EMS: Prolonged Care and Care in Place

1. EMS: Prolonged Care and Care in Place Timothy R. Hurtado, DO Front Range Emergency Specialists Penrose-St. Francis Hospitals

2. Disclosure • Nothing to disclose

3. Objectives • Discuss issues for prolonged field care to include • Trauma • Cardiac • Pediatrics

4. Overall goals • Unique aspects • “stay and play” • “load and go”

5. Case 1 • 58 y/o male • Rollover MVC • Restrained • 60 MPH, moderate damage to interior • c/o CP, leg pain, pain in his pelvis

7. Case 1- Now what??

8. Exam • ABCs • Secondary • Appears to be in pain • Obvious open femur fracture • Crepitus and pain with palpation of pelvis • 178/110, 100, 22, 95% RA

9. History • NKDA • Medications: prn ibuprofen • Past Medical History: “I never go to the doctor, I don’t have any problems” • Last meal: 10 minutes ago, “I was eating a supersize meal while driving” • Events prior: “I became nauseous, got horrible heartburn then passed out I think”

11. Case 1 • What else do you want to know?

12. Case 1

13. Case 1 • Assessment? • Open femur fracture • Possible pelvic fracture • STEMI • MVC • Plan? • IVx2, O2, monitor, Fluids?, ASA?, Nitroglycerin?, pain meds?

14. Subacute trauma management • Management of: • Hypotension • Pain • Fluids • Environment

15. Fluid management • What is the optimum fluid? • Isotonic fluids • Colloids • Hypertonic fluids • Blood substitute (oxygen carrying substitutes)

16. Fluid management • What is the optimum amount? • When should it be given?

17. Bleeding control • Direct pressure • Proximal pressure points? • Topical hemostatic agents • Tourniquets

18. Tourniquets • Apply 2 inches proximal to bleeding site • Tighten until bleeding stops • Provide pain medication • Recheck

20. Pelvic pain and crepitus • Stabilization required • Sheet adequate • Commercially available devices

21. Pain control • Options? • Route? • Amounts? • Side effects?

22. Environment • Environmental control paramount • Lethal triad in trauma • Acidosis • Hypothermia • Coagulopathy • So keep your patient warm!

23. Case 1 • Pitfalls of the acute management of a STEMI • Hypotension • Arrythmias • Mechanical complications • Cardiogenic shock • Vfib/Vtach arrest/sudden cardiac death • Pericarditis

24. Arrhythmias • Generalized autonomic dysfunction that results in enhanced automaticity of the myocardium and conduction system • Increased concentrations of circulating catecholamines, and local release of catecholamines • 90% of patients will develop a arrythmia • Greastest risk in first hour after event

25. Arrhythmias • Sinus tachycardia • Afib/Aflutter • Bradycardia • AV blocks • Bundle branch blocks • Ventricular arrhythmias

26. Arrhythmias • Sinus tachycardia

27. Arrhythmias • Atrial flutter

28. Arrhythmias • Atrial fibrillation

29. Arrhythmias • Bradycardia

30. Arrhythmias • AV blocks 1st degree 2nd degree Mobitz 2nd degree type II

31. Arrhythmias • Premature Ventricular Contractions

32. Arrhythmias • Nonsustained ventricular tachycardia

33. Arrhythmias • Sustained ventricular tachycardia

34. Arrhythmias • Ventricular fibrillation

35. Cardiogenic shock • clinical definition is decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. • diagnosis at bedside by observing hypotension, absence of hypovomeia, and clinical signs of poor tissue perfusion, which include oliguria, cyanosis, cool extremities, and altered mentation. • Treatment- O2, vasopressors (dopamine), (+/-) diuretics if volume overloaded

36. Mechanical complications • Ventricular free wall rupture • Ventricalseptal rupture • Acute mitral regurgitation

38. Pericarditis • Acute pericarditis • 10%, and this complication usually develops within 24-96 hours • clinical presentation may include severe chest pain, usually pleuritic, and pericardial friction rub. • aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

39. Summary • Prolonged transport times • Keep patient warm • Crystalloids are still fluids of choice • Avoid over resuscitation with fluids in patients with uncontrolled hemorrhage • Many options for adequate pain control • Be aware of multiple complications in cardiac patients

40. Patient 2 • 4 y/o female • CC: abdominal pain and chest pain • History: Restrained passenger involved in MVC • PMHx: Asthma • 112/84, 138, 28, 92% RA

41. Exam • ABCs • Interactive, appropriate for situation • Multiple ecchymotic regions to the right chest wall, flank and abdomen

43. Case 2 • Assessment? • Blunt chest and abdominal trauma • Plan? • IV, O2, monitor, pulse ox • Fluids? • Pain medications?

44. So what’s different about kids? • Vital signs • Hypotension is a late sign of shock • SBP= 70+ (2 x age in years) • Children have a larger body surface area • Larger calvarium compared to adults percentage wise • Consider early IO access • Consider a fluid bolus of 20 ml/kg

45. Chest trauma • Children have relatively compliant chest walls • May be no external signs of trauma • Higher incidence of pulmonary contusions • Usually delayed in onset

46. Abdominal Trauma • Abdominal palpation most helpful part of exam • Ask child where they hurt • Two most common injuries are blunt hepatic and splenic lacerations

47. Sudden deterioration? • Airway • Position? • Tidal volume? • Rate? • Pneumothorax? • ET tube • Dislodged? • Plugged? • Right main? • IV/IO access • Infiltrated? • Dislodged? • Medications? • Unrecognized bleeding • Chest? • Pelvis? • Abdomen? • Ext? • Retroperitoneum? • Unrecognized injuries

48. Summary • Consider potential complications of patients when there are long transport times • Control environment to the greatest extent possible • Be prepared for the decompensating patient and have a plan

49. Questions?

50. References • Nolan J. Fluid resuscitation for the trauma patient. Resuscitation. 2001;48:57. • Santry et al. Fluid resuscitation: past, present and the future. Shock. 2010;33:229. • Cotton et al. Guidelines for fluid resuscitation in the injured patient. J Trauma, Inj and Crit Care. 2009;67:389. • Rosamond et al. Heart disease and stroke statistics--2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69. • Bloch Thomsen et al.. Long-term recording of cardiac arrhythmias with an implantable cardiac monitor in patients with reduced ejection fraction after acute myocardial infarction: the Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) study. Circulation. 2010;122:1258. • Kondur et al. Complications of Myocardial Infarction. Overview of MI Complications. http://emedicine.medscape.com/article/164924-overview#aw2aab6b2. Accessed April 10, 2013. • Bruner et al. Complications of acute myocardial infarction. Manual of cardiovascular care. Lipincott. 2013. • Britt et al. Priorities in the management of profound shock. SurgClin North Am. 1996;76:645. • Legomeet al. General principles of trauma. Clinical practice of emergency medicine. Lipincott. 2005. • Place et al. General approach to pediatric trauma. Clinical practice of emergency medicine. Lipincott. 2005. • Koerner et al. Chest and abdominal trauma. Clinical practice of emergency medicine. Lipincott. 2005. • Bliss et al. Pediatric thoracic trauma. Crit. Care Med. 2002;30:S409. • Holmes et al. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med. 2002;39:492. • Rocthrock et al. Abdominal trauma in infants and children: prompt identification and early management of serious life-threatening injuries. PediatrEmerg Care. 2000;16:189.