of air between the
atmosphere and pleural space if the open
wound is at least 2/3rd the size of the
diameter of the trachea
– Size of trachea about the size of pt’s 5th finger
• Air is drawn into the chest cavity, not into
the lungs
• Air replaces lung tissue
• Lung collapses
Sucking Chest Wound
• Severe dyspnea
• Open chest wound
– Check anterior, posterior, axilla areas
• Frothy blood at wound opening
• Sucking sound as air moves in and out
• Tachycardia with hypovolemia
Treatment Sucking Chest Wound
• Immediate treatment is to seal the
opening
– May start by placing a gloved hand over the
wound
– When able, place an occlusive dressing, taped
on 3 sides, over the wound
• Wound now converted to a closed
pneumothorax
• Monitor for signs of tension pneumothorax
– May need to lift a corner of the dressing to
release trapped air via burping dressing
Flail Chest – Category I Trauma
• 3 or more adjacent ribs broken in 2 or more
places
– Segment becomes free with pardoxical chest wall
motion during respirations
– Paradoxical movement more evident after the muscles
splinting the flail segment fatigue
• Usually takes a tremendous amount of blunt
•
•
trauma to cause a flail chest
Associated severe underlying injury (ie:
pulmonary contusion) will often be present
Respiratory volume reduced and respiratory
effort increased
Treatment Flail Chest
• Place patient on the injured side (may not be possible
to do this in the field based on mechanism of injury)
• High flow oxygen – non-rebreather mask
•
– Monitor for need to assist ventilations via BVM
to deliver positive pressure ventilations
• Evidence of underlying pulmonary injury
• Effort and fatigue
• Pulse oximetry
EKG monitoring
– Tremendous amount of force is delivered to the
chest wall and cardiac injury is highly likely as a
result
Pericardial Tamponade – Category I
Trauma
• Blood or other fluid fills the pericardial sac
restricting cardiac filling & contractility
• Most often related to penetrating trauma
• Venous return to the heart is restricted
• Decreased cardiac output
• Pressure on the coronary arteries restricts
blood flow to the myocardium
Pericardial Tamponade Signs &
Symptoms
• Usually history of penetrating trauma
• Agitated patient
• Diminished strength of pulses (weak and
•
•
•
•
•
thready) with tachycardia
Narrowing pulse pressure
– Diastolic & systolic numbers moving closer
together
Distended neck veins (JVD)
Diaphoretic and pale
Muffled, distant heart tones
Hypotension
Treatment Pericardial Tamponade
• Treatment in the field is limited to being
supportive
• Patient requires high index of suspicion
and/or rapid identification with rapid
transport
– In ED will perform needle thoracentesis and
then transfer the patient to the OR for open
heart surgery
General Assessment Pearls
• Restlessness and agitation
– You must consider hypoxia, shock,
influence of alcohol and/or drugs
– This is one time you need to assess for
all reasons of restlessness and not just
stop when you discovered one cause –
there may be more than one pathology
going on at a time
Evaluation Pearls – Low SaO2
• SaO2 reading may be inaccurate in the presence of:
•
– Hemorrhagic shock with delayed capillary refill
– Hypothermia
– Lung damage
Evaluate all parameters together to get the best
overall picture in ventilated patient
– What does the ETCO2 indicate?
– Are you able to ventilate the patient?
– Are there extenuating circumstances where the
circulation is affected and would affect the pulse
ox reading like those listed above?
More
Case
Studies
Case Study #3
• Your 34 year-old
patient received a
GSW to the right
upper abdomen.
• They are conscious
and alert; B/P 90/62;
HR 120; RR 28;
bleeding is minimal
• Category trauma?
• What interventions are
appropriate in field?
Case Study #3 – Category I Trauma
• Consider need for spinal immobilization
• During assessment of wound, consider thoracic
•
injury in addition to abdominal injury depending
on the angle of the GSW.
Examine for an exit wound
– Check the back and the axilla
• Prepare for the worst – assume the patient will
•
•
deteriorate before ED arrival
Repeat VS: B/P 80/; HR 140; RR 32, remains
conscious and in pain
Category I is transported to the highest level
Trauma Center within 25 minutes
Case Study #3 - Treatment
• Routine trauma care
• Question – is this an isolated abdominal wound or
•
•
is it a combination abdominal/ chest wound?
– Need to treat patient for potential injuries of
both body cavities
– EMS cannot determine in the field the angle of
the trajectory
Cover the wound and watch for evisceration
Fluid resuscitation – keep B/P at low levels; the
higher the B/P the faster the patient bleeds out
Case Study #4
• A 10 year-old patient
has a penetrating
injury to the right leg
near the knee while
playing in his backyard
• Initial VS: B/P 90/70;
HR; 130; RR 32; no
active
bleeding
• Category trauma? Field interventions?
Case Study #4 – Category III
• Next VS: B/P 92/64; HR 110; RR 20.
• Stabilize foreign body in place (gauze, trauma
•
dressing)
Obtain distal neurovascular status
– Distal pulses
– Movement – “can you wiggle your toes?”
– Sensation – “close your eyes and tell me which toe I
am touching”
• Document distal neurovascular status and
describe how the foreign object is stabilized in
place
Case Study #5
• Your 62 year-old patient had abdominal surgery
•
•
•
1 week ago. Today at home he sneezed hard
and felt a tearing
sensation in his
abdomen and
called EMS.
VS: B/P 100/60;
HR 110; RR 24
No active
bleeding
What
interventions
are appropriate
in the field?
Case Study #5 - Interventions
• Immediately cover the wound
– Need to minimize contamination
– Need to prevent more organs from protruding
– Need to prevent loss of fluids
• Place a saline moistened dressing over the
•
•
exposed tissue
Place dry gauze over the saline dressings
Can place light manual control over the organs
to prevent further evisceration especially during
movement, coughing, sneezing, deep breaths
Case Study #6
• Your 45 year-old patient is a construction
worker who was accidentally shot in the
head with a nail gun
• Upon EMS arrival, the patient is awake,
alert, talking (GCS 15)
• VS: B/P 132/78; HR 96; RR 20; complains
of a minor headache; minimal bleeding at
a few puncture wounds noted on the
occipital area of the scalp (patient has
thick hair).
X-ray
from
ED
No
deficits
noted
Case Study #6 - Treatment
• Consider any injury above the level of the clavicles
•
to include a c-spine injury until proven otherwise
and immobilize the patient
Control bleeding
– The face and scalp have such a rich blood supply small
wounds tend to bleed heavily
• Protect from further contamination
– The open wound may be in direct contact with the brain
• Document neurological evaluation to establish
baseline for comparison (AVPU, GCS, movement)
Case Study #7
• EMS was called to the scene for a 10 year-old
•
•
•
•
•
•
female who has been run over by a bus
As patient exited bus, she bent down to tie her
shoe and was caught under the wheels of the
bus
EMS noted a large amount of avulsed tissue with
bleeding from the left hip, left buttock, and left
upper thigh area
The patient is screaming in pain
VS: B/P 110/70; HR 110; RR 26 GCS 15
What is your impression?
What is your treatment plan?
10 y/o run over by bus
Case Study #7 – Category I or II?
• General impression
•
– Category II minimally – pedestrian run-over
– Category I trauma – if unstable pelvis or 2 or
more long bones (proximal bones) fractured or
unstable vital signs
Potential problems to consider & address
– Massive hemorrhage & control of hemorrhage
– Spinal injury
– Additional injuries
– Airway control
– Equipment to fit a 10 year-old
– Further wound contamination
1 year F/U with skin grafts
Glasgow Coma Scale – GSC
Review and Practice
• Tool used to evaluate and monitor a
patient’s condition
• Evaluates
Best eye opening
Best verbal response
Best motor response
• Serves as an indicator/predictor of survival
• To be obtained on all EMS patients
GCS
• Possible total score 3 (lowest) – 15
(highest)
• Minor head injury – patient scores
13 – 15
• Moderate head injury – patient scores
9 – 12
• Severe head injury – patient scores <8
–Significant mortality risk
GCS Pearls
• The change in the GCS is more important than
•
•
•
•
the absolute score
Check for associated injuries
– Manage a head injury as a multiple injured
patient until other injuries ruled out
Stabilize the neck for any head injury
Don’t assume the level of consciousness is
altered just because of ETOH and/or drugs
– Is there an occult (hidden) injury present?
Provide accurate, clear, detailed documentation
GCS – Eye Opening 1-4 Points
• Spontaneous (4) – eyes open; may or may not focus
• To voice (3) – prior to touching the patient, eyes will
•
•
open to sounds around them calling/yelling to them
to open eyes
– Often difficult to accurately assess due to EMS
gaining immediate c-spine control so difficult at
times to determine if patient responded to voice
or touch (pain). Eyelid flutter to voice is 3 points
To pain (2) – doesn’t necessarily imply you must
apply painful stimulus, could be just to touch
– Flutter of eyelids when touched is scored as 2
None (1) – eyes remain closed with no eyelid flutter
or other eye movement; eyes do not open
What’s the Eye Opening Score?
• When the patient is asked to open their eyes,
•
they refuse and actually close them tighter
What is their eye opening?
– The score is 3 (don’t open their eyes but there is
eyelid movement to voice command)
– Later, if the patient is more cooperative and then
open their eyes, their GCS will improve
MAKE SENSE?
GCS – Verbal Response 1-5 Points
• Oriented (5)
• Confused (4)
– Words may be appropriate to situation but
pt does not respond to questions
• Inappropriate words (3)
– Words are spoken and understood but
nonsensical to the situation (“over there”)
• Incomprehensible words (2)
– Includes mumbling, unintelligible speech,
moaning, groaning
• None (1)
What’s the Verbal Response Score?
• You have touched the patient’s injured arm and
•
•
the patient yells “stop, ow, don’t you’re hurting
me”
The patient does not carry on any other
conversation with you
The comments were appropriate for the
situation but the patient is not oriented nor are
the words inappropriate.
So by default this patient is scored a 4
for confused
GCS – Motor Response 1-6 Points
• Obeys command (6)
• Localizes pain (5)
– Patient who pulls equipment off; pushes your hands
away; purposeful movement
– This patient knows where the obnoxious stimuli is
contacting his body
• Withdraws to pain (4)
– Pt cannot isolate where they feel the noxious stimuli
so just pulls back/withdraws
• Flexion (3) – arms bent towards midline when
•
•
stimulated (decorticate)
Extension (2) – arms extended when stimulated
(decerebrate)
None (1) – remains flaccid
What’s the Motor Response Score?
• This patient is constantly trying to pull off the
•
cervical collar, take off the B/P cuff, and pull out
the IV (you call this uncooperative)
This patient is aware of what part of the body is
feeling some noxious stimuli so they are trying
to get rid of it/escape from it
This is purposeful movement (the
patient localizes the annoyance) and
is scored 5
GCS Pearls
• Give the patient the best score possible
– If the patient moves the right side of their
body but no movement on their left, score
them for the movement they currently exhibit
on the right
– If patient deteriorates, easier to see the drop
or change in the GCS score
• When testing for responses, watch even
for minimal activity like eyelid flutter or a
grimace
GCS Pearls
• Acceptable noxious stimuli
– Armpit pinch or nailbed pressure
– Sternal rub, pinching web space
between fingers, pinching shoulder
muscle (trapezius)
– Earlobe pinch is out of favor
•Can cause movement of head & neck
in response to the pain
GCS and RTS Tools
• See end of document for full size print of
the GCS and RTS forms
• This information is also on the radio run
report
– The ECRN is to fill out a GCS score on every
EMS call
– The ECRN calculates the RTS on every trauma
patient
RTS – Scoring 0 – 12 points
Practice GCS and RTS
• Calculate the scores for the next 6 cases
• Assign GCS (3 – 15 points)
• RTS
Convert the raw GCS number to its
respective score 0 – 4
Add the converted GCS number to the
points (0 – 4) for the respiratory rate
and systolic B/P
Determine the RTS (0 – 12 points)
GCS & RTS Practice #1
• Patient eyes are open and they watch you
•
•
•
•
•
during the examination
The patient is confused; they don’t remember
how they got hurt and can’t remember the day
of the week
When you ask the patient to “show me 2
fingers”, they respond but are slow to do so
VS: B/P 120/70; HR 88; RR 18
Total GCS?
Total RTS?
Practice #1
• Total GCS – 14
Eye opening 4 (spontaneous)
Verbal response 4 (confused)
Motor response 6 (follows commands)
• Converted GCS 4
• Respiratory rate 4
• Systolic B/P 4
• Total RTS - 12
GCS & RTS Practice #2
• The patient does not open their eyes
• The patient groans when pinched or an
injured body part is touched
• The patient does not follow commands
and will push your hands away when you
touch them
• VS: B/P 96/68; HR 102; RR 22
• Total GCS?
• Total RTS?
Practice #2
• Total GCS - 8
Eye opening – 1 (none)
Verbal response - 2 (groans)
Motor response – 5 (pushes you away)
• Converted GCS - 2
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 10
GCS & RTS Practice #3
• The patient’s eyes are open
• When asked “what month is this?”, the
patient responds, “he, umm, he…my
jacket. I don’t ..”
• If touched or pinched, the patient pulls
away from the contact
• VS: B/P 132/72; HR 96; RR 16
• Total GCS?
• Total RTS?
Practice #3
• Total GCS – 11
Eye opening – 4 (spontaneous)
Verbal response – 3 (inappropriate words)
Motor response – 4 (pulls away/withdraws)
• Converted GCS -3
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 11
GCS & RTS Practice #4
• Your patient’s eyes are closed but they
open wide if the patient’s injury is touched
• The patient yells “don’t” or “stop” when
there are pinched but does not answer
questions or speak in sentences
• The patient will push your hands away
when you touch them or try to put on
equipment
• VS: B/P 108/64; HR 102; RR 18
• Total GCS?
• Total RTS?
Practice #4
• Total GCS - 11
– Eye opening – 2 (opens when touched
“pain”)
– Verbal response – 4 (appropriate to being
touched but doesn’t carry on a
conversation – marked confusion)
– Motor response – 5 (pushes you away)
• Converted GCS -3
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 11
GCS & RTS Practice #5
• The patient’s eyes are closed but the
eyelids flutter when you loudly call out
their name
• The patient does not answer questions but
will groan when touched but not say
recognizable words
• The patient does not follow commands but
will push away your hands when touched
• VS: B/P 80/52; HR 112; RR 12
• Total GCS?
• Total RTS?
Practice #5
• Total GCS - 10
Eye opening – 3 (eyelids flutter to voice)
Verbal response – 2 (groans)
Motor response – 5 (pushes you away;
purposeful movement)
• Converted GCS - 3
• Respiratory rate - 4
• Systolic B/P - 3
• Total RTS - 10
GSC & RTS Practice #6
• The patient’s eyes are closed but will open when
•
•
•
•
•
the patient is touched
The patient says “leave me alone” and “what are
you doing?” and goes back to sleep. When eyes
are open they respond “I don’t know” to
questions
They do not follow command and will push your
hands away when touched
VS: B/P 110/68; HR 88; RR 20
Total GCS?
Total RTS?
Practice #6
• Total GCS - 11
Eye opening – 2 (opens to touch “pain”)
Verbal response – 4 (appropriate to the
situation but not oriented – marked
confusion)
Motor response – 5 (pushes you away)
• Converted GCS - 3
• Respiratory rate - 4
• Systolic B/P - 4
• Total RTS - 11
Practice Rhythm Strip Identification
and ID of ST elevation on 12 Lead
• Identify the lead II strip and think over
the SOP treatment appropriate if the
patient is symptomatic
• Identify the leads/location of the ST
elevation
– At CMC check the bulletin board outside
the EMS office for Cardiac Alert writeups and more examples of ST elevation
Identify Rhythm Strip #1
Strip #1
• Second degree Type I – Wenckebach
– PR interval gets longer, longer, longer and
then there is a dropped QRS
– The PR interval resets and the cycle
starts again
– Type I “drops one”
– Wenckebach “winks” at you
– Notice grouped beating (group and a
space, group and a space)
– Patient usually not symptomatic
Treatment IF Symptomatic
Bradycardia
• Bradycardia or Type I Wenckebach
– Atropine 0.5 mg rapid IVP (“when they’re alive give 0.5”)
– May repeat every 3-5 minutes to total of 3mg
– If ineffective, begin pacing
• Type II or 3rd degree heart block
–
–
–
–
–
–
–
Begin TCP
Valium 2 mg slow IVP for discomfort
May repeat 2 mg IVP every 2 minutes to max 10 mg
TCP set at rate 80/minute and start at lowest mA
Watch for capture
If TCP not effective, give Atropine 0.5 mg rapid IVP
May repeat Atropine 0.5 mg every 3-5 minutes; max 3mg
Identify Rhythm Strip #2 –
6 second strip
Strip #2 - Sinus Rhythm
• No treatment necessary for this rhythm
• Treat the patient’s complaint
• IF ACS complaint, then ACS SOP
– Aspirin 324 mg chewed (faster absorption)
– Nitroglycerin 0.4 mg sl
• May repeat in 5 minutes; watch B/P
• Screen for recent Viagra type drug usage
– Morphine if 2nd NTG dose not effective
• 2 mg slow IVP
• May repeat every 2 minutes to max 10 mg
Identify Rhythm Strip #3 –
6 second strip
Strip #3 – Atrial fibrillation
• A risk associated with atrial fibrillation is
stroke
– Clots form and are stagnant in the atria
– Clots can break off and migrate into the
circulation
• Important with new onset atrial fibrillation
to determine how long they have been in
it to guide therapies
– >48 hours higher risk of throwing a clot if
rhythm converted to sinus rhythm
EMS Treatment Rapid Atrial
Fibrillation
• Symptoms most likely dependent on the
heart rate
– The faster the heart rate, the less tolerable the
rhythm is especially for elderly patients
• Stable patient with B/P >100 mmHg
– Verapamil 5mg SLOW IVP over 2+ minutes
– If no response in 15 minutes & B/P stable,
repeat 5mg SLOW IVP over 2+ minutes
• Unstable patient with B/P <100 mmHg
– Contact Medical Control for direction
#1 – Identify ST Elevation
#2 – Identify ST elevation
#3 – Identify ST Elevation
ST Elevation Answer Key – Evaluate
the 3 12 Lead EKG Examples at the
end of the packet
• EKG #1 – Leads V 1 - 4
• EKG #2 – Leads V 2 - 5
• EKG #3 – Leads II, III, aVF
Bibliography
• Bledsoe, B., Porter, R., Cherry, R. Paramedic
•
•
•
•
•
Care Principles & Practices 2nd Edition Brady.
2006.
ITLS Bulletin. Case Study: ITLS Patient ETCO2.
June 2008.
Region X SOP’s Eff date March 1, 2007; Revised
January
2008.
www.chems.alaska.gov/ems/document/GCS
www.merck.com
www.swsahs.nsw.gov.au/