Test Bank For Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES • • • • • •

Detailed Lesson Plan Chapter 1 Trauma and Trauma Systems 135–155 Minutes

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Trauma and Trauma Care A. Trauma: physical injury or wound caused by external force or forces B. Third leading cause of death in United States; leading killer of persons < age 44 C. Steals greatest number of productive years from victims, and may be most expensive medical problem due to lost productivity and high cost of care D. More than 170,000 deaths per year; 34,500 due to automobile crashes, 31,500 due to gunshot wounds; other causes include falls, blasts, burns, stabbing, crush injuries, drowning, sports injuries E. Overall trauma and injury mortality rates have been increasing over the past decade F. Of EMS response, 30% is for trauma G. Role of EMS is to understand design and purpose of trauma care system, promote injury prevention, and provide care to trauma patients

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Critical Thinking Questions Why do you think that trauma injuries are increasing, even though prevention programs and engineering have attempted to reduce trauma incidence?

Knowledge Application For an assignment, have students define each key term.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 10

40

Content Outline III. Trauma A. Severity ranges from slight abrasions to multiple-system trauma B. Broken down into blunt and penetrating trauma C. Penetrating trauma: occurs when arrow, bullet, knife, or other object enters the body and exchanges energy directly with the human tissue, thereby causing injury D. Blunt trauma: occurs as energy and collision forces associated with an object—not the object itself—enter the body and damage tissue E. Presentation can often mask patient’s true condition— assessment must be aggressive and look past distracting injuries F. Of trauma injury, less than 10% is life-threatening; lifethreatening injuries are mostly internal with hemorrhage into head or body cavity G. Prehospital care does not offer definitive stabilization of these injuries; definitive care is only available at a specialized treatment center (trauma center) H. Determining the difference between life-threatening trauma and those less injured is essential in the prehospital setting—guideline of trauma triage will aid determination, ensuring proper transport to correct facility IV. Trauma as a Disease A. Only since the publication of “Accidental Death and Disability” has trauma been viewed and managed as a disease B. Major factor of medicine is prevention: five factors to prevent or reduce trauma C. Surveillance 1. Collection of data to identify the existence, significance, and characteristics of disease 2. Trauma is number one cause of mortality from 1–44 years of age 3. Study of disease based on surveillance is epidemiology

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Teaching Tips Using pictures, go over blunt versus penetrating injuries, and their presentations.

Class Activities With the class, create a call on the board, with initial time, time dispatched, time en route, time on scene, and so on, until the squad reaches hospital. Go over how much time is actually left in the Golden Period, and how making a transport error can cost a patient possible loss of life and/or limb.

Discussion Topics Discuss with students the various trauma injury prevention programs in your area.

Critical Thinking Questions What do you think is a leading trauma risk today? Has this changed over the past 10, 20, 30, or 40 years? Why? What sort of behaviors do you believe make people at risk for trauma?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline D. Risk Analysis 1. Looks at disease and determines various factors that impact its development, course, and consequences 2. Due to risk analysis, we know that behavior plays an important role in trauma 3. The Haddon Matrix is a helpful tool in identifying risk elements a.

Three-by-three matrix b.

Incident (pre-event), during the incident (event), after the incident (post-event) c.

Victim (host), causative factors (agent), factors surrounding incident (environment) d.

Pre-event factors: things that happen well before collision and cause, influence, or prevent the outcome (injury)—include defensive driver training, traffic law compliance, use of safety equipment, behavior, general health, physical and medical conditioning, alertness, distractions e.

Agent: kinetic energy exchange, reduced by auto designs, use of safety equipment f.

Environment: improved traffic patterns, visibility, speeds, traffic law enforcement g.

Event factors: exist during the crash; include health of occupant, alertness, influences in behaviors, use of safety equipment h.

Agent: impact; lower vehicle speeds, braking, crumple zones, safety equipment i.

Environment: crash barriers, weather visibility, vehicle control, stopping distance j.

Post-event factors: those that worsen or improve victim’s outcome after energy exchange k.

Host: knowledge of first aid, accessing EMS, victim ability to deal with blood loss and shock, general health, medication effects l.

Agent: fire-resistant fuel systems, OnStar

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Class Activities As a group, identify a possible risk of trauma, and apply the five factors of prevention/reduction.

Using the Haddon Matrix, have students change events and other details for different patient outcomes (e.g., use of safety equipment, texting, prevention programs, etc.)

Host

Agent

Environment

Pre-event Event Post-event

*This works really well, especially if you print off an 8 × 11 copy and laminate. You will be able to use markers to continuously change the outcomes of the trauma. Make sure that students also include EMS response in the postevent (BLS versus ALS, transport time, etc.)

Create scenarios in which students have an opportunity to use a teachable moment. Have them explain the behaviors that caused the risk, and what steps the patient can take to prevent future risk.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline m.

Environment: video surveillance, priority dispatch, EMS response, teachable moments, adverse weather conditions E. Intervention Development 1. Creates or modifies programs to reduce both the incidence and the seriousness of trauma 2. Technology allows information to be tracked during a motor vehicle collision (MVC) that will allow for accurate auto crash dynamics (OnStar, SYNC, Assist) 3. EMS is a post-event intervention 4. Includes safer automobile designs, use of safety equipment, prevention programs F. Implementation 1. Putting an intervention into practice 2. It includes enforcing laws, reducing speed limits, safer automobiles, gun safety programs, safety education, continually improving EMS systems, and so on 3. As health care providers, we must promote, teach, and teach by example 4. Use of teachable moment—patient comes near harm due to carelessness or disregard for safety; in a nonjudgmental manner, we can suggest that a positive behavior change can prevent event from occurring again G. Evaluation 1. Repeating the surveillance that took place before an intervention to identify benefits of the intervention 2. Continued searching of risk factors, development and implementation of interventions, and evaluation of performance must always be performed

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

10

V. The Trauma Care System A. Development of today’s trauma care system came from investigation of death toll on U.S. highways B. Studies in the 1960s revealed that victims suffered from crash-related injuries and lack of organized approach to

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Critical Thinking Questions Discuss the advantages and disadvantages of a staged response of EMS providers (i.e., EMR initial, EMT-B second, ALS as needed third).

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline providing definitive care C. Trauma Care Systems Planning and Development Act of 1990 helped established guidelines, funding, and state-level leadership support for trauma systems D. Proper hospital care for serious trauma includes immediate availability of skilled surgical intervention E. Well-designed EMS systems utilize hospitals with special resources and commitments to trauma patient care— hospitals designated as trauma centers

15

VI. Trauma Center Designation A. The current model for a trauma system includes four trauma center levels: 1. Level I: regional trauma center, usually a teaching hospital, prepared to handle all types of specialty trauma on a 24 hour a day basis a.

Neurosurgery, microsurgery, care for multisystem trauma b.

Provides leadership to other trauma center levels, data collection, research, continuing medical and public education 2. Level II: area trauma center has high commitment to trauma care, but not as great as Level I; surgical care capabilities at all times, can handle all but most seriously injured; staff can stabilize patients for transport to Level I 3. Level III: community trauma center; general hospital with commitment to special staff training and resource allocation for trauma patients; located in smaller communities and well prepared to care for most trauma patients and to stabilize and triage the more seriously injured for transport to high-level care 4. Level IV: patients taken for stabilization and care before transport; in these areas, trauma incident rate does not support resource allocation to meet requirement for

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discussion Topics Go through a trauma call with students. Start with first responders, and end with rehabilitation. Estimate costs for each level of care.

Critical Thinking Questions Discuss the initial purpose of the “Golden Hour” with students. Discuss if this is a reasonable expectation within their EMS system.

Discussion Topics Discuss with students the different trauma level hospitals available in your area.

Touch on patient flow between centers and critical care transfer of patients.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

trauma center B. Trauma system designs must be flexible enough to meet regional needs C. Specialty Centers 1. Certain medical facilities may be designed as specialty centers a.

Neurocenters, burn centers, pediatric trauma centers, hand and limb replantation, hyperbaric oxygenation b.

Specialty centers have a commitment of trained personnel, equipment, and other resources, along with specialized intensive care and state-of-the-art injury management 60

VII. Your Role as a Paramedic A. Role likely to begin with an appropriate patient assessment and triage; expeditious patient care and appropriate transport B. Trauma Assessment 1. Follows general patient assessment, but differs from medical with increased scene hazards, analyzing mechanism of injury and impact of environment, scene oversight, trauma triage guidelines, appropriate transport decision 2. Rapid trauma assessment versus focused assessment C. Scene Survey 1. Attention on scene safety and scene evaluation, mechanism of injury, environment, scene oversight D. Scene Safety 1. Associated hazards can include traffic, electrocution, jagged metal, glass, toxic substances, confined space, rough terrain, slippery spills, violence 2. Scene safety is the utmost importance for you, your crew, patient, and bystanders 3. Must look for scene hazards and rule them out

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Review with students the trauma triage criteria.

Review velocity in regard to trauma, along with mass.

Review the Glasgow Coma Scale score with students.

Review with students your local air medical service protocols.

Discussion Topics Discuss with students different hazards that can present on trauma calls, and the appropriate resources to be notified.

Discuss with students mechanism of injury, and the different injuries that can present based on various trauma.

Discuss with students the use of the CUPS when deciding to transport.

Critical Thinking Questions

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

E.

F.

G.

H.

4. Do not enter scene unless it is safe; always request assistance to make scene safe if necessary Mechanism of Injury Analysis 1. Mentally re-creating incident from evidence available at the scene 2. Attempt to identify strength of forces involved, direction, and areas of patient’s body injured 3. Automobile collisions require you to look at energy exchange between auto, patient, auto interior, and body organs; inspect collision and damage to auto 4. Index of suspicion: mental summation of anticipated injuries based on event analysis 5. Kinetic energy, velocity, body area have to be taken into account; strength and nature of impact can allow anticipation of injuries 6. Mechanism of injury (MOI) is an indirect indicator of energy transmission; signs of physical injury must be assessed 7. Signs and symptoms, vital signs, Glasgow Coma Scale (GCS), and level of consciousness (LOC) assessed in addition to MOI 8. Physical signs include: signs/symptoms of shock, head injury, LOC, GCS, vital signs; constant reassessment in necessary Environmental Impact Consideration 1. Adverse weather can impact assessment and patient care 2. Use available resources to protect patient from weather conditions Scene Oversight 1. Scene organization is critical to scene safety 2. Establish oversight and report any findings; relinquish when appropriate resources arrive Primary Assessment 1. Patient impression; rule out spinal precautions; secure

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

How could an incomplete run report affect the trauma registry information?

Class Activities Have students use different safety equipment and simulate injuries; you can use bicycle helmets, motorcycle helmets, seat belts, and so on. Show the proper use, and then have students identify what injuries can present when the equipment is used incorrectly.

Create a trauma scenario and include different weather conditions. Have students discuss what actions they can take to protect their patients from the different weather elements.

Create a trauma scenario, have students perform an assessment, and document the care. As a group, go over the call in a QI fashion, focusing on the injury and potential ways to prevent the injury in the future.

Using hard boiled eggs, throw them at a wall or at the ground using different forces and speeds. This allows students to visualize the damage that occurs when speed is increased (this makes a mess, so make sure you use tarps, or do it outside where the mess can be hosed down).

Knowledge Application For homework, have students research various trauma prevention programs that are offered in your area.

Points to Emphasize Remind students that speed increases the level of injuries sustained.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline airway, breathing, circulation (discuss ABC vs CAB); identify priority patient for care and transport 2. Determine orientation, responsiveness, chief complaint, and anxiety level, which will form your general impression 3. Spinal precautions cannot be excluded if your patient is a poor or reliable reporter (decreased LOC, significant distracting injury, elderly or very young) 4. Patients who cannot make it out of primary assessment are critical patients (C) 5. Patients with limited injuries and stable ABCs are stable (S) 6. Patients in between are either unstable (U) or potentially unstable (P) 7. CUPS categorization of patient severity I. Secondary Assessment 1. Stable patients receive a focused trauma assessment, which is a detailed assessment focusing on suspected injury or chief complaint 2. Vital signs, LOC, GCS will be reassessed continuously 3. Unstable or potentially unstable patients will receive a rapid trauma assessment, including LOC, vital signs (VS), and GCS J. Reassessment 1. Reassessment includes any primary and secondary assessment elements that revealed signs or symptoms and a set of vital signs.

2. Repeat every 5 minutes for unstable patient and every 15 minutes for stable patients K. The Golden Period 1. Goal for incident-to-surgery time is 1 hour 2. Important for EMS to minimize scene and transport time 3. Golden Period used to be called the Golden Hour 4. Some time-consuming factors are out of EMS control (extrication for instance)

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Trauma patients may initially present with stabile vital signs, so reassessment is imperative when treating your patient.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 5. Primary and secondary stabilization, packaging, and initiation of transport should be kept under 10 minutes 6. Prolonged ground transport may indicate air medical service 7. Measure air service request against patient condition, transport times, weather conditions L. Decision to Transport 1. Trauma triage criteria: GCS, vital signs (physical findings), anatomy of injury, mechanism of injury, age are all elements of trauma care and transport decision tree 2. MOI is first element of patient assessment, as it will provide preliminary information to determine patient priority (CUPS) 3. One of most difficult decisions made is when to transport 4. Patients who display key clinical and anatomical findings, particular MOI need to be transported immediately 5. IVs, intubation, other time-consuming procedures should be done en route 6. When using the trauma triage criteria, err on side of caution if suspicious about your patient 7. Trauma triage protocols are sensitive for injury and can lead to “over-triage” M. Injury Prevention 1. Prevention is the best, most cost-effective way to reduce trauma 2. EMS has responsibility to support prevention programs, participate in and promote development 3. Technical (engineering) developments play major roles in reducing injury and death N. Data and the Trauma Registry 1. Surveillance is the only way to recognize trauma care practices and procedures that benefit the patient

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 2. Trauma registry: uniform and standard set of data collected by regional trauma centers that is analyzed to describe types of patients and injuries responded to, how well system is performing, and identifying factors that may lessen or increase survival 3. Patient prehospital care reports need to be completed accurately and completely to describe assessment findings, patient care, reassessment, and times associated with calls 4. Consider taking part and supporting prehospital research projects O. Quality Improvement (QI) 1. Examines system performance with aim of providing better patient care 2. Looks at selected care indicators to determine if designated system care standards are being met 3. Studies trauma triage criteria application, field skill performance, time spent in response, assessment, care, transport, and documentation 4. If criteria not met, suggested steps include continuing education programs, EMS equipment modifications, protocol revision 5. True QI does not identify fault with individual providers

5

VIII. Summary A. Trauma remains one of society’s greatest tragedies B. Accounts for frequent death and disability C. A well-implemented trauma system offers ways to lessen the incidence and impact D. System consists of trauma centers, prevention programs, trauma triage protocols E. EMS must evaluate mental status, physical signs of injury, vital signs, mechanism of injury, trauma criteria

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 objectives can be found on text p. 1.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

X. You Make the Call

Class Activities Read and discuss the call and questions as a group.

XI. Review Questions

Class Activities

5

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Pass out review questions before the lesson starts. Have students answer them. Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 2 Mechanism of Injury 290–330 Minutes

• • • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

5

II. Introduction to Mechanism of Injury A. Mechanism of injury is the manner by which the injury occurred B. Trauma is typically classified as either blunt or penetrating C. Patients commonly have some component of both injury types

20

III. Kinematics of Trauma A. Kinetics: a branch of physics dealing with objects in motion and energy exchanges that occur as these objects collide 1. Measurement of how much energy an object in motion has; significant energy applied to human anatomy results in trauma B. Kinematics: studies the motion of a body or a system of bodies without consideration given to mass or force C. Inertia: Newton’s first law; a body in motion will remain in motion unless acted upon by an outside force—a body at rest will remain at rest unless acted upon by an outside force D. Energy Conservation: Energy can neither be created or destroyed; it can only be changed from one form to another E. Force: Newton’s second law; force strength is related to an object’s weight (mass) and the rate of its change in velocity: Force = [mass (weight) × acceleration (or deceleration)] / 2 F. Kinetic Energy: energy of an object in motion – object’s mass and velocity: Kinetic Energy = [mass (weight) × velocity squared] / 2; as speed increases, so does kinetic injury

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Knowledge Application For an assignment, have students define each key term.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

15

IV. Kinetics of Impact A. Can provide insight into the events that produce injury (the mechanism of injury) B. The manner in which energy exchange damages human tissue is known as biomechanics of trauma C. Index of suspicion: anticipation of the nature and severity of likely injuries

Master Teaching Notes Teaching Tips Using small toy cars, begin the explanation of the laws of motion.

Discussion Topics Discuss the engineering advances that change the outcomes of blunt trauma (e.g., seat belts, air bags, etc.)

Class Activities Have students practice the formulas of kinetic energy, changing acceleration and deceleration speeds; once this is done, have them begin to discuss the possible injuries that may be sustained in highversus low-velocity situations.

30

V. Biomechanics of Trauma A. Biomechanics of trauma is an investigation of the injury process 1. Examines kinetic energy forces as they progress from body’s external surface to internal organs 2. Bound by laws of inertia, force, and energy conservation 3. Divided into blunt and penetrating trauma 4. Penetrating—object physically enters body and directly or indirectly injures tissue 5. Blunt trauma—kinetic energy forces; object does not enter body and damage tissue 6. As kinetic energy and rate of velocity change, blunt impact causes injury (may be that person in motion contacts stationary object or stationary person is struck by something in motion) 7. Blunt trauma involves continuous series of collisions—compressing, stretching, shearing forces a.

Compression injury—blunt trauma abruptly halts a portion of the body while inertia causes remaining anatomy to continue its motion b.

Stretch—protein fibers that hold tissues together are pulled and

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Using balloons filled with water, show students the attachment point versus the weight of organ.

Use a cantaloupe to illustrate the laws of kinetic energy by dropping it on the ground to observe the damage. You can do this from various heights. This makes a mess, so do it in an area that can be cleaned easily.

Discussion Topics Discuss the most common organs that shear or tear from their point of attachment.

If possible, obtain a steering wheel from the local auto junk lot. Have students attempt to

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

85

Content Outline

Master Teaching Notes

injured or torn; occurs as one part of body is pulled away from another c.

Shear—occurs along edges of impacting force or at organ attachments; attaching ligaments resist motion and tears B. The laws of physics play a significant role in the pathophysiology of both blunt and penetrating injuries.

1. Solid organs are at greater risk of injury following blunt trauma than hollow organs C. Assessment of the mechanism of injury can provide important information regarding the likelihood of patient injuries 1. The Centers for Disease Control and Prevention has identified several mechanisms of injury as good predictors of the need for trauma center care

bend it, then reiterate the amount of energy that is required to bend the steering wheel.

VI. Blunt Trauma A. Blunt trauma most can result from motor vehicle collisions involving automobiles, motorcycles, bicycles, pedestrians, or off-road vehicles. It can also result from falls, explosions, crush injuries, and sports injuries.

B. Looking at the different blunt trauma types allows for understanding of MOI and effects on human body (indexes of suspicion) C. Vehicular Collisions 1. Large portion of paramedic responses 2. Rapid assessment and appropriate care must be performed 3. Recognition of types of vehicular impacts, possible mechanisms of injury, and index of suspicion allows for excellent patient care in a situation of time constriction D. Events of Impact 1. Vehicle collision—begins when vehicle strikes object a.

Vehicle kinetic energy causes damage as it converts to mechanical/heat energy and vehicle stops b.

Forces developed depend on initial velocity and stopping distance (rate of deceleration) c.

Degree of auto deformity is indicator of strength and direction of forces experienced 2. Body collision—occurs when occupant strikes vehicle interior a.

Unrestrained occupant remains at or close to initial speed

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Critical Thinking Questions Why would identifying the index of suspicion provide better patient care?

Knowledge Application For an assignment, have students define each key term.

Class Activities Have students review the coup contracoup injuries commonly seen in deceleration/acceleration collisions and identify signs and symptoms.

As a demonstration, drop a cantaloupe to determine the damage. Place a bicycle helmet on another cantaloupe and then drop it. You should be able to observe that without safety equipment, more damage occurs.

Teaching Tips Using several pictures of skeletons, mark the likely fractures students will see with the different types of falls, and the pathway the energy takes.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline b. c.

Kinetic energy is transformed into initial tissue deformity Restraints decrease occupant’s rate of deceleration, impact force strength, and seriousness of expected injuries 3. Organ collision—tissues behind contacting surface of occupant’s body collide, one into another, as body comes to a halt a.

Causes compression, stretching, shearing as tissues and organs violently press into each other b.

Organs may twist or tear at point of attachment or at blood vessel 4. Secondary collision—occurs when occupant is impacted by objects traveling within the auto a.

Always consider possibility of secondary collisions 5. Additional impacts—occurs when vehicle receives a second impact a.

Vehicle hit by another vehicle, deflected b.

May induce additional injuries or increase seriousness of present injuries 6. Restraints a.

Seat belts, air bags, child safety seats b.

Have a profound effect on injuries; significantly reduce collisionrelated deaths c.

Consider the use of restraints when assessing the scene d.

Paramedic should always use restraints when driving ambulance 7. Seat Belts a.

Prevents wearer’s continuous and independent movement during a vehicle collision b.

Allows occupant to slow with auto, reducing deceleration rate and lessening likelihood of serious injury (including ejection) c.

Shoulder and lap belts must be worn properly to be effective, and they must be worn together; improper use may cause injury Does not protect against intrusion; rapid deceleration may cause injury even with lap and shoulder belt 8. Supplemental Restraint Systems (SRSs) a. Air bags b. Effective for frontal collisions c. Explosive inflation upon auto impact, providing a cushion to absorb energy ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Use pictures of various motor vehicle collisions and go over the expected injuries with each impact.

Using pictures, show students expected injuries when lap and shoulder belts are worn incorrectly.

Obtain crash test dummy safety videos to watch.

Discussion Topics Discuss how people who fall < 15 feet tend to land in the position in which they originally fell, whereas people who fall > 15 feet are generally able to turn themselves to land on their feet.

Discuss the likelihood of head and spine trauma in motorcycle riders, even with helmets worn.

Discuss different distractions that can occur that may cause motor vehicle collisions, and ways that they could be prevented.

Discuss the dangers of ATVs, due to young riders and lack of experience.

Discuss the expected injuries when dealing with a jet ski.

Discuss the expected “crumple zones” of an automobile, and how these zones are

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline d.

Ignition depends on detectors that sense very strong frontal deceleration e. Ignition is instantaneous; reduces vehicular trauma and death f.

Positioned in steering wheel, with SRS insignia, dash for passengers, sides of car, and so on g. May induce injury to hands, face, arms due to rapid inflation; residue from SRS may cause irritation of eyes h. Children and infants at risk for serious injury; children under the age of 12 should ride in the back seat i.

Paramedic should always check under the airbag to determine if any structural damage has occurred j.

Fire, rescue, and extrication personnel should be trained in SRS deactivation and should deactivate any undeployed devices at the crash scene.

9. Child Safety Seats a. Anatomy of child makes vehicle collision protection difficult b. Infants and very small children (up to two years of age) should be placed in rear seating area, facing backward, and latched firmly c. Infants and small children should be placed in appropriate child safety seats d. Children held on an adult’s lap are not protected during a collision; child becomes an unrestrained moving object 10. Head Rests a. Designed to prevent unopposed rearward motion of head during rear-end collision b. If there is no headrest, or headrest is pushed down, head will fling back in relation to torso c. Properly aligned head rest will cause the head to move with the rest of the body, preventing violent backward rotation and extension; this reduces injury to spinal column, neck ligaments, and neck muscles d. Check head rest whenever evaluating a rear-end collision 11. Passenger Compartment Intrusion a. Occurs when collision forces push through the vehicle’s structure and deforms occupant compartment ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes created to absorb the energy and will appear as destruction to the automobile.

Discuss the risks of intoxicated driving.

Class Activities Using toy cars (plastic, can usually be purchased at garage sales, thrift stores, etc.), create an impact—you will need several cars. Have students discuss the injuries, then add SRS and seat belts to identify what injuries might be prevented (you can even add dolls—Barbie dolls work well—to shade in expected injuries).

Points to Emphasize Any intrusion into occupant compartment suggests stronger forces and failure of crumple zones, allowing for greater injury.

The more rapid the deceleration (shorter stopping distance), the greater the force and resulting injury for any trauma.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline b. c.

Suggests increased kinetic forces and likelihood of injuries Lateral impact intrusion is frequent, due to associated crumple zone limitations, and associated with high occupant mortality rate

E. Types of Impacts 1. Frontal impact—most common type of impact; four pathways of patient travel a. Restrained pathway: use of lap and shoulder belts retrains movement and allows deceleration with vehicle, limiting interior impact and energy b. Up-and-over pathway: unrestrained occupant tenses legs, preparing for collision; upper body pivots forward and upward; femurs, abdominal cavity, and lower chest impinged with steering wheel; head propelled toward windshield, resulting in compression on cervical spine (axial loading); large number of deaths attributed to up-and-over pathway c. Up-and-over pathway injuries: bilateral femur fractures, holloworgan rupture, liver laceration, diaphragmatic rupture, thoracic injuries, soft-tissue injuries, skull or facial fractures, internal head injuries, vertebral fractures d. Down-and-under pathway: unrestrained occupant slides downward, with knees contacting firewall; upper body rotates, crashing against wheel or dash e. Down-and-under pathway injuries: knee, femur, and hip dislocations or fractures; flail chest; cardiac injury; aortic tears; tracheal and vascular injuries; “paper bag” syndrome (occupant takes deep breath as impact is imminent, impact with steering wheel causes lungs to rupture); pneumothorax; pulmonary contusions f.

Ejection: up-and-over pathway may lead to ejection; two impacts occur, contact with interior of vehicle and impact with outside environment (ground, tree, etc.), most commonly associated with frontal impacts g. Vehicle design has created the “crumple zone” with realization that frontal impacts more common—this allows front of vehicle to absorb impact energy, resulting in structural damage to vehicle and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 2.

3.

4.

5.

reduced force to occupants h. Air bags and seat belts also aid in reducing injuries Lateral impact—occupants present in different position to collision forces, and limited amount of space available to absorb energy a. Greater likelihood of vehicle intrusion into occupant space, resulting in injuries b. Index of suspicion is higher in lateral impact due to kinetic forces c. Lateral injuries: clavicle, humerus, pelvis, and femur fractures on impact side; lateral rib fractures; cervical spine injury; lateral compressions may cause diaphragmatic rupture, pulmonary contusions, splenic injury (driver), liver injury (passenger), aortic injury, aortic tearing d. Unrestrained passengers may become objects that can strike other passengers Oblique impact—struck at angle; four subcategories include left front, right front, side, or rear a. Index of suspicion blends lateral, front-end, and rear-end injuries b. If impact not directed at vehicle’s center of mass, impact will induce rotation, which will accelerate or decelerate from auto’s center, allowing deflection rather than abrupt stopping (rotation more common with oblique impact) c. Oblique impact injuries: any injuries can occur, although may be less serious than vehicle damage suggests Rear-end impact—collision force pushes auto forward a. Seat propels occupant forward, neck extends and neck muscles and ligaments stretch while head rotates backward b. Once acceleration stops, head snaps forward and neck flexes c. Rear-end impact injuries: rapid hyperextension and hyperflexion can result in severe connective tissue and cervical vertebra injuries; other injuries may be present, but rear-end impacts tend to result in limited injuries Rollover—normally caused by change in elevation and/or affecting a vehicle with high center of gravity a. As vehicle rolls, impacts ground at various points, while occupant impacts with each vehicle impact

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline b.

Rollover injuries: ejection; head, limb, or torso trapped between vehicle and ground c. Mortality increases significantly when ejection is associated with a vehicle collision d. Seat belts are very effective in reducing ejection and injury during a rollover 6. Vehicle Collision Analysis a. Collisions often produce hazards to occupants, bystanders, and care providers b. Hazards include: hot engine, exhaust and transmission parts, hot fluids (radiator coolant, oil), battery acid, transmission and steering fluids, jagged metal edges, broken glass, slippery surfaces from gasoline or oil, along with fire danger, traffic moving near crash, downed electrical lines, and terrain of scene. Hybrid vehicles pose two additional hazards: First, high-voltage electrical propulsion system components, although well protected, can cause electrocution. Second, the electrical propulsion system in a hybrid vehicle can engage even when the engine does not seem to be running and cause unexpected movement of the vehicle; this danger can be eliminated by removing the ignition key or moving a proximity-ignition fob more than 16 feet from the steering column. c. Rule out all scene dangers before entering d. Collision evaluation includes: direction of impact, amount of vehicle damage, recognition of crumple zones, size of vehicles, deceleration or acceleration forces, striking objects e. Interior vehicle collision evaluation includes: vehicle intrusion into occupant compartment, spider-webbed windshield; deformed steering wheel; dented dash; deformities of gas, brake, or clutch pedals; deployed air bag; firewall or dashboard in occupant compartment; parts of vehicle may be imbedded in occupant, complicating extrication; assess use of restraints and headrest position 7. Impairment a. Consider possibility of alcohol or drug intoxication b. Assessment must be more diligent for use with suspected ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline intoxication, due to reduced reaction time, alertness, and masking of signs and symptoms of injury—patient may be anesthetized from trauma pain c. Look at all evidence surrounding collision for signs of driver trying to stop or avoid collision, possibility of distraction or medical condition causes 8. Vehicular Mortality a. Certain areas of anatomy prone to life-threatening injury b. Blunt trauma to head and body cavity accounts for 85% of vehicular mortality c. Assessment is focused on ABCs, rapid assessment of head, neck, thorax, abdomen, pelvis 9. Collision Evaluation a. Questions for collision evaluation include: how did objects collide; what direction and speed; similar sized or grossly different; secondary collisions present; anything contribute to collision; alcohol involved; any skid marks present? b. Questions for interior collision evaluation include: windshield damage, steering wheel deformed, dash dented, passenger compartment intrusion, seat belts worn, air bags deployed, head rest up? c. Answers to these questions will allow you to develop indices of suspicion F. Motorcycle collisions—lack the protection of vehicle structure; rider tends to absorb much of crash energy; injuries can be severe; high incidence of head injury 1. Frontal—bike front dips downward, propelling rider upward and forward; handlebars catch rider’s lower abdomen or pelvis, causing abdominal or pelvic injuries; rider may travel at higher speed, with handlebars trapping femurs, resulting in bilateral fractures and ejection 2. Angular—bike strikes object at oblique angle, with lower extremity trapped between object and bike, crushing foot, ankle, knee, and femurs; open wounds often result 3. Sliding—occurs when experienced rider faces imminent collision and “lays the bike down”; slides bike sideways into object, so bike hits object

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline first, absorbing most of energy; this reduces chances of ejection; increase in lacerations, abrasions, minor fractures 4. Ejection—common and usually results in serious injury; can occur with initial bike/object collision, rider/object collision, rider/ground impact 5. Likely ejection injuries include skull fractures, head injury, spinal fractures, paralysis, internal thoracic or abdominal injuries, extremity fractures 6. Protective equipment such as helmets, leather clothing, and boots help to reduce certain injuries G. Pedestrian collisions—often severely injured due to vehicle’s mass and speed and pedestrian’s lack of protection 1. Adult pedestrians: tend to turn away from oncoming vehicle, resulting in impact to lower leg, lateral upper body movement into hood, then possible ground impact 2. Adult pedestrian injuries include: lower leg, knee, and femur injuries; lateral chest and upper extremity fractures; head, neck, and shoulder trauma; injuries from secondary collision with ground 3. Pediatric pedestrians: tend to turn toward oncoming vehicle, resulting in impact to femur and pelvis, thrown into front of vehicle, then run over or pushed to side by vehicle; may be thrown onto hood 4. Pediatric pedestrian injuries include: femur fractures, thoracic and cardiac injuries, head and neck injuries 5. Look at the scene to determine speed at impact, distance pedestrian thrown H. Off-road collisions—increased incidence of related trauma, injuries similar to auto collision, but with no benefit of structural protection and restraint system 1. Response can be delayed due to difficulty in reaching and retrieving victims 2. Snowmobiles, watercrafts, and all-terrain vehicles (ATVs) are most often involved 3. Snowmobiles: collisions can be very violent due to speed and limited crumple zones; collisions usually result in ejection, crush injuries from rollover, and striking obstructions in snow 4. Snowmobile injuries include: severe head and neck injuries, neck lacerations, decapitation (running into unseen wire fence), cold

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

I.

exposure, and hypothermia 5. Watercrafts: commonly result from impact with other boats, obstructions in water; not designed to absorb energy 6. Watercraft injuries include: head, neck, and spinal injuries; drowning; and hypothermia in colder water 7. ATV center of gravity high, contributing to rollover 8. ATV injuries include: head, neck, and spine injuries; upper and lower extremity fractures Falls 1. Most common form of blunt trauma, very infrequently result in lifethreatening injury 2. Very young and very old are most at risk 3. Falls are a release of stored gravitational energy 4. As height of fall increases, so do velocity and kinetic energy at impact 5. Stopping distance may be more important than fall height 6. Newton’s second law in falls: the more rapid the deceleration (the shorter the stopping distance), the greater the force and resulting injury 7. Landing surface also affects injury 8. Feet-first landing: energy transmitted up skeletal structure to calcaneus, tibia, femur, pelvis and lumbar spine; lumbar spine prone to compression injury 9. Fall forward after initial impact may result in wrist, shoulder, clavicle fractures 10. Fall backward after initial impact may result in pelvic, thoracic, and head injuries 11. Axial loading can result in crushed vertebra, as a result of shallow dives 12. Outstretched-arm falls result in hand, wrist, elbow, arm, and shoulder injuries 13. Greater than three times a person’s height constitutes a severe fall, and internal organs may be compressed, displaced, or twisted; exsanguination may occur if heart is torn away from aortic attachments 14. Evaluation of a fall includes: fall height, anatomical point of landing, force of impact, impact surface, transmission of energy along skeleton 15. Falls are common in elderly, due to decreased coordination, decreased eyesight, and weakened muscles and bones, with injuries sustained

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Teaching Topics Using pictures, describe the different categories of an explosion.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline from less energy J. Blast Injuries 1. Explosions can be caused by dust, fumes, explosive compounds—may be intentional or unintentional 2. Explosion a. Occurs when agent or environment combusts b. Fuel and oxidizing agent combine, chemical bonds broken and reestablished, releasing energy in form of rapidly moving molecules, known as heat c. Heat creates great pressure between exploding agent and surrounding air d. MOIs created include pressure wave, blast wind, projectiles, displacement of person, heat 3. Pressure Wave a. Superheating of surrounding air from combustible agent b. Compressed air pushes air further out from ignition point, creating a pressure wave c. This is a narrow compression wave that that moves rapidly outward (overpressure) d. Pressure of exploding cloud is extremely lethal and area can be extensive (confined space, underwater) e. Injuries include: body’s air-filled spaces subject to rapid and severe compression and decompression-—ear drum, middle ear, sinuses, bowel, lungs f.

The greater the surface of the victim presented to the blast wave, the greater the impact and damage 4. Blast Wind a. Follows the pressure wave and travels just behind b. Outward movement of heated and expanding combustion gases from explosion epicenter c. Less strength but greater duration than pressure wave 5. Projectiles a. Container fragments become high-speed projectiles b. Ordnance: military explosion casing c. Flechette; arrow-shaped missiles

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discussion Topics Discuss with students how they would proceed if the explosion was the result of a terrorist attack.

Discuss the explosions that have occurred in your local area. Focus on incident command, treatment, and transport.

Class Activities Have students list the injuries they expect to find in each blast-type injury and the care they would provide.

Points to Emphasize Only personnel trained in confined-space rescue should enter this scene.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline d.

6.

7.

8.

9.

Some explosions may contain nails, screws, ball bearings, other material that enhances range and potential for injury e. “Dirty bomb” is a conventional explosive that distributes radioactive material f.

If victim close to blast, debris may be forceful enough to tear off limbs or cause serious open wounds, impalement of bomb elements Personnel Displacement a. Overpressure wave and blast wind may be strong enough to physically propel victim away from blast’s epicenter b. Victim becomes a projectile, then impacts the ground or other objects Confined-Space Explosions and Structural Collapses a. Pressure wave maintains energy longer b. Danger of structural collapse, blast overpressure, and deadly overpressure c. Most lethal blasts are those that cause structural collapse, with confined-space blasts second d. Structural collapse causes severe crush injuries, makes victims difficult to find and difficult to extricate e. Hazards to rescuers increased by secondary collapse, fire, electrocution, and secondary explosions Burns a. Flash burns may occur to those close to detonation, or as blast ignites combustible material (clothing, debris, etc.) b. Some devices designed to induce damage through combustion (Napalm) c. Some material spontaneously combusts when exposed to air (phosphorus) Blast Injury Types a. Primary—caused by heat of explosion and overpressure wave; pressure injuries usually most serious and life threatening; generally damage air-filled body spaces b. Secondary—trauma caused by projectiles; may be as serious or more severe than primary blast injuries; generally multiple

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline penetrations, impalement, bleeding Tertiary—results from personnel displacement and structural collapse; crush injuries; soft tissue, skeletal system, nervous system, vascular tissue damage d. Quarternary—any other injuries caused by the explosion mechanism including crush injuries, burns, asphyxia, toxic exposures, and exacerbations of preexisting or chronic illnesses.

10. Blast Injury Assessment a. Attempt to determine if result of terrorist attack (due to suspicion of other exploding devices) b. Assess scene; request trained assistance; look for gas leaks, electrical wiring, debris, structural collapse c. Attempt to determine blast epicenter by noticing greater damage and injury d. Victims close to epicenter sustain extreme injury e. ABCs, and normal assessment priorities normally will be the role of a paramedic f.

Most common life-threatening trauma is lung injury; anticipate with any patient involved; evaluate breathing, breath sounds, oxygen saturation (note: suspect lung injury in anyone with hearing loss or epistaxis) 11. Blast Injury Care a. Lungs i.

Pulmonary blast trauma most frequent life-threatening pressure injury ii. Pressure wave rapidly and forcefully compresses, distorts, and then decompresses chest cavity, air passages, and alveoli iii. Extreme pressure damages/ruptures thin alveoli, resulting in inflammation, fluid accumulation, hemorrhage, air entry into bloodstream iv. Signs and symptoms include: pulmonary edema, difficulty breathing, hemoptysis, frothy sputum, reduced level of consciousness (LOC), history of detonation exposure v. Treatment includes: use extreme caution if using bag-valve c.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline mask (BVM) with these patients, as positive pressure ventilation may cause small air bubbles to be pushed into vascular system and create emboli; if using BVM, only use enough pressure to create moderate chest rise and fall and adequate respiratory volume, along with high-concentration oxygen (O2) as supplied with reservoir b. Abdomen i.

May damage air-filled bowel, resulting in hemorrhage and possible wall rupture and release of bowel contents into abdominal cavity (peritonitis) ii. Be alert to signs of developing shock; provide rapid transport and fluid resuscitation c. Ears i.

Suffer greatly from blast wave forces ii. Eustachian tube cannot equalize pressure changes, causing stretching/rupture to tympanic membrane, and resulting in hearing loss iii. Treatment includes: support to victim and ensure that ear canal remains uncontaminated d. Penetrating Wounds i.

Care is same as with any penetrating wound; remove any contaminated material if possible, cover with sterile dressing, stabilize any impaled objects e. Burns i.

ABCs, stop burning process K. Sports Injuries 1. Most commonly produced by extreme exertion, fatigue, direct trauma forces 2. Secondary to acceleration, deceleration, compression, rotation, hyperextension, hyperflexion 3. Results in soft tissue damage, connective tissue injury to tendons and ligaments, skeletal trauma, and internal damage to hollow or solid organs 4. If debilitating injury occurs, transport for evaluation must occur before athlete can further participate in sport

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Discuss steps that can be taken to prevent sports injuries.

Discuss the pathophysiology of crush injuries and compartment syndrome, as well as the causes and treatments.

Critical Thinking Questions What sports equipment can cause injuries?

Class Activities Have students review the concussion checklist.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

15

Content Outline 5. Some contact sports can create severe head impacts; any period of unconsciousness, neurological deficit, lowered orientation requires physician evaluation 6. Protective equipment reduces chance for significant injury, but can be a contributing factor 7. Removal of helmet is indicated if airway cannot be controlled and helmet is hindering care; otherwise, immobilize with helmet on L. Crush Injuries 1. Common type of trauma that can result from structural collapse, limb caught in machinery, and other mechanisms 2. Great force to soft tissue and bones, compressing surfaces and causing severe tissue disruption and hemorrhage 3. If crushing pressure remains in place for extended period, blood flow disrupted, anaerobic metabolism begins, and tissue death follows; if blood flow returned to limb, toxins carried back to central circulation, causing cardiac arrhythmias or damage to kidneys; may also cause severe hemorrhage once limb is released 4. Treatment may include: sodium bicarbonate, other medications to combat acidosis, limit damage, and preserve kidney function M. Compartment Syndrome 1. Blunt trauma associated with crush injuries 2. Swelling to a large muscle mass may be faster than fascial (connective) tissue can accommodate 3. Pressure increases and blood flow is reduced; after 3 to 4 hours, muscle stiffens and becomes painful 4. It is unlikely that compartment syndrome will be recognized in the field.

5. Frequent cause of post-blunt trauma disability; patient will complain of muscle pain long after injury is healed VII. Penetrating Trauma A. Perforating trauma, a form of penetrating trauma, occurs when an object enters and exits the body B. Overview and Incidence 1. The most common causes of penetrating trauma in the United States are gunshots and stabbings.

2. Penetrating trauma can also occur with motor vehicle collisions, falls,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Points to Emphasize When responding to a sports emergency, look at the sports equipment used. If there is damage to the equipment, greater force is implied.

Knowledge Application For an assignment, have students define each key term.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

industrial injuries, and similar events.

3. Three levels of penetrating trauma—low, medium, high a. Low velocity: bladed and pointed objects such as knives, swords, ice picks, arrows, ski poles, wire, nails, reinforcing rods; injuries usually limited to tissue actually contacted by object b. Medium velocity: handgun bullets; injuries usually more severe due to extensive injury pathways c. High-velocity: rifle bullets; injuries usually more severe due to extensive injury pathways

30

VIII. Kinetics of Penetrating Trauma A. When projectile hits a target, exchanges kinetic energy (energy of motion) with object struck B. Formula: Kinetic Energy = [mass (weight) × velocity (speed)2] / 2 C. The greater the mass or speed of an object, the greater the kinetic energy D. Mass to energy is direct, whereas velocity to energy is squared E. As speed increases, so does kinetic energy F. Mass and velocity relationship explains why different weights of bullets traveling at different velocities can cause different degrees of damage G. Medium velocity: handguns, shotguns, low-powered rifles (.22) H. High velocity: hunting and assault rifles I. Law of conservation of energy explains why projectile’s kinetic energy is transformed into damage as it slows—kinetic energy lost by bullet as it passes through tissue is transferred into tissue displacement, and converted to tissue damage J. Deceleration rate—force formula: Force = mass × acceleration (deceleration) K. The more quickly an object slows, the more rapidly it gives up kinetic energy L. Ballistics: study of projectiles in motion and their effects on objects they impact M. Trajectory, Drag, and Cavitation 1. Trajectory: curved path that a bullet follows after it is fired; pulled down by gravity; the faster the bullet and the farther it travels, the less gravity is able to change path—trajectory is straighter; close range = flat trajectory; longer distance = more trajectory curve

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Review the Patho Pearls feature in the main text that discusses the bullet’s travel.

This is very good information for students to understand the injuries caused by bullets.

Use pictures to show the different velocities of penetrating trauma, and the damage that can occur with each.

Draw the pressure wave, cavity, and anatomy affected for GSWs.

Discussion Topics Discuss the different factors that can increase or decrease a bullet’s energy exchange rate.

Critical Thinking Questions Are the military and police departments allowed to use bullets that defragment? Is this ethical?

Why is a secondary impact dangerous to

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 2. Drag: wind resistance bullet experiences in traveling through air; the faster the travel, the greater the drag and the greater the slowing effect; close range = greater damage due to minimal to no drag; longer distance = slowed by drag 3. Cavitation: semifluid body tissue set in motion, creating a shock wave and a temporary cavity; extent is determined by bullet’s velocity and rate of energy exchange related to size of projectile’s contracting surface, which is determined by profile and shape N. Profile: portion of bullet you would see if you looked at it as it traveled straight toward you 1. Cross-section of the bullet along its direction of travel 2. The larger this surface profile, the greater the energy exchange rate; the more quickly bullet slows, the more extensive the damage to surrounding tissue 3. Profile is bullet’s diameter, or caliber 4. To increase energy exchange rate, bullets designed to become unstable in travel as they pass from air into another medium, or deform through expansion or fragmentation O. Shape: shape of bullet affects energy exchange rate and resulting damage 1. Handgun bullets tend to be blunt, more resistant to travel through human tissue, and release kinetic energy more quickly 2. Rifle bullets more pointed, cut through soft tissue more efficiently; if rifle bullet tumbles, energy exchange more rapid P. Stability: location of bullet’s center of mass 1. Affects stability during flight and upon impact into semisolid object 2. The longer a bullet, the farther its center of mass is from the leading edge; can cause bullet to tumble if tip is at angle, resulting in slower speed and diminished accuracy 3. Bullets are sent spinning through air by gun-barrel rifling, to prevent tumbling; if spinning bullet slightly deflected, it wobbles (yaw), then slowly returns to straight flight 4. Once a bullet impacts soft tissue, if yaw present, it will increase as bullet penetrates because of bullet mass trying to overrun leading edge 5. Gyroscopic spin will become insufficient (bullet needs to spin at rate 30 times greater in soft tissue than in air to maintain stability

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes the patient?

Why might a .22 caliber cause more damage to a patient?

Class Activities Invite a ballistics expert to review the kinetics of penetrating trauma and provide an overview of bullet characteristics.

Knowledge Application Assign the ballistics vocabulary to students for homework.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

6. In handgun bullets, center of mass not far back from leading edge, so rather stable; side profile slightly greater than front and will do only slightly more damage if tumbling occurs 7. Rifle bullet more likely to tumble as it hits body tissue—with tumbling and large presenting profile, rifle bullet’s kinetic energy exchange rate increases, as does potential for injury; in human tissue, rifle bullet tends to rotate 180 degrees, then continue, base first Q. Expansion and fragmentation: deforming when striking object denser than air 1. As bullet’s nose contacts target, it slows and then is compressed by weight of bullet, causing nose to mushroom outward, increasing diameter of projectile 2. Initial impact may be so great that bullet separates into several pieces (fragments), which increases impact energy exchange rate 3. Some bullets are specifically designed to mushroom/fragment on impact and cause increased damage 4. If bullet fragments, it means that projectile gave up energy more rapidly than a bullet that remained intact R. Secondary impacts: any object the projectile strikes during travel 1. Branches, window glass, articles of clothing may deflect bullet and induce yaw and tumble, as well as deform bullet 2. Occurs with impact with body armor (Kevlar)—energy absorbed by armor distributed to victim over large surface area; may produce blunt trauma to person 3. High-energy projectiles may pass through body armor, but dissipate energy to blunt trauma 20

IX. Characteristics of Specific Weapons A. Handguns 1. Often short-barreled, medium-velocity guns with somewhat limited accuracy 2. Most effective at close range; potential for damage at far distance limited 3. Blunter bullet shape may mushroom and fragment, dissipating energy faster

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Use pictures to identify each type of weapon and bullet used.

Show pictures of wounds sustained by each type of weapon.

Using the Patho Pearls feature “When a

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 4. Injury severity usually determined by which organs, vessels, other structures damaged B. Rifles 1. Heavier projectile through longer barrel and greater muzzle velocity 2. Manually loaded, single shot or semiautomatic—no more than one bullet expelled with trigger squeeze 3. Rifle bullets travel farther, with greater accuracy, and retain more kinetic energy 4. Transfers greater damaging energy to target—extensive wounds with injuries that extend beyond projectile track 5. Hunting ammunition especially lethal because designed to expand upon impact 6. Military rifles have larger magazine capacity and fire in both semiautomatic and automatic modes 7. Examples of military rifles include M16, AR15, AK47 8. Injuries from military rifles are similar to those from hunting rifles, although multiple wounds and casualties can be expected 9. Military ammunition designed not to expand (fully jacketed)—terrorists may use hunting-type ammunition C. Shotguns 1. Fire a single slug or numerous spheres (pellets or shot) at medium velocity 2. Size varies from 00 (1/3 diameter) to #9 (size of pin head) 3. The larger the shot, the fewer the projectiles—projectiles free of barrel add to drag 4. Close range will create entrance wound that appears as single bullet wound 5. Farther out, smaller entry wound surrounding central and larger wound 6. Plastic and fiber material used as wadding penetrate wound, increasing infection risk D. Bladed Instruments and Arrows 1. Slow-moving penetrating objects that cause low-velocity, low-energy wounds 2. Damage usually limited to physical injury caused by direct contact between blade and object

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Projectile Enters the Body,” re-create this on the board by drawing the biomechanics as they occur.

Discussion Topics Discuss different penetrating MOIs that are low energy and low velocity.

Critical Thinking Concepts What reasons can you think of for the increase in GSW trauma? What prevention strategies might decrease this number?

Class Activities Create scenarios with patients sustaining various types of gunshot wounds. Have students perform assessments, including run reports and radio reports.

If able, have a ballistics expert talk about specific weapons when discussing ballistics.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

3. Can cause serious internal hemorrhage or injury to body organs E. Other Penetrating Wound Mechanisms 1. Can occur from pieces of wire thrown from lawnmowers, nails that are stepped on or fired from nail gun, falls onto reinforcing rods 2. Usually low-velocity, low-energy injury confined to object path, depth of penetration, contamination, impaled object 20

X. Biomechanics of Penetrating Trauma A. High-velocity projectile inflicts damage pathway related to direct injury, pressure wave, and cavitation B. Direct injury—damage done as penetrating object strikes tissue, contuses and tears and pushes tissue out of way 1. Direct injury pathway limited to bullet’s profile, fragments (note: handgun damage usually limited to direct injury) C. Pressure wave—tissues in front of bullet pushed forward and to side at great speed 1. All adjacent tissues pushed forward and outward, creating moving wave of pressure and tissue in front of bullet 2. Pressure travels very well through fluid, injuring vessels distant from pathway 3. Air-filled cavities compress easily and absorb pressure, limiting shock wave 4. Solid and dense organs suffer greatly, as dense tissue transmits pressure efficiently and tears structure D. Temporary cavity—space created behind high-energy bullet as tissue moves rapidly 1. Creation of this temporary cavity is called cavitation 2. Depends on amount of energy transferred during bullet’s passage 3. Tissue elasticity causes temporary cavity to close 4. Produces a subatmospheric pressure within cavity, which causes air to be drawn in from entrance wound and exit wound, with debris entering cavity E. Permanent cavity—tissue damages from cavitation that cannot heal 1. Tissues torn, stretched, and crushed from bullet’s path 2. Tissue damage may be beyond repair, and can be larger than diameter

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Discuss the damage that is sustained in hollow versus solid organs, and what signs and symptoms may be present.

Discuss the injuries that can occur from cavitation into the lungs.

Class Activities Draw the biomechanics of penetrating trauma and have students identify each mechanism.

Have students reenact low-velocity attacks (not using any weapons) to demonstrate defense wounds, and gender differences in holding weapons.

Knowledge Application Assign students the vocabulary of the biomechanics of penetrating trauma.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

of bullet; filled with disrupted tissue, blood, debris, and so forth F. Zone of injury—wounds that extend beyond permanent cavity 1. Contains crushed, torn, and contused tissue that does not function normally, may be slow to heal due to cell damage, disrupted blood flow, and infection G. Heat injury—bullet heated by burning of propellant friction 1. Bullet temperature will reach about 300°F; burn injury is minimal and usually associated with final resting location H. Low-velocity wounds—relatively slow speed limits kinetic energy exchange rate 1. Injury generally limited to tissue that is contacted 2. Object may be twisted, which may not be reflected in entrance wound 3. Assessment would include stroke of knife, protection of victim (defense wounds) 25

XI. Specific Tissue/Organ Injuries A. Damage caused by projectile varies with tissue type encountered B. Resiliency: tissue’s connective strength and elasticity; influences damage that occurs C. Connective Tissue 1. Muscles, tendons, ligaments, skin, and other connective tissues are dense, elastic, and hold together very well 2. Cavitation wave pressure and stretching cause absorption of energy while limiting damage 3. Wound tracks close due to resiliency and elastic nature; serious injury usually limited to projectile’s pathway D. Organs 1. Particular organs involved in penetrating injury can dictate seriousness of injury 2. Heart and brain are critical to life, and injury can cause immediate death 3. Blood vessels may cause rapid hemorrhage 4. Anticipation of organs injured and effect of injury will affect patient condition and survivability E. Solid Organs 1. Liver, spleen, kidneys, pancreas, and brain have density but no

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Use pictures to compare entrance and exit wounds.

Discussion Topics Discuss why an elderly patient may suffer worse connective tissue damage than a younger patient.

Discuss all of the specific injuries listed, along with signs/symptoms and treatments.

Go over the signs and symptoms of neck injuries, including subcutaneous emphysema. Have a student put bubble wrap under his or her collar, and have other students do a hands-on assessment to identify.

Critical Thinking Questions

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline resilience like muscles and connective tissues 2. Solid organs are pushed outward by pressure wave and cavitation, then compressed and stretched, resulting in greater damage associated with cavitation 3. Hemorrhage is often severe F. Hollow Organs 1. Bowel, stomach, urinary bladder, heart are muscular containers that hold liquid 2. If hollow organ filled at time of impact, energy release can tear organ apart; if container empty, more tolerant of forces 3. Leakage may occur in heart (pericardial tamponade), in bowels (peritonitis) G. Lungs 1. As bullet and pressure waves travel through lungs, air sacs compress, slowing and limiting wave transmission 2. Injury to lung tissue can be less extensive due to absorption of energy 3. A bullet may open the chest wall or disrupt larger airways—open pneumothorax, sucking chest wound, hemothorax H. Bone 1. Bone is body’s densest, most rigid, and nonelastic tissue; bone resists displacement until fractures, often in numerous pieces, which may disrupt surrounding tissue I. Pathophysiology of Penetrating Trauma 1. Penetrating trauma can affect all body regions, cavities, and structures 2. Head: highly susceptible to projectile injury; cavitational energy trapped within cranium, exposing brain to extreme pressures; bullet may shatter skull, or travel along interior and disrupt more brain tissue; airway may be compromised 3. Neck: larynx, trachea, esophagus, major blood vessels, vertebral column, spinal cord packed into very small space; injury leads to airway compromise, severe bleeding, neurological dysfunction, air embolism from air drawn into open jugular vein; most commonly injured neck structures are major blood vessels and trachea 4. Chest: houses heart, lungs, major blood vessels, esophagus, and trachea; bullet can impact ribs, sending bone fragments into soft tissues;

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes How will jugular veins present in a tension pneumothorax? Hemothorax? Why?

Class Activities Create scenarios involving injuries to specific organs/tissues. Have students identify the injuries and treat accordingly.

Have students practice chest decompression using pork ribs, a bicycle inner tube, and plastic wrap.

Have students compare signs and symptoms of lung injuries.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

great vessel damage can cause massive hemorrhage and death; injuries to lower chest may also include abdomen and diaphragm 5. Abdomen: largest body cavity and contains most organs; not well protected by skeletal structures; projectile through abdominal cavity can produce significant injuries to hollow and solid organs 6. Extremities: skin covering muscles that surround large lung bones; may be debilitating but not immediately life threatening unless associated with vascular injury and hemorrhage; injuries above elbow and /or knee more likely to cause significant vascular injury J. Entrance Wound 1. No larger than bullet profile, unless bullet deforms or tumbles 2. Characteristics include tattooing residue causing darkened circle or oval around entry wound, small ridge of discoloration around entrance, subcutaneous emphysema and crepitus, burns K. Exit Wound 1. Caused by physical damage from passage of bullet and resulting cavitation wave 2. May have blown-out appearance, with tearing in a star-like pattern 3. A bullet may be deflected as it travels through the body, so there may not be a direct route between entrance and exit wounds.

4. Avoid entrance and exit statements; instead focus on describing wound

XII. Special Concerns with Penetrating Trauma 20

A. Scene Size-Up 1. Special concerns regarding dangers of further violence 2. Do not approach scene unless law enforcement is present and the scene is secure 3. Stage your arrival away from the scene until police arrive 4. Survey patient area for weapons 5. Attempt reconstruction of event, including victim’s position, angle, and distance; if possible, find out caliber and type of weapon 6. Preserve crime scene B. Penetrating Wound Assessment 1. Determine pathway of object and organs affected, anticipate potential organ injury, set priorities in assessment and transport

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Discuss the signs and symptoms of pneumothorax, hemothorax, and pericardial tamponade—Beck’s triad.

Critical Thinking Questions What is a contraindication for cricothyrotomy?

Class Activities Have students perform multiple scene sizeups with various danger scenarios. Have students walk their way through each

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 2. Always suspect worst with bullet wounds that involve head, chest, abdomen C. Facial Wounds 1. May endanger airway and destroy airway landmarks; endotracheal (ET) intubation may be essential but is extremely difficult to perform 2. Look for bubbling during compressions to pass ET 3. Carefully assess breath sounds and monitor capnography 4. Percutaneous cricothyrotomy may be indicated if airway cannot be secured D. Chest Wounds 1. Requires large wound to create opening big enough to permit free air movement through chest wall—open pneumothorax 2. Air built up under pressure in thorax—tension pneumothorax 3. Cover open chest wound with occlusive dressing sealed on three sides; if dyspnea present, assess for tension pneumothorax, release occlusive dressing, perform needle decompression as indicated 4. Consider possibility of heart and great vessel damage—pericardial tamponade E. Impaled Objects 1. Removal may be dangerous; may lie against severed blood vessel, restricting blood flow; removal may increase blood hemorrhage 2. Immobilize object in place and transport patient 3. Only remove impaled object if it is lodged in cheek, neck, or trachea and interferes with airway, or if you cannot perform cardiopulmonary resuscitation (CPR) 4. If impalement is too large for transport, cut it while stabilizing patient

5

XIII. Summary A. Trauma is a major cause of death and disability B. Trauma, at its most fundamental level, is a surgical disease C. Trauma patients tend to experience less death and disability when they are treated by experienced personnel in an accredited trauma center

D. Ensure that trauma patients are taken to the closest trauma center

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes scene, noting what dangers they will look for.

Have students practice needle and surgical cricothyrotomy.

Knowledge Application Have students write the different injuries sustained in penetrating injury and the treatment that is provided.

Points to Emphasize Recognition of serious injuries, along with techniques of sealing an open pneumothorax, recognizing pericardial tamponade, recognizing and treating a tension pneumothorax, and managing an airway, help to stabilize the trauma patient.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 2 objectives can be found in on text pp. 17-18.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 5

Content Outline XIV.

Case Study

Master Teaching Notes Class Activities Discuss the case with students now that they are familiar with the chapter.

5

XV. You Make the Call

Class Activities Read and discuss the call and questions as a group.

5

XVI. Review Questions

Class Activities Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 3 Hemorrhage and Shock 170–190 Minutes

• • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Knowledge Application

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

80

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Hemorrhage and Shock A. Shock is a state of inadequate perfusion B. Complicated transitional stage between normal life (homeostasis) and death C. Ultimate killer of all trauma and medical patients D. Very limited signs and symptoms until body can no longer compensate— causing quick move toward death E. Understanding shock principles and recognizing signs and symptoms will allow for quick and aggressive care F. Common form of shock associated with trauma is hemorrhagic—due to blood loss; may be massive and continue until here is no longer any blood to be pumped to cells G. Young adult males are most at risk for trauma and trauma death (risk-taking behaviors and diminished regard for safety can be causes)

Knowledge Application

III. Hemorrhage A. Loss of blood from vascular space may be serious threat to life B. Critical skills for paramedic include recognition and treatment of hemorrhagic shock C. The Circulatory System—Also called cardiovascular system; three components are heart, blood vessels, and blood; all three contribute to homeostasis D. The Heart 1. Two-sided muscular pump with four valves and four defining chambers 2. Cardiac conduction system responsible for heart contractions, which

Teaching Tips

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

For an assignment, have students define each key term.

Use images of hydrostatic and oncotic pressure to walk students through the fluid push into the interstitial side, along with the fluid pull from proteins that returns blood and fluids to venous side. You can use this to explain the diffusion of partial pressure of oxygen (O2) and carbon dioxide (CO2) and the problems that can cause edema.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline provide primary driving force of blood pumping though system Stroke volume—preload, cardiac contractility, and afterload Preload—blood returning to heart Cardiac contractility—strength of contraction Afterload—resistance to blood flow from heart (peripheral vascular resistance); E. The Vascular System—Continuous series of hollow tubes that distribute blood to and from body tissues; arteries, capillaries, veins; microcirculation consists of arterioles, capillaries, and venules 1. Arteries a.

Distribute blood to all body tissues and contain about 13% of total blood volume b.

Largest arteries have thick adventitia that determines the artery’s maximum diameter c.

Mean arterial pressure (MAP) is well maintained through the arteries as they distribute blood to the arterioles (the smallest arteries) 2. Capillaries a.

Found in close proximity to all body cells and contain 7% of vascular volume b.

Microscopic vessels only large enough for red blood cells (RBCs) to pass through in single file c.

Walls are one cell thick, allowing efficient gas and metabolic substrates to move in and out of interstitial space d.

Have small spaces between cells of wall to permit retention of RBCs and hemoglobin, but allowing O2, carbon dioxide (CO2), fluid, electrolytes, and other material to move into and out of vascular space e.

Hydrostatic pressure pushes arterial fluid into interstitial space, with large plasma proteins staying inside and catching in capillaries; these plasma proteins cross over to the venous portion, called oncotic pressure, and allow fluids from interstitial space to be pulled back into the venous side, to be returned to the heart = net filtration 3. Veins a.

Contain about 64% of blood volume at any given time b.

Small amount of connective and muscular tissue (adventitia and 3.

4.

5.

6.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Draw the heart, vessels, and fluid for students, and indicate to them the problems that could occur in each one that will affect the whole cardiovascular system, and explain why.

Use pictures to teach students the stages of shock.

Use pictures to review the nervous system with students, particularly the sympathetic and parasympathetic nervous systems.

Discussion Topics Discuss the three different types of bleeding, and how they present.

Discuss the different body cavities affected by bleeding and the amounts of blood that can be contained in each.

Discuss the three stages of the clotting process.

Review the oxyhemoglobin disassociation curve (hemoglobin can hang on to O2 in high-pressure areas, and release it in lowpressure areas). What will happen to patient oxygenation if there is a problem with the ability of hemoglobin to hang on or let go?

Discuss longitudinal and transverse wounds, and why bleeding would be more

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline media) Collect blood and return it to heart Venous pressure less than arterial; veins have larger lumens, ensuring that blood flow back to the heart equals blood flow leaving e.

Any constrictions in veins significantly reduce vascular volume; effective at maintaining venous return and preload in early stages of dehydration, shock, and hemorrhage f.

Called the capacitance system because it holds and controls such a large portion of circulating blood volume 4. The Blood a.

Mixture of cells, proteins, water, and other elements b.

Plasma (fluid portion) makes up 55% and consists of proteins, water, and other materials; carries nutrients directly to cells and waste products away and serves as medium for blood cell transport c.

Red blood cells (erythrocytes) make up 45% and contain hemoglobin, which is an iron molecule that O2 attaches to; RBCs serve as efficient O2 transporters; % of blood volume comprised of RBCs is hematocrit d.

Oxyhemoglobin dissociation curve is the ability of hemoglobin to hold onto O2 in high pressure and release in low pressure (partial pressures of oxygen) e.

Platelets are important for clotting and blood vessel repair G. Types of Hemorrhage 1. Blood loss from vascular space resulting from blood vessel injury 2. Whole blood (plasma and RBCs) loss can be external or internal 3. Hemorrhage usually classified by capillary, venous, or arterial injury 4. Capillary: smallest blood vessels, oozing from wound, can be caused by abrasions and clots quickly on its own; bright red bleeding 5. Venous: flows quickly, and generally stops in a few minutes; dark red bleeding 6. Arterial: very rapid flow that may spurt from wound, continues to bleed and commonly associated with greater rate and volume loss; bright red bleeding H. Hemostasis 1. Complex three-step process in response to hemorrhage 2. Vascular phase: smooth muscle within vessel wall contracts, causing c. d.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes severe with longitudinal wounds.

Critical Thinking Questions How would a decrease in the pumping action of the heart affect preload? How can you help increase preload in these patients?

What type of blood flow is caused by injury and has platelets respond? How can you prevent further injury to this area?

How many minutes does it take for the clotting process to begin?

What should you expect your patient’s signs and symptoms to be if he is experiencing blood loss and is taking beta blockers?

Why will a trauma patient in shock get worse if experiencing hypothermia?

Class Activities Have students practice direct pressure and tourniquet use. Make sure that students DO NOT actually apply pressure with the tourniquet. If possible, use commercial device, cravats, and blood pressure cuff.

Have students practice writing TK and the time on the patient’s forehead (you can use tape to simulate this).

Dye 10 500-cc bags of normal saline (NS) with red food coloring; in an area that is open and can be cleaned up, proceed to

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

I.

vessel to withdraw into wound, thicken wall, and reduce lumen, which reduces blood flow rate and volume 3. Platelet phase: turbulent blood flow occurs from injury, causing platelets to become adherent and stick to each other and to collagen fibers, along with blood vessels; as platelets aggregate, hemorrhage can halt rapidly, although clot will be unstable 4. Coagulation phase: final step that occurs when clotting factors are activated and released into bloodstream, initiating clotting factor release—release from damaged blood vessels and tissues is the extrinsic pathway and platelets damaged by turbulence is the intrinsic pathway 5. Chemical reaction from clotting factors causes strong protein fibers called fibrin, which creates a strong mesh that entraps RBCs, forming a strong and durable clot that can halt all but most severe bleeding 6. Coagulation usually takes 7–10 minutes 7. Nature of wound affects hemostatic mechanism’s response 8. Wound transverses vessel—wall muscle contracts and draws torn vessel into surrounding tissue, assisting hemostatic mechanism 9. Wound longitudinal to vessel—smooth muscle contraction pulls wound open, resulting in heavier bleeding 10. If severe hemorrhage continues, hypotension will reduce blood pressure at site, limiting blood flow and loss, enhancing clot development and improving hemostasis (note: instance where systemic hypotension may be beneficial in controlling serious internal hemorrhage) Factors Affecting Hemostatic Process 1. May be helped or hindered by variety of factors 2. Movement around wound will break down forming clots and disrupt fibrin; immediate immobilization is considered a hemorrhage control technique 3. Aggressive fluid control will increase pressure, which will push against forming clots and dilute clotting factors; fluid resuscitation kept at keeping blood pressure at 90 systolic, with extreme caution against overloading of fluid 4. If body temperature falls below normal, clot formation is slow and not as effective; patient must be kept warm 5. Medications to prevent or limit heart attacks/strokes may interfere with

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes pour out the NS using the stages of shock percentages. Start with 15% (750 cc), allowing students to view what this amount of blood loss looks like on the ground or patient; continue to increase the blood loss by stage percentages until you have reached stage four. This gives students a visual for comparison.

Create scenarios of shock patients, and have students identify early shock through irreversible shock.

Knowledge Application For homework, have students list the parasympathetic and sympathetic responses of the body.

Have students review the various medications that affect the clotting process, and write a very quick summary of their actions.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline body’s ability to coagulate and halt hemorrhage—aspirin (prevents platelet aggregation); NSAIDs (similar effects as aspirin); Heparin, Lovenox, warafin, and Pradaxa (interfere with normal protein fiber generation); Plavix (inhibits platelet aggregation by reducing use of ATP by platelets)—these drugs will prolong or worsen hemorrhage J. Hemorrhage Control 1. External hemorrhage a.

Relatively easy to recognize and control, but can be hidden by clothing or body position b.

Always search for severe external hemorrhage during primary assessment c.

Direct pressure may be needed for bleeding control d.

Tourniquet may be necessary if persistent, life-threatening hemorrhage cannot be controlled by direct pressure; tourniquet must be applied slightly above arterial pressure, and will create lactic acid and anaerobic metabolism due to lack of perfusion to the distal portion of limb e.

Tourniquet must be kept in place until blood replacement is available (emergency department, etc.); negative effects of reperfusion f.

A commercial tourniquet device is recommended, although a wide cravat or blood pressure cuff may be used 2. Internal Hemorrhage a.

Associated with almost all serious blunt or penetrating trauma b.

Can involve capillary, venous, and arterial bleeding c.

Blood accumulating in interstitial spaces, between layers of fascia (tissue), for pockets of blood called hematomas; blood loss is selflimiting due to pressure of tissue or fascia d.

Humerus and tibia/fibula fractures can = 500–750 mL of blood loss e.

Femur fractures can = up to 1,500 mL of blood loss f.

Pelvic fractures can = 2,000 mL of blood loss or higher g.

Large body cavities are resistant to bleeding control, causing large amounts of bleeding to continue until halted by clotting process, drop in blood pressure, or surgical intervention h.

Best indications of internal hemorrhage are local injury signs and symptoms and early signs of blood loss and shock

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Using the hydrostatic/oncotic model, discuss the various causes of fluid shift.

Discuss the alpha and beta receptors and their normal body responses.

Discuss the normal compensatory mechanisms for shock.

Discuss the hormonal compensatory mechanisms.

Critical Thinking Questions What medications can prevent compensatory mechanisms from working?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline i.

Significant trauma to chest, abdomen, or pelvis can cause continuing and uncontrolled hemorrhage that you must anticipate with careful assessment and rapid transport for possible surgical repair j.

Mechanism of injury (MOI) may help to identify possible injury sites that guide assessment, but not a good severity of injury predictor; Glasgow Coma Scale (GCS) and assessment used in conjunction with MOI will aid in the determination of patient priority k.

Providing effective immobilization, warmth, and transport aids in care of the hemorrhage l.

Evidence of hemorrhage at body’s orifices can help identify blood loss and location—epistaxis, oral cavity, hemoptysis, esophageal varices, hematemesis, hematochezia, melena, vaginal bleeding, urethral hemorrhage K. Classes of Hemorrhage 1. Identify the time since incidence, class of hemorrhage at EMS arrival, and movement from one class to another to help with determining the need for intervention 2. There are four progressive classes of blood loss 3. Class I hemorrhage—loss of up to 15% of circulating blood volume, easily compensated in healthy adult by constriction of vascular beds; blood pressure, pulse pressure, respiratory rate, and urine output constant and pulse rate increases, along with catecholamine release (nervousness and cool skin); arterial and venous capillary constriction 4. Class II hemorrhage—loss of 15–30% of circulating blood volume; firstline compensatory mechanisms do not maintain perfusion and secondary mechanisms begin: tachycardia, rise in diastolic pressure, narrowing pulse pressure, diminished pulse strength; strong release of catecholamine causes peripheral vasoconstriction, cool and clammy skin, increased anxiety, restlessness, and thirst; respiratory rate increase—arterial precapillary sphincters open and venous postcapillary close 5. Class III hemorrhage—blood loss is 30–40% and body’s compensatory mechanism unable to cope with loss; classic signs of shock, including pronounced tachycardia as blood pressure falls; barley palpable pulse; pulse pressure narrowed; air hunger; tachypnea; anxiety; restlessness ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes What will happen to your patient’s breathing when chemoreceptors sense too much CO2 in the bloodstream?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline and thirst; decreased responsiveness; pale, cool, and diaphoretic skin; decreased urinary output; survival at risk and blood pressure more difficult to maintain 6. Class IV hemorrhage—blood loss greater than 40%, and patient presents with barely palpable pulse centrally; rapid, shallow, and ineffective respirations; lethargy; confusion; rapid move toward unconsciousness; cool, clammy, and pale skin; no urinary output; patient survivability unlikely 7. Blood loss rate has profound effect on how quickly patient moves from Class I to Class IV. 8. Pregnant women, athletes, obese patients, children, alcohol-intoxicated patients, and elderly all react differently to blood loss 9. Hemorrhage can lead to systemic consequences called shock L. Stages of Shock 1. Can be divided into three stages based on the body’s ability to compensate M. Compensated Shock 1. Initial shock state where body is capable of meeting metabolic needs through compensatory mechanisms 2. Signs and symptoms become apparent—increased pulse rate; narrowing pulse pressure; thirst sensation; pale, cyanotic, or ashen, clammy skin; increased capillary refill time; respiratory rate increase; air hunger; tachypnea N. Decompensated Shock 1. Compensatory mechanisms unable to continue, and body system moves toward collapse; hallmark sign is drop in blood pressure O. Irreversible Shock 1. Body’s cells badly injured; die in large numbers so that body cannot carry out normal functions; clinical differentiation between decompensated and irreversible shock is impossible with just signs and symptoms P. Etiology of Shock 1. Shock can have many causes, and common classification is on origin of shock 2. Hypovolemic shock—reduction in fluid volume as from burns, vomiting, diarrhea, third-space losses

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

3. Cardiogenic shock—from cardiac insufficiency as from cardiac artery blockage, electrical conduction disturbances, valve failure, rupture, and pumping failure 4. Neurogenic shock—from interruption of communication pathway between CNS and body, as from spinal cord injury or some head injuries 5. Anaphylactic shock—caused by immune system response to introduction of a foreign substance into the body 6. Septic shock—from massive infection releasing toxins into the vascular system 40

IV. Assessment of the Patient with Hemorrhage and Shock A. Shock assessment and discovery important primary skills B. Scene Size-Up 1. Standard Precautions (gloves, mask, gown, sharps, any other precautions necessary) 2. Rule out hazards (traffic, violence, unstable structures, weather, etc.)

3. Evaluate MOI, time between injury and EMS arrival, patient presentation 4. Scene oversight—ensure that there is scene oversight i. In a limited event, assign roles to the members of your team ii. In a large event employ a more involved system of incident management C. Primary Assessment 1. Patient impression, mental status, facial expression 2. Patient body surface, skin condition 3. ABCs; spinal precautions if indicated; O2, pulse oximetry, capnography 4. CUPS for patient priority D. Secondary Assessment 1. Critical patient does not receive secondary assessment because ABCs are unable to be stabilized 2. Unstable: rapid trauma; stable: focused exam E. Rapid Trauma Assessment 1. Serious injury signs and/or MOI; inspect and palpate from head to toe 2. Control immediate hemorrhage 3. Head: bleeding, facial fracture/injuries that may affect airway 4. Neck: jugular venous distention (JVD), bleeding, deviation, subcutaneous emphysema 5. Chest: bleeding, trauma, dyspnea, asymmetrical movement,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Go over each form of shock, noting signs and symptoms and treatments.

Explain orthostatic hypotension and the tilt test.

Teaching Tips Review the steps involved with the various types of assessment.

Critical Thinking Questions You are first to arrive at an accident and you determine it to be an MCI. How does it affect your priorities? How do you take control of the scene? How do you transfer control once a qualified person arrives?

Class Activities Create a scenario with each listed classification of shock; have students perform an assessment, identify the type of shock, and treat accordingly.

Using scenarios created for shock, have students continue to practice assessment

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

F.

G.

H. I.

J.

30

absent/diminished breath sounds, muffled heart sounds 6. Abdomen: contusions, abrasions, rigidity, guarding, tenderness 7. Pelvis: pelvic ring integrity, bleeding 8. Lower extremities: fracture; bleeding; motor, sensory, and distal pulses 9. Upper extremities: fractures; bleeding; motor, sensory, and distal pulses 10. Posterior: bleeding, injuries hidden from view 11. Vital signs, GCS, medical history, inventory of injuries, priority of transport Focused Trauma Assessment 1. Patients without serious signs of injury or blood loss 2. Focus of exam on area injured; inspect, palpate area, vital signs, history, transport Additional Assessment Considerations 1. Bleeding—color, location; look for signs of internal hemorrhage 2. Dizziness/syncope—orthostatic hypotension; determine by using tilt test Patient Medical History 1. Chief complaint, medical conditions, medications, last oral intake Detailed Physical Exam 1. Considered only after all patient priorities and transport have been addressed 2. Look for bruising, redness, areas of warmth Reassessment 1. Reassessment performed every 5 minutes in unstable and every 15 minutes in stable patients; a repeat of primary assessment, vital signs, GCS, oximetry and capnography, and monitoring of patient improvement

V. Management of the Patient with Hemorrhage and Shock A. Hemorrhage Management 1. Airway, breathing adequate; ventilatory support as indicated 2. Circulation and hemorrhage control: look for early signs of shock 3. Wound care B. Direct Pressure 1. Can control all but the most persistent hemorrhage 2. Finger pressure can stop hemorrhage when applied properly 3. Dressing can be applied over wound before direct pressure 4. Continue to keep pressure on wound

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes and finding signs and symptoms of shock.

Using pictures, have students match up the stages of shock and pre-/postcapillary sphincter actions in each stage.

Discuss the meaning behind assessment findings; facilitate group discussion.

Review CUPS and the GCS. Have students perform a step-by-step scene size-up with various scenarios and conduct a primary assessment, looking for signs of shock. This can be done as a group, as most discussion is in terms of what students would be looking for at each stage of assessment.

Have students practice the tilt test.

Have students practice performing assessments on each other and/or a manikin.

Discussion Topics Review the different hemostatic agents available, along with their mechanisms of action. If possible, obtain a packet to demonstrate absorption of fluid.

Discuss the various blood and blood products available.

Review overdrive ventilations, and when

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

C.

D.

E.

F.

G.

5. Head—do not apply direct pressure to skull; use finger pressure at scalp edges; eye orbits—do not place direct finger pressure to eye; neck— firm finger pressure may be necessary, avoid airway structures 6. Use of immobilization will help in limiting blood loss Elevation and Pressure Points 1. Elevation and pressure points cause movement to injured area; use is limited 2. If direct pressure does not work, elevation may be considered, depending on protocols; should be used only for isolated injury 3. Arterial pressure points proximal to wound may be used if bleeding continues; this must be maintained once applied Topical Hemostatic Agents 1. Applied directly or indirectly to active hemorrhage 2. May be dust or powder form applied directly to wound, contained in fabric pouch or inside dressings; adherent when moistened by blood 3. Types of agents include: made from shells of crustaceans, chemically altered volcanic rock, or starch-based powder derived from plants Tourniquets 1. Last resort when hemorrhage is prolonged, crush injury, deep penetrating trauma with uncontrolled hemorrhage 2. Commercial device, blood pressure cuff 3. Tourniquet pressure must exceed systolic BP Specific Wound Considerations 1. Head wounds, neck wounds, large gaping wounds, crush injuries 2. Head injuries—bleeding from skull fractures, fluid or blood loss from ears/nose, facial injuries threatening airway 3. Cerebrospinal fluid (CSF) relieves intracranial pressure (ICP) and should be allowed to escape 4. Cover neck wounds with an occlusion dressing; do not circumferentially wrap bandages around neck 5. Gaping wounds require dressing to be placed to allow for control direct pressure; crush injuries require dressing to area, splint/ tourniquet use Transport Considerations 1. Rapid transport for any patient who experiences serious external hemorrhage that cannot be controlled, or suspected internal hemorrhage

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes they may be needed.

Critical Thinking Questions Why are we, in the prehospital setting, unable to provide whole blood to patients?

Pneumatic Anti-Shock Garments (PASG) are rarely seen in EMS and have fallen out of favor in the treatment of shock. Why could the use of a PASG to treat shock worsen your patient’s condition?

Is the PASG still a good choice for splinting? Why? Why not?

Class Activities Create scenarios so that students have to identify and treat hemorrhage and shock signs and symptoms. Have students perform the necessary treatments.

Have students practice the skills of hemorrhage and shock management.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline H. Shock Management—The management of hemorrhage and of hypovolemic shock have similar priorities and goals.

I. Airway and Breathing Management 1. Ensure adequate tissue oxygenation and carbon dioxide offloading 2. Secure and patent airway, adequate tidal volumes 3. Positive pressure ventilation if necessary; overdrive respirations may be necessary for the breathing patient 4. Positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP) 5. Chest decompression if tension pneumothorax present J. Hemorrhage Control 1. Provide rapid hemorrhage control to any external hemorrhage K. Fluid Resuscitation 1. Whole blood is fluid of choice for significant blood loss 2. Use isotonic electrolyte solutions in prehospital setting L. Isotonic Fluid Administration 1. Indicated in patient with classic shock signs and symptoms 2. Lactated Ringer’s (LR) or normal saline (NS) until blood pressure at 90– 100 systolic; 14- or 16-gauge IV catheters; fluid resuscitation enroute 3. Patients with head injuries and GCS < 8 need to have fluid until blood pressure at 100 systolic to maintain cerebral perfusion pressure 4. Differentiate “hemodynamically stable” patients from those who are “hemodynamically normal” 5. Children require 20 cc/kg 6. Patients in hypovolemic shock respond to IV fluids in one of three ways: rapid response, transient response, and minimal or no response 7. Rapid responders, will respond quickly to the initial bolus of intravenous fluids and remain hemodynamically normal after the initial fluid bolus 8. Transient responders will respond favorably to the initial fluid bolus but, once the initial fluid bolus has been administered, they will begin to show deterioration in perfusion 9. A minimal or no response to intravenous crystalloid and/or blood administration indicate an ongoing uncontrolled hemorrhage or rarely to an obstructive process such as myocardial contusion, pericardial tamponade, or a tension pneumothorax M. Temperature Control

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

1. Blood loss affects the mechanisms that control the body’s core temperature; cover patient with a blanket, keep ambulance warm, use fluid warmers if possible N. Pharmacological Intervention 1. Medications generally limited in trauma patient 2. Cardiogenic shock: dopamine, vasopressors, fluid challenge 3. Spinal and obstructive shock: NS, LR 4. Distributive shock: IV fluids, vasopressors 5

VI. Summary A. Significant shock and hemorrhage are genuine threats to patient’s life.

Careful analysis of MOI, injury, and patient signs and symptoms, along with pathophysiologic knowledge of body systems, will allow an aggressive treatment plan and better chance for patient survival.

VII. Case Study 5

Class Activities Discuss the case with students now that they are familiar with the chapter.

VIII. You Make the Call 5

Class Activities Read and discuss the call and questions as a group.

IX. Review Questions 5

Class Activities Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

X.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 3 objectives can be found on text pp. 57–58.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline XI.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 4 Soft-Tissue Trauma 150–160 Minutes

• • • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

10

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Soft Tissue Trauma A. Skin is largest organ, providing protection and temperature control B. Known as integumentary system: first tissue to experience trauma; energy transmission recognized in skin by careful observation C. May appear as abrasions, lacerations, incisions, punctures, avulsions, amputations, contusions, hematomas, or crush injuries D. Blood vessels, nerves, connective tissue, and other structures may also be affected; blood loss, pathway to infection E. Epidemiology 1. Most common form of trauma 2. Most open wounds require simple care and/or suturing; others may damage nerves, arteries, and tendons and lead to disability 3. Severe hemorrhage, infection 4. Closed tissue wounds occur commonly; can result in pain, morbidity 5. Risk factors include: age, alcohol, drug abuse, occupation 6. Prevention includes: padding to areas common to falls, safety switches and equipment, protective clothing; EMS must also practice prevention measures in the field

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Knowledge Application For an assignment, have students define each key term.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 15

Content Outline III. Anatomy and Physiology of Soft Tissue Injury A. Each layer of the skin helps to maintain homeostasis B. Epidermis 1. Outermost layer, cells that divide rapidly—this layer constantly is refreshed and able to maintain thickness 2. Movement of skin cells allows resistance to bacterial invasion 3. Sebum lubricates surface, keeping skin strong, flexible, and resistant to water penetration 4. The epidermis is responsible for pigmentation that protects from ultraviolet (UV) radiation C. Dermis 1. Beneath the epidermis, connective tissue that helps contain body and supports function of epidermis 2. Loose connective tissue, capillaries, nerves, collagen, blood vessels, nerve endings, glands, and hair follicles 3. Sebaceous glands (sebum production); sudoriferous glands (sweat secretion) 4. Macrophages and lymphocytes (white blood cells [WBCs]), mast cells, fibroblasts D. Subcutaneous Tissue 1. Body layer beneath dermis—fatty (adipose) tissue helps absorb forces of trauma, protects tissues and organs 2. Very important in conserving body temperature E. Blood Vessels 1. Blood is an important medium that moves through lower layers of skin and consists of water, electrolytes, proteins, and cells 2. Lymphatic system—system of channels and tissues that carries some of the fluid delivered to the cells by the vascular system and by-products of pathogen destruction to be further broken down and returned to the vascular system.

F. Muscles 1. Provide power for movement, give body its shape, and produce heat 2. Strong contractile tissues, provide protection to organs 3. Connected to skeleton by tendons—driving force of movement 4. Tendons made up of collagen G. Fasciae

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Teaching Tips Using pictures and models, review the anatomy and physiology of the skin, blood vessels, fascia, muscles, and tension lines.

Discussion Topics Discuss static and dynamic tension lines, and common injuries with each.

What risks are associated with the clotting and healing process of a dynamic tension wound?

Critical Thinking Questions What can you do in the field to help prevent risks?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

1. Fibrous sheets that bundle skeletal muscles together and segregate them from one another 2. Made up of collagen, very strong; define compartments H. Tension Lines 1. Skin is spread over body and attached to fit contours of structures 2. Tension lines—natural stretch or tension in skin 3. When cut across a tension line, wounds will spread widely and gape; will heal slower and tend to bleed more 4. When cut parallel to a tension line, wounds have very little gape; quicker healing 5. Static tension: areas of limited movement of tissue and structures (anterior abdomen, between joints) 6. Dynamic tension: areas subject to great movement (skin over joints); mending process frequently interrupted 45

IV. Pathophysiology of Soft Tissue Injury A. Soft tissue injuries can affect health, causing blood and fluid loss, infection, hypothermia B. May be blunt or penetrating injury C. Blunt injury may cause open wounds D. Closed Wounds 1. Contusions—blunt, closed wounds that crush and damage small blood vessels; reddened area called erythema; blood leaks into interstitial spaces, resulting in a black-and-blue discoloration (ecchymosis); may not be evident in prehospital setting; more pronounced in area where mechanism of injury (MOI) caused injury 2. Hematomas—soft tissue bleeding that involves larger blood vessels and pools in a pocket; pronounced in areas that are unyielding; severe hematomas can contribute to hypovolemia 3. Crush injuries—collection of traumatic insults that includes the crush injury and syndrome; body part compressed and sustains deep injury to muscles, blood vessels, bones, with massive damage 4. Crush syndrome—systemic effects of large crush injury; destruction of skeletal muscles leads to large amount of myoglobin, potassium, lactic acid, uric acid, toxins; when pressure released, products enter bloodstream causing metabolic acidosis; they also are toxic to heart and kidneys

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Use pictures to review the different types of soft tissue injuries.

Use pictures to review keloid and hypertrophic scars, and review common locations for each.

Discussion Topics Discuss various mechanisms of injury that can result in soft tissue damage.

Review the inflammatory process, and discuss what can negatively affect this process (e.g., medications, etc.)

Discuss the steps of wound healing and what could prevent these from working.

Discuss the differences in clean cuts versus tearing or jagged cuts, focusing on gaping

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline E. Open Wounds 1. Abrasions—minor injuries that interrupt protective barrier of skin; scraping or abrasive action that removes layers of epidermis and upper layer of dermis; serious infection can occur in large areas 2. Lacerations—open wounds that penetrate deeper into dermis; usually small surface area limited to area of penetration and may damage significant vasculature and possible underlying organs; open to infection 3. Incisions—smooth lacerations caused by sharp instruments; bleed freely and do not show the extent of injury 4. Punctures—special lacerations that involve small entrance wound with damage that extends into body’s interior; increased risk of infection 5. Impaled objects—wound complication associated with puncture or laceration that involves embedded objects; high risk with removal; prehospital care involves stabilizing object and not removing unless affecting airway 6. Avulsions—flap of skin is not torn completely from body; tends to be seen with animal bites, machinery accidents, and blunt trauma to skull; seriousness depends on area, circulation, and contamination 7. Degloving injury—special type of avulsion where skin is torn off of underlying muscle, tissue, vessels, and bone; skin torn off while skeletal muscle held stationary; gruesome injury that is often severely contaminated and poor prognosis 8. Ring injury—ring caught, pulling skin of finger against weight of person, tearing upper layers of tissue away 9. Amputations—partial or complete loss of limb; hemorrhage may be limited if limb cleanly cut, or severe if wound jagged or crushed; limb replacement may be attempted, or skin grafting performed for wound closure and future prosthetic F. Hemorrhage 1. Blood loss can range from minimal to life threatening 2. Arterial (bright red and spurting), venous (dark and oozing), or capillary (red and self-limiting) 3. The amount of blood visible and time since injury allow for relative rate of hemorrhage 4. Clean lacerations and amputations usually do not bleed profusely; wound laid open, increasing blood loss

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes wounds and lack of muscle contractions and the healing process.

Discuss the various infections of wounds and their causes.

Review compartment syndrome, crush injuries, and injection injuries; discuss signs and symptoms and treatments.

As a group, discuss ways students can help limit and possibly prevent infection in their patients.

Critical Thinking Questions Why is it a good idea for paramedics to not wear jewelry or rings when working?

What happens to a wound if you continually remove the bandage to check the healing process?

How can immobilization devices cause compression and pressure injuries?

Class Activities Use laminated pictures of soft tissue injuries and index cards with definitions of soft tissue injuries. Have students match up the pictures with the meanings.

Have students practice soft tissue wound care for all of the listed wounds.

As a group, review all of the various

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

G. Wound Healing 1. Essential part of homeostasis that begins immediately following injury and may take months to complete; phases overlap 2. Hemostasis: body’s ability to stop most bleeding on its own a.

Vascular phase—immediately after injury, arteries, arterioles, and some veins constrict, and longitudinal muscles retract, reducing blood flow; capillaries cannot constrict and continue to ooze b.

Platelet phase—platelets begin clotting phase as walls of vessels become sticky and platelets stick to vessel wall and one another, forming a platelet plug c.

Coagulation phase—proteins activated enzyme reactions that change certain blood proteins into long fibrin strands, which entrap red blood cells (RBCs) and produce a gelatinous mass that further occludes bleeding 3. Inflammation a.

Complex process of healing b.

Involves WBCs, proteins in immunity, hormone-like chemicals c.

Damaged cells release proteins and chemicals called chemotactic factors that recruit cells responsible for consuming cellular debris, bacteria, and foreign or damaged cells d.

Granulocytes and macrophages first to arrive; engulf foreign material and release by-product, called phagocytosis e.

Lymphocytes attack pathogens directly or through antibody response f.

Mast cells release histamine, which dilates precapillary vessels, increases capillary permeability, and increases blood flow to injured tissue; (hyperemia) transfers protein into tissue (called edema) g.

Hyperemia brings oxygen (O2) and phagocytes to injured area, increases temperature of injured area h.

Characteristics of this response are: swollen, reddened, and warm area 4. Epithelialization—early stage of wound healing where epithelial cells migrate over wound, restoring uniform layer of skin along edges of healing wound; equally functional skin 5. Neovascularization; new blood vessels generated that form from undamaged capillaries in wound margins; very fragile and takes weeks

bandages and dressing materials available for caring for soft tissue injuries.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline to months for new vessels to become resistant to injury 6. Collagen synthesis—main structural protein a.

Cells called fibroblasts brought to wound surface and synthesize collagen to rebuild damaged tissue b.

Collagen binds wound together and creates scar tissue, taking up to 4 months to gain full maturity c.

Remodeling involves placing collagen into neat, parallel bonds to strengthen healing, taking up to 6 to 12 months 7. Infection a.

Most common complication and a serious risk b.

Staphylococcus, streptococcus bacteria are common causes of infection, due to common placement in environment c.

MRSA and VRSA are staph infections resistant to drugs normally used to combat them and a major cause of wound infections d.

Pseudomonas aeruginosa (diabetic and foot punctures) and pasteurella multocida (cat and dog bites) e.

Takes bacteria 2 to 3 days to grow into numbers that cause signs and symptoms; pus may be visible from wound, foul smell and visible red streaks (lymphangitis), fever, malaise 8. Infection Risk Factors a.

Health of patient, wound type and location, associated contamination and treatment b.

Diabetics, elderly, infirm, those with chronic diseases at greater risk c.

Cancer, anemia, liver failure, HIV/AIDS increase risk, along with smoking, immune-suppressive drugs, steroids d.

Wound type affects infection likelihood: punctures, avulsions, crush injuries e.

Wound locations such as distal extremities and feet have greater risk due to decreased circulation f.

Clean versus dirty objects that create injury g.

Human, dog, and cat bites very high risk for infection h.

Treatment type—sterile dressings, clean gloves, wound irrigation with pressurized steam device i.

Antibiotics may help if given within first hour after deep major wounds if foreign body suspected 9. Gangrene—tissue decomposition by bacteria that results from loss of

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline blood supply, crush injury, infection; deep space infection usually caused by Clostridium perfringens that produces gas within the wound, causing subcutaneous emphysema and foul smell; leads to sepsis and death if untreated 10. Tetanus—Clostridium tetani bacterium; few signs at injury site, instead causes widespread, painful, involuntary muscle contractions, especially mandibular trismus (lockjaw); preventable through immunization H. Other Wound Complications 1. Impaired hemostasis—medications such as ASA, Plavix = prolong clotting time; Coumadin, heparin, TPA, streptokinase interfere with fibers that form clots; hemophiliacs have abnormalities in proteins involve in fibrin formation 2. Rebleeding—possible due to movement, dislodgment of clots from bandages, partially healed wounds 3. Delayed healing—diabetics, elderly, chronically ill, and malnourished at risk for delayed or arrested healing due to limited blood flow, poor nutrition 4. Compartment syndrome—complication associated with closed injuries to the extremities, due to swelling within compartment that causes increased pressure and restricts capillary blood flow to muscles and nerves that becomes ischemic after 10 hours a.

Most commonly affects extremities (leg, thigh, buttocks, hand, forearm, arm); leg’s anterior compartment is most common location 5. Abnormal scar formation—keloid is excessive scar tissue beyond boundaries of wound and most common in darkly pigmented people; hypertrophic scarring is excessive accumulation within injury border and often associated with dynamic skin tension lines (flexion joints) 6. Pressure injuries—caused by prolonged compression of skin and tissue that can occur in bedridden patients, patient who falls and remains unconscious for hours; weight against ground or bed compresses tissue and induces hypoxic injury 7. Crush injuries—body tissues subjected to severe compressive forces, causing disruption and extensive damage a.

Large area of destruction with limited circulation, which creates growth medium for bacteria b.

Limb may appear “wood-like” due to muscle rigor resulting from

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

tissue hypoxia and acidosis 8. Associated injuries—additional fractures, direct injury from falling debris, dust and smoke inhalation, dehydration, and hypothermia 9. Crush Syndrome a.

Occurs when body part entrapped for 4 or more hours b.

Crushed skeletal muscle undergoes necrosis and cellular changes; traumatic rhabdomyolysis c.

Releases toxins, including myoglobin, phosphate, potassium, and lactic acid, that accumulate in crushed limb d.

Once pressure released, toxins flood central circulation e.

Myoglobin lodges in kidneys, leading to renal failure (leading cause of delayed death) f.

Increased potassium reduces cardiac muscle response to electrical stimuli, causing cardiac dysrhythmias and sudden death g.

Phosphate levels lead to calcifications in vasculature and nervous system h.

Increased cellular acidity and injury 10. Injection injury—soft tissue injury from a bursting high-pressure injection that pushes fluid into tissue layers a.

Body unable to remove injected materials, causing severe damage and possible loss of limb; systemic toxicity can be sustained 10

V. Dressing and Bandage Materials A. Dressings: material placed directly on wound to control bleeding and maintain cleanliness 1. Sterile/nonsterile dressings: sterile—prepared to be without microorganisms, packaged individually, remain sterile until open, used in direct contact with wounds; nonsterile—clean but not free of microscopic contamination, not intended to be placed directly on wound, placed over sterile dressing for bulk or absorption 2. Occlusive/nonocclusive dressings: occlusive—sterilized wrap plastic and petroleum gauze designed to prevent air and fluid movement (chest/neck); nonocclusive—most dressing material not petroleum gauze 3. Adherent/nonadherent dressings: adherent—untreated pads that stick to drying blood and fluid, advantage of clot formation but removal painful

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Critical Thinking Questions What type of dressing becomes a breeding ground for bacteria and infection?

When would the use of an occlusive dressing be indicated?

Class Activities Have students practice dressing and bandaging on each other.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

and can disrupt clot; nonadherent—treated with chemicals to prevent fluids from sticking to dressing (preferred for most wounds) 4. Absorbent/nonabsorbent dressings: absorbent—soak up fluids, helpful in situations of bleeding; nonabsorbent—absorb little or no fluid and used as barrier (dressing placed over IV puncture sites) 5. Wet/dry dressings: wet—burns, complicated postoperative wounds, normal saline used to wet dressing, increase infection risk (eviscerations, burns); dry—often used in prehospital care 6. Hemostatic dressings: applied directly to wound to slow or stop bleeding; Celox, HemCon, QuickClot, TraumaDEX B. Bandages—hold dressing in place 1. Self-adherent roller bandages: most common and convenient, limited stretch and resist unraveling, conform to body contours 2. Gauze bandages: convenient, do not stretch or conform to body contours as well as self-adherent, may increase pressure at injury site 3. Adhesive bandages: adhesive that secures small dressing; circumferential use does not allow for swelling and increases pressure at site 4. Elastic (or Ace) bandages: stretch and conform to contours easily, providing stability and support; very easy to apply too much pressure, reducing blood flow 5. Triangular bandages: cravats, strong and nonelastic and used to make slings and swathes and affix splints 15

VI. Assessment of Soft Tissue Injuries A. Observation of skin is essential in assessment, as trauma must pass through skin to cause deeper injury; skin is the first and may be the only organ to display effects of trauma B. Scene Size-Up 1. MOI, body substance isolation (BSI), anticipation of likely injuries, including hemorrhage C. Primary Assessment 1. General impression, spinal precautions, level of consciousness (LOC), ABCs, skin—assessment of color, temperature, and condition 2. Location and visibility of wounds, MOI, correct life threats, prioritize transport

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Class Activities Have students go through the assessment process step by step, with a focus on soft tissue trauma and presentation, using inquiry, inspection, and palpation.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline D. Secondary Assessment 1. Serious trauma will receive rapid trauma assessment; all others will receive focused exam E. Significant Mechanism of Injury—Rapid Trauma Assessment 1. Swift evaluation of head, neck, chest, abdomen, pelvis, extremities, and posterior 2. Internal or life-threatening injuries 3. Discolorations, deformities, temperature, muscle tone, open wounds 4. Immediate care focused on maintaining ABCs and controlling severe blood loss 5. Vital signs, Glasgow Coma Scale (GCS), history, medication use, and confirm transport decision 6. Establish order of care and plan management process F. No Significant Mechanism of Injury—Focused Trauma Assessment 1. Focused trauma assessment, examine injury site in detail 2. Chief complaint, inspection, palpation, distal pulses, and transport options G. Detailed Physical Exam 1. Head-to-toe evaluation of skin and body requires inquiry, observation, and palpation 2. Purpose is to find any additional information regarding condition and search for unsuspected or subtle injuries 3. Never delay transport for a detailed exam, and only perform if patient condition permits H. Assessment Techniques 1. Inquiry: question about MOI, pain, loss of function or sensations, use OPQRST for nature of pain, sensory or motor loss; always question patient about signs and symptoms before touching 2. Inspection: discolorations, deformities, open wounds; local or systemic implications; depth and potential damage of wounds; identify object used to create injury, if possible; observe for contamination, impaled objects, or foreign bodies; if amputation, perform brief search for missing limb 3. Palpation: deformities, asymmetry, temperature, masses, loss of skin or muscle tone; palpate all closed wounds for tenderness, swelling, crepitus, subcutaneous emphysema; presence of distal pulses and

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

capillary refill, motor and sensory function 4. Reassessment: reexamine LOC, ABCs, vital signs, and injuries and interventions; every 5 in unstable and every 15 in stable patients

30

VII. Management of Soft Tissue Injuries A. Objectives of Wound Dressing and Bandaging 1. Control all hemorrhage, keep wound clean, immobilize wound B. Hemorrhage Control 1. Direct pressure most effective, using finger pressure and dressing right to bleeding site 2. If not effective, reevaluate direct pressure; consider tourniquet if lifethreatening hemorrhage cannot be controlled 3. Tourniquets should be applied to a pressure above systolic blood pressure 4. Do not remove tourniquets applied in the field C. Cleanliness 1. Any contamination makes healing more difficult; use every attempt to keep wound clean 2. If wound grossly contaminated, consider saline irrigation or physical removal of large particles (glass, gravel, debris) if it will not cause further damage D. Immobilization 1. Stabilization of wound allows for natural clotting mechanisms to operate without disruption and reduces patient discomfort 2. Monitor any limb that is immobilized for distal pulses, motor and sensory function 3. If distal circulation compromised due to immobilization, elevate extremity and loosen bandages E. Pain and Edema Control 1. Apply cold packs and pressure bandages 2. Cold pack will reduce inflammatory response and local edema, and dull pain 3. RICE: rest, ice, compression, elevation 4. Morphine, fentanyl, other analgesics per medical control

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Review the pathophysiology of crush syndrome and the specific treatments.

Discussion Topics Review the steps in using a tourniquet, and the associated risks.

Critical Thinking Questions What can happen to a person’s skin if he is bedridden and rarely moved from a fixed position?

Why is it so important to allow cerebrospinal fluid (CSF) to drain?

Class Activities Have students practice bandaging the specific body areas listed.

Have students practice bandaging and immobilization of injuries.

Points to Emphasize Three goals for management are hemorrhage control, keeping the wound clean, and immobilization.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline F. Anatomical Considerations for Bandaging 1. Scalp: rich vascular supply that can bleed heavily; direct pressure if no skull injury present, wrap dressing in place by wrapping bandage around head; if fracture present, apply direct pressure at small scalp arteries, avoiding fracture site, and apply dressing and bandage same 2. Face: bleeds heavily, may be gruesome; apply direct pressure; wrap bandage around head, ensuring open airway; watch for emesis, as swallowed blood is a gastric irritant; have suction ready 3. Ear or mastoid: wrap head circumferentially, use open gauze to collect any bleeding or fluids; do not stop flow of cerebrospinal fluid (CSF) 4. Neck: direct manual pressure, occlusive dressings, tape to hold dressing in place; continuously observe airway, as swelling in this area may obstruct airway 5. Shoulder: soft, self-adherent bandages, using axilla, arm, and neck as points of fixation; no pressure on anterior of neck and trachea 6. Trunk: adhesive tape holding dressing in place, occlusive dressing, ladder splint to posterior to give fixation point of bandage to avoid circumferential wrapping and respiratory difficulties 7. Groin and hip: bandages that follow contour; movement may cause tightness to bandages; complete bandaging after patient is in final position for transport 8. Elbow and knee: difficult to bandage; use circumferential wraps and splint in place, halfway between flexion and extension (position of function) 9. Hand and finger: easy to bandage; splint in position of function; malleable finger splints; remove jewelry if possible 10. Ankle and foot: wrap circumferentially; bleeding control warrants wrapping from toes and working proximally G. Complications of Bandaging 1. Increased swelling, pressure to area, decreased blood flow, ischemia 2. Pain, pallor, tingling, loss of pulses or capillary refill typical signs of developing pressure and ischemia 3. Avoid by making bandages snug but not too tight, allowing one finger to be easily slipped beneath bandage 4. If left on too long, become soaked and serve as breeding grounds for infection (2–3 days of development)

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 5. Dress a wound using dressing that is just larger than wound, but not small enough to get lost in wound H. Care of Specific Wounds 1. Amputations: may bleed heavily or minimally; bleeding control with direct pressure and large, bulky dressing; tourniquet for severe bleeding that can’t be controlled or crush injury a.

Place amputated part in plastic bag, wrapping part in gauze moistened with lactated Ringer’s (LR) or normal saline (NS), and immerse bag in cold water 2. Impaled objects: immobilize in place using bulky dressing and tape a.

May have to cut object if too large to transport or affixed; limit heat, vibration, and jolting b.

Remove impaled object if necessary to maintain patent airway, or if inhibits cardiopulmonary resuscitation (CPR) 3. Crush syndrome: successful prehospital care is anticipation of problem and prevention of effects a.

Rapid transport, adequate fluid resuscitation, diuresis, and possibly systemic alkalinization b.

Scene safety, specialized rescue c.

Primary assessment, ABCs, control reachable bleeding d.

Patient complaints include pain, lack of motor function, tingling, loss of sensation in affected limb e.

By-products of crush injury contained as long as body part still trapped f.

Extrication will release toxins into bloodstream, causing patient to rapidly develop shock and die; kidney failure, compartment syndrome g.

ABCs, IV, contact medical control, frequent vital signs, fluid administration, alkalizing agents (sodium bicarbonate 1 mEq/kg), diuretics to help kidney perfusion (Mannitol) h.

Tourniquet to compressed area before compressing force removed to prevent reperfusion injury, although tourniquet will continue crush injury i.

Cardiac electrocardiogram (ECG) due to dysrhythmias from potassium release; calcium chloride may be ordered j.

Treat rapidly progressing shock

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

k. Definitive care involves medications, hemodialysis, debridement, hyperbaric oxygenation 4. Compartment Syndrome a.

Common symptom is pain out of proportion to physical findings b.

Five P’s—pain, paresthesia, paresis, passive stretching pain, pulselessness—help to identify syndrome (note: the sixth P is poikilothermia [cold to touch]) c.

Motor, sensory function and pulses usually normal d.

Compartment syndrome occurs within 4 to 8 hours or longer e.

Steps for care include care of underlying injury, immobilization of fractures, cold packs, elevation I. Special Anatomical Sites 1. Face and neck—challenge for airway patency and control 2. Thorax—internal bleeding, air entering cavity 3. Abdomen—injury to hollow or solid organs; subtle signs of internal injuries J. Wounds requiring transport: wounds involving nerves, blood vessels, ligaments, tendons, muscles, contaminated wounds, impaled object, cosmetic implications K. Soft tissue treatment and release/refer: may be permitted to refer patients with minor and superficial wounds to personal physician, based on protocols 5

VIII. Summary A. Soft tissue injuries can compromise skin and the protection it provides B. Look for early signs and symptoms of soft tissue trauma, using MOI and patient complaint C. Basic goals include: controlling hemorrhage, keeping wound as clean as possible, and immobilizing injury site IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

X. You Make the Call

Class Activities Read and discuss the call and questions as a group.

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 4 objectives can be found on text p. 83.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline XI. Review Questions

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Class Activities Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 5 Burns 140–150 Minutes

• • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Knowledge Application

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Burn Trauma A. Incidence of burns has declined for several decades B. Persons at risk include very young, old, infirm, and workers exposed to occupational combustion and chemical sources C. Second leading cause of death in children under 12 years of age and fourth overall cause of trauma death D. Male patients account for 70% of burn mortality E. Decline in burn mortality attributed to improved building codes; safer construction techniques; sprinkler system and smoke detector use; educational campaigns—reducing hot-water temperatures in the home, keeping matches and lighters away from children F. Burns are specific soft tissue injury that produces a chemical change to body tissues, evaporating water and denaturing proteins G. Effective treatment of burns includes understanding of the structures and functions of integumentary system, along with the pathological effects of thermal, chemical, electrical, and radiological injuries

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Knowledge Application For an assignment, have students define each key term.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 10

50

Content Outline

Master Teaching Notes

III. Anatomy and Physiology of the Skin A. Skin is largest and least appreciated human organ that covers entire body, protects from fluid loss and bacteria, provides sensation and thermoregulation B. Layers of the Skin 1. Epidermis—outermost layer of skin that regenerates continuously 2. Dermis; underneath, contains oil and sweat glands, nerves, blood vessels 3. Subcutaneous tissue—composed of adipose and connective tissue, serving as insulation 4. Underlying structures—muscles, fascia, nerves, tendons, bones, organs C. Functions of the Skin 1. Protects body from bacterial and microorganism invasion 2. Sensation of temperature, pressure, and pain 3. Control of fluid loss and movement of fluid into body 4. Temperature regulation through sweat and shunting of blood 5. Insulation from trauma 6. Flexible body movement IV. Burn Pathophysiology A. Result from protein disruption in cell membranes and can be caused by several mechanisms B. Four types of burns: thermal (heat), electrical, chemical, and radiation C. Thermal Burns 1. Cause damage by increasing rate at which molecules move and collide with each other; degree of heat is a measure of the speed of molecules that make up an object 2. The greater the molecules move and the more frequently they collide, the greater the object’s temperature 3. Heat energy creates chemical changes that cause protein breakdown (denaturation) 4. Extent of burn injury is related to amount of heat energy transferred to patient’s skin; temperature of burning agent, concentration of heat, length of contact 5. The greater the temperature, the greater the damage, along with amount of heat energy possesses, duration of exposure 6. Initial burn damages epidermis; as exposure continues, dermis,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Use pictures to identify the different degrees of burns.

Discussion Topics Use pictures to discuss the Jackson burn theory. Have students identify ways to prevent the zones from enlarging.

Discuss resistance to electricity, and areas of the body that have low resistance (think of children with oral burns from chewing electrical cords).

Discuss the entrance and exit of electrical burns, including the damage seen at these locations, compared to lack of visible

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline subcutaneous tissues, muscles, other tissues may be affected 7. Jackson’s theory of thermal wounds includes: zones of coagulation, stasis, and hyperemia 8. Zone of coagulation: area of skin nearest heat source suffers most damage, with cell destruction, blood coagulation, and structural protein denaturing (full-thickness or partial-thickness burns) 9. Zone of stasis: less damaged yet still inflamed region where blood flow decreases 10. Zone of hyperemia: area distant from burn source where inflammation and change in blood flow limited (redness associated with burns) 11. Phases of body response to burn are emergent, fluid shift, hypermetabolic, and resolution phases 12. Emergent phase: immediately following a burn, body’s initial reaction that includes pain, catecholamine release (tachycardia, tachypnea, mild hypertension, mild anxiety) 13. Fluid shift phase: can last 24 hours, but usually peaks in 6–8 hours; occurs in thermal burns larger than 15–20%; damaged cells initiate inflammatory response that increases capillary permeability, causing fluid to shift from vascular space into interstitial space (extravascular), causing massive edema 14. Hypermetabolic phase: lasts days to weeks, depending on burn severity; large increase in body demand for nutrients as repair process begins 15. Resolution phase: scar tissue formed and rehabilitation begins D. Electrical Burns 1. Power result of electron flow from point of high concentration to low concentration; difference between two is voltage 2. Voltage—pressure of electrical flow 3. Current—rate or amount of flow in a given time (measured in amperes) 4. Direct current—electrons flow in one direction (DC) 5. Alternate current—reverses flow in short intervals (AC) 6. Resistance—factor that affects flow of electricity (measured in ohms) 7. Ohm’s law: voltage (V) = current (I) × resistance (R) 8. Human tissue: internal tissue moderately resistant, while skin is highly resistant; sweat/moisture lowers resistance, nerve tissue readily conducts electricity

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes external damage along the pathway.

Discuss the different radiation exposures, and the types of safety equipment needed for protection.

Discuss the various causes of carbon monoxide poisoning.

Review inhalation injuries, and common signs and symptoms.

Discuss the strides engineering has made in the prevention of burns.

Critical Thinking Questions Your patient has just been pulled out of a burning home and is suffering second- and third-degree burns. This patient presents in shock with a low blood pressure. Is this low blood pressure from the burns suffered?

Why or why not?

What types of scenes would you expect to respond to for gamma radiation exposure?

Is the person who has been exposed to radiation a radioactive threat to the rescuer?

Why would ischemia and cardiac arrhythmias be a risk for carbon monoxide poisoning?

What are ways you, as the paramedic, can help reduce the patient’s exposure to

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 9. Human body and voltage: initial resistance by tissues; voltage passing through and into body is strong, creating heat energy, which occurs at points of great resistance (skin) 10. If voltage or current high, along with duration of contact, profound damage occurs 11. The heat produced by the electrical current is expressed in Joule’s law—P = I2 Rt 12. Electricity burn heats victim from inside out, causing damage to internal organs with possibly little visible external damage (except for entrance and exit) 13. Current may follow blood vessels and nerves due to less resistance, leading to serious vascular and nerve damage 14. Interferes with nervous control of muscle tissue; respiratory arrest, ventricular fibrillation, tetanic convulsions or contractions of muscles (unable to let go of wire or fall away from contact) 15. Flash burns from electrical arc, ignition of clothing or combustibles E. Chemical Burns 1. Denature the biochemical makeup of cell membranes and destroy cells 2. Not transmitted as thermal injuries; instead destroys tissue before it can chemically burn any deeper (may limit burn unless very strong); usually from strong acids or alkalis 3. Acid burns: usually form a thick, insoluble mass at point of contact (coagulation necrosis) that helps limit depth of burn; cause immediate pain, burn usually occurs in 1–2 minutes 4. Alkali burns: limited pain with no coagulum formed, continued cell destruction causing progressively deeper burns (liquefaction necrosis) F. Radiation Injury 1. Danger when people exposed to synthetic sources that increase radiation intensity 2. Safety measures commonly prevent exposure; accidental exposure has potential for large-risk injuries 3. Damage caused through ionization: radioactive energy particles travel into substances and change internal atoms (human body cell will repair itself, die, or produce damaged cells) 4. Four types of ionizing radiation: alpha, beta, gamma, and neutron 5. Alpha radiation: released from unstable nucleus; very weak and can

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes pathogens after a burn?

For what area of the body would eschar be a life-threatening risk?

Why would geriatric, pediatric, and chronically ill patients have more difficulty healing from burns?

Class Activities Have students rub their hands together very quickly for 15–30 seconds to experience the warmth created, then have them do the same thing, only very slowly and for 5 seconds. Use this as a way to explain how molecules that move fast and frequently create heat.

Have students practice the Rule of Nines (adult, child, infants) and Rule of Palms.

Knowledge Application Have students research common household products that are strong acids and alkalis.

Have students research the incidence of carbon monoxide poisoning in your area.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline travel only inches in air; easily stopped by paper or clothing and cannot penetrate epidermis; hazard if inhaled or ingested 6. Beta radiation: lightweight; can penetrate a few layers of clothing, first few millimeters of skin; can cause external and internal injury 7. Gamma radiation: most powerful; can travel through entire body; most dangerous and feared; difficult to protect against; many feet of concrete or many inches of lead needed to shield 8. Neutron radiation: great penetrating power; uncommon outside of nuclear reactors and bombs 9. Exposure occurs through unshielded person exposed to strong radioactive source or contaminated by dust, debris, fluids 10. Duration of exposure, distance from radioactive source; and shielding between you and patient and source are important factors during a response a.

Duration: radiation exposure is accumulative danger; the longer the exposure, the greater the injury b.

Distance: radiation diminishes as you travel away from the source c.

Shielding: more material between radiation and yourself = less exposure 11. Measured with Geiger counter as units-per-hour and cumulative exposure recorded by dosimeter; records units of radiation as rad or Gray (1 Gray = 100 rads) a.

Whole-body exposure and dose increase appearance of signs and symptoms b.

First signs: slight nausea, fatigue (4–24 after exposure) c.

Lethal range: severity of nausea increases, anorexia, vomiting, diarrhea, malaise, intense fatigue, and erythema (2– 6 hours) d.

Fatal dose: all radiation exposure signs immediately, confusion, watery diarrhea, and physical collapse e.

Prolonged exposure: long-term and delayed problems, infertility, cancer G. Inhalation Injury 1. Commonly occurs if a patient is trapped or unconscious in enclosed space, or if smoke is extremely dense; inhalation of gases, heated air,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline flames, or steam will result in airway and respiratory injury 2. Toxic Inhalation a.

Synthetic and plastics release toxic gases as they burn, and combustion can form cyanide, hydrogen sulfide, and other toxic substances b.

Inhalation can react with lung tissue, diffuse across alveolar capillaries, and interfere with oxygen (O2) delivery and use of O2 c.

Signs and symptoms may be immediate or delayed and occur more frequently than thermal inhalation burns 3. Carbon Monoxide Poisoning a.

Significant concern; product of incomplete hydrocarbon combustion b.

Tasteless, odorless, and unrecognizable; as concentration increases, danger of poisoning begins c.

Improperly ventilated open flame in contained area, or internal combustion engines d.

Competes for sites on hemoglobin, and hemoglobin has 200 times more affinity for carbon monoxide (CO); prevents O 2 from being transported e.

Attaches to myoglobin, inducing cardiac arrhythmias and ischemia f.

Signs and symptoms include: malaise, headache, dizziness, blurred vision, nausea, vomiting; increased exposure: confusion, weakness, dyspnea, syncope, tachypnea, tachycardia, chest pain; extreme exposure: hypotension, cardiac ischemia, arrhythmias, pulmonary edema, seizures, coma, pulmonary arrest, cardiac arrest, and death g.

Always keep suspicion as temperature drops, due to malfunctioning heating units, or when group of people living or working together suffer flu-like symptoms h.

CO poisoning special concern in young, elderly, preexisting disease, and fetuses 4. Airway Thermal Burn a.

Moist mucosa of airway may absorb heat, preventing lower airway burns; lower airway thermal burns are rare due to this

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline b.

c.

d.

protection Superheated steam exposure can cause lower and/or upper airway burns (firefighter risk), along with screaming and yelling, trapped in closed burn environment, standing in burn environment Signs and symptoms include: hoarseness, dyspnea, stridor, high-pitched crowing sounds on inspiration (ominous); look for: singed facial hair, black-tinged sputum, facial burns 60% to 80% of burn patients who die have associated inhalation injury

H. Burn Depth 1. Superficial burn: first-degree burn; involves only epidermis and upper dermis, resulting in pain, minor edema, and erythema; heals without complications 2. Partial-thickness burn: second-degree burn, involving dermis, resulting in blisters, pain, edema, erythema a.

Sunburn, and arc welder eye injury—usually heals without complications 3. Full-thickness burn: third-degree burn; involves epidermis, dermis, and subcutaneous layer; may go deeper, resulting in white, brown, dark red, or charred color, and dry, leathery appearance; pain not present in thirddegree burns, but will be present with first- and second-degree burns; skin grafting required I. Body Surface Area (BSA) 1. Rule of Nines—11 adult body regions that each approximate 9% of BSA: head and neck, anterior chest, anterior abdomen, posterior chest, lower back, anterior surface of each lower extremity, posterior surface of each lower extremity, entirety of each upper extremity, genitalia make up 1% 2. Must be modified in infant and child due to anatomy differences—divide neck and head into anterior and posterior surface and count 9 for each; reduce lower extremities by 4.5 3. Rule of Nines is a quick and useful tool to help measure burn extent 4. Rule of Palms: use of palmer surface of patient’s palm to gauge size of affected area; equals 1% of BSA 5. Used for burns up to 10% ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

J. Systemic Complications 1. Hypothermia: ability of body to regulate core temperature decreases due to tissue destruction; fluid leaks into wound, causing evaporation and removal of heat; wound does not have vasoconstrictive reflexes 2. Hypovolemia: fluid and electrolyte shift into burned tissue due to damaged capillary permeability; takes hours to develop; modern aggressive fluid resuscitation effective; electrolytes become overwhelmed, leading to cardiac dysrhythmias 3. Eschar: skin becomes hard and leathery; circumferential burns can occlude blood flow and movement 4. Infection: most persistent killer of burn victims; does not appear immediately; pathogens invade due to loss of protection of skin 5. Organ failure: myoglobin clogs kidney tubules; circulating by-products induce liver failure; potassium affects cardiac electrical system 6. Special Factors a.

Geriatric, pediatric, and chronically ill have greater difficulty coping with burn injuries 7. Physical Abuse a.

Mechanism of injury (MOI) regarding burns can indicate suspicion for abuse b.

Burn injuries that don’t make sense, multiple circular burns (cigarette), circumferential burns to buttocks, stocking burns to feet, branding 20

V. Assessment of Thermal Burns A. Assessment of skin must be deliberate, careful, and complete B. Establishment of nature and extent of injury allows for appropriate priority of care C. Scene Size-Up 1. No danger to you or partner, use extreme caution if entering an enclosed space (bedroom, garage, etc.), do not enter potentially hazardous scene, have patient brought to you if fire not extinguished, stop burning process on patient with water or smother flames with blanket, look at clothing or jewelry worn and remove, look at burn mechanism, and look for any other possible injury mechanisms 2. Carbon monoxide, cyanide, and hydrogen sulfide are common

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Discuss the hazards associated with burn scenes, from inhalation to structural collapse.

Obtain a pulse CO-oximeter so that students can observe its use.

Review with students the Legal Notes on Transporting a Burn Patient, along with the Baux score.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline byproducts of combustion and can be produced in large quantities in some fires.

D. Primary Assessment 1. General impression of patient; rule out associated danger of trauma or head/spine injury; level of consciousness (LOC), airway patency, breathing, circulation; O2 and intubation if indicated; pulse oximetry; pulse CO-oximetry; rapid-sequence intubation (RSI) for rapid intubation if indicated; nasal tracheal intubation; bag-valve mask (BVM) E. Secondary Assessment 1. Rapid or focused trauma assessment; vital signs; Glasgow Coma Scale (GCS); history; burn surface area and depth (Rule of Nines or Rule of Palms); look at entire body, remove any clothing (cut around if adhered to patient); determine pain sensation in burn area, and anatomy burned (feet, hands, face, circumferential burns); look at facial burns for airway and respiratory involvement; MSPs; categorize minor, moderate, or severe burn F. Reassessments 1. Vital signs, early signs of hypovolemia, airway problems; use caution with fluid resuscitation; monitor lung sounds and respiratory effort; assess distal circulation; electrocardiogram (ECG)

15

VI. Management of Thermal Burns A. Local and Minor Burns 1. Cooling can be used to treat local and minor burns 2. Used for partial thickness of < 15% or full thickness < 2% 3. Large-surface-area cooling subjects patient to hypothermia 4. Remove clothing, jewelry; evaluate distal pulses 5. Comfort and support; consider pain medications; try to keep burn area elevated, if possible 6. Cover burn if necessary with clean, nonadherent dressing or sheet B. Moderate to Severe Burns 1. Dry, clean, nonadherent dressing; clean sheet (helps to reduce pain) or bulky dressing 2. Keep patient warm by covering with blanket, keep squad warm 3. With large burn area, aggressive fluid therapy may be ordered (4 mL of fluid/kg × BSA of burn over 24 hours, with only half of amount given in

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Critical Thinking Questions Why would rapid intubation be indicated in a patient with burns and stridor?

What medication must be used cautiously if performing rapid-sequence intubation (RSI) in a burn patient, due to hyperkalemia risk?

What could happen to your patient’s treatment if you used your palm instead of your patient’s when estimating burn area?

What might you see on the electrocardiogram (ECG) if your burn patient is suffering from hyperkalemia?

Discussion Topics Discuss ways in which IVs can be started on patients suffering burns to extremities, and ways to secure IVs in places where the skin has been burned away.

Review cyanide kit administration.

Critical Thinking Questions Would the firefighter with a small exposure to cyanide during a working fire be a candidate for the cyanide kit?

Class Activities Have students open burn sheets and burn

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline first 8 hours); Parkland formula 4. Prehospital fluid administration in short transport may be 0.25 mL × kg × BSA = amount of fluid 5. Use caution, as rapid administration can cause edema 6. Pain medications may be administered, as indicated 7. Clean environment will help with infection risk 8. Escharotomy may be indicated if circumferential burn is preventing respiration (incise perpendicular to constriction to about 1 cm deeper than developing eschar, to release pressure); medical control order only C. Inhalation Injury 1. Intubation lifesaving if airway compromise imminent 2. Cricothyrotomy may be required 3. High concentration indicated, due to hypoxia and carbon monoxide and cyanide poisoning (continuous positive airway pressure [CPAP] will also displace CO rapidly) 4. CO-poisoned patients may require transport to hyperbaric chamber 5. Cyanide toxicity: dyspnea, chest pain, altered mental status, seizures, unconsciousness 6. Cyanide antidote includes: amyl nitrate, sodium nitrate, and sodium thiosulfate or Cyanokit (hydroxocobalamin) a.

Cyanokit: safer; hydroxocobalamin is precursor to vitamin B12 (cyanocobalamin) and binds cyanide, allowing normal cellular metabolism b.

Cyanide kit (amyl nitrate, sodium nitrate, and thiosulfate): two-stage process; nitrate compound, then sulfur compound; amyl nitrate converts hemoglobin to methemoglobin, which binds to cyanide; sulfur compound removes cyanide (risk due to methemoglobin acting as CO) VII. Assessment and Management of Electrical, Chemical, and

20

Radiation Injuries A. Electrical Injuries 1. Be certain power has been turned off before approaching—DO NOT allow anyone to approach until the power is turned off 2. Establish a safety zone to prevent accidental electrocution 3. Search for entrance/exit wound, ground contact points, and electrical

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes dressings and practice wrapping burn injuries.

Have students practice the Parkland formula, especially the half amount every 8 hours.

Discussion Topics Discus with students how they can be at risk for lightning strikes when caring for their patients, and how to avoid these risks.

Review the signs and symptoms students would expect to see with a chemical burn to

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline source 4. Assess cardiac, respiratory, neurologic systems and possible fractures 5. Remove any smoldering clothing or jewelry that may constrict 6. Monitor ECG for arrhythmias B. Lightning 1. Lightning strikes occur on open water, golf courses, tractors, under trees, in open fields, and in other areas; up to 100,000 volts, 10,000 amperes, and 50,000°F; usually lasts fraction of second 2. Lightening often travels sideways, striking nearby object first, then transferring to patient 3. No danger of electrical shock from touching patient, although lightning risk remains as long as storm nearby 4. Aggressive circulatory, ventilatory, and airway management (CAB) 5. Ventricular fibrillation treated with defibrillation and ACLS 6. Consider sodium bicarbonate and mannitol, usually at the discretion of medical direction, to prevent the complications of rhabdomyolysis C. Chemical Burns 1. Identify spill/contamination; approach uphill and upwind 2. Do not enter until hazmat team has cleared your approach 3. Take appropriate body substance isolation (BSI) precautions 4. Take appropriate protective action against airborne dust, toxic fumes, and splash exposure for both yourself and the patient to protect from agent 5. ABCs of patient; prevent secondary contamination from patient clothing 6. ECG, examine any chemical burn 7. Phenol: caustic, gelatinous and used in industrial cleaners; very difficult to remove due to stickiness and insolubility in water; alcohol needed to dissolve, then flush with large volumes of cool water; if alcohol not available, use water 8. Dry lime: calcium oxide; strong corrosive that reacts with water, producing heat and thermal injuries; brush dry lime off of patient completely, then rinse with water (this will allow reaction to occur with applied water, rather than patient’s soft tissues) 9. Sodium: unstable metal that reacts destructively with human tissue; reacts with water, creating heat, explosive gas, and possible ignition; normally stored in oil; decontamination consists of brushing off sodium

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes the eye.

Discuss the steps to decontamination, and the role of the paramedic in this process.

Review various products that contain phenol, dry lime, sodium, and so forth.

Critical Thinking Questions Do you need to follow the Parkland formula for fluid administration in an electrical or lightning injury?

What is the reason that the oldest rescuer is suggested during a radiation emergency?

Class Activities Have students research the incidence of lightning strikes is your area.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

gently, then covering in oil 10. Riot agents: pepper spray, mace, CS; intense eye, mucous membrane, and respiratory tract irritant; coughing, gagging, vomiting, eye pain, eye tearing, temporary blindness; supportive treatment with irrigation 11. Decontaminate any patient who has come in contact with chemicals; stop damage with irrigation, remove clothing, wash area with mild soap, irrigate again, continuing until arrival at emergency department 12. Do not use neutralizing agents unless directed by medical control 13. Chemical burns to eyes require rapid irrigation, continuing during transport; may use lactated Ringer’s (LR) or normal saline (NS) with a nasal cannula or a Morgan’s lens; remove contact lenses before irrigation D. Radiation Burns 1. Approach to scene is limited until radiation isolated by specially trained personnel 2. Use shielding; limit exposure time; oldest rescuer considered for patient removal 3. Decontaminate patients as necessary, before moving to ambulance 4. Decontaminated patient is no threat to you or others, although contaminated materials remaining on patient are a source of radiation E. Reassessments 1. Always asses for signs of increasing complications; monitor blood pressure (BP), pulse, respirations 5

VIII. Summary A. Burn injuries compromise the skin, damaging thermoregulation and disrupting infection protection B. Depth and body surface area affected are assessed during burn identification, allowing for assessment of overall burn severity and patient complications C. Electrical, chemical, or radiation burns require special care and assessment, including scene safety IX. Case Study

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Class Activities Discuss the case with students now that they are familiar with the chapter.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 5 objectives can be found on text p. 116.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

X. You Make the Call

Class Activities Read and discuss the call and questions as a group.

XI. Review Questions

Class Activities

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 6 Head, Neck, and Spinal Trauma 345–365 Minutes

• • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Knowledge Application

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

15

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Head, Neck, and Spinal Trauma A. Common with major trauma, with severe head injury most frequent cause of trauma death B. May be lethal in auto crashes, and frequently produces long-term disability C. Gunshot wounds (GSWs) to head result in a mortality of 75–80% D. Injuries to face and neck threaten airway and are suggestive of injury to central nervous system (CNS) E. Ages most at risk are males 15–24, infants, young children, and the elderly F. Prevention programs and use of safety equipment help to reduce injuries G. Time is critical once a head injury has occurred; intracranial hemorrhage and edema can increase intracranial pressure (ICP) and hypoxia, creating permanent damage H. Severity may be difficult to recognize; recognition of signs and symptoms allows direction of supportive care I. The paramedic must learn to recognize the signs and symptoms of head, face, neck, spinal column, and central nervous system injury early in the assessment; maintain a clear airway and adequate respirations; maintain the patient’s blood pressure; and provide rapid transport to a facility that can administer proper care.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Knowledge Application For an assignment, have students define each key term.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 65

Content Outline III. Head, Face, Neck, and Spine Anatomy and Physiology A. Anatomy and physiology of the head—the head is made up of three structures that cover and protect the brain: the scalp, the cranium, and the meninges B. The Scalp 1. Strong, flexible layer that can withstand and absorb tremendous energy; also very vascular 2. Connective tissue sheet called galea aponeurotica, along with other tissue, contains veins that become routes for infection when disrupted 3. SCALP mnemonic—S: skin, C: connective tissue, A: aponeurotica, L: layer of areolar tissue, P: periosteum C. The Cranium 1. Bony structure supporting the head and face; vault for brain 2. Several bones fused together at pseudojoints called sutures 3. Cranium effective at protecting brain from direct effects of trauma, although very little space available for swelling, causing ICP, reducing cerebral perfusion, and damaging brain tissue D. The Meninges 1. Connective tissue beneath scalp, skin, and skeletal components of cranium and spinal cord 2. Three layers: outermost layer (dura mater), middle layer (arachnoid membrane), and innermost layer (pia mater) E. Cerebrospinal Fluid (CSF) 1. Clear, colorless solution of water, proteins, and salts that surround the central nervous system (CNS) and absorb shock of minor acceleration and deceleration 2. Constantly generated by brain 3. Cerebrospinal fluid provides buoyancy and is a medium through which nutrients and waste products, such as oxygen, proteins, glucose, salts, and carbon dioxide, are diffused into and out of the brain tissue F. The Brain 1. Occupies 80% of volume of cranium 2. Cerebrum: largest nervous system element; exterior made of gray matter; central region made of white matter (axons); portion of brain that performs highest functions—conscious thought, personality, speech, motor control, and visual, auditory, and touch perception; divided into

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Teaching Tips Using an anatomy model, review the anatomy of the head, face, neck, and spinal column.

Use a skeleton to review the spinal column with students.

Review the three meningeal layers, along with purpose of each. Use anatomical models for this review.

Review the anatomy of the brain and spinal cord.

Discussion Topics Review the cranial nerves, covering their location and function.

Review the anatomy of the eye.

Review the blood supply to the brain including placement of facial arteries. Map out the arteries and show students the circle of Willis.

Draw the neck for students, illustrating the nerves, vessels, thyroid, and trachea.

Review the cranium, brain, and functions of each.

Attach a bowling ball to a broomstick; this gives a good visual on the size of the head in relationship to the neck.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline lobes Frontal lobe: personality Parietal lobe: motor, sensory direction, memory and emotions Occipital lobe: sight Temporal lobe: long-term memory, hearing, speech, taste and smell Falx cerebri: divides cerebrum into right and left hemispheres Tentorium cerebelli, a fibrous sheet similar to the falx cerebri, within the occipital region, separates the cerebrum from the cerebellum 9. Cerebellum: “fine tunes” motor control and allows body to move smoothly; balance and muscle tone maintenance 10. Brainstem: communication junction between cerebrum, spinal cord, cranial nerves, and cerebellum; midbrain, pons, and medulla oblongata 11. Pons: communication between cerebellum, cerebrum, midbrain, and spinal cord; sleep control for reticular activation system (RAS) 12. Midbrain: hypothalamus—controls endocrine functions, vomiting reflex, hunger, thirst, kidney function, body temperature, and emotions; thalamus—switching center between pons and cerebrum and critical element in ascending RAS (maintains consciousness), as well as tract for optic and olfactory nerves 13. Medulla oblongata: respiratory center, cardiac center, and vasomotor center 14. Brain has high metabolic rate; receives 15% of cardiac output and 20% of oxygen G. Central Nervous System (CNS) Circulation 1. Internal carotid arteries, vertebral arteries, basilar artery (circle of Willis) 2. Venous drainage occurs through bridging veins that drain into the dural sinuses (large, thin-walled veins) and ultimately drain into the internal jugular veins H. Blood–Brain Barrier 1. CNS capillary walls thicker and not as permeable; proteins and material not able to flow as freely; ensures that substances found in circulatory system do not affect CNS 2. No lymphatic circulation in brain; replaced by CSF, allowing protection of brain 3. Blood into CNS is irritant, resulting in inflammation and edema I. Cerebral Perfusion Pressure 3.

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©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Critical Thinking Questions What signs and symptoms might you find with a patient suffering from a frontal lobe injury?

What systolic pressure should be maintained for your central nervous system (CNS) trauma patient to keep CPP at normal level?

What is the formula for establishing mean arterial pressure? (Answer: diastolic + 1/3 of pulse pressure.)

What part of the brainstem may be injured to cause a protracted waking state?

What common drugs can get through the blood–brain barrier? What common drugs cannot?

What portion of the eye allows for muscular contraction?

What cervical vertebra is the strongest?

What would happen if your patient had no motor nerve innervation?

Class Activities Assign the following terms for students to define: cervical concavity, thoracic convexity, lumbar concavity, sacral convexity, vertebral arch, vertebral body, spinous process, transverse process.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 1.

2.

3.

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5.

J.

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Adequate cerebral perfusion critical for proper brain function Mean arterial pressure (MAP) normally 70–95 mmHg Intracranial pressure (ICP) normally 10–15 mmHg Cerebral perfusion pressure (CPP) is MAP – ICP As intracranial pressure rises, the cerebral perfusion pressure decreases The Monroe-Kellie Doctrine 1. Intracranial volume = brain volume + CSF + blood volume 2. Increased ICP reduces blood flow; systemic blood flow increases; causes ICP to rise and CPP to diminish 3. Increased pressure may push contents through tentorium and toward foramen magnum; called herniation Cranial Nerves 1. Nerve roots originating in cranium and along brainstem; 12 pathways for senses, facial area, control of body functions Ascending Reticular Activating System 1. Tract of neurons within upper brainstem, pons; and midbrain 2. Responsible for sleep-wake cycle; monitors amount of stimulation body receives 3. Helps regulate respiration, heart rate, peripheral vascular resistance 4. Injury can cause unconsciousness, coma Anatomy and physiology of the face—there are several specialized concerns related to facial trauma; these include airway complications, injuries to the sensory organs, and similar issues The Face, Nasal Cavity, and Oral Cavity 1. Facial bones are zygoma, maxilla, mandible, and nasal bones; protect and support sense organs of face 2. Facial region covered with flexible, thin, and vascular skin 3. Circulation provided by the carotid artery; branches into facial, temporal, and maxilla arteries 4. Cranial nerves most important traversing nerves are V (trigeminal) and VII (facial) 5. Nasal cartilage defines shape of nose and divides nostrils into nares 6. Oral cavity formed by maxillary bone, palate, upper teeth, mandible, and lower teeth 7. Tongue connects with hyoid bone

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Class Activities Using a blank anatomy drawing, have students identify various portions of the brain.

Have students identify the 12 cranial nerves and their functions.

Have students practice identifying the nerve and motor innervation of the spinal nerves.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 8. Cranial nerves at oral cavity XII, IX, V, and VII O. The Ear 1. Outer visible portion called pinna; made of cartilage; poor blood supply 2. Inner ear structures protected from almost all trauma, except those that involve pressure differentials 3. Ear provides hearing and positional sense 4. Hearing—middle and inner ear 5. Positional sense—semicircular canals P. The Eye 1. Provides input to interact with the environment 2. Protected from trauma by facial bones 3. Posterior chamber: vitreous humor 4. Anterior chamber: aqueous humor 5. Light enters through pupil; sclera is the white portion of eye; conjunctivais the smooth layer over eye 6. Lacrimal fluid—provides corneal lubrication 7. Cranial nerves—III (oculomotor), IV (trochlear), and VI (abducens) Q. Anatomy and physiology of the neck—the neck contains numerous essential structures and is vulnerable to trauma R. Vasculature of the Neck 1. Carotid arteries and jugular veins 2. Carotid arteries arise from brachiocephalic artery on right and aorta on left 3. Jugular veins—internal and external; join brachiocephalic vein beneath clavicles 4. The carotid arteries, internal jugular veins and vagus nerve run together in a sheath S. Airway Structures 1. Begin with larynx—made up of thyroid and cricoid cartilage 2. Epiglottitis is cartilaginous soft tissue flap that covers thyroid opening 3. Vocal cords vibrate with air and form sounds; may close during swallowing 4. Trachea is series of C-shaped cartilages that maintain tracheal opening; extends into sternum; bifurcates into left and right mainstem bronchi T. Other Neck Structures 1. Esophagus, cranial nerves, lymphatic and thoracic ducts, thyroid and

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline parathyroid glands, brachial plexus 2. Esophagus—smooth muscle tube behind trachea; carries food and liquid to stomach 3. Cranial nerves—IX, X (vagus nerve essential for parasympathetic activities) 4. Lymphatic and thoracic ducts—deliver lymph to venous system 5. Thyroid—controls metabolic rate and calcium levels 6. Brachial plexus—network of nerves for lower arm and hand function 7. Muscles, fascia, soft tissue in neck that can lead to rapid swelling in injury 8. Neck divided into Zone I (below cricoid ring), Zone II (above cricoid ring and below angle of jaw), Zone III (above angle of jaw) U. Anatomy and physiology of the spine—the major components of the spine are the spinal column (and its components) and the spinal cord V. Vertebral Column 1. Spinal column made up of 33 bones that provide support for axis of body 2. Each bone called vertebra 3. Intervertebral disc separates each pair of vertebrae; inner sphere called nucleus pulposus; outer collar called annulus fibrosis 4. Common features shared by vertebra; column held together and supported by ligaments 5. Vertebral column divisions—divided into cervical, thoracic, lumbar, sacral, coccyx a. Cervical Spine i. Seven cervical vertebra—between base of skull and shoulders ii. Skeletal support for head (head weighs 16–22 pounds) iii. First two cervical vertebra allow rotation and nodding of head; CI: atlas; C2: axis iv. Range of motion of cervical vertebrae greater than any other portion of spine b. Thoracic Spine i. Twelve vertebrae that support more weight than cervical ii. Thoracic vertebra articulates with ribs at demifacets; limits rib movement and increases strength of thoracic spine c. Lumbar Spine

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline i. Five vertebrae that carry weight of head, neck, upper extremities, and thorax ii. Bending and lifting functions; largest and thickest of vertebra d. Sacral Spine i. Five vertebrae that fuse and form posterior wall of pelvis ii. Protects urinary and reproductive organs, and point of attachment between spinal column and lower extremities e. Coccygeal Spine i. Four fused vertebrae that represent evolutionary tail; no major function, but can be fractured in a fall or during childbirth W. The spinal cord—the main communication route of CNS; transmits messages from brain to organs and tissues and from sensory nerves in organs, skin, and tissues back to brain 1. Principal CNS pathway responsible for transmitting sensory input from body to brain and conducting motor and control impulses from brain to various muscles and organs 2. Extends from base of brain to L1 or L2 (adult) 3. Requires constant supply of oxygenated blood 4. Gray matter made largely of neural cell bodies and plays important role in reflexes 5. White matter forms myelinated nerve fibers on each side of cord around gray matter 6. Axons: nerve cell pathways—ascending tracts transmit signals upward to brain and descending tracts transmit signals downward through cord 7. Ascending tracts: fasciculi gracilis and cutaneous sensory impulses located on posterior portion of cord; injury can cause disruption on ipsilateral side of body; spinothalamic tracts include lateral and anterior tracts, and injury causes disruption on contralateral side 8. Descending tracts: motor, corticospinal tract and is responsible for voluntary and fine muscle movement on ipsilateral side X. Spinal Meninges 1. Protective structures that cover spine and are contiguous with meninges that cover brain 2. Dura mater, arachnoid membrane, and pia mater 3. Not as strongly secured to spine as brain meninges are 4. CSF bathes spinal cord in subarachnoid space

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

5. Thoracic spine is where movement is most limited Y. Spinal Nerves 1. Peripheral nerve roots that branch in pairs from spinal cord; both sensory and motor 2. There are 31 spinal nerve roots; first pair exits spinal column between skull and first cervical vertebra 3. Nerve roots often converge in cluster called plexus (braiding) 4. Phrenic nerves—C3–C5, control of diaphragm 5. Brachial plexus—C5–T1, nerves controlling upper extremity 6. Dermatomes—specific areas of spinal nerve innervation; collar region is C3; little finger is C7; nipple line is T4; small toe is S1 7. Myotomes—motor component of innervation; arm extension—C5; elbow extension—C7, small finger abduction—T1; knee extension—L3, ankle flexion—S1 8. Reflex—special neurons in cord send intense signal to brain 9. Parasympathetic innervation—cranial/sacral 10. Sympathetic innervation—thoracic/lumbar Z. Blood Supply to the Spinal Cord 1. Anterior spinal artery and two posterior spinal arteries 2. Occlusion or damage will give signs and symptoms identical to spinal cord injury 100

IV. Head, Neck, and Spinal Pathophysiology A. General Mechanisms of Injury to the Head, Neck, and Spine 1. Blunt Injury a. These structures are protected very well; but blunt forces that overcome protection cause serious injuries; most serious affect CNS, brain, and spinal cord b. May also affect head, face, airway, and sense organs c. Head frequently injured in blunt trauma, due to size and location d. Spine vulnerable due to displacement of vertebrae e. Auto crashes, falls, sports injuries 2. Penetrating Injury a. Not as common as blunt trauma, but more severe and life threatening when they occur; also produces route for serious infection from meninges b. GSW, stabbing, clothesline injury, animal bites, impaled object from

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Obtain pictures of different cranium fractures and injuries, and review the different signs and symptoms, along with the causes.

Discussion Topics Using a doll, review the different motions of the neck, along with causes of injury.

As a group, have students list injuries based on blunt and penetrating trauma mechanisms.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline fall c. Knife wounds to the head and face tend to be superficial because of the region’s extensive skeletal components, the anterior and lateral neck, however, is not as well protected. Neck wounds may compromise the airway, esophagus, and major blood vessels B. Pathophysiology of Brain Injury 1. Direct Injury a. Caused by trauma forces: acceleration, deceleration, direct injury, jarring forces b. Coup injuries: tissue disruptions that occur directly at point of impact c. Contrecoup injuries: produce tissue damage away from impact point of brain 2. Focal injuries—occur at a specific location in the brain a. Cerebral contusions: caused by blunt trauma to local brain tissue that produces capillary bleeding into brain; common with blunt head injuries; often produces prolonged confusion or other neurologic deficits, with dysfunction related to injury site b. Intracranial hemorrhage: can occur at several locations, with each presenting a different pathologic process—epidural, subdural, and intracerebral hemorrhage c. Epidural hematoma: bleeding between dura mater and skull’s interior surface; usually involves arterial vessels (often meningeal artery); patient often moves toward unresponsiveness quickly due to rapid build-up of intracranial pressure d. Subdural hematoma: bleeding beneath dura mater and within subarachnoid space; occurs slowly, and is usually venous bleeding (bridging vessels between cerebral cortex and dural sinuses); may not show overt signs and symptoms until hours or days e. Intracerebral hemorrhage: ruptured blood vessel that releases blood into brain’s surface (frequently an artery); often presents like a stroke f. Cerebral edema: inflammation process occurring in brain tissue that allows fluid and proteins into brain; expansion of fluid into interstitial space of brain g. Hydrocephalus: may occur with hemorrhage into subarachnoid

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discuss the “halo” sign, Battle’s sign, and raccoon eyes.

Review the injuries of the face; use pictures to demonstrate the fractures that can occur.

Review cervical fractures and what areas of respiration are affected.

Use a Slinky and Pringles to demonstrate vertebrae fractures. This is a good visual that demonstrates different fracture types.

Review the various brain injuries listed, along with the pathophysiology of each.

Have students list the different mechanisms of injury (MOIs) that can cause brain injuries.

Critical Thinking Questions What sign might appear on a hyperflexion patient’s shirt?

Why is infection greater with an open head wound?

What sign is present with a Le Fort III fracture?

What might your patient complain of with a subarachnoid bleed?

Class Activities Have students review the correct ways to

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline space; causes an accumulation of CSF 3. Diffuse Injuries a. General scenario of injury b. Mild, moderate, and severe axonal disruptions—stretching, shearing, or tearing may be distributed throughout brain (diffuse axonal injury [DAI]) c. Concussion: mild to moderate DAI is the most common outcome; dysfunction without substantial anatomical damage; transient episode of confusion, disorientation, event amnesia that rapidly returns to normal d. Moderate DAI: minute brain tissue bruising; “classic concussion”; 45% of all DAI cases; commonly associated with basilar skull fracture; some degree of impairment common e. Severe DAI: significant mechanical disruption of many axons with extension into brainstem; many patients do not survive, and those who do have some degree of permanent neurologic impairment 4. Indirect Injuries a. Secondary injuries result from factors that occur because of initial injury b. Progressive and cause deterioration; may be more damaging than initial injury c. First process—diminished circulation to brain tissue d. Second process—progressive pressure against brain tissue 5. Intracranial Perfusion a. Brain is body’s most perfusion-sensitive organ b. Any injury that affects perfusion has devastating effect on brain c. Cranial volume is fixed d. If intracranial pressure rises, cerebral perfusion pressure will decrease e. Reduction in cerebral blood flow triggers a rise in systolic blood pressure, increasing ICP; this further increases resistance to cerebral blood flow, reduces cerebral circulation, and produces more cerebral hypoxia and hypercarbia f. ICP and circulation affected by carbon dioxide (CO2) in CSF; as CO2 rises, cerebral arteries dilate to encourage greater blood flow and reduce hypercarbia; low CO2 triggers cerebral arterial constriction,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes control a nosebleed.

Have students practice identifying the different brain injuries based on their definitions.

Create scenarios that involve the various injuries listed. Have students perform assessment and treat accordingly.

Have students practice occlusive dressing placement.

Knowledge Application Create a chart that lists the various injuries listed. Have students write the signs and symptoms and definitions.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline reducing cerebral circulation g. Capnography valuable tool in guiding ventilation for head injury patients h. Hypotension and hypoxia increase severity of head injury 6. Pressure and Structural Displacement a. Expansion of brain tissue puts pressure on adjacent tissue, commonly the brainstem; as mass increases, brainstem may be compressed and push tissue into and around tentorium cerebelli, causing herniation b. Upper brainstem herniation (tentorium incisura) causes vomiting, changes in level of consciousness (LOC), pupillary dilation c. Lower brainstem herniation (foramen magnum) causes disturbances in breathing, blood pressure, and heart rate 7. Injury Progression and Development of Signs and Symptoms a. Direct injury, increased ICP, and compression/displacement of brain tissue produce altered LOC b. Brain injury can be mapped as pressure increases and injury moves downward c. Cerebral Cortex i. Specific activity in lobe is affected ii. Level of awareness reduced; event amnesia, retrograde amnesia, anterograde amnesia iii. Disoriented, confusion, combative, hemiplegia, hemiparesis, seizures, lethargy, somnolence, coma d. Cerebellum i. Pressure first directed to midbrain, then pons, finally medulla ii. Predictable signs and symptoms known as central syndrome e. Central Syndrome i. Upper brainstem compression produces increased blood pressure to maintain CPP and reflex decrease in heart rate in response to vagus nerve, Cheyne-Stokes respirations (Cushing’s triad); if hypothalamus involved, vomiting and body temperature changes occur; decorticate posturing may occur as neural pathways through upper brainstem disrupted ii. Middle brainstem causes widened pulse pressure, bradycardic heart rate, rapid and deep respirations (central neurologic

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Using a brain anatomy model, take students step by step through a brain injury, the subsequent pressure produced, and signs and symptoms.

Critical Thinking Questions What should you expect your patient’s temperature to be if the hypothalamus has been injured?

Class Activities Have students identify the various postures experienced by the traumatically braininjured patient, along with the respirations that accompany each.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline hyperventilation), sluggish pupils or nonreactivity as cranial nerve III compressed; decerebrate posturing occurs iii. Lower brainstem causes dilated and unreactive pupils, ataxic respirations, irregular heart rate, electrocardiogram (ECG) changes, hypotension, flaccid muscle tone iv. If mass is more lateral, pupil response tends to be ipsilateral C. Pediatric Head Trauma 1. Different pathway than adult 2. Skull is easily distorted, but may allow some intracranial expansion due to incomplete formation of “soft spots,” the fontanelles 3. Fontanelles may bulge with increased ICP, which can slow progression of ICP 4. Intracranial hemorrhage may contribute to hypovolemia in pediatric patient D. Pathophysiology of spinal injury—can involve the spinal column, spinal cord, peripheral nerve roots, ligaments, muscles, or any combination 1. Mechanisms of Spinal Injury a. Extremes of Range of Motion i. Hyperextension and hyperflexion forcibly bend spine beyond range of motion ii. Hyperextension: rear-impact auto crash; compressive forces on posterior vertebral structures, causing disk disruption compression of ligaments, fracture of vertebral elements, bone displacement; injury to spinal cord iii. Hyperflexion: “kiss-the-chest” injury from frontal impact, leading to anterior vertebral wedge fractures, ligament stretching, compression injury, pedicle fracture, disruption of disks iv. Excessive rotation: lateral impact forces body to move to side, with cervical attachment turning head violently, leading to stretching or tearing of ligaments, rotational subluxation or dislocation, vertebral fractures v. Lateral bending: may take place along entire column, but most common in cervical and lumbar; one part of body moves sideways and remaining portion is fixed, leading to compression injury, fracture, tearing and stretching of ligaments, vertebral instability, and bone fragments

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Critical Thinking Questions What other signs, in addition to bulging fontanelles, might you see in your pediatric head trauma patient?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline b. Axial Stress i. Occurs when compression or distraction forces applied to spinal axis ii. Axial loading: compression stress that may occur when person lifts weight too great for lumbar spine, falls from height and lands on feet, or from helicopter crashes, shallow water dives, head propelled into windshield in motor vehicle collisions (MVCs) iii. Common location of axial loading is between T-12 and L-2 and cervical region iv. Distraction: stretching of spinal column and tearing of ligaments, hanging end of bungee-jump stretch; common location is cervical region v. Spinal injury often involves combinations of mechanisms— distraction, lateral bending, rotational, axial loading, hyperflexion, etc. vi. Connective tissue and skeletal injuries may not injure spinal cord, but do cause instability that can injure spinal cord; injury to spinal cord can also occur without noticeable injury c. Other Mechanisms of Spinal Column Injury i. May result from both direct blunt and penetrating trauma ii. Damage can occur directly to spinal cord, or result from stretching, tearing, bone fragments iii. Tissues around spinal column may swell, putting pressure on cord, causing direct compression or interruption of blood flow iv. Electrocution may cause injury due to extreme and uncontrolled muscular contractions that can fracture or tear vertebra or ligaments v. Direct injury can cause tissue ischemia and interfere with circulation vi. Coccygeal fractures can occur with falls and childbirth E. Pathophysiology of Spinal Cord Injury 1. Involves spine, which can disrupt communication to organs and muscles and prevent sensory nerves from communicating with brain 2. Two phases of damage: initial = mechanical event that injures cord; secondary = hemorrhage and edema that compress cord and reduce

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Review spinal anatomy and physiology.

Create a section of vertebrae (you can use clay, or anything that will harden) and place thin wiring inside. Using this model,

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 3.

4.

circulation Spinal Cord Injuries a. Concussion—temporary and transient disruption of cord function; no structural damage b. Contusion—bruising of cord; some tissue damage, vascular leakage, inflammation and edema c. Compression—may occur secondary to vertebral displacement, bone fragment, swelling; results in restricted circulation, ischemia, and physical damage d. Laceration—bony fragments or stretching; results in hemorrhage into cord tissue, swelling and disruption of cord e. Hemorrhage—contusion, laceration, or stretching injury f. Transection—partially or completely severs the cord Spinal cord syndromes—signs and symptoms seen following a spinal cord injury are directly related to the level of the spinal cord affected and the degree of damage that results from the injury a. Complete cord transection—total severing of spinal cord i. Signs and symptoms related to level of cord injury, and occur in phases ii. Acute phase of high cervical injury results in respiratory insufficiency, quadriplegia, areflexia, lack of sensation below affected area, loss of rectal and bladder tone, hypothermia iii. Acute phase of low cervical injury will have paralysis, but spares respiratory muscles iv. Acute phase of high thoracic injury can cause lower extremity paralysis or weakness v. Acute phase of lower thoracic and lumbar injuries, urinary and bowel retention common vi. Subacute phase: three to four weeks; muscle flaccidity replaced by muscle spasms and stiffness, spinal shock sign may persist, autonomic hyperreflexia common b. Anterior Cord Syndrome i. Bony fragments of pressure compressing arteries that perfuse anterior spinal cord ii. Flexion-extension injury that damages vertebral artery iii. Loss of motor function, sensation to pain, touch, temperature

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes demonstrate the different injuries listed, so that students can visualize them.

Discuss the different MOIs that can cause spinal injury.

Critical Thinking Questions What procedures can you perform that could cause a spinal cord injury?

How can you, as the paramedic, help to lessen the effects of secondary injury to the spinal cord?

Class Activities Have students identify the various spinal cord injuries by definition and presentation.

Create scenarios involving spinal cord injuries and have students perform assessments to identify them.

Have students practice cervical spine immobilization in patients of all ages, along with long board application.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

5.

6.

below injury site iv. Retains motion, positional, and vibration sensation (second most common type of spinal injury) c. Central Cord Syndrome i. Hyperflexion of cervical spine, preexisting degenerative disease ii. Motor weakness more likely to affect upper extremities, bladder incontinence d. Brown-Séquard syndrome i. Penetrating trauma that affects one side of cord ii. Sensory and motor loss ipsilateral; pain and temperature perception lost on contralateral side iii. Has the best prognosis of the three cord syndromes e. Cauda Equina Syndrome i. Nerve roots at lower end of spinal cord are compressed, interrupting sensation and motor control ii. May result from herniated disk, infection, tumor, fracture, narrowing of spinal canal iii. Signs and symptoms include bowel or bladder incontinence, weakness in lower extremities, and loss or altered sensation between legs and over buttocks, at inner thighs and back of legs, and at feet and heels Spinal Shock a. Temporary insult to spinal cord affecting body below level of injury b. Flaccid, no feeling, unable to move extremities, loss of bladder/ bowel, priapism in males, body temperature decreased, hypotension Neurogenic Shock a. Injury to spinal cord or brain disrupts brain’s ability to control body (autonomic functions) b. Lack of sympathetic tone causes vasodilation, reduced cardiac output, reduced strength of contraction, loss of control over adrenal medulla; no longer releases epinephrine and norepinephrine c. Relative hypovolemia with no compensatory mechanisms d. Signs and symptoms include slow heart rate, low blood pressure, warm and dry skin below injury site and cool and moist skin above

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

injury site Autonomic Hyperreflexia Syndrome a. Body’s response to neurogenic shock b. Commonly associated with injuries at or above T5 c. Signs and symptoms include sudden hypertension (as high as 300 mmHg), bradycardia, pounding headache, blurred vision, sweating, and flushing above injury site d. Autonomic hyperreflexia syndrome is a medical emergency; the patient is at risk of developing seizures, stroke, or death.

8. Transient Syndromes a. Stinger—sports related injury to nerves in or near neck or shoulder (burner or pinched nerve); painful electric sensation through neck or arm b. Transient quadriplegia—temporary injury to spinal cord; numbness, pain with or without weakness, or complete paralysis 9. Other Causes of Neurologic Dysfunction a. Injury may occur anywhere along nerve path; fractures, soft tissue injury, penetrating trauma, compartment syndrome anywhere along nerve root travel b. There are also several nontraumatic processes that affect the spinal cord 10. Pediatric Spinal Injuries a. At risk for spinal injuries, although occur less frequently b. Elasticity of spine provides more protection against spinal trauma; young spine will bend, but not break (at risk for distraction injuries) c. Spinal cord injury may occur without radiographic abnormality 7.

V. Specific Injuries to the Head, Neck, and Spine 50

A. Scalp Injury 1. May be only indication of more serious injury 2. Scalp wounds tend to bleed heavily, can contribute to shock, provide a route for infection to enter meninges; wounds do heal well due to rich circulation 3. Wounds may present in a manner that confuses assessment; assess and record nature of head wound early 4. Avulsion common type of scalp wound

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topic Discuss the difficulties of treating a patient with a severe facial injury who has lost all associated landmarks.

Critical Thinking Questions How would you establish the level of consciousness of a patient who has lost all facial landmarks? Why is this important?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline B. Cranial Injury 1. Fractures occur with extreme trauma 2. Linear, depressed, comminuted, or basilar 3. Linear—small cracks in cranium; 80% of fractures 4. Depressed—inward skull surface displacement; greater likelihood of intracranial damage 5. Comminuted—multiple skull fragments that may penetrate meninges; severe brain injury can occur; common with GSW 6. Basilar—involves base of skull; signs vary with location; injury to auditory canal and lower lateral areas will cause retroauricular ecchymosis (Battle’s sign) and bilateral periorbital ecchymosis (raccoon eyes), but both take time to develop, and neither is likely to be seen in prehospital setting 7. Basilar—fracture can tear dura mater, CSF seeping into nasal cavity or auditory canal; halo sign may be produced 8. Bullet wounds can cause specific types of cranial fracture. a. The entrance wound often produces a small, comminuted fracture b. The exit wound site is usually blown outward and is often more severe in appearance than the entrance wound. c. Another wound type occurs when a bullet enters the skull at an angle and is deflected along the skull’s interior until its energy is completely exhausted 9. Impaled objects must be stabilized, due to delicate brain tissue C. Facial Injury 1. Serious complication due to airway, vascular system, sense organs, and cosmetic appearance 2. Facial soft tissue injury a. Common; may threaten airway and physical appearance; heavy bleeding, aspiration, soft tissue swelling 3. Facial dislocations and fractures a. Common injuries include mandibular, maxillary, nasal, and orbital fractures/dislocations b. Mandibular dislocations—may result in malocclusion of mouth, misalignment of teeth, deformity of facial region, immobility of jaw, pain; airway control may be decreased c. Mandibular fractures—painful; present with deformity along jaw

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline surface, loosening of a few teeth, blood-stained saliva (if open fracture); may be serious life threat if patient in supine position due to no support of tongue, and displacement posteriorly, blocking airway; look for second fracture site due to energy transfer d. Maxillary fractures—classified by Le Fort criteria e. Le Fort I—slight instability involving maxilla alone f. Le Fort II—fracture of both maxilla and nasal bones, instability of maxilla and nasal region, CSF leakage g. Le Fort III—entire facial region below brow, including zygoma, nasal, and maxilla; CSF leakage h. Dental injury commonly associated with serious blunt trauma; may chip, loosen, break, or dislodge; may become foreign objects that occlude airway i. Orbital fractures (blowout fractures)—most commonly involve zygoma or maxilla; zygomatic fractures painful and present with unilateral depression over one cheek (most common as pressure fractures weakest region); may cause diplopia, limit jaw movement; maxilla fractures cause swelling, pain j. Soft tissue injuries—vascular, rapid swelling, deformation of region injured k. Special injury involves suicide attempt using rifle or shotgun barrel under chin; may be deflected from entering cranium, causing severe, if not complete, disruption of facial tissues, bleeding, destruction of airway 4. Nasal Injury a. Painful; often presents with deformity; usually not life threatening b. Epistaxis common result of nasal injury c. Anterior hemorrhage usually slow and self-limiting; posterior hemorrhage may be severe and cause blood to drain down patient’s throat d. Any attempt at nasal equipment insertion may permit tube to enter cranium and damage brain 5. Ear Injury a. Pinna frequently subjected to trauma; minimal blood supply; may be partially avulsed or cartilage may separate b. Internal ear injuries may result from inserted objects or pressure;

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline basilar skull fractures may also tear tympanic membrane 6. Eye Injury a. Anterior eye structures do not regenerate effectively; penetrating trauma may cause loss of eye fluid and loss of vision b. Foreign objects can cause abrasions and lacerations c. Blunt trauma may present with hyphema (collection of blood in front of iris and pupil) d. Subconjunctival hemorrhage occurs when small blood vessels burst e. Avulsion can occur, presenting as protruding; depressed eye presentation known as enophthalmos f. Retinal detachment—retina separates from posterior wall of eye; dark curtain obstructs field of view g. Soft tissue lacerations—if not repaired, can disrupt lacrimal duct, lubrication and oxygenation; contact lens may dry out eye surface D. Neck Injury 1. Trauma may result in airway, spine, blood vessel, and structural injuries 2. Trauma to Blood Vessels of the Neck a. Hemorrhage may produce expanding hematoma that becomes trapped in fascia and applies restrictive pressure to jugular veins b. Lacerations may result in severe hemorrhage, leading to shock c. Arterial interruption can lead to brain hypoxia and infarct—signs and symptoms of stroke; open neck wounds may form air embolism 3. Airway Trauma a. Larynx and trachea may sustain injury; separation, fractures, crushing injuries that can lead to airway hemorrhage, vocal cord contusion, swelling, trauma to epiglottis 4. Other Neck Trauma a. Subcutaneous emphysema may present from tension pneumothorax, tracheal injury, penetrating trauma b. Esophageal trauma may cause gastric contents to spill c. Deep penetrating trauma may disrupt vagus nerve, causing tachycardia, gastrointestinal (GI) disturbance, thyroid and parathyroid injury 5. Spinal Column Injury a. Cervical region accounts for over half of all spinal injuries (C1–C2

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

cause of fatal injuries) b. C7 frequently injured due to location c. Thoracic and lumbar injuries equally divided d. Spinal cord ends at L1–L2 region

50

VI. Assessment of the Patient with a Head, Neck, or Spine Injury A. Follows standard assessment process—scene size-up, primary assessment, secondary assessment, detailed assessment, reassessment B. Airway patency, breathing, signs of local injury, level of consciousness (LOC), pupils, Glasgow Coma Scale (GCS) score, distal neurologic signs, pulse rate/strength, blood pressure, rapid transport decision C. Scene Size-Up 1. MOI analysis, scene safety, observe scene and look at forces that were involved in injury (vehicle, weapons, fall, etc.) a. Typical MOIs include auto collisions, falls, sports, explosions, violence, penetrating trauma b. Visualize movements of brain and spine during impact c. Flexion, extension, lateral bending, rotation, axial loading, distraction 2. Use of safety equipment, restraints 3. Body substance isolation (BSI) application, environment D. Primary Assessment 1. Spinal precautions—immobilize head and neck if MOI or patient signs and symptoms suggest injury; neutral and in-line position (immobilization, stabilization, spinal motion restriction) 2. Initial patient impression—formed from LOC, physical condition; use patient response to build patient impression and index of suspicion 3. Spinal clearance—decided on injury mechanism and patient findings; spinal clearance protocols based on emergency department (ED) protocols; include patient A&O x4, no alcohol or drug influence, GCS of 15, no significant fight-or-flight response, no distracting injuries, no signs or symptoms of spinal injury, age. Research reveals that penetrating trauma is unlikely to injury the spinal cord or cause spinal instability. Do not initiate spinal precautions for this patient unless there are signs and symptoms of spinal cord injury.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Review the causes of spinal injury and the use of spinal precautions, including spinal clearance.

Review the assessment tools used. Obtain a video of irregular respirations commonly seen in head-injured patients.

Review the simplified motor score (SMS) and Glasgow Coma Scale (GCS) score.

Review Cushing’s triad, along with the different respirations seen.

Review the signs and symptoms of spinal cord injury.

Class Activities Have students perform a spinal immobilization and a spinal clearance.

Have students perform assessments that focus on head, face, neck, and spinal column injuries.

Have students perform CNS assessments with the appropriate treatment modalities.

Practice eye response, vital signs, and

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 4. Simplified Motor Score (SMS) a. Perform when impression of traumatic brain injury present b. Purpose is predicting possible brain injury c. Obeys commands (2), localizes pain (1), withdraws to pain or worse (0) d. SMS of less than 2 suggests transport to a neurology or trauma center; score of 0 suggests need for endotracheal tube (ET) intubation 5. Airway—firm immobilization to a spine board may make securing the airway more difficult. Apply the long spine board only when you cannot clear a patient with the spinal clearance protocol. a. Critical to maintain airway; reduced LOC leaves patient unable to protect airway b. Intubation, suctioning, recovery position 6. Breathing—determine rate, volume, chest excursion, pulse oximetry, capnography, respiratory effort (cervical spinal injuries will affect respirations), oxygenation; positive pressure ventilation (PPV) and advanced airway techniques if indicated a. If < 10 times/min, < 500 mL of breath, or minute volume < 4 liters, consider ventilating b. Irregular breathing patterns produced by head injuries c. Ventilations guided by capnography d. Herniated injury requires adjusted ventilation rates to maintain proper oxygen (O2) and CO2 (30–35 mmHg CO2 reading); ventilation about 10 breaths per minute higher in these patients e. Pulse oximetry reading must be above 95% 7. Circulation—monitor rate, rhythm, strength; observe for hemorrhage; direct pressure may be indicated a. pulse; < 60 and strong should suspect brain injury; rate 60–100 with injuries or hemorrhage present that suggest shock, suspect traumatic brain injury as cause of relative bradycardia b. Control external hemorrhage 8. Recognition of Herniation a. Signs represent rapidly developing life threat b. Increasing systolic blood pressure, slow and decreasing pulse, irregular respirations (Cushing’s triad) c. Decreased LOC, singular or bilaterally dilated and fixed pupils,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes motor, sensory, and nerve innervation response.

Have students practice ventilating the airway manikin with normal ventilations and those used with a herniated brain injury.

Knowledge Application Have students define the following terms: kyphosis, scoliosis, ankylosing spondylitis, bamboo spine.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline posturing 9. Patient priority—identification of care and transport after primary assessment (CUPS) E. Secondary assessment/rapid trauma assessment—patients with suspected CNS injury need to have a rapid trauma assessment, along with neurological assessment 1. Eye Exam a. Eye reactivity reflects brain’s oxygenation status b. Look for sluggishness, nonreactivity, constriction, or dilation (bilateral) c. Both eyes should respond to changes (consensual reactivity) d. Normal eye movement will move slowly as head turns; eyes that move with head suggestive of head injury (oculocephalic response); doll’s eyes e. Problems with eye can indicated problems with cranial nerves II, III, IV, and VI, along with perfusion f. Pupil size and reactivity can give clues to underlying conditions— drugs, hypoxia, increased pressure 2. Full Body Physical Exam a. Observe and palpate each body region b. Look for demarcation between normal sensation and paraesthesia, differences in muscle tone; start at feet and work up c. Observe myotomes to determine muscular control; give good indication of level of spinal cord disruption d. Check both sides of body to determine motor activity and sensation e. Inspect motor function, sensory function, and pulses; limb sensations, Babinski’s sign, glucose levels 3. Vital signs—pulse rate, strength, blood pressure, pulse pressure, respiratory pattern, pulse oximetry, capnography a. Monitor for signs of increased ICP b. Note pulse rate and strength, blood pressure, pulse pressure c. Electrocardiogram (ECG), respiratory rate, body temperature, determine need for transport d. It is essential to maintain a systolic blood pressure of at least 90 mmHg e. Monitor the patient’s temperature carefully

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 4. Glasgow Coma Scale a. Evaluation of patient’s mental status b. Determine initial score and repeat evaluation frequently c. Eye opening, verbal and motor response—can range between 3 and 15 d. Score of 13–14 considered mild injury; 9–12 moderate injury; < 8 severe head injury e. Record the best response for each of the GCS criteria, and note any differences, either from side to side or in the upper versus lower extremities f. Some systems are beginning to use the Simplified Motor Score [SMS] 5. Other Signs of Nervous System Injury a. Most frequent sign in male is priapism, prolonged and painful nonsexual erection of male genitalia due to unopposed parasympathetic stimulation b. Midcervical sign may present with “hold-up” sign (arms rise to a position above shoulders and head) c. Monitor extremities for signs of neurologic impairment d. Seizures complicate the airway and respirations, increase intracranial pressure, and exacerbate existing brain injury 6. Patient questioning—painful or unusual sensations, paresthesia, anesthesia, weakness, paralysis, difficulty swallowing, numbness, tingling, visual disturbances, SAMPLE, GCS F. Reassessment 1. Every 5 minutes with serious injuries and every 15 minutes for stable patients 2. Observe vital signs, slowing pulse, increasing blood pressure, changes in respirations, GCS or SMS, eye changes, posturing, sensation changes, pulse oximetry, capnography

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 50

Content Outline VII. Management of Head, Neck, and Spinal Injuries A. Rapid Extrication in Motor Vehicle Collisions 1. Applying spinal immobilization can be a time-consuming process.

Research has demonstrated that it is relatively ineffective and, in some cases, harmful 2. Many EMS systems have significantly altered their approach to potential spinal injuries 3. Rapid extrication technique does not provide maximum protection for the spine, it does permit rapid movement of the patient with a spinal injury when other considerations demand it B. Spinal Precautions 1. Neutral, in-line positioning is very important in spinal injury patient care because it maintains the best spinal column positioning and the greatest clearance between the cord and the spinal foramen interior 2. If the patient feels any increase in pain or if there is a significant resistance to movement, immobilize the head and neck or other portion of the body in the position achieved 3. Spinal Clearance Protocols a. Various spinal clearance protocols have been developed and proven reliable i. National Emergency X-Radiography Utilization Study (NEXUS) ii. Maine protocol iii. Canadian C-Spine Rule b. Any doubt about the patient’s potential for spinal injury or the patient’s ability to accurately report, use spinal precautions as dictated by local protocols.

C. Airway—the airway is a primary concern for patients who have sustained head neck and spinal injuries 1. Studies have shown that the presence of hypoxia and hypercapnia in the prehospital setting worsens outcomes and survival of patients with these injuries 2. For patients with a Glasgow Coma Scale score of 8 or less, an airway device may be indicated 3. Sedation and neuromuscular blockers may facilitate intubation of headinjured patients 4. Rapid Sequence Induction/Intubation

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Teaching Tips Pull out all of the airway equipment for students to look at. Go over all of the indications and contraindications.

Discussion Topics Discuss the Patho Pearls beginning on page 193 regarding spinal immobilization and the use of cervical collars.

Discuss the difference between capnography and pulse oximetry (capnography: what the body is doing right now; pulse oximetry: what the body just did).

Review the rapid-sequence intubation (RSI) indications, procedures, and complications.

Review the indications, contraindications, and dosages of the medications listed.

Critical Thinking Questions What is considered the gold standard for confirmation of initial and continuing advanced airway placement?

What are some injuries that can be caused by cricoid pressure?

What can you administer to lessen the risk of increased intracranial pressure (ICP) when intubating a head-injured patient?

What is the inspiration and expiration ratio

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline a. Head injury patients may be unable to maintain airway and are at high risk for vomiting b. RSI may be indicated if patient unable to maintain airway and not completely unresponsive c. The role of RSI in the prehospital management of a head injury patient remains controversial b. The decision to use prehospital RSI rests with the system medical director D. Breathing 1. Near-normal ventilation is essential for patients with severe traumatic brain injury 2. It is essential to avoid hypercapnia, hypoxia, and hyperoxia 3. Patients with the neurologic injury should be monitored with pulse oximetry and waveform capnography E. Circulation 1. Blood Pressure Maintenance a. The problems of hypovolemia and hypotension are compounded if there is any increase in intracranial pressure b. Provide rapid fluid (electrolyte) administration and other shock care measures to maintain a systolic blood pressure of 90 mmHg c. In the child (6–12 years), young child (2–5 years), and infant (0–1 year), maintain a systolic blood pressure of at least 80, 75, or 65 mmHg, respectively F. Medications 1. Sedatives a. Diazepam—benzodiazepine with both antianxiety and muscle relaxant qualities; used to premedicate patients to facilitate intubation b. Lorazepam—one of most potent benzodiazepines with shorter halflife 2. Analgesics with Sedative Properties a. Morphine—opium alkaloid used to relieve pain, to sedate, and to reduce anxiety; may mask signs/symptoms of head injury and mildly increase ICP; also can cause hypotension, respiratory depression, and nausea and vomiting b. Fentanyl—opiate narcotic; provides immediate and effective pain

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes with a needle cricothyrotomy?

Class Activities Immobilize a manikin with C-collar, head blocks, and long board. Have students practice the airway skills listed while spinal precautions are applied.

Have each student practice a needle and a surgical cricothyrotomy. This can be done on a manikin or pig trachea (if allowed).

Have students create flashcards of the medications listed, noting their indications and effects.

Knowledge Application Have students write the indications and contraindications of all of the airway equipment listed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline control; does not cause hypotension to same degree as morphine c. Ketamine—analgesic and sedative with predictable dose-related response; does not cause hypotension but may induce hypertension and tachycardia.

3. Other Medications a. Mannitol is osmotic diuretic that draws water from interstitial space and into cardiovascular system; may reduce cerebral edema and ICP. b. Dextrose—administer if significant hypoglycemia is found; significant hypoglycemia especially detrimental to the patient with head injury.

4. Medications and spinal cord injury—routine use of steroids for treatment of spinal injury no longer recommended 5. Medications and neurogenic shock—fluid challenge is the initial treatment 6. Medications and the combative or seizing patient a. Sedatives may be indicated to reduce anxiety and further motion to spine b. Benzodiazepines—carefully monitor patient respirations c. Sedatives can be considered as permitted by system protocols.

G. Transport Considerations 1. Attempt to prevent agitating patient, which may increase ICP and induce seizures 2. Consider air transport if necessary H. Emotional Support 1. Identify someone to remain with the patient with the specific role of providing calming reassurance during care and transport 2. Head injury patients may be very confused, distressed, abusive, or even combative, do not take this behavior personally

5

VIII.Summary A. Head, face, neck, and spinal column are key elements of CNS, airway, alimentary canal, organs of sensation B. If MOI suggests spine injury, spinal precautions indicated 1. Ensure airway, ventilations, and LOC; oxygen and CO2 levels guided by oximetry and capnography

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics What procedures or transport activities may agitate the patient?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline IX. Case Study

5

Master Teaching Notes Class Activities Discuss the case now that they are familiar with the chapter.

X.

You Make the Call

5

Class Activities Read and discuss the call and questions as a group.

XI.

Review Questions

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Class Activities Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 6 objectives can be found on text p. 143.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Content Outline

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 7 Chest Trauma 140–150 Minutes

• • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Knowledge Application

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

10

30

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture

II. Introduction to Chest Trauma A. Thoracic cavity (chest) contains vital structures, including heart, great vessels, esophagus, tracheobronchial tree, and lungs B. Any injury to structures could lead to death C. Mortality from penetrating thoracic wounds has decreased from 8 to 40 percent during World War II to 3 to 18 percent today D. Abdominal injuries are associated with traumatic chest injuries (comorbidity) E. Increase in thoracic penetrating trauma in areas associated with violent crimes; gunshot wounds (GSWs) of various caliber III. Thoracic Anatomy and Physiology A. Thoracic cage is a chamber that moves air in and out and where oxygen (O2) and carbon dioxide (CO2) exchange for metabolism support B. Thoracic Skeleton 1. Forms thoracic cage, 12 pairs of C-shaped ribs 2. Upper seven pairs of ribs join at sternum 3. The 8th–10th ribs have indirect cartilage connections at sternal margin 4. The 11th and 12th ribs have no anterior attachment (floating ribs) 5. Sternum consists of manubrium, body, and xiphoid process 6. Mid-clavicular, mid-axillary, anterior axillary, posterior axillary, and medial scapular are used to describe positions lateral to sternum 7. Space inferior to each rib is intercostal space, and each is given the number of the rib above it

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Knowledge Application For an assignment, have students define each key term.

Teaching Tips Using anatomy models, review the thoracic anatomy.

Use anatomic models to point out the accessory muscles used in breathing.

Discussion Topics Review the lung volume numbers and their relevance.

Discuss the respiratory centers, covering their locations and functions.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 8. Thoracic outlet is formed by 12th vertebra and extends anteriorly and superiorly along costal margin C. Diaphragm 1. Dome-like muscular sheet that separates abdominal cavity from thoracic cavity 2. Affixed to lower border of rib cage 3. Penetrating wounds can affect diaphragm, allowing abdominal contents to enter chest cavity D. Associated Musculature 1. Intercostal, diaphragm, and sternocleidomastoid muscles are major muscles of respiration 2. Sternocleidomastoid muscles—raise upper rib and sternum 3. Intercostal muscles—elevate ribs and increase anterior-posterior dimension of thorax 4. Diaphragm—contracts and flattens to further increase thoracic cavity volume 5. As thoracic volume increases, pressure within falls to less than atmospheric pressure; air rushes in 6. As thoracic muscles relax, pressure decreases in thorax and increases intrathoracic pressure, and pressure is greater than atmosphere; air rushes out 7. Changing volume to move air is called bellows effect 8. Changing pressure and volume assists with moving arterial blood into and venous return from systemic circulation E. Trachea, Bronchi, and Lungs 1. Progressively narrowing and dividing tubes beginning with trachea and ending at alveoli 2. Trachea is a hollow, cartilage-supported respiratory pathway; divides into right and left mainstem bronchi at carina 3. Mainstem bronchi enter lungs at pulmonary hilum (also where pulmonary arteries and veins enter and exit); it is the sole fixation point in thoracic cage 4. Bronchi divide into bronchioles, that then end in alveoli 5. Alveoli—Basic lung unit of structure and function (must remain expanded to function); O2 and CO2 diffuse across alveolar-capillary (external respiration)

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Critical Thinking Questions How could inadequate ventilation cause poor blood return?

What injuries could cause your patient’s alveola to not remain open?

What is often programmed into ventilator settings to prevent atelectasis?

Why would a decreased cough reflex make a patient more at risk for pneumonia?

What fetal anatomy becomes the ligamentum arteriosum?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

6. O2 and CO2 diffusion into and out of tissues (internal respiration) 7. Lungs divided into right and left lobe 8. Lungs covered with thin membrane: visceral pleura and parietal pleura, which lubricate and permit smooth lung expansion F. Mediastinum 1. Central space within thoracic cavity bounded laterally by lungs, inferiorly by diaphragm, and superiorly by thoracic inlet 2. Heart, great vessels, trachea and esophagus, vagus nerve, phrenic nerve, and thoracic duct found in this area G. Heart 1. Four-chambered pump divided into right and left, with upper atrium and lower ventricle; right heart circulates blood to the lungs; left heart circulates blood to the rest of the body 2. Contraction of the myocardium compresses the coronary arteries, limiting blood flow; epicardial vessels are not affected because they lie on the surface of the heart 3. Pericardium creates a potential space, just like that of pleural space in lungs 4. The epicardium is the outer surface of the heart or visceral pericardium 5. The pericardial space usually contains 35 to 50 mL of fluid H. Great Vessels 1. Large arteries and veins that enter and leave heart 2. Aorta, superior and inferior vena cava, pulmonary arteries, pulmonary veins 3. Injury can lead to rapid blood loss and death 4. Aorta can tear from ligamentum arteriosum during deceleration mechanism of injury (MOI), along with other vessels I. Esophagus 1. Smooth muscle tube that transports food and water 2. Is contiguous with posterior tracheal wall 45

IV. Pathophysiology of Thoracic Trauma A. Blunt Trauma 1. Results from kinetic energy forces transmitted through tissue 2. Blast, crush, deceleration injuries 3. Blast: explosive chemical reactions that creates pressure wave; damaging to hollow, air-filled structures (blood vessel tears,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Using a cardiac anatomy model, show students the three points of attachment of the aorta.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline pneumothorax, hemothorax, air embolism, diaphragmatic rupture, and tracheobronchial disruption) 4. Crush: body compressed between object and hard surface (direct injury or disruption of chest wall, diaphragm, heart, tracheobronchial tree, traumatic asphyxiation, and rhabdomyolysis) 5. Deceleration: body is in motion and impacts a fixed object (direct blunt trauma; shearing or tearing of organs, ligaments, vessels; tracheobronchial rupture and pneumothorax from “paper-bag syndrome”) 6. Extremes of age alter forces of blunt trauma in regard to flexibility of pediatric bones and rigidness of geriatric bones B. Penetrating Trauma 1. Injury induced from object entering chest (direct trauma or forces related to wave of projectile) 2. Low energy—arrows, knives, handguns, slow-moving objects; injury caused by direct contact or limited cavity creation 3. High energy—military and hunting rifles; creates cavitation and tissue damage that is extensive and worsened by bullet construction 4. Penetrating thoracic trauma related to structures involved 5. Lung tissue are very “spongy,” allowing absorption of energy; vessel disruption can cause massive bleeding; pneumothorax frequently occurs C. Chest wall injuries: commonly caused by blunt trauma, disrupting air movement in and out and creating respiratory insufficiency; penetrating trauma causes open wounds and deep injuries within thoracic cavity 1. Chest Wall Contusion a. Most common cause of blunt trauma b. Signs and symptoms include: erythema, pain that worsens with deep breathing, tenderness, limited breath sounds, hypoventilation 2. Rib Fracture a. Found in over 50% of serious chest trauma; likely to occur at point of impact or along object border b. Ribs 4–8 most commonly fractured; ribs 1–3 require great force to fracture; ribs 9–12 tend to transmit injury to internal organs c. Signs and symptoms include: crepitus, pain, limited respiratory excursion, grunting during expiration (helps to keep alveoli open),

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Draw the thoracic cavity on the board, and demonstrate the different injuries, pathways, and damage that can occur.

Obtain pictures of the listed injuries, to point out the particular signs and symptoms presented.

Discussion Topics Discuss the different injuries seen in thoracic trauma, and the various mechanisms of injuries.

Critical Thinking Questions What one piece of equipment and procedure can actually make a diaphragmatic rupture and tracheobronchial injury worse, and needs to be used with extreme caution?

Where is disruption of the tracheobronchial tree more likely to occur in the anatomy of the thoracic cavity?

What medical condition can occur in the alveoli when a patient has rib fractures and is unable to take a deep breath?

Class Activities Prepare scenarios with each thoracic and cardiac injury listed. Have students perform assessments, identify particular injuries, and treat accordingly (this is best done in a lab setting, as it takes a few hours to get through).

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline hypoxia, hypoventilation, muscle spasms, atelectasis, and internal injuries from bone ends 3. Sternal Fracture and Dislocation a. Usually associated with blunt anterior trauma, severe direct impact b. Dislocation is uncommon and requires significant force c. Injuries include higher mortality, cardiac rupture, cardiac tamponade, pulmonary contusion, flail chest 4. Flail Chest a. Three or more adjacent ribs fractured in two or more places b. Serious chest wall injury often associated with underlying pulmonary injuries c. Signs and symptoms include: reduced tidal volume, paradoxical movement d. Treatment includes: splinting and positive pressure ventilation D. Pulmonary Injuries 1. Simple Pneumothorax a. Also called a closed pneumothorax, occurs when lung tissue is disrupted and air leaks into pleural space b. Pressure in thorax does not exceed normal expiratory pressure c. Occurs with blunt and penetrating trauma d. Signs and symptoms include: mild dyspnea, local chest pain, diminished lung sounds 2. Open pneumothorax—often called a sucking chest wound a. Commonly caused by high-velocity bullet creating chest wall wound b. Free air passage between atmosphere and pleural space; air drawn into wound, thoracic pressure drops, air rushes through wound and replaces lung tissue (sucking chest wound) c. Unimpeded opening must be two-thirds the tracheal diameter d. Signs and symptoms include increased dyspnea, hypovolemia 3. Tension Pneumothorax a. Open or simple pneumothorax that maintains pressure greater than atmospheric pressure in thorax b. One-way valve formed, which creates increased intrapleural pressure and collapses lung on injury side

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Use paper bags blown up with air to demonstrate the “paper-bag” effect.

Use a water balloon and a balloon filled with air as examples of wet and dry lungs.

Use pork ribs and a bicycle inner tube to practice chest decompressions.

Knowledge Application Create a chart that lists the thoracic and cardiac injuries. Have students write out the definition, signs and symptoms, and treatment for each.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline c. Signs and symptoms include severe dyspnea, jugular venous distention (JVD), narrow pulse pressure, tracheal shift, hypotension, diminished/absent lung sounds, hyperresonance on injured side, cyanosis, diaphoresis, altered mental status 4. Hemothorax a. Accumulation of blood in pleural space due to internal hemorrhage b. Often accompanies pneumothorax (a hemopneumothorax) and occurs 25 percent of the time with penetrating trauma c. Each hemithorax can hold 3,000 cc d. Associated with rib fractures, blunt or penetrating trauma e. Signs and symptoms include signs of shock, respiratory distress, dullness on percussion, muffled or distant breath sounds 5. Pulmonary Contusion a. Soft tissue contusion affecting lung, frequently associated with rib fractures b. Deceleration injury—moving body strikes a fixed object c. Explosion or bullet pressure—compresses and stretches lung tissue d. Signs and symptoms include pain, increasing dyspnea, increased respiratory effort, hypoxia, crackles, faint breath sounds, hemoptysis E. Cardiovascular Injuries 1. Blunt Cardiac Injury a. High mortality rate and occurs most often with blunt anterior chest trauma b. Heart compressed between sternum and thoracic spine, resulting in cardiac contusion c. Disrupts muscle cells; results in hemorrhage, edema, and reduced cardiac output d. Injury can lead to hematoma, tamponade, ectopic beats, bundle branch blocks, necrosis of heart tissue, congestive heart failure (CHF), cardiogenic shock, myocardial infarction (MI), aneurysm, myocardial rupture e. Signs and symptoms include: MOI, pain, arrhythmias, murmur, friction rub

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline f. Commotio cordis: rare event where ventricular fibrillation induced by direct chest blow; second leading cause of death in athletes 2. Pericardial Tamponade a. Restriction of cardiac filling caused by blood or fluid within pericardial sac b. Almost always related to penetrating trauma c. Tear in sac with blood seeping into pericardial sac, exerting pressure on heart; limits cardiac filling and venous return d. Takes about 150–200 mL of blood to exert pressure, but as little as 20 mL removed provides significant relief e. Signs and symptoms include MOI, diminished pulse strength, decreased pulse pressure, JVD, agitation, tachycardia, cyanosis to upper body, muffled or distant heart sounds (JVD, hypotension, distant heart tones known as Beck’s triad), Kussmaul’s sign (decrease or absence of JVD during inspiration), pulsus paradoxus, pulsus alternans 3. Myocardial Aneurysm or Rupture a. Occurs almost exclusively in blunt thoracic trauma b. May be sudden or delayed—all portions of heart may be involved c. Signs and symptoms include MOI, pericardial tamponade, heart failure, absent vital signs 4. Traumatic Dissection or Rupture of the Aorta a. Extremely life-threatening condition from blunt or penetrating trauma b. Aorta most commonly injured in blunt trauma, with mortality of 85–95%; aorta fixed at three locations: aortic annulus, ligamentum arteriosum, exit through diaphragm c. Signs and symptoms include hypotension, loss of vital signs, death, tearing pain, pulse deficit between upper extremities and decreased pulse strength in lower extremities, harsh systolic murmur F. Other Vascular Injuries 1. Pulmonary arteries, vena cava can sustain injuries; usually caused by penetrating trauma 2. Signs and symptoms include hypotension, respiratory insufficiency, MOI, hypovolemia, shock, hemothorax

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline G. Other Thoracic Injuries 1. Traumatic Rupture or Perforation of the Diaphragm a. Occurs in both blunt and penetrating trauma b. Common in patients with penetrating trauma to the lower chest c. Diaphragmatic herniation commonly occurs on the left side d. Signs and symptoms include dyspnea, hypoxia, hypotension, JVD, MOI, bowel sounds in chest, scaphoid abdomen 2. Traumatic Esophageal Rupture a. Rare blunt trauma complication that usually coincides with other mediastinal injuries b. Mortality is related to serious infection or chemical irritation from emesis or other materials c. Signs and symptoms include MOI, difficult or painful swallowing, respirophasic chest pain, pain radiating to midback, subcutaneous emphysema 3. Tracheobronchial Injury (disruption) a. High mortality rate, but rare trauma occurrence b. Signs and symptoms include respiratory distress with cyanosis, hemoptysis, massive subcutaneous emphysema, pneumothorax 4. Traumatic Asphyxia a. Severe compression force applied to thorax, reversing blood flow from right heart into superior vena cava and venous vessels of upper extremities b. Extrication of patient may result in rapid deterioration due to hemorrhage and accumulated toxins into central system c. Signs and symptoms include hypotension; hypoxemia; deep red, purple, or blue skin; swollen face (plethora); eye bulge; conjunctival hemorrhage; severe dyspnea V. Assessment of the Chest Injury Patient

15 A. Assessment critical to anticipating, detecting, and treating injuries B. Scene Size-Up 1. Standard Precautions, face shield if attending to airway, gown for splashes, safe scene 2. MOI, determination of weapon (if used), path of blunt trauma ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Discuss the different injuries that can occur with different mechanisms of injury. Have students list these injuries in order of mechanism.

Review the various types of body isolation

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline C. Primary Assessment 1. Mental status, potential for spinal injury, ABCs 2. Intervene for all life threats 3. Look for dyspnea; asymmetrical, paradoxical, exaggerated, or limited chest movement; chest hyperinflation; scaphoid abdomen 4. Ashen or cyanotic skin, JVD, accessory muscle usage, subcutaneous emphysema 5. High-concentration oxygen as indicated (use caution with bag-valve mask [BVM] in some thoracic injuries) 6. IV, electrocardiogram (ECG), pulse oximeter, waveform capnography, rapid transport if indicated D. Secondary/Rapid Trauma Assessment 1. Observe a. Look for impact evidence such as redness, penetrating trauma, entrance/exit wounds, accessory muscle usage, chest rise and fall, paradoxical movement, hyperinflation, subcutaneous emphysema, sucking chest wounds, skin color, swelling of head and neck 2. Question a. Pain, pain on motion, pain with breathing, crushing pain, tearing pain, severity, radiation, other sensations, SAMPLE and OPQRST 3. Palpate a. Feel for swelling, deformity, crepitus, crackling, chest rise and fall 4. Auscultate a. Listen in all lung fields, anteriorly and posteriorly b. Inspiratory and expiratory air movement, crackles, diminished breath sounds, muffled heart sounds 5. Percuss a. Note response to percussion—normal, hyperresonance, dull b. Hyperresonance—air inflation; dullness—fluid or blood 6. Blunt Trauma Assessment a. Chest surface discoloration reflective of contusions b. Assess for additional signs indicating internal injury—dyspnea, accessory muscle usage c. Lung sounds will help to differentiate between contusions and pneumothorax 7. Penetrating Trauma Assessment

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes equipment available.

Class Activities Fill a balloon with water and one with air.

Have students percuss each balloon to determine whether it is filled with air or fluid.

Have students practice listening to lung sounds in all fields, and in all positions (supine, prone, sitting).

Use bubble-wrap to simulate subcutaneous emphysema, and have students palpate.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

a. Different set of signs associated with different injuries b. Inspect wounds for frothy blood, air sounds c. Look for signs of a tension pneumothorax, hemothorax, cardiac tamponade, myocardial rupture 8. Reassessment a. Repeat of primary assessment, vital signs; reexamination of injuries 20

VI. Management of the Chest Injury Patient A. Ensure good oxygenation and adequate respiratory volume and rate B. High-concentration oxygen via nonrebreather (NRB); intubation if indicated; rapid-sequence intubation (RSI) may be indicated in combative patient C. Assess minute volume; monitor pulse oximetry, capnography, level of consciousness (LOC) D. Support cardiovascular functions with IV and fluids (500mL boluses if systolic pressure is below 80 systolic), titrating fluids to 80 mmHg and watching for signs of pulmonary edema E. Rib Fractures 1. Analgesics if indicated, to improve respiratory effort F. Sternoclavicular Dislocation 1. Supportive therapy with oxygen 2. Dislocation reduction if patient in significant distress with no improvement with treatment; only if patient has isolated injury, no multiple-system trauma G. Flail Chest 1. Place patient on injured side if spinal immobilization not required 2. If spinal injury suspected, place bulky dressing with bandaging against flail segment to stabilize 3. High-concentration oxygen, pulse oximetry, ECG 4. Positive pressure ventilation (PPV), intubation, end-tidal CO2 H. Open Pneumothorax 1. High-concentration oxygen; monitor pulse oximetry, respiratory effort; if open, cover with occlusive dressing taped on three sides or a commercial one-way valve dressing 2. PPV, intubation if indicated; if no improvement after care and removal of occlusive dressing, decompression may be indicated I. Tension Pneumothorax

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Review the technique for a sternoclavicular reduction.

Critical Thinking Questions Why do you think sandbags are no longer used for a flail chest?

What signs will you see in the neck for a pneumothorax, but not a hemothorax?

Why? Class Activities Have students practice the treatment modalities for the listed injuries in the lab setting, starting with assessment and ending with run and radio report.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 1. Confirm tension pneumothorax by following MOI and signs and symptoms 2. High-concentration oxygen 3. Needle decompression by inserting 14-gauge IV into second intercostal space, midclavicular line; if patient remains symptomatic, place second or third catheter in 3rd or 4th intercostal space, midaxillary line; make sure to secure catheters 4. IV and fluids, with systolic to remain at 80 mmHg only if patient hemodynamically unstable J. Hemothorax 1. Oxygenation; ventilatory support; IV with fluid bolus of 250–500 mL to maintain systolic of 80 mmHg;(for newborns <30 days, 10 mL/Kg; for children 20 mL/Kg.) listen carefully to breath sounds for pulmonary edema; PPV, positive end-expiratory pressure (PEEP), or continuous positive airway pressure (CPAP) if necessary K. Blunt Cardiac Injury 1. High-concentration oxygen, ECG, IV, antidysrhythmics (if indicated) L. Pericardial Tamponade 1. Oxygen administration, IV administration 2. Definitive care is pericardiocentesis M. Aortic Dissection 1. Gentle and rapid transport, IV therapy en route with systolic kept at 80 mmHg 2. Cardiovascular resuscitation (CPR) may be necessary if aneurysm ruptures N. Tracheobronchial Injury 1. High-concentration oxygen and clear airway of blood and secretions 2. Intubation and PPV may be indicated if unable to maintain airway 3. Tension pneumothorax may develop due to PPV; treat accordingly O. Traumatic Asphyxia 1. Oxygenation and support airway/respirations 2. PPV if indicated; IV; ECG; prepare for possible chest decompression 3. Sodium bicarbonate may be indicated with prolonged extrication time

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 7 objectives can be found on text p. 204.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 5

Content Outline

Master Teaching Notes

VII. Summary A. Blunt or penetrating thoracic trauma has great life-threat potential B. Assessment and anticipation of these injuries will allow guidance in interventions C. Aggressive airway management, oxygenation, ventilation, and fluid resuscitation can make difference between life and death for your patient VIII. Case Study

Class Activities Discuss the case now that they are familiar with the chapter.

IX. You Make the Call

Class Activities Read and discuss the call and questions as a group.

X. Review Questions

Class Activities

5

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 8 Abdominal and Pelvic Trauma 120–130 Minutes

• • • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

40

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Abdominal and Pelvic Trauma A. One of body’s largest cavities, and contains organs essential to life B. Not well protected by skeletal structures; trauma may damage vital organs, and cause large volumes of blood loss C. Three common mechanisms associated with blunt abdominal and pelvic trauma: deceleration, crushing, and compression D. Injuries may not present immediately, and do not often appear in prehospital setting E. Prevention is the best way to reduce mortality; penetrating trauma increasing due to violence; lap-belt application concern due to compression injuries

Knowledge Application

III. Abdominal and Pelvic Anatomy and Physiology A. Bound by the diaphragm, pelvis, vertebral column, ribs, and muscles B. Abdominal cavity divided into 1. Peritoneal space—organs covered by peritoneal lining 2. Retroperitoneal space—organs posterior to peritoneal lining 3. Pelvic space—organs within pelvis C. Landmarks—umbilicus, xiphoid process, iliac crests, symphysis pubis D. Four Quadrants 1. Right upper—gallbladder, right kidney, most of liver, small bowel, ascending/transverse colon, small portion of pancreas 2. Left upper—stomach, spleen, left kidney, most of pancreas, portion of

Teaching Tips

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

For an assignment, have students define each key term.

Using an anatomy model of abdomen, review anatomy and physiology with students.

Discussion Topics Discuss the injuries that can occur in the abdominal cavity.

Have students list the hollow and solid organs of the abdomen, and the signs and

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline liver, small bowel, transverse/descending colon Right lower—appendix, portions of urinary bladder, small bowel, ascending colon, rectum, female genitalia 4. Left lower—sigmoid colon, portions of urinary bladder, small bowel, descending colon, rectum, female genitalia The major structures include the digestive tract, accessory organs of digestion, structures and organs of urinary system, spleen, and female genitals Digestive Tract 1. Hollow muscular organ 25 feet long 2. Responsible for churning materials to be digested, absorbing nutrients and water 3. Stomach, duodenum, jejunum, ileum, colon, rectum, and anus Accessory Organs 1. Liver—vascular; responsible for detoxifying blood, providing bile, storing glycogen 2. Gallbladder—hollow; stores bile until needed for fatty food digestion 3. Pancreas—production of glucagon, insulin, and digestive enzymes Spleen 1. Part of immune system, vascular, located behind stomach Urinary System 1. Kidneys, ureters, urinary bladder, urethra 2. Removal of wastes 3. Significant regulatory control over the salt/water (osmotic) balance of the body Genitalia 1. Female Sexual Organs Located within Peritoneum a. Ovaries, fallopian tubes, uterus, vagina b. Reproduction 2. Pregnant Uterus a. Pregnancy creates anatomy of abdominal cavity b. Growth of uterus will displace organs c. Uterus lying on vena cava in pregnant patient in supine position creates supine hypotensive syndrome 3. Male reproductive organs are outside and include the testes, scrotum, and penis

Master Teaching Notes symptoms of injury to each.

3.

E.

F.

G.

H. I.

J.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Class Activities Using flashcards that have the organs listed, have students place the organs in their correct quadrants.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

K. Vasculature 1. Blood supplied by abdominal aorta, bifurcates into iliac arteries, which become femoral arteries 2. Inferior cava collects blood from lower extremities L. Peritoneum 1. Covering of many abdominal organs 2. Visceral and parietal pleura 3. Mesentery is a double peritoneal fold that contains blood vessels, lymphatic vessels, nerves, and fatty tissue; restrains and protects digestive tract from tangling 30

IV. Pathophysiology of Abdominal and Pelvic Trauma A. Mechanism of injury (MOI)—greater trauma energy due to no skeletal protection B. Penetrating Trauma 1. Trauma is direct to tissues touched, or transmitted from high-velocity projectiles 2. Damage includes compression, spilling of hollow organs, peritonitis 3. Gunshot wounds have higher morbidity and mortality C. Blunt Trauma 1. Least visible signs of injury 2. Deceleration—organs injured by contents slamming into each other 3. Compression—between anterior abdominal cavity and spinal column 4. Shearing—part of organ moves freely, while other part restricted, tearing at ligament or vascular attachment 5. Early signs include erythema, MOI D. Abdominal Wall Injury 1. Abdominal wall must be disrupted 2. Redness first to appear; bruising may take hours to develop 3. Evisceration (abdominal contents protrude through abdominal wall) may appear, usually associated with large and deep laceration 4. Back, buttocks, and flank injuries may also include abdominal organs 5. Diaphragmatic tears can disrupt abdominal organs E. Hollow Organ Injury 1. Stomach, small bowel, large bowel, rectum, urinary bladder, gallbladder, and pregnant uterus 2. May rupture or tear with blunt forces or with penetrating trauma

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Draw the abdominal cavity, with organs, and take students through the pathway of a bullet, listing possible injuries that can occur.

Discussion Topics Discuss the possible injuries that could cause tears in the diaphragm.

Have students list the signs and symptoms of the mechanisms of injury listed.

Review the treatment for eviscerated bowel.

Critical Thinking Questions What type of patient has a higher risk of rupturing the urinary bladder?

If a patient has abdominal hemorrhage that is irritating the diaphragm, where might pain be referred to?

Why would an increased heart rate possibly not be present in a patient with an

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

F.

G.

H.

I.

J.

3. Small bowel most frequently ruptured 4. Results in hemorrhage, peritonitis, delayed infection, hematochezia, hematemesis, hematuria Solid Organ Injury 1. Spleen, liver, pancreas, kidneys 2. Bruising common, which results in organ damage, hemorrhage, or rupture 3. Spleen—profuse bleeding, resulting in pain in left shoulder (Kehr’s sign), shock 4. Pancreas—well protected from injury due to deep location in cavity 5. Penetrating trauma will release blood and digestive enzymes into cavity; enzymes will begin to digest pancreas and surrounding tissues; presents with upper abdominal pain that radiates to back 6. Kidneys—well protected; frequently injured with trauma to flank; back pain and hematuria 7. Liver—largest single organ in cavity; may lacerate from ligament; presents with tenderness to right upper quadrant, pain in upper shoulder, serious internal hemorrhage Vascular Injury 1. Arteries and veins prone to injury, with severe consequence, by blunt or penetrating trauma 2. Cavities expand and do not resist hemorrhage, resulting in continued bleeding Mesentery and Bowel Injury 1. Mesentery provides circulation, innervation, and attachment to bowel 2. Stretching at point of attachment commonly occurs at points of immobility; hemorrhage and spilling of contents Peritoneal Injury 1. Inflammation (peritonitis) can be caused by bacterial and chemical irritation; bacterial peritonitis—torn bowel or open wound; chemical peritonitis—digestive enzymes, acids 2. Progressive process—signs and symptoms include a slight tenderness at location, expanding tenderness over time, rebound tenderness, and guarding Pelvic Injury 1. Serious skeletal injury with possible life-threatening hemorrhage and

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes abdominal cavity hemorrhage?

Where might discoloration be present in a male patient with an abdominal bleed?

Why?

Knowledge Application Create a chart with the listed injuries to abdominal cavity. Have students write the definition, signs and symptoms, and treatment for each injury listed.

Have students list the definitions for Kehr’s sign, Cullen’s sign, McBurney’s point, and Grey-Turner’s syndrome.

Points to Emphasize Remember that signs of shock with no obvious external bleeding must be considered as due to internal abdominal bleeding until proven otherwise.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

damage to organs in pelvic cavity K. Injury During Pregnancy 1. Trauma number one killer of pregnant females 2. Changes associated with pregnancy affect abdominal organs, displacing organs higher; trauma to mother means trauma to fetus 3. Increased maternal vascular volume helps protect the mother from hypovolemia, however, this increase in maternal blood volume does not protect the fetus 4. Blunt trauma can result in abruptio placentae, premature rupture of amniotic sac L. Pediatric Abdominal Trauma 1. Poorly developed abdominal muscles, increasing incidence and seriousness of abdominal injuries 2. Compensation very good, until half of blood volume lost 15

V. Assessment of the Abdominal or Pelvic Trauma Patient A. Definitive care is often surgical intervention B. Scene Size-Up 1. Ensure safe scene, body substance isolation (BSI); identify MOI, index of suspicion 2. Identify objects that caused trauma 3. May be blunt or penetrating injury 4. Determine which organs are at risk of injury C. Primary Assessment 1. Level of consciousness (LOC), ABCs, Glasgow Coma Scale (GCS) score, signs of shock 2. When evaluating the airway, breathing, and circulation, be observant for any associated signs and symptoms of hypovolemia D. Secondary/Rapid Trauma Assessment 1. Full rapid assessment, with close attention to abdomen 2. Look for erythema, position of patient, ecchymosis, open wounds, distention; cut away clothing to view hidden hemorrhage; evaluate pelvic stability; note any pain in patient after palpation, guarding, pulsating masses, entrance/exit wounds, and eviscerations 3. Ultrasonography is a new technique allowing identification of pooling of blood within abdomen (this procedure must improve patient care to be

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics If possible, have an ultrasound technician discuss the benefits of ultrasound in the prehospital setting.

Critical Thinking Questions What reassessment signs can indicate worsening shock?

Class Activities Have students perform abdominal injury assessments, focusing on signs and symptoms particular to abdomen. Have them note treatments accordingly.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

valuable) 4. Question the patient about pain, history, SAMPLE, OPQRST; obtain vital signs E. Special Assessment Considerations with Pregnant Patients 1. Attention to abdominal area and possibility of injury; blood volume of mother increased by up to 45% and blood loss of 30% before signs and symptoms of hypovolemia appear 2. Supine hypotension syndrome can occur if pregnant patient placed supine; must be placed in left lateral recumbent position. If spinal injury is also suspected, immobilize her firmly to the spine board and rotate the entire board and patient 15 degrees to the left side F. Reassessment 1. Look for signs of progressing abdominal injuries 2. Perform every 5 minutes in patients with any significant suggestion of abdominal injury 3. Repeat primary assessment, vital signs, LOC, and GCS 4. Look at pulse pressure, capillary refill time, pulse oximetry reading, and response to fluid resuscitation 10

VI. Management of the Abdominal Trauma Patient A. Mainly supportive, with emphasis on rapid definitive care B. Rapid packaging, transport, fluid resuscitation C. Proper positioning, shock care, specific injury care D. Airway control due to possibility of vomiting; ventilations; high-concentration oxygen if indicated E. Control external bleeding; fluid bolus to systolic of 80 mmHg; keep patient warm F. Cover evisceration with moist, sterile dressing; stabilize any impaled objects G. Management of the Pregnant Patient 1. Placement in left lateral recumbent position, if the patient is on a spine board, tilt it 15 degrees to the left to achieve a similar effect 2. High-concentration oxygen, aggressive airway due to vomiting risk

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Class Activities Have the class practice treatment modalities for the patient with abdominal injuries.

Using an impaled object, have students practice stabilizing with bulky dressings and tape.

Have students practice placing a pregnant patient (stuff shirts with pillows) on a backboard, and tipping the backboard to the left.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 8 objectives can be found on text p. 235.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 5

Content Outline

Master Teaching Notes

VII. Summary A. Blunt or penetrating trauma can result in serious organ damage, hemorrhage, and death B. Injuries may be nonspecific and may not reflect seriousness C. Care includes rapid transport for definitive care (surgery) D. Prehospital care includes airway and breathing support, prevention of shock E. Special care for pregnant female due to vascular and organ-placement changes due to pregnancy VIII. Case Study

Class Activities Discuss the case now that students are familiar with the chapter.

IX. You Make the Call

Class Activities Read and discuss the call and questions as a group.

X. Review Questions

Class Activities

5

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 9 Orthopedic Trauma 190–210 Minutes

• • • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

10

35

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Orthopedic Trauma A. Musculoskeletal trauma is second only to soft tissue injuries B. Usually result of direct or transmitted force; can result from penetrating trauma C. Sports injuries, motor vehicle collisions (MVCs), falls, acts of violence D. Lower extremities injuries can result in severe blood loss, and threaten life and limb 1. Forces that cause musculoskeletal trauma can also damage spine, internal organs, nerves, and blood vessels

Discussion Topics

III. Prevention Strategies A. Stopping the injury before it happens is the best way to deal with musculoskeletal trauma B. Programs aimed at prevention include restraint systems in vehicles; safe driving courses; improved engineering in automobiles; protective gear and improved equipment in sports; and safety aids in homes, such as handrails, nonslip rugs, stair railings, and so forth

Critical Thinking Questions

IV. Musculoskeletal Anatomy and Physiology A. Consists of skeleton and muscles: skeleton is structure; muscles supply power of motion B. Produce heat, store energy sources, create blood cells C. Skeletal Tissue and Structure 1. Gives body structural form, protects vital organs

Teaching Tips

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discuss the different prevention programs available that help to decrease the incidence of musculoskeletal trauma.

Knowledge Application For an assignment, have students define each key term.

What prevention programs are active in your community? What programs are needed?

Using a skeletal model bone, or a turkey/chicken bone (dried and cleaned), review the bone structure and anatomic areas of the bone. Using a bone that you can write/color on is a good idea, as you

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 2. Effective movement despite gravity, stores salts and other items for metabolism, produces red blood cells (RBCs) D. Bone Structure 1. Cylinders of bone with minute blood vessels that travel lengthwise (haversian canals) 2. Bone cells (osteocytes) maintain collagen and calcium 3. Osteoblasts lay down new bone during growth and repair 4. Osteoclasts dissolve bone structures 5. Continuous blood supply brings oxygen (O2) and nutrients to bone, while removing wastes 6. Blood vessels enter and exit bone through perforating canals 7. Devascularization results in loss of bone integrity 8. Long bones: diaphysis, epiphysis, metaphysis, medullary canal, periosteum, cartilage a. Diaphysis: central portion, or shaft, of long bone; very dense and thin layer of compact bone that supports weight, although lateral forces cause shaft to break easily b. Epiphysis: widened, articular bone located at bone ends, where structural changes occur; covered with articular surface c. Metaphysis: intermediate region between epiphysis and diaphysis, where epiphyseal plate is located (growth plate), and where cartilage is generated and widening occurs, allowing bone growth during childhood; damage to this area during childhood can cause growth discrepancies d. Medullary canal: chamber of diaphysis that is filled with yellow bone marrow that stores fat; red bone marrow fills the cancellous bone chambers of larger long bones, sternum, and pelvis e. Periosteum: tough fibrous membrane that covers exterior of diaphysis and transmits pain sensation with fractures and initiates bone repair; tendons help to form strong attachments f. Cartilage: connective tissue that covers epiphyseal surface that functions as articulation between bones g. Bone classification: classified by shape (long, short, irregular, flat) A. Joint Structure 1. Bones move and are held together by a joint 2. Three basic types of joints that are classified by amount of movement

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes can draw the blood vessels, shade the different areas, and so forth.

Obtain X-rays of infant, adult, and elderly patients. Compare the differences in integrity and growth plates.

Discussion Topics Discuss the bones that make up the upper and lower extremities.

Critical Thinking Questions What type of occupations would have a higher risk of injury to the bursae?

Why does a cartilage injury take so long to heal?

What paramedic skill, when performed in the improper location, could cause damage to the growth plate?

What skills performed by paramedics can have increased fracture risk for elderly patients?

Class Activities Have students practice finding the different joints on each other, along with discussing the various movements of the body.

Have students practice on a full-body skeleton model in naming all of the bones.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 3. Synarthroses—immovable joints (sutures of skull, between jaw and teeth) 4. Amphiarthroses—allow very limited movement (joints between vertebra, between sacrum and ileus 5. Diarthroses/synovial: free movement (elbow, knee, shoulder, hip) 6. Diarthroses/synovial joints divided into movements they allow a. Monaxial joints—hinge joints that allow bending in single plane (knee, elbow, fingers); pivot joints allow head rotation (atlas and axis of spine) b. Biaxial joints: gliding joints that allow movement in two places (carpals, clavicle, and sternum); ellipsoidal joints providing sliding motion in two planes (wrist, metacarpals); saddle joints allow movement in two planes at right angles (bases of thumbs) c. Triaxial joints: ball-and-socket joints allow limb to rotate (hip, shoulder) 7. These joints allow various movement—flexion/extension, abduction/adduction, rotation, circumduction 8. Ligaments: connective tissue bands that hold bones together at joints; stretch and permit motion 9. Joint capsules: ligaments that surround a joint form a synovial or joint capsule that holds a small amount of fluid to lubricate surface; known as synovial fluid, helps to reduce friction during movement; small sacs filled with synovial fluid are bursae sacs, located between tendons and ligaments in elbows, knees, and other joints, to also help reduce friction B. Skeletal Organization 1. Axial and appendicular skeleton formed of 206 bones 2. Axial skeleton: head, thorax and spine; form axis of body, protect central nervous system (CNS), and make up thoracic cage 3. Appendicular skeleton: upper and lower extremities and their girdles; provide structure to extremities and permit articulation of body C. Upper Extremities 1. Shoulder girdle: clavicle and scapula 2. Humerus, radius, ulna, carpal bones, metacarpals, phalanges D. Lower Extremities 1. Pelvis: ilium, ischium, pubis 2. Femur, patella, tibia, fibula, talus, calcaneus, metatarsals, phalanges

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Then have students name the bones just by classification.

Have students practice assessing range of motion on each other.

Knowledge Application Assign the following terms to students for homework: acromion process, protuberance, articulation, tuberosities, condyles, olecranon, acetabulum, flexion, extension, insertion, opposition, abductor, and adductor.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

E. Bone Aging 1. At birth and during infancy, bones are more cartilage and there is little ossified bone; ossified bone begins along long bones and grows outward; as child grows into young adulthood, bones solidify and growth plates close 2. Bone maturation is complete by 18 to 20 3. In youth, bones flexible; as aging continues, bones begin to lose ability to maintain structure (begins in 40s); increases bone fracture risk F. Muscular Tissue and Structure 1. More than 600 muscle groups; large number of EMS calls due to injuries to muscular system 2. Skeletal: striated/voluntary muscle; under conscious control; associated with mobility and largest component of muscular system 3. Protection of muscle system from skin and subcutaneous fat 4. Individual muscle cells layer together to form muscle fiber, and many fibers form muscle fasciculus, which forms muscle bodies 5. Attached at bones called origin and insertion: origin is point that remains stationary, whereas insertion is movement 6. Muscles usually paired on either side of joint, allowing flexion and extension by opposition; several ranges of motion at various joints 7. Tendons are bands of connective tissue that attach muscle to bone; do not stretch 8. Muscle tissue responsible for movement and heat production 9. Muscle tone is the CNS message to muscles for firmness 30

IV. Musculoskeletal Pathophysiology A. Muscular Injury 1. May result from blunt or penetrating trauma, overexertion, problems with O2 supply 2. Contusion: leaking of blood into interstitial spaces 3. Compartment syndrome: localized swelling in soft tissue that increases pressure in area, cutting off blood flow (pain that appears out of proportion to injury) 4. Penetrating injury: deep laceration that affects muscle mass and may injure tendons, reduce strength, increase infection risk, and increase risk of hemorrhage 5. Fatigue: muscles reach performance limit, causing hypoxia, acidosis,

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Obtain X-rays of various fractures and review them with students.

Discussion Topics Review the various muscular, joint, and bone injuries, along with common causes.

Review the Slater-Harris Pediatric Scheme.

Critical Thinking Questions

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline pain, and loss of energy 6. Muscle cramping: painful muscle tissue spasm that results when available O2 and energy sources depleted (exercise), causing pain, spasm 7. Muscle spasm: intermittent (clonic) or continuous (tonic) contractions, and may feel like a deformity 8. Strain: muscle fibers overstretched, causing pain with use B. Joint Injury 1. Sprain: tearing of joint capsule’s connective tissue, usually a ligament, that causes sudden pain at site, swelling, bruising; classified as Grade I—minor, incomplete tear with minimal swelling (joint stable); Grade II— significant but incomplete tear, swelling and pain (joint unstable); Grade III—complete ligament tear, severe pain and swelling (may present as fracture) 2. Subluxation: partial bone end displacement, reducing joint’s integrity, with pain, swelling, and limited range of motion (ROM) 3. Dislocation: complete displacement of bone ends from joint position, with abnormal position, deformity, pain, swelling, immobility C. Bone Injury 1. Fracture is a disruption in bone continuity 2. May be direct or indirect; displaced bone ends may affect vascular system, with increased capillary refill, diminished pulse, decreased temperature, discoloration, paresthesia, anesthesia, paresis, paralysis 3. Closed fracture: no penetration of skin from bone fracture; skin around injury intact 4. Open fracture: sharp bone ends that displace through skin, or penetrating injury object; high risk of infection 5. Hairline fracture: small crack that doesn’t disrupt total structure 6. Impacted fracture: bone impacts on self, causing fracture 7. Transverse fracture: complete break in bone that runs straight across at 90-degree angle 8. Oblique fracture: fracture that runs at angle across bone 9. Comminuted fracture: bone splinters into several smaller fragments 10. Spiral fracture: twisting motion that results in curved break around shaft 11. Fatigue fracture: prolonged or repeated stress on bone that weakens and fractures

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes How can a dislocation affect nerve and blood supply to the extremity?

How might a surgeon allow for complete healing of a greenstick fracture?

Why would a patient in hemorrhagic shock have a difficult time with bone healing?

What would happen if a bone begins to heal when it is misaligned?

Class Activities Take a broom handle and break it in two.

Apply red paint to the broken ends and place together. Wrap the broken handle in a large towel. Have students attempt to immobilize the handle. Students will see the red color on the inside of the towel, which indicates injury manipulation and tissue damage.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

D.

E.

F.

G.

12. Fracture complications include fat embolism, which is infrequent but very serious; usually associated with severe crush injuries, postinjury manipulation of larger bones Pediatric considerations—pediatric bones contain more cartilage, allowing for flexibility 1. Greenstick fracture: partial fracture that disrupts only one side of bone 2. Buckle or torus fracture: buckling of bone on one side due to increased cartilage and flexibility 3. Epiphyseal fracture: weak spot in bone that can be site of fracture—this fracture site can reduce or halt bone growth 4. Fracture repair aggressive in children, ensuring rapid return to normal bone shape 5. Salter-Harris Pediatric Scheme: epiphyseal fracture grading (Type 1– Type 5; the higher the number, the longer and more difficult the healing) Geriatric considerations—progressive decrease in bone mass and collagen structure; bones less flexible, more brittle and easily fractured 1. Lumbar spine and femoral fractures can occur with stress, and without significant trauma 2. Osteoporosis is an accelerated bone tissue degeneration that leads to bone structure degeneration, increasing bone fracture risk Pathological fractures—result from disease pathologies that affect bone development or maintenance 1. Caused by tumors, diseases that increase osteoclast activity and osteoporosis, radiation treatment 2. Be suspicious of fracture in patient with history of cancer or low-energy mechanisms that cause fractures in patients with no medical history General Considerations with Musculoskeletal Injuries 1. Skeletal system and musculature should be examined together 2. Long bones are smallest through diaphysis and largest at epiphyseal area, although external diameter is greatest at mid-shaft 3. Any injury can compromise nerve and vessel supply; fractures near joint more likely to compress or sever blood vessels or nerves 4. Fractures close to epiphysis displaces bone ends, compromising blood supply and destroying joint and function 5. Even slight injury site manipulation can increase pain, damage soft tissue, cause injury to nerves and blood vessels, introduce bone

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

fragments and fat emboli into venous system; muscle spasms with long bone fractures H. Bone Repair Cycle 1. Periosteum, local blood vessels, soft tissues, and endosteum tear 2. Blood fills injured site, congeals, and forms an RBC and collagen clot called fracture hematoma 3. Fracture hematoma stops further bleeding and becomes a weak immobilizer for injury site 4. Cartilage-forming cells strengthen the site, and a more stabilized skeletal area is formed 5. Skeletal stabilization is called callus 6. Osteoblasts lay down calcium along stress lines in the bone and osteoclasts remove calcium from areas with limited stress resulting in gradual bone shaping (remodeling) that will eventually resemble the original bone 7. Original strength in about four months 30

V. Musculoskeletal Injury Assessment A. Fractures, dislocations, or muscular injuries infrequently threaten life or seriously contribute to shock. In most circumstances, a patient with an isolated fracture, dislocation, or muscular or connective tissue injury should receive focused trauma assessment and management at the scene.

B. Scene Size-Up 1. Body substance isolation (BSI), safety, mechanism of injury (MOI) to anticipate severity, necessary resources available C. Primary Assessment 1. General impression, level of consciousness (LOC), ABCs 2. Identify possible spinal injury and use spinal precautions 3. Remember that distracting injuries can mask more life-threatening injuries 4. Injury classified as: a. Life- and limb-threatening injuries b. Life-threatening injuries and minor musculoskeletal injury c. Non-life-threatening injuries and serious limb-threatening musculoskeletal injury d. Non-life-threatening injuries and isolated minor musculoskeletal

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Discuss the four injury classifications, and have them come up with various injuries for each.

Critical Thinking Questions Why would an athlete downplay any injury or pain he or she might be experiencing?

What is the best course of action when dealing with a distracting injury?

Class Activities Have students practice assessing musculoskeletal injuries using the focused exam.

Take a pencil, break it in half, then wrap it in gauze and tape (all the way around, so

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

injuries 5. Exam and transport decision based on life and injury assessment D. Secondary Assessment 1. Rapid Trauma Assessment a. Performed on any patient with signs, symptoms, or MOI that suggests serious injury b. Always maintain high suspicion for internal injury c. Evaluate head, neck, chest, abdomen, pelvis, extremities, and posterior d. Blood loss in thighs can equal 1,500 mL; this blood loss can be hidden in tissues and thigh muscles e. Check motor function, sensory function, and pulses in all extremities, and assess muscle strength; assess for crepitus, and if present, stop touching injured area f. Obtain vital signs, patient history, Glasgow Coma Scale (GCS) score 2. Focused Assessment a. Attention directed to injuries found or suggested during primary assessment b. Look for discoloration, limited or no ROM, deformities, unequal limb length, crepitus, touch response, open skin at injury site c. Six P’s of evaluation: pain, pallor, paralysis, paresthesia, pressure, and pulses; poikilothermia (loss of temperature) is an additional P d. Treat all injuries as if a fracture or dislocation exists e. Observe for compartment syndrome in fractures of extremities, although this takes time to develop, and may not be seen in prehospital setting f. Question patient about injury, and determine location of pain, tenderness, dysfunction 3. Detailed Physical Exam a. Usually perform on a patient with lowered LOC or unconscious, and only after all potential life threats have been attended to; most likely performed en route to hospital b. This is a search for signs and symptoms of further injury not suggested by MOI, complaints, or assessment c. Head-to-toe exam that helps identify subtle indications of injury

you no longer see pencil). Have the students practice palpating, so they can feel crepitus.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

4. Reassessment a. Vital signs, LOC, signs and symptoms of affecting trauma, MSPs 5. Sports Injury Considerations a. Assess MOI, along with kinetic force involved, hyperextension or flexion, or fatigue injury b. Major body joints tend to be injured in athletes; serious ligament damage can occur c. Sprains usually associated with sports injuries, especially knee; common is anterior cruciate ligament, which prevents anterior displacement of tibia, resulting in complaint of knee “giving out” 65

VI. Musculoskeletal Injury Management A. Some fractures can contribute to hemorrhage and shock, and require high priority in care, along with any injury that threatens limb B. Injury care involves reduction of any further injury and reducing patient discomfort, typically by splinting C. General Principles of Musculoskeletal Injury Management 1. Protecting Open Wounds a. Any open wound near injury is to be considered open wound b. Look for muscle, tendon, ligament, or vessel damage c. Cover with sterile dressing d. Splinting may draw protruding bone back into wound; this is an expected consequence and must be brought to the attention of physician 2. Positioning the Limb a. Proper limb position essential to patient comfort, reduction of further injury, and encouragement of venous drainage b. Alignment appropriate for mid-shaft fractures of femur, tibia/fibula, humerus or radius/ulna; splints, air splint, vacuum, traction splint c. Use caution in alignment, as to prevent bone ends from causing more tissue damage d. Keep proximal limb in position, while bringing distal limb to alignment e. Stop if resistance met or patient complains of increased pain f. Do not generally attempt alignment in fractures/dislocations within 3 inches of joint and only attempt if distal circulation compromised

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Review the steps to positioning limbs.

Pull out all of the splinting devices you have available. Review the indications for each.

Critical Thinking Questions What splinting device would be indicated for a patient with arthritis and deformity of joints?

Why is it so important to assess motor function, sensory function, and pulses before, during, and after immobilization?

Class Activities Have students practice immobilizing bones and joints, along with evaluation of MSPs. Have students practice applying the various splinting devices available.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline g. Reduction of dislocation attempted if dislocation going to be extended in time 3. Immobilizing the Injury a. Immobilization is performed to prevent further injury caused by movement of injured limb; restricts bone ends from further lacerating tissues, nerves, and blood vessels and displacing clots; or restricts dislodged bone ends from compressing nerves and blood vessels b. Always immobilize bone injuries at the joints above and below injured site; joint injuries immobilized at bones above and below injured site 4. Checking Neurovascular Function a. Check circulation, motor and sensory function in injured extremity before, during, and after immobilization b. May also use pulse oximeter during immobilization, to assess for any circulation changes 5. Local Cooling and Gentle Compression a. Local cooling will reduce swelling, inflammation, and pain b. Apply ice or cold packs wrapped in a towel directly to skin c. Pressure from immobilization will also help with pain and swelling reduction D. Splinting Devices 1. Rigid Splints a. Firm support, can be made out of cardboard, plastic, metal, wood, other products; require padding that may be built into splint or added to splint b. Cardboard splints, preformed splints—bandaging may be required to completely immobilize limb 2. Formable Splints a. Malleable, easily shaped to match limb; attached with bandaging b. Ladder splint, SAM splint 3. Vacuum Splints a. Sized for almost all long bone fractures; air-tight fabric bag that is placed around limb and air is then drawn out 4. Soft Splints a. Padding or air pressure for immobilization b. Pelvic sling, air splint, pillow splints

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

E.

F.

G.

H.

5. Traction Splints a. Developed to reduce mortality and limb loss from femur fractures; such fractures are infrequent today as is the need for traction splinting. b. Applies a pull to injured extremity and against trunk c. Pain will cause muscle spasms, which will cause bone ends to move, increasing damage; traction splints prevent bone ends from overriding d. Bipolar or unipolar traction splints; the eel Splint is a variation of the bipolar splint 6. Other Splinting Aids a. Cravats, Velcro straps, buddy splinting using body, and immobilization to long board Fracture Care 1. A fracture near a joint carries a high probability of damage to blood vessels, nerves, and joint capsule 2. Immobilization in position found will protect against further damage 3. Begin fracture care by ensuring distal pulses, sensation, and motor function, align limb, reassess MSPs, immobilize and assess MSPs again 4. To move an injured limb from an angulated position into alignment, use gentle distal traction applied manually; stop if resistance met or patient complains of increased pain or discomfort Joint Care 1. Immobilization in position found, assessment and reassessment of MSPs 2. Reduction of injury may be indicated in cases of significant neurovascular deficit, delayed arrival to emergency department (ED), and make sure that it is a dislocation Muscular and Connective Tissue Care 1. Large hematomas can contribute to blood loss and hypovolemia 2. Injury may be painful and threaten limb 3. Immobilize area of injury, apply cool compress, ensure that your actions do not compromise motor function, sensation, or circulation Care for Specific Fractures 1. Pelvis

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Using a picture of the pelvis, discuss the four types of pelvic fractures.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline a. Can involve either iliac crest or pelvic ring b. Iliac crest injuries tend to be isolated and stable fractures c. Pelvic ring fractures associated with high-velocity trauma and hypovolemia carry high mortality d. Pelvis strong skeletal structure that supports abdomen, thorax, upper extremities, neck and head; protects genitalia, bladder, terminal end of alimentary canal, and major blood vessels in lower extremities e. Four types of fractures: i. Type I—fractures not involving pelvic ring, include pubis, sacrum, coccyx, ischium, iliac, and avulsion fractures ii. Type II—single break in pelvic ring, pelvic stability maintained, and can include unilateral ring fractures, symphysis pubis, sacroiliac fractures iii. Type III—high-energy involvement, multiple ring fractures, likely hypovolemia iv. Type IV—involve acetabulum f. Pelvic ring has great strength but ring breaks usually cause fractures at two sites; forces this strong are likely to produce injuries elsewhere g. Heavy hemorrhage (2 liters) and impaired neurovascular impairments, along with damage to bladder, female reproductive organs, urethra, prostate, and anus/rectum h. Care includes stabilizing fracture, supporting hemodynamic status of patient, and rapid transport i. Pelvic binder may be recommended, which is a wide band or sheet that is placed under patient and secured j. If the patient is hypotensive, start a large-bore IV with trauma tubing and one 1,000-mL bag of normal saline, administer fluid boluses as needed to maintain a systolic blood pressure of at least 80 mmHg k. Consider a pelvic fracture patient to be a candidate for rapid transport 2. Femur a. May be caused by traumatic forces, or result from degenerative disease b. Degenerative disease fractures—immobilization, traction splint not

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discuss the indications for PASG use, and when it might be beneficial in musculoskeletal trauma.

Knowledge Application For homework, have students list the different signs, symptoms, and positions with which fractured limbs and joint dislocations will present.

Points to Emphasize Remember that you must adapt the equipment to fit the patient; you cannot make the patient fit the equipment.

Check motor function, sensory function, and pulses before, during, and after immobilization—ALWAYS.

Class Activities Have students practice using a commercial pelvic binder and one made with a sheet, along with the immobilization process.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline necessary, as bone ends are not overriding and causing muscle spams c. Traumatic fracture—extreme discomfort, writhing pain; traction splint will relieve muscle spasm, reduce pain; it is not to be used if patient has pelvic, knee, tibia, or foot injuries d. Proximal injuries—frequently caused by hip injuries (commonly referred to as hip fractures); no traction splint e. Mid-shaft femur fractures—high-energy, lateral trauma and blood loss; will benefit from traction splint f. Femur fracture generally presents with foot externally rotated and shortened limb g. If traction splint used, patient’s pain response is generally from your application of traction guide h. Immobilization to backboard indicated, due to high-energy forces 3. Tibia/Fibula a. May occur separately or together b. Fibular fractures often associated with damage to knee or ankle c. If tibia fractured and fibula intact, angulation may not be present, but patient will not be able to bear weight d. If only fibula fractured, limb may be stable e. This fracture can result in compartment syndrome f. Immobilization with gentle traction and appropriate splint 4. Clavicle a. Most frequently fractured bone in the body b. Usually results from transmitted forces c. May cause serious injury if powerful forces applied d. Often presents with pain and shoulder shifted upward, with palpable deformity along clavicle e. Dislocation at the sternum (sternoclavicular) joint can be immobilized with a figure-eight dressing gently pulling the shoulders back f. Dislocation at the shoulder immobilized with sling and swathe 5. Humerus a. Very difficult to immobilize at proximal end b. Most effective splinting is a sling and swathe “cuff and collar”; prevents pressure to humerus at elbow

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline c. May use rigid splinting; ensure that pressure not applied to axilla 6. Radius/Ulna a. Forearm may fracture anywhere along length, most commonly at distal end of radius, displacing bone end toward the palm (Colles’ fracture) b. Colles’ fracture will present with wrist turned up at unusual angle (silver fork deformity); risk of neurovascular compromise c. Immobilize in position found, use sling and swathe, place hand in position of function I. Care for Specific Joint Injuries 1. Hip a. May dislocate anterior or posterior b. Anterior dislocation—foot turned outward and femur’s head palpable in inguinal area c. Posterior dislocation—most common, knee flexed and foot rotated internally with femur’s head buried in buttocks muscle and impinging on sciatic nerve d. Immobilize on long board with padding e. Reduction if neurovascular compromise present 2. Knee a. Knee joint held together by anterior and posterior cruciate and medial and lateral collateral ligament b. Bears great amount of weight and an injury can threaten a patient’s ability to walk in the future; blood loss (popliteal artery) c. Patellar dislocations—more common, knee usually in flexed position with lateral patellar displacement d. Anterior dislocations—extended limb that lifts at knee (proximal to distal) e. Posterior dislocations—limb that drops at knee f. Reduction may be necessary if neurovascular compromise present or if definitive care will not be available for > 2 hours g. Immobilize in position found 3. Ankle a. Often grossly deformed b. Anterior, posterior, or lateral dislocations c. Anterior—upward-pointing foot that appears shortened

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Review the skill of reducing joint dislocations. Use a skeleton model to show the different reduction techniques.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

4.

5.

6.

7.

d. Posterior—downward-pointing foot that appears lengthened e. Lateral—most common, foot turned outward from ankle f. Reduction may be necessary if neurovascular response is altered g. Splint as found using commercial devices or pillow splint Foot a. Injuries to calcanei (heel bone), metatarsals, and phalanges b. May result from falls, stubbing of toe c. Immobilization is similar to an ankle injury Shoulder a. Commonly involves proximal humerus, lateral scapula, and distal clavicle b. May be anterior, posterior, or inferior displacement of humeral head c. Anterior—humeral head forward, shoulder appears hollow or squared-off, with patient holding arms close to chest and forward of mid-axillar line d. Posterior—rotate arm internally, patient presents with elbow and forearm held away from chest e. Inferior—humeral head displaced downward, with patient arms locked above head f. Immobilize as found unless reduction indicated due to diminished neurovascular response Elbow a. High incidence of vascular and nerve involvement, especially in pediatric patients b. If deficit detected, careful movement of joint to restore circulation indicated c. Splint the elbow with a single padded rigid splint and keeping the wrist slightly elevated above the elbow, secure the limb to the chest using a sling and swathe. d. Keep wrist slightly higher than elbow, which will increase venous return and reduce swelling Wrist/Hand a. Common with direct trauma; noticeable deformity and pain b. Immobilization with splint, and position in use of function; a gauze roll placed in hand will allow this position c. Colles’ fracture is a particular wrist fracture that presents with a

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline “silver-fork” appearance 8. Finger and Toes a. Use tongue blades, malleable splints, or adjoining fingers/toes to immobilize b. Reduction and or realignment may be necessary J. Soft and Connective Tissue Injuries 1. Massive muscular contusions and hematomas can contribute to hypovolemia 2. Prevention of further stress to injured extremity and reduction of pain are goals of care K. Medications—administered to relieve pain and premedicate before reduction 1. Sedatives/Analgesics a. Diazepam, morphine, fentanyl L. Pediatric Musculoskeletal Injury 1. Higher risk due to activity level and incomplete coordination 2. Greenstick and epiphyseal plate fractures are common to pediatric patients 3. Rule out abuse by looking for injury not consistent with MOI, multiple bruises in various stages of healing; report to appropriate authorities M. Athletic Musculoskeletal Injuries 1. Higher incidence of injuries, especially to joints 2. Usually occur due to significant kinetic force 3. Athletic trainers can aid in care of athlete, although once EMS arrives, athlete becomes patient of EMS 4. RICE: rest, ice, compression, elevation; common acronym used by trainers for treatment of sprains, strains, other soft tissue injuries 5. Application of elastic bandage in athletic setting is usually for strengthening of the limb for further activity; not common in prehospital setting N. Patient Refusals and Referral 1. Evaluate patient complaint to determine if medical attention necessary 2. If refusal or referral occurs, communicate with medical direction and follow local protocols O. Psychological Support for the Musculoskeletal Injury Patient 1. You as paramedic can have positive impact on patient’s psychological well-being by displaying a concerned and professional attitude, constant

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Review the indications, contraindications, actions, and dosages of medications used for musculoskeletal injuries.

Class Activities Invite an athletic trainer in to discuss the commonly seen injuries and treatment modalities.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 9 objectives can be found on text p. 257.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

communication, and compassion

VIII. Summary 5

A. Injuries to bones, ligaments, tendons, and muscles rarely threaten life of patient, but can threaten integrity and use of limb B. Hemorrhage can occur from large bone fractures, and serious musculoskeletal injury usually indicates possibility of other life-threatening injuries C. Care for isolated musculoskeletal injuries is after all life-threatening injures stabilized and ABCs are intact D. Immobilization will allow for decreased continued injury and reduction of pain in all bone, joint, and muscular injuries E. Care for injuries to connective and muscular tissues by immobilizing the area of injury in the position of function. Evaluate distal extremities for pulse, capillary refill, color, temperature, sensation, and motor function before, during, and after any immobilization or movement of a limb and provide frequent monitoring thereafter

IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

X. You Make the Call

Class Activities Read and discuss the call and questions as a group.

5

5

XI. Review Questions 5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Class Activities Pass out review questions before the lesson starts. Have students answer them.

Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 10 Environmental Trauma 160–180 Minutes

• • • • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

5

10

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction A. Environment is defined as all of the surrounding external factors that affect the development and functioning of a living organism B. A medical condition caused or exacerbated by environmental factors is known as an environmental emergency C. Emergencies include heatstroke, hypothermia, drowning, diving accidents/barotrauma, altitude sickness, and nuclear radiation D. Factors that predispose individuals include age, health, fatigue, preexisting conditions, and medications III. Homeostasis A. Body must interact with environment to obtain oxygen, nutrients, other necessities in order to function properly B. Homeostasis is the process of maintaining constant suitable conditions within body IV. Pathophysiology of Heat and Cold Disorders A. Mechanism of Heat Gain and Loss 1. Body gains and loses heat from within body and contact with external environment 2. Thermal gradient is difference in temperature between environment and body B. Thermogenesis (Heat Generation)

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Review the definitions of each heat mechanism, along with its function.

Discuss the five heat-loss mechanisms, and have students cite examples of each.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

C.

D.

E.

F.

1. Body gains heat from both external and internal sources and through metabolism 2. Creation of heat = thermogenesis 3. Types include work-induced thermogenesis, thermoregulatory thermogenesis, diet-induced thermogenesis Thermolysis (Heat Loss) 1. Loss of heat = thermolysis 2. Heat is transferred through: conduction, convection, radiation, evaporation, respiration Thermoregulation 1. Maintenance or regulation of temperature 2. Core temperature: 98.6°F or 37°C 3. A naked person can be exposed to an external environment ranging anywhere from 55°F (12.8°C) to 144°F (62.2°C) and still maintain a constant internal body temperature; this characteristic is called steady-state metabolism.

4. Evaluation of peripheral body temperature measured by touch or taking temperature 5. Balance between production and loss of heat maintained through nervous system and negative feedback mechanism 6. Hypothalamus—responsible for temperature control; increased heat will stop creation of heat; decrease in temperature will allow cooling Thermoreceptors 1. Receptors in skin and mucous membranes—both cold and warm 2. Cold receptors outnumber warm Metabolic Rate 1. Basal metabolic rate—metabolism that occurs when body completely at rest 2. Body consumes energy just to maintain itself 3. Exertional metabolic rate—rate of metabolism that supports additional activity 4. When the environment is too cold, countercurrent heat exchange is used to shunt warm blood away from the superficial veins near the skin and back into the deep veins near the core

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Critical Thinking Questions What would happen to a patient whose heat mechanism is not functioning properly?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 25

Content Outline V. Heat Disorders A. Heat-related illness is increased core body temperature resulting from inadequate thermolysis B. Hyperthermia 1. State of unusually high body temperature 2. Usually created by heat transfer from external environment for which body cannot compensate, excessive heat generation within body, medications 3. Signs and symptoms include diaphoresis, increased skin temperature, flushing, altered mentation, altered level of consciousness C. Predisposing Factors 1. Age of patient, health of patient, medications, level of acclimatization, length of exposure, intensity of exposure, environmental factors such as humidity and wind D. Preventive Measures 1. Adequate fluid intake, gradual acclimatization to heat, limited exposure to hot environments E. Specific Heat Disorders 1. Heat Cramps (Muscle Cramps) a. Muscle cramps caused by overexertion and dehydration in presence of high atmospheric temperatures b. Loss of sodium and water will cause cramping of skeletal muscles c. Signs and symptoms include cramps in fingers, arms, legs, abdominal muscles; weakness, dizziness; stable vital signs; moist and warm skin d. Treatment includes: remove patient from environment, administer water or sports drink, IV of normal saline (NS) if unable to take fluids orally, educate patient on heat cramps and prevention, massaging of painful muscles, application of moist towels 2. Heat Exhaustion a. Mild heat illness; acute reaction to heat exposure; most common heat illness seen in prehospital setting b. Loss of water, sodium, general vasodilation leads to decreased

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discussion Topics Review the definitions of the heat disorders.

Critical Thinking Questions Why is a rapid decrease in temperature in a patient with a fever dangerous?

Class Activities Create heat emergency scenarios and have students perform assessments and proper treatment modalities for each.

Knowledge Application Create a chart that lists the heat emergencies. Have students write the definition, signs and symptoms, and treatment for each.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline circulating blood volume, venous pooling, and reduced cardiac output c. Signs and symptoms include increased body temperature (> 100°F), cool and clammy skin with heavy perspiration, rapid and shallow breathing, weak pulse, diarrhea, muscle cramps, weakness, loss of consciousness, headache, anxiety, paresthesia, impaired judgment; psychosis in patients requires treatment as heatstroke d. Treatment includes: remove patient from environment, supine position, administer water or sports drink, IV of NS if unable to take fluids orally, remove clothing and fan patient, treat for shock 3. Heatstroke a. True environmental emergency that occurs when hypothalamic temperature regulation is lost; cell death and damage to major organs b. Core body temperature of at least 105°F c. Signs and symptoms include hot skin, cessation of sweating; high core temperature; deep respirations that become shallow; rapid at first, then slow, rapid, full pulse that may slow; hypotension; confusion; disorientation; unconsciousness; central nervous system (CNS) symptoms; seizures d. Classic heatstroke—caused by deficient thermoregulatory function e. Exertional heatstroke—good general health with increased core body temperature (CBT) due to overwhelming heat stress f. Treatment includes: remove patient from environment, initiate rapid active cooling, administer oxygen if patient hypoxic, administer fluid therapy, monitor electrocardiogram (ECG), avoid vasopressors and anticholinergic drugs, monitor body temperature F. Role of Dehydration in Heat Disorders 1. Dehydration often goes along with heat disorders 2. Signs and symptoms include nausea, vomiting, abdominal distress, vision disturbances, decreased urine output, poor skin turgor, hypovolemic shock 3. Treatment includes rehydration, oral fluids, IV if unable to take fluids

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

orally G. Fever (Pyrexia) 1. Elevation of body temperature above normal 2. Develops when pathogens enter and cause infection 3. Pyrogens—substances that can cause fever, resetting thermostat to higher level 4. Signs and symptoms include warm, diaphoretic skin; history of infection and illness 5. Treatment includes antipyretics (acetaminophen, ibuprofen) 30

VI. Cold Disorders A. Hypothermia 1. State of low body temperature (< 95°F) 2. Inadequate thermogenesis, excessive cold stress 3. Induced therapeutic hypothermia (ITH) common following cardiac arrest B. Mechanisms of Heat Conservation and Loss 1. Cold exposure triggers compensatory mechanisms that conserve heat (piloerection, shivering, increased muscle tone, peripheral vasoconstriction, increased cardiac output and respiratory rate) C. Predisposing Factors 1. Factors that increase danger of hypothermia include age, health, medications, prolonged or intense exposure, coexisting weather conditions D. Preventive Measures 1. Precautions include dressing warmly, rest, eating appropriately, limiting exposure E. Degrees of Hypothermia 1. Mild hypothermia—CBT > 90°F with signs and symptoms (tachycardia, shivering, vasoconstriction, tachypnea, fatigue, impaired judgment) 2. Moderate hypothermia—CBT between 82 and 90°F, with signs and symptoms (bradycardia, Osborne wave, hypotension, respiratory depression, altered mental status, loss of shivering) 3. Severe hypothermia—CBT < 82°F with signs and symptoms (coma, apnea, ventricular arrhythmias or asystole)

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Using pictures of frostbite, show students superficial and deep, and the difference in appearance.

Discussion Topics Discuss acute, subacute, and chronic hypothermia, and have students give examples of each.

Freeze a piece of fruit (apples work well) and cook a piece of fruit. Use these two temperature differences to show students how something can always be thawed, but you can never unheat something.

Critical Thinking Questions What can happen to your hypothermic patient when he is handled roughly?

What would happen to your hypothermic patient if given rescue medications while still hypothermic, and then warmed up?

What can prevent the onset of rewarming shock in the prehospital setting?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 4. Compensatory hypothermia may be exhibited (signs and symptoms of hypothermia with normal CBT) 5. Acute, subacute, and chronic hypothermia F. Assessment and Management of Hypothermia 1. Signs and symptoms include shivering, lethargy, dulled mentality, stiff muscles, uncoordinated and staggering gait, disorientation, confusion, stupor, coma, J waves (Osborne), atrial fibrillation, bradycardia, ventricular fibrillation 2. Treatment includes: remove wet garments, protect against further heat loss and wind, maintain horizontal position, avoid rough handling, monitor CBT, monitor ECG a. Active Rewarming i. Active external methods: warmed blankets; heat packs over axilla, groin, base of neck (use insulation between skin and hot packs); warmed IV fluids ii. Active internal methods: warmed, humidified oxygen; warmed IV fluids b. Rewarming Shock i. Rewarming shock occurs from reflex peripheral vasodilation, causing return of cool blood and acids to core of body ii. Paradoxical “afterdrop” of core temperature, worsening hypothermia c. Cold Diuresis i. Occurs from volume depletion—vasoconstriction increases blood volume and pressure, causing kidneys to remove excess fluids 3. Resuscitation a. Basic Cardiac Life Support i. Cardiopulmonary resuscitation (CPR); humidified, warmed oxygen; single shock at 360 J if V-fib present b. Advanced Life Support i. CPR; intubation; humidified, warmed oxygen; initial defibrillation attempt; active rewarming; medications are not indicated until patient is warmed 4. Transportation

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes How can you warm IV fluids in the field?

What could happen to the tissues of a patient who has frostbite if the affected area is vigorously rubbed or massaged?

Class Activities Create scenarios with the listed cold emergencies. Have students perform assessments, identify the emergencies, and treat accordingly.

Using a frozen steak, place medications on top, so students can see what will happen to the heart in a hypothermia scenario. Explain that once the steak thaws, all of the medications will be absorbed at one time.

Points to Emphasize Your hypothermic patient is not dead until he is WARM and dead.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

a. Gentle transportation; consider cardiac bypass rewarming centers G. Frostbite 1. Environmentally induced freezing of body tissue 2. Ice crystals form, destroying cells 3. Superficial and deep frostbite a. Superficial—freezing of some epidermal tissue, with redness and blanching, diminished sensation b. Deep—epidermal and subcutaneous layer; white appearance and hard to touch; loss of sensation c. Common in areas of head and face exposed to cold, along with extremities 4. Treatment includes: do not thaw if possibility of refreezing, do not massage or rub with snow, administer analgesics before thawing, transport to hospital for rewarming, cover affected area with dry and sterile dressing, elevate and immobilize, do not puncture blisters, do not rewarm frozen feet if required to walk due to hazardous situation H. Trench Foot 1. Occurs at temperatures above freezing 2. Symptoms similar to frostbite; occurs when standing in cold water over period of time 3. Treatment includes: warm, dry, aerate, and elevate feet; change wet socks; do not allow patient to sleep in wet boots or socks 30

VII. Drowning A. Process of experiencing respiratory impairment as the result of submersion or immersion in liquid B. Outcomes include mortality, morbidity, or no morbidity C. Drowning is third most frequent cause of accidental death in U.S. D. Leading cause of death in children under age 5 E. Of victims, 85% are male, and two-thirds do not know how to swim F. Drowning in hypothermic waters provides protective effect on organs and tissues G. Pathophysiology of Drowning 1. Conscious patient—initial struggle with attempted breath holding, then violent inspiratory and swallowing efforts, with water entering

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Teaching Tips Obtain an X-ray of lungs with acute respiratory distress syndrome (ARDS) and normal lungs. Compare the physical changes.

Discussion Topics Review the risk factors for drowning, as well as the measures that can prevent such occurrences.

Discuss the pathophysiology of drowning.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline mouth and stomach 2. Unconscious patient—apneic from involuntary reflex, shunting of blood to heart and brain 3. Both types of patients—apneic, PCO2 increases, PO2 falls; with hypoxia overriding sedative effects of hypercarbia, triggering patient to gasp 4. Laryngospasm and bronchospasm occur from water in mouth and throat 5. Coma results from hypoxia, with reflex swallowing continuing, filling stomach and increasing risk of vomiting and aspiration 6. Hypotension, bradycardia, and death will result shortly with no treatment 7. Water in lungs causes blocked exchange at alveolar level and washed-away surfactant 8. Surfactant—substance that allows alveoli to stay open H. Freshwater versus Saltwater Drowning 1. Prehospital treatment does not change in regard to type of water due to low volume of water that actually enters lungs I. Factors Affecting Survival 1. Cleanliness of water, length of time submerged, age and general health of patient 2. Children have greater probability of successful resuscitation and longer survival time 3. Immediate CPR is most important factor affecting survival 4. Cold or near-freezing water may initiate the mammalian diving reflex, which inhibits breathing and causes bradycardia and vasoconstriction; the colder the water, the more oxygen is diverted to the heart and brain J. Treatment for Drowning 1. Reversal of hypoxia; remove patient from water—trained rescue swimmer 2. Initiate ventilations, even if still in water 3. Position patient (do not allow blood to pool at head or feet) 4. Oxygen, ABCs, 100% oxygen, CPR, defibrillation 5. Airway suction and adjuncts; anticipate vomiting and laryngospasm 6. Cervical immobilization if suspected head and neck injury

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Critical Thinking Questions When would you not attempt revival of a drowning victim?

Out of all the factors of survivability, which one has the greatest impact in survival?

Class Activities Have students research drowning incidents in your local area.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

7. Protect from heat loss; use respiratory rewarming if transport > 15 min 8. IV, follow ACLS protocols K. Special Considerations 1. No role for compression-only CPR in drowning, as drowning causes hypoxic arrest 2. Airway management—anticipate vomiting, laryngospasm, bronchospasm; consider positive expiratory end pressure (PEEP) or continuous positive airway pressure (CPAP) 3. Heimlich maneuver—should never be done during drowning resuscitation 4. Acute respiratory distress syndrome (ARDS)—patients with respiratory symptoms (cough, foam, crackles, rhonchi); severe postresuscitation complication that causes fluid leak into alveoli 25

VIII.Diving Emergencies A. Scuba diving popular recreational sport; inexperienced divers have higher rate of injury B. Effects of Air Pressure on Gases 1. Water is an incompressible liquid 2. Density equated to pressure, which is defined as weight or force acting on a unit area (pounds per square inch) 3. Boyle’s Law—as pressure increases, gas compressed into smaller space 4. Dalton’s Law—at different altitudes, pressure of air will change 5. Henry’s Law—amount of gas dissolved in a given volume is proportional to pressure of gas above it C. Pathophysiology of Diving Emergencies 1. Gases dissolved in diver’s blood and tissues under pressure 2. As diver goes deeper, pressure increases, causing more gases to dissolve in blood (Henry’s Law); controlled ascent will allow dissolved gases to come out of blood and tissues slowly 3. Too rapid of an ascent will expand gases and form bubbles in blood, brain, spinal cord, skin, inner ear, muscles, joints D. Classification of Diving Injuries 1. Injuries on the Surface

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Review the laws regarding air pressure and gases—use a bottle of pop to demonstrate.

Critical Thinking Questions When might someone complain of symptoms similar to “the squeeze,” but not during a dive?

What medications may be ordered by medical control for patients with decompression sickness and signs of central nervous system (CNS) involvement?

Class Activities Create scenarios involving the listed diving emergencies. Have students assess, identify, and treat them accordingly.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline a. Entanglement of lines, kelp fields, injury by boats b. Cold water may cause shivering and blackout c. Diving area must be flagged 2. Injuries during Descent a. Barotrauma—injuries caused by changes in pressure; commonly called “the squeeze” b. Cannot equilibrate pressure between nasopharynx and middle ear c. Signs and symptoms include middle ear pain, ringing in ears, dizziness, hearing loss, rupture of eardrum, headache, pain beneath eyes 3. Injuries on the Bottom a. Nitrogen narcosis often called “rapture of the deep” b. Due to effect of high concentration of nitrogen on cerebral function c. Signs and symptoms include intoxicated appearance, unnecessary risk taking 4. Injuries during Ascent a. Serious and life-threatening emergencies b. Decompression sickness: the “bends”; develops with rapid reduction of air pressure while ascending to surface c. Pulmonary overpressure: results from diver holding breath during ascent; alveoli rupture, causing arterial gas embolism, pneumomediastinum, pneumothorax E. General Assessment of Diving Emergencies 1. Times at which signs and symptoms started, type of breathing apparatus used, type of hypothermia protection, depth of dive, number and duration of dive(s), any aircraft travel after dive, rate of ascent, any panic forcing ascent, experience of diver, medical diseases, functioning equipment, previous injuries, medications, alcohol F. Pressure Disorders 1. Decompression Sickness (Dysbarism) a. Results when nitrogen bubbles come out of solution in blood and tissues, causing increased pressure in various parts of

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Invite a rescue diver to come in and discuss with students the particular emergencies seen in dives

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

2.

3.

4.

5.

body b. Signs and symptoms include joint and abdominal pain, fatigue, paresthesia, CNS disturbances, rash, ataxia c. Treatment includes: oxygen (high concentration), recompression through hyperbaric chamber, IV fluids Pulmonary Overpressure Accidents a. Lung overinflation caused by rapid ascent b. Signs and symptoms include substernal chest pain, respiratory distress, diminished breath sounds c. Treatment includes: oxygen, secure airway and ventilations, observe and treat pneumothorax Arterial Gas Embolism a. Pressure buildup in lung that damages alveoli, causing air bubbles to escape into circulation b. Signs and symptoms include 2- to 10-minute onset from ascent; rapid, sharp, and tearing pain; may mimic stroke (note: any patient who presents with neurological deficits while using scuba equipment) c. Treatment includes: ABCs, 100% oxygen, supine position, corticosteroid if ordered, recompression chamber Pneumomediastinum a. Release of gas through visceral pleura into mediastinum and pericardial sac b. Signs and symptoms include substernal chest pain, irregular pulse, abnormal heart sounds, reduced blood pressure, narrow pulse pressure, change in voice, cyanosis c. Treatment includes: high-concentration oxygen, ABCs, IV, transport Nitrogen Narcosis a. Develops during deep dives; higher nitrogen concentrations result in intoxication and altered levels of consciousness, similar to effects of alcohol or narcotics b. Signs and symptoms include altered level of consciousness and impaired judgment c. Treatment includes: return to shallow depth; oxygen mixed

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

with helium during dive to avoid problem

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

G. Other Diving-Related Conditions 1. Oxygen toxicity, hyperventilation, faulty equipment, hypercapnia H. Hyperbaric Chambers 1. Emergency stabilization at closest appropriate emergency department 2. Recompression takes place after stabilization I. Divers Alert Network (DAN) 1. DAN will provide assistance with potential diving emergencies 2. Phone number: 919-684-9111 15

IX. High-Altitude Illness A. Caused by a decrease in ambient pressure; high altitude is a lowoxygen environment B. Prevention 1. Gradual ascent—allow period of acclimatization with slow, gradual ascent over days to weeks, to allow body to adjust to high altitude (ventilator changes, cardiovascular changes, blood changes) 2. Limited exertion—limit body’s need for oxygen 3. Sleeping altitude—descending to lower altitude for sleep will improve rest allow for recovery from hypoxia 4. High-carbohydrate diet—provides quick energy (controversial) 5. Medications—acetazolamide, nifedipine C. Types of High-Altitude Illness 1. Acute Mountain Sickness (AMS) a. Rapid ascent to altitude of 2,000 m or greater b. Signs and symptoms include lightheadedness, breathlessness, weakness, headache, nausea, vomiting, decreased urine output, shortness of breath, altered mental status (usually will improve within one or two days if no further ascent) c. Treatment includes: halting ascent, lowering altitude, acetazolamide, oxygen if indicated, hyperbaric chamber if necessary 2. High-Altitude Pulmonary Edema a. Increased pulmonary pressure and hypertension caused by changes in blood flow at high altitude

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Discussion Topics Review the different high-altitude emergencies, along with signs/symptoms and treatment.

Obtain a hyperbaric bag so that students can observe its use.

Critical Thinking Skills What occurs in the respiratory system, cardiac system, and blood when acclimating to higher altitudes?

Class Activities Invite a trained high-altitude rescuer to discuss high-altitude illnesses with students.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

b. Signs and symptoms include dry cough, mild shortness of breath (SOB) on exertion, slight crackles, dyspnea, cyanosis, frothy sputum, coma, death c. Treatment includes: descent, oxygen, acetazolamide, morphine, nifedipine, furosemide (used with caution) 3. High-Altitude Cerebral Edema a. Progressive neurologic deterioration in patients with altered mental status (AMS) or HAPE b. Signs and symptoms include AMS, ataxia, decreased level of consciousness (LOC), coma c. Treatment includes: descent to lower altitude, oxygen, steroids

5

X. Summary A. Extremes of environment can have significant impact on human metabolism B. Knowledge of common environmental emergencies is imperative in identifying and treating patients C. Scene safety is the first course of action with all environmental emergencies XI. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

XII. You Make the Call

Class Activities Read and discuss the call and questions as a group.

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 10 objectives can be found on text pp. 296-297.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline XIII.Review Questions

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Class Activities Pass out review questions before the lesson starts. Have students answer them. Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 11 Special Considerations in Trauma 140–160 Minutes

• • • •

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

5

5

5

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction to Shock Trauma Resuscitation A. In the mid-1960s, trauma was identified as the neglected disease of a modern society.

B. EMS has become a highly sophisticated system, yet 193,000 lives are still lost yearly to trauma C. Carefully looking at actions and care for patients will ensure optimal prehospital treatment D. Injury prevention, current practices, integration into health care setting will improve trauma care in the community III. Injury Prevention A. Best way to reduce mortality and morbidity B. EMS system must encourage and conduct prevention programs— drinking and driving, use of safety equipment, home inspection for hazards, motor vehicle safety C. Encourage behavior changes in young

Discussion Topics Review with students the various prevention programs listed in previous chapters.

Critical Thinking Questions What behaviors can you think of that can be modified to prevent injuries?

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 55

Content Outline IV. Trauma Assessment A. Identify/prioritize patient injuries and transport priority for care B. Dispatch Information 1. Nature of call, specific mechanism of injury (MOI) 2. Allows preparation for patient care 3. Prepare equipment and review assessment and care intended to be provided C. Scene Size-Up 1. Identification of hazards, Standard Precautions, MOI, environmental factors, scene oversight 2. Analysis of the Mechanism of Injury a. Re-create incident in your mind; anticipate cause, nature, and severity of injuries (index of suspicion) b. External/internal damage, impact location, use of restraints or air bags, velocity, landing surface, penetrating trauma location, weapon, distance, anatomy injured 3. Hazard Identification a. Traffic, assailants, objects on scene (glass, metal, etc.), fire, heat, explosion, electricity, chemicals, radiation, placards, bystanders b. Rule out immediately, due to risk of injury 4. Standard Precautions a. Body fluids and substances with infection potential b. Gloves, eye mask, face mask, gown as required 5. Accounting for and Locating All Patients a. Identify number of patients and their locations b. Look at number of vehicles, damage, personal articles, child seats, toys, and other clues 6. Determining Resource Needs a. Estimate number of rescuers needed b. Specialty resources (police, fire, extrication, hazmat, power company, etc.)

7. Environmental Considerations a. Weather impacts the care the rescuer can provide to the patient

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discussion Topics Create a scenario and have students prepare a mechanism of injury (MOI) analysis.

Review with students the Glasgow Coma Scale (GCS) score and the revised trauma score.

Critical Thinking Questions Why would preplanning a scene allow for improved patient care?

What prescription drugs may cause a negative impact to your trauma patient?

Class Activities Review with students the abnormal findings of the assessment. Have students work as a group to list signs and symptoms for abnormal findings, along with probable causes (this takes time, and so may be a good group project).

Have students continue to perform trauma assessments, with identification of injuries and appropriate treatment. If possible, use live adult victims and moulage.

Have students prepare a run report based on a refusal of care.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline b. Weather extremes like excessive heat or cold may give you less time at the scene to assess and care 8. Scene Oversight a. Overall incident response, special focus of assessment b. Define and assign tasks to personnel D. Primary Assessment 1. Identification of immediate patient life threats and their correction 2. General Impression a. The mechanism of injury analysis and the index of suspicion for injuries begin the development of a general patient impression b. Add the general appearance and mental status you observe during these first few minutes at the patient’s side to the patient’s mental status, airway, breathing, and circulation c. Modify your general patient impression and the care it suggests 3. Mental status—AVPU (alert, verbal stimuli, response to pain, unresponsive); alert and oriented × 3; Simplified Motor Score (SMS) 4. Spinal precautions—MOI indicates, suspicion, direct injury, decreased level of consciousness (LOC) a. Use the NEXUS criteria, the Canadian C-Spine Rule, or similar protocols 5. Airway—look, listen, feel, listen to patient talking, position airway and adjuncts, maintain airway protection, observe for airway sounds (gurgling, stridor, etc.)

6. Breathing—pulse oximetry < 96% (nonrebreather [NRB] required), symmetrical chest rise and fall, lung sounds, diaphragmatic breathing, percussion, tidal volume, respiratory rate, capnography a. Respirations are less than 10 per minute and/or the tidal volume appears less than a normal breath in the unconscious patient, consider overdrive ventilation 7. Circulation—pulse strength, regularity, rate; skin condition, capillary refill, external hemorrhage; signs of early shock

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 8. Concluding the primary assessment—modify MOI analysis based on evidence gained at scene; transport decision, CUPS format E. Secondary Assessment 1. General examination technique that is a rapid trauma assessment to either whole body or a specific body area 2. Questioning—question about any symptoms, such as discomfort, pain, tingling, numbness, weakness, and so on prior to palpation of region 3. Inspection—skin color, deformities, wounds 4. Palpation—touch for skin and muscle tone, masses, crepitus, subcutaneous emphysema, pain 5. Auscultation—quality of breath sounds, crackles, rhonchi, heart sounds a. Abdominal auscultation is not merited in trauma 6. Percussion—resonance, hyperresonance, dullness F. Rapid Trauma Assessment 1. If suspected serious injury to body, examine entire body G. Focused Trauma Assessment 1. If limited injuries, assessment directed to location of patient complaint 2. Detailed Physical Exam a. Head—deformity, asymmetry, hemorrhage, cerebrospinal fluid (CSF), pupils, drainage from eyes or ears, raccoon eyes, Battle’s sign, Le Fort fractures b. Neck—position of trachea, jugular venous distention (JVD), subcutaneous emphysema, hematomas, hemorrhage c. Chest—accessory muscle usage, chest rise and fall, redness, heart sounds, stability of ribs and sternum, subcutaneous emphysema d. Abdomen—asymmetry, pulsating masses, lap-belt injuries, guarding of quadrants or flanks, discoloration e. Pelvis—pressure on iliac crests, instability, crepitus, blood from urethral injury f. Extremities—muscle tone, pulses, temperature, color, capillary refill, motor function, sensory function, limb strength

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline g. Back—total surface of back, palpate spinal column, deformities, reddening, pain, tenderness h. DCAP-BTLS 3. Trauma Patient History a. SAMPLE history assessment b. Signs and symptoms—complaints of patient and observation of paramedic c. Allergies—any medications, especially ones used in emergency care d. Medications—prescription and nonprescription medication use e. Past medical history—any significant medical history f. Last oral intake—last fluid and solid oral intake g. Events leading up to incident—may indicate a medical problem caused by trauma h. Vital signs—pulse rate and quality, blood pressure, respiration rate and quality, skin temperature and condition H. Glasgow Coma Scale (GCS) score—determine score by recording eye opening, verbal response, and motor response I. Transport Decision 1. Made at end of primary assessment using trauma triage criteria 2. Rapid transport—specified vital signs, anatomic signs of injury or MOI per trauma triage criteria 3. Revised trauma score—numeric evaluation using GCS, respiratory rate, and systolic blood pressure 4. Treat and transport—on-scene care and transport 5. Treat and release—treatment of patient with minor injuries and release to personal physician based on protocol and medical direction 6. Patient care refusals—advise patient of all risks, involve family and medical direction, document refusal and have someone witness J. Reassessment 1. Continuously reassess at every 5 minutes in critical patient and every 15 minutes in noncritical patient 2. Components of primary assessment, vital signs, GCS, interventions, and changes

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

35

V. Shock/Multisystem Trauma Resuscitation A. Hypovolemia/Hypotension/Hypoperfusion 1. Used to describe status of cardiovascular system in trauma 2. Hypovolemia: reduced volume in cardiovascular system, caused by hemorrhage, excess fluid loss, third-space fluid loss 3. Hypotension: reduction in blood pressure caused by cardiac, vascular, neurogenic, or volume problems 4. Hypoperfusion: low or inadequate distribution of blood to body organs and tissues 5. Care includes ABCs, control of hemorrhage, fluid resuscitation, pleural decompression B. Hypothermia 1. Unappreciated complication of serious trauma and shock 2. Body’s energy and heat production decrease, increasing impact of injury and shock 3. Critical body enzymes do not function efficiently at lower body temperature, disrupting oxygen utilization and causing decreased metabolism and exacerbating acidosis 4. Care includes warmed IV fluids, blankets, rewarming C. Body Splinting 1. Must be done effectively and quickly; can be accomplished with long board D. Rapid Transport 1. Best way to reduce trauma mortality is surgery as soon as possible 2. On-scene time of no more than 10 minutes (platinum) 3. IV fluids, immobilization en route E. Fight-or-Flight Response 1. Autonomic nervous system responds with release of adrenaline and increase in heart rate, stroke volume, respiratory rate and volume, and release of glucose and insulin 2. Four critical factors directly related to preventable trauma death: controllable airway obstruction, external hemorrhage, pneumothorax, hypothermia.

F. Noncritical Patients 1. Patients who do not demonstrate the vital signs, anatomic signs, or MOI of trauma triage criteria

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes Discussion Topics Review with students the different types of resuscitation of the trauma patient.

Discuss what steps should be taken to prevent the four critical causes of trauma death: airway obstruction, external hemorrhage, pneumothorax, hypothermia.

Critical Thinking Questions Why would the fight-or-flight response hinder patient injuries from trauma?

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 2. Receive care directed at the specific injury G. Special Patients 1. Pediatric Patients a. Most likely to suffer blunt trauma, and trauma is greatest cause of death and disability after first year of life b. Auto impacts, pedestrian/bicycle collisions, falls, abuse c. Larger ratio of body surface area to volume causes loss or gain of heat from environment d. Do not show compensation of blood loss quickly; may lose up to 50% of volume before compensation fails 2. Management of the Pediatric Patient a. Same process of assessment and care, although allowances must be made for differences in pediatric anatomy 3. Pregnant Patients a. Endangers life and health of both mother and developing fetus b. Response to trauma altered in mother c. Trauma is most common cause of both maternal and fetal death 4. Physiology of the Pregnant Patient a. Blood volume of pregnant female increases, along with heart rate and cardiac output b. Inferior vena cava may be compressed by enlarged uterus and result in supine hypotension syndrome c. At third trimester, uterus is thinner and fetus is more exposed to trauma 5. Pathophysiology of the Pregnant Patient a. Fetus is at risk whenever mother at risk b. Hypovolemia, shock, or hypoxia endangers fetus before mother c. Best fetal care is to care for mother d. Seat belts reduce the incidence of premature delivery, abruptio

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Discussion Topics Have students review the pediatric anatomic differences, along with proper adaption of equipment and treatment.

Review with students the physical changes in the pregnant female.

Review with students the physical changes in the geriatric patient.

Critical Thinking Questions What are common mechanisms of trauma that the pregnant patient may experience?

What is an EMS target of prevention in the pregnant mother?

Where would you place the electrocardiogram (ECG) electrodes on an obese patient?

Class Activities Have students practice assessment and treatment of the special patient populations.

Have students discuss and practice adapting equipment for pediatric, geriatric, pregnant, and bariatric patients.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline placentae, and fetal death e. Be suspicious if you note the explanation of what happened does not fit with the injuries found, there is a series of unexplained injuries, the patient has a lowered self-image, or the domestic partner attempts to monopolize the conversation 6. Assessment of the Pregnant Patient a. Primary assessment is same as for any patient b. Ask about length of pregnancy and trimester, visualize abdomen, rotate long board to left, ensure airway is adequate, evaluate respirations, look for signs of hemorrhage c. The third-trimester pregnant patient may not display a significantly elevated pulse rate until late in the shock process d. Use CUPS to determine assessment and transport 7. Management of the Pregnant Patient a. Adequate airway, ventilation, and circulation b. Oxygen saturation of at least 96%—supplemental oxygen c. Fluid resuscitation; suspect abruptio placenta if complaints of abdominal pain and uterine bleeding H. Bariatric Patients 1. Of population, more than 25% obese, in part due to higher caloric food and sedentary lifestyle 2. Increased blood volume and cardiac output; may lead to systemic hypertension, myocardial hypertrophy arrhythmias, cardiac failure, and cardiac arrest 3. Reduced tidal volume, vital capacity, and total lung capacity 4. Obese patients’ care often complicated by multiple disease pathologies (e.g., diabetes), multiple medications 5. The obese patient’s primary assessment follows the standard primary assessment 6. Pay special attention to the thorax and pelvic ring because of the increased incidence of rib fractures, pulmonary contusions, and

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline pelvic fractures Geriatric Patients 1. The geriatric trauma patient often has coexisting problems associated with aging and chronic disease 2. Reduced cardiac reserves 3. Assessment of the geriatric patient is often difficult because the problem is often masked or confused by signs and symptoms of preexisting disease or by a diminished response to pain 4. Management of Geriatric Patient a. Initiate shock care early; use caution to not cause fluid overload b. IV, electrocardiogram (ECG), oxygen; prevent hypothermia J. Cognitively Impaired Patients 1. Special challenge due to lower IQ, difficulties in communication, atypical presentation of symptoms I.

10

VI. Interaction with Other Care Providers A. Tiered structure of care providers that interact among EMS system B. Appropriate interactions allow for good continuum of care C. Mechanism of Injury 1. Describe with enough detail to identify nature and severity of energy exchange D. Results of Assessment 1. Communicate findings of assessment, SAMPLE, vital signs, GCS, trends, treatment provided E. Interventions 1. Identify all care provided, along with patient response 2. Patient report needs to be complete and concise

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Master Teaching Notes

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 objectives can be found on text pp. 328-329.

These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 10

5

5

Content Outline VII. Air Medical Transport A. Indications for Air Medical Transport 1. Request when ground transport will exceed 45 minutes or when air medical can provide care not otherwise available 2. Rough-terrain searches 3. Expensive and not always available

Master Teaching Notes Discussion Topics Review with students the indications for air medical transport.

VIII.Research and Trauma A. Research has allowed for continued improvements in patient care over years B. Paramedics play key role in research; proper documentation allows for continued research availability IX. Summary A. Trauma is number-one killer of people under 44 years of age B. Support and injury prevention most effective way to reduce mortality and morbidity C. Anticipate and look for early signs of shock upon arrival

Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

XI. You Make the Call

Class Activities Read and discuss the call and questions as a group.

XII. Review Questions

Class Activities

X. 5

5

5

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Pass out review questions before the lesson starts. Have students answer them. Then go over the questions again after the lecture, to assess their understanding of the information.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

CHAPTER 1 Trauma and Trauma Systems

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 1-1 EVALUATION

CHAPTER 1 QUIZ Write the letter of the best answer in the space provided.

1. A physical injury or wound caused by an external force or violence is known as a: a. mechanism. c. directed injury. b. trauma. d. forceful entry.

2. Penetrating trauma refers to an injury in which a(n): a. projectile is forced through the tissue and embedded in an organ. b. object enters and exits the body, resulting in two wounds. c. object enters the body and exchanges energy directly with human tissue. d. object is impaled in the body.

3. An injury that occurs as energy and collision forces associated with an object—NOT the object itself, enters the body and damages tissue is called: a. an internal injury. c. surgical trauma. b. a closed injury. d. blunt trauma.

4. Definitive trauma care is only available at facilities with rapid access to: a. an MRI machine. b. a helicopter landing pad. c. a CT scan. d. a surgery.

5. The collection of data to identify the existence, significance, and characteristics of a disease or disease process is called: a. risk analysis. b. surveillance. c. intervention development. d. implementation.

6. A helpful tool to identify risk elements associated with trauma is the: a. trauma assessment matrix.c. Haddon matrix. b. Glasgow Coma Scale. d. risk probability matrix.

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Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

7. A medical facility that commits resources to address the MOST common trauma emergencies with surgical capability available 24 hours a day, 7 days a week, is classified as a: a. Level I trauma center. c. Level III trauma center. b. Level II trauma center. d. Level IV trauma center.

8. Neurocenters, burn centers, and pediatric trauma centers are examples of: a. Level II trauma centers. c. specialty centers. b. clinics. d. community medical centers.

9.

are standards established by your system’s medical direction to assist you in determining which patients require urgent transportation to a trauma center. a. Trauma triage criteria b. Trauma transport protocols c. Prehospital standing orders d. Trauma system triage

10. Recreating the incident from evidence available at the scene will help you determine the: a. nature of injury. c. compression factor. b. force of trauma. d. mechanism of injury.

11. The mental summation of anticipated injuries based on your event analysis is called: a. suspicion of trauma. c. mechanism index. b. index of suspicion. d. consideration of injury.

12. The purpose of the concept is to remind prehospital providers to hasten care and delivery to a trauma center. a. Platinum Period c. Golden Period b. Platinum Hour d. Golden Hour 13. The three elements of the transport decision tree are Glasgow Coma Scale, anatomy of the injury, and: a. level of responsiveness. b. vital signs. c. distance to trauma center. d. availability of air transportation.

14. The MOST cost-effective, and BEST way to reduce trauma morbidity is:

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Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

a. prevention. b. stronger laws. c. greater availability of trauma centers. d. nationwide protocols for EMS responders.

15. The health care surveillance process, put in place for trauma systems, is called the: a. criteria. c. associated statistics. b. database. d. registry.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 1-2 EVALUATION

CHAPTER 1 SCENARIO Review the following real-life situation. Then answer the questions that follow.

Lowell Medic One is dispatched to a construction site where it is met by the site safety manager. He tells the paramedics an employee has fallen off some scaffolding. When the paramedics reach the base of the scaffolding, they see a middle-aged man holding the right side of his head. The man turns and walks away from the paramedics. The safety manager shouts out his name, “George!” but the man continues to walk away. The paramedics hurry to him and, when they reach his side, ask him what has happened. He says, “I just bumped my head and I want to be left alone.” Both paramedics notice a hematoma on his forehead and believe they smell alcohol on the patient’s breath. The patient continues to refuse treatment from the paramedics but finally agrees to be transported. He is taken to the nearest hospital where he is admitted for overnight observation.

1. What other information about the mechanism of injury should the paramedics have tried to obtain from the site manager or patient?

2. What type of traumatic injury does the patient have, blunt or penetrating?

3. Do you believe the patient should be transported? Why? 4. When should stabilization occur? In the field or en route to the hospital?

Why? 5. What are at least three injuries or medical conditions that may have led to the fall or been incurred as a result of it?

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 1-3 REINFORCEMENT

CHAPTER 1 REVIEW Write the word or words that best complete the following sentences in the space(s) provided.

1. A physical injury or wound caused by external force or violence is called .

2.

is the leading killer of persons under age 44 in the United States.

3. An injury caused by an object breaking the skin and entering the body is called .

4. An injury caused by the collision of an object with the body in which the object does NOT enter the body is called .

5. Modern medicine uses a five-step approach to prevent or reduce the impact of disease. These steps are , , , , and .

6. A Level

, or , trauma center commits resources to address all types of specialty trauma 24 hours a day, 7 days a week.

7. A Level

, or , trauma center commits resources to the MOST common trauma emergencies with surgical capability available 24 hours a day, 7 days a week.

8. A Level

, or , trauma center commits resources to special emergency department training and has some surgical capability.

9. Certain medical facilities, such as neurocenters and burn centers, may be classified as centers.

10. are the guidelines to aid ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

prehospital personnel in determining which trauma patients require urgent transportation to a trauma center.

11. The force or process that causes trauma is called the .

12. The is the anticipation of injury to a body region, organ, or structure based on analysis of the mechanism of injury.

13. The current goal for incident-to-surgery is about one hour, often referred to as the Period.

14. The three components of the transport decision tree are , , and the of the injury.

15.

is the BEST, and MOST cost-effective way to reduce trauma morbidity and mortality.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 1 Answer Key Handout 1- 1: Chapter 1 Quiz 1. b

6. c

11. b

2. c

7. b

12. c

3. d

8. c

13. b

4. d

9. a

14. a

5. b

10. d

15. d

Handout 1-2: Chapter 1 Scenario 1. The height of the fall. Was it greater than 20 feet?

2. Blunt.

3. Yes; there appears to be at least the possibility of a fall greater than 20 feet; if in doubt, transport.

4. Because the patient refuses in-field treatment, the best thing to do is to provide rapid and safe transport to the hospital and hope that personnel there can convince him to accept treatment.

5. Possible injuries/conditions include intracranial bleeding, diabetes, alcohol intoxication, neck injury; possible internal injuries if the fall was greater than 20 feet.

Handout 1- 3: Chapter 1 Review 1. trauma 2. Trauma 3. penetrating trauma 4. blunt trauma 5. surveillance, risk analysis, intervention development, implementation, evaluation 6. I, regional 7. II, area 8. III, community 9. specialty 10. Trauma triage criteria 11. mechanism of injury ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

12. index of suspicion 13. Golden 14. Glasgow Coma Scale, vital signs, anatomy 15. Prevention

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

CHAPTER 2 Mechanism of Injury

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 2-1 EVALUATION

CHAPTER 2 QUIZ 1 Write the letter of the best answer in the space provided.

1. The study of the processes that bring forces to bear upon the human body is called: a.

conservation of energy.

c.

kinetics of impact.

b.

inertia.

d.

kinematics.

2. The two basic principles of kinetics are the laws of energy conservation and . a.

inertia.

c.

velocity.

b.

motion.

d.

energy.

3. The law of energy conservation states that neither be created or destroyed. a.

inertia

b.

energy

c.

momentum

d.

motion

can

4. The formula “mass multiplied by velocity squared, divided by two” equals: a.

acceleration.

c.

deceleration.

b.

force.

d.

kinetic energy.

5. When significant kinetic energy is applied to human anatomy, it is called: a.

trauma.

c.

mass.

b.

velocity.

d.

force.

6. When the kinetic energy force, but NOT the object, enters the body and damages tissues, the result is called: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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7.

a.

penetrating trauma.

c.

exsanguination.

b.

blunt trauma.

d.

internal trauma.

injury occurs as blunt impact abruptly halts a portion of the body while inertia causes the remaining anatomy to continue its motion. a.

Stretching

b.

Shearing

c.

Compression

d.

Open

8. When a vehicle occupant strikes the vehicle’s interior, it is called a(n): a.

vehicle collision.

c.

secondary collision.

b.

body collision.

d.

additional collision.

9. Which of the following is TRUE regarding the use of seat belts?

10.

a.

Because of the security of the ambulance patient compartment, it is not necessary for EMS personnel to wear seat belts while caring for the patient.

b.

Lap belts alone will effectively restrain the torso, neck, and head.

c.

In very strong impacts, a shoulder strap may induce chest contusions and rib fractures.

d.

The combination of seat belt and shoulder strap protects the occupant against intrusions into the passenger compartment.

Which of the following is TRUE regarding air bags? a.

Child carriers should be secured in the back seat because air bag inflation may push the carrier into the seat with tremendous force causing serious injury or death to the child.

b.

Air bags, overall, have had little affect in reducing injury and death in vehicular crashes.

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11.

c.

If an air bag has deployed, there is no need to check the steering wheel for deformity.

d.

The air bag must be triggered by the driver to deploy.

The frontal impact is the MOST common type of impact in motor vehicle crashes. One of the pathways of patient travel during a frontal impact is: a.

around-and-through.

c.

through-and-out.

b.

down-and-under.

d.

up-and-out.

12. An injury process frequently associated with steering column impact is the “paper bag” syndrome in which the:

13.

a.

driver yells just before impact, and the impact with the steering wheel presses all of the residual air from the lungs.

b.

driver “gulps” air into the stomach, and the stomach ruptures when the abdomen impacts the steering wheel.

c.

driver takes a deep breath in anticipation of the collision, and lung tissue ruptures when the chest impacts the steering wheel.

d.

car seat breaks loose and comes forward, crushing the patient between the seat and the steering wheel much like an inflated paper bag caught between clapping hands.

Your patient was involved in a frontal impact collision when his car hit a tree. He was ejected from the vehicle. An important point to remember when assessing this patient is that: a.

the ejection was the result of the down-and-under pathway.

b.

ejected victims experience two impacts.

c.

older cars may have “crumple zones,” which allow energy to pass easily to the vehicle interior from the point of impact.

d.

because of advanced vehicle design, ejection is responsible for very few vehicular fatalities.

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14.

15.

16.

17.

Rear-impact collisions usually result in limited injuries, especially if the: a.

head rest is positioned properly.

b.

airbags deploy immediately at the time of impact.

c.

both a shoulder and lap seatbelt are worn.

d.

combined speed of the two vehicles involved is not significant.

An important point to remember when analyzing vehicle crashes is that: a.

alcohol intoxication is not present in most serious crashes.

b.

head trauma accounts for a small number of deaths in vehicle crashes.

c.

spider-webbing of the windshield sometimes indicates window frame alteration during impact rather than occupant contact.

d.

you should stay focused on analyzing the mechanisms of injury, not on the cause of the crash.

Which of the following is TRUE regarding motorcycle crashes? a.

Helmets have greatly reduced the incidence of spinal trauma.

b.

“Laying the bike down” results in the bike absorbing much of the energy.

c.

Actual ejection during a motorcycle crash is uncommon.

d.

Leather clothing and boots protect the rider against fractures and dislocations.

When responding to a vehicle versus pedestrian collision, remember that: a.

adults tend to turn away from the oncoming vehicle, whereas children turn toward it.

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18.

19.

20.

b.

because of their lower centers of gravity, children are often thrown onto the hood and into the windshield.

c.

adults are frequently thrown in front of vehicles, and then run over by them.

d.

children will usually be hit by the vehicle first in the leg.

The MOST lethal explosions are those: a.

causing structural collapses.

b.

in confined spaces.

c.

involving volatile chemicals.

d.

creating a blast wind.

The MOST common and serious trauma associated with explosions is: a.

head injury.

c.

lung injury.

b.

abdominal injury.

d.

airway blockage.

Cardiac arrhythmias and kidney damage can occur with crush injuries due to: a.

hypotension.

b.

decreased cardiac output.

c.

buildup of toxins in the crushed limb.

d.

increased capillary pressure in the crushed limb.

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HANDOUT 2-2 EVALUATION

CHAPTER 2 QUIZ 2 Write the letter of the best answer in the space provided.

1.

The relationship between mass and velocity explains why: a. very small and relatively light bullets have a potential to do great harm. b. if you double the speed of an object, its kinetic energy also doubles. c. handguns and shotguns are considered low-energy/low-velocity weapons. d.

a high-energy rifle bullet’s kinetic energy is the same as that of a medium-energy handgun bullet.

2. The formation of a shock wave and subsequent cavity within a semifluid medium is called: a. trajectory.

c. cavitation.

b. drag.

d. expansion.

3. A bullet’s profile is the: a. diameter of a bullet expressed in hundredths of an inch. b. portion of the bullet you would see if you looked at it as it traveled straight at you. c. swing or wobble around the axis of a projectile’s travel. d. path a projectile follows.

4. Which of the following is TRUE regarding bullets? a. Handgun bullets generally deform significantly on impact with soft tissue. b. Most military ammunition seldom deforms solely with soft-tissue collision. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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c. Some bullets are designed to mushroom on impact, decreasing their profile and energy exchange rate. d. Some firearm projectiles fragment, which decreases their profile and damage potential.

5. Knives and arrows are objects that: a. cause low-energy/low-velocity wounds. b. are considered medium-velocity projectiles. c. produce pressure shock waves and cavitation just as bullets do. d. generally cause little internal damage.

6. One of the three factors associated with the results inflicted by the damage pathway of a projectile wound is: a. indirect injury. b. secondary impact. c. creation of a temporary cavity. d. fragmentation.

7. The damage done as a projectile strikes tissue, contuses and tears that tissue, and pushes the tissue out of its way is called: a. the pressure shock wave.

c. cavitation.

b. direct injury.

d. zone of injury.

8. Tissue cells in front of bullets are pushed forward and to the side.

They, in turn, push adjacent cells forward and outward. This is known as: a. the pressure shock wave.

c. cavitation.

b. direct injury.

d. zone of injury.

9. Damage caused by low-velocity objects: a. can create a pressure shock wave. b. is usually restricted to tissue the object actually contacts. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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c. may include creation of a “blown-out” appearing exit wound. d. is usually very obvious by the size of the entrance wound.

10. Hollow organs are muscular containers holding fluid. When considering a penetrating injury to a hollow organ, remember that: a. if the container is filled with fluid at the time of impact, the energy can tear the organ apart explosively. b. if the container is filled with fluid at the time of impact, the energy is dispersed in the fluid, and little damage is done to the organ. c. a penetrating wound to the heart may result in pericardial tamponade, which results in a sudden release of blood into the thorax. d. if a hollow organ holds air, the air compresses with the passage of the pressure, resulting in explosive tissue damage and hemorrhage.

11. The extent of damage that a penetrating projectile causes varies with the particular type of tissue it encounters. One important point to remember about tissues in relation to penetrating wounds is that: a. solid organs have the resiliency of muscle and other connective tissues. b. muscles, the skin, and other connective tissues are thin, delicate tissues. c. when muscle tissue is penetrated, the wound track closes and serious injury is limited. d. penetrating injury to lung tissue is generally less extensive than can be expected with any other body tissue.

12. When caring for a patient with a penetrating injury to the abdomen, keep in mind that: a. the area is well protected by skeletal structures. b. the passage of a projectile through the abdominal cavity produces little cavitational wave. c. the bowel is very tolerant of compression and stretching. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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d. if the small or large bowel is perforated by a penetrating injury, serious peritoneal irritation may result, with signs and symptoms developing almost immediately.

13. The appearance of the entrance wound caused by a bullet: a. is always the size of the bullet’s profile. b. will often have a “blown-out” look. c. may indicate signs of subcutaneous emphysema if the shot was fired at very close range. d. may accurately reflect the potential for damage caused by the bullet’s passage.

14. When arriving at the scene of a shooting or stabbing, your FIRST priority is: a. the patient’s airway. b. your safety. c. removing any weapons from the patient’s reach. d. the preservation of evidence.

15. Your patient has been shot in the chest with a handgun. Care would include all of the following EXCEPT: a. high-concentration oxygen by nonrebreather mask. b. sealing the wound with an occlusive dressing secured on all four sides. c. consideration of needle decompression for tension pneumothorax. d. preparation for endotracheal intubation if breathing becomes inadequate.

16. You should consider removing impaled objects in: a. the head.

c. the abdomen.

b. the cheek.

d. an extremity.

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HANDOUT 2-3 EVALUATION

CHAPTER 2 SCENARIO 1 Review the following real-life situation. Then answer the questions that follow.

Medic 3 responds to a motor vehicle collision at a busy intersection. The paramedics are met by a police officer who tells them, “It looks like a real nasty T-bone crash.” The paramedics notice two vehicles. One is a small sports car, which appears to have struck the driver’s side of an older station wagon. The front end of the sports car is heavily damaged. The station wagon’s door is caved in.

The paramedics see that the driver of the sports car is slumped over the steering wheel. The driver of the station wagon is sitting motionless. One paramedic assesses the driver of the sports car and finds an unconscious patient with respirations of 30 and a pulse of 130. The other paramedic checks on the driver of the station wagon and finds the patient is conscious and complaining of slight chest pain. His respirations are 12 and his pulse is 98. A Basic Life Support unit arrives. Both patients are extricated from their vehicles.

The patient from the sports car is immobilized and intubated, and two large-bore IVs are established. The patient is then transported to the trauma center where, following emergency department evaluation, he is sent to the operating room.

Later, he is admitted to the intensive care unit.

Against the paramedics’ advice, the patient from the station wagon refuses transportation. However, a couple of hours later he arrives at the emergency department by private vehicle. At this time, his blood pressure is 80/60, his pulse is 160, and his respiratory rate is 32. He is rushed into the operating room for surgical repair to his aortic arch. After a period of hospitalization, he recovers.

1.

What types of auto impacts are present in this scenario?

2.

Besides the obvious vehicle deformity to both cars, what other indicator would it have been helpful to know?

3.

Based on the mechanism of injury and physical findings of the patient taken from the sports car, when should the IVs have been started?

4.

List five types of traumatic injuries you might expect to find in the patient taken from the sports car.

5.

List at least five types of traumatic injuries you might expect to find in the patient taken from the station wagon.

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HANDOUT 2-4 EVALUATION

CHAPTER 2 SCENARIO 2 Review the following real-life situation. Then answer the questions that follow.

The emergency medical dispatch center sends Medic 7 to the Wilson High School parking lot. As the unit arrives, a police officer directs the paramedics to a far corner of the lot where, she tells them, a student has just been stabbed. As paramedics approach, they see a young male lying prone on the asphalt near a pickup truck. He yells, “I know who did this, and I’m going to get him!” There is blood seeping through the patient’s shirt. The paramedics notice the blood is coming from the patient’s left posterior chest. The paramedics cut away the patient’s shirt and see a small round wound near the spine at approximately T-4.

1. At this point in the scenario, what question should the paramedics ask to determine the mechanism of injury?

Next, the paramedics place the patient on a long backboard. They decide to provide care en route to the hospital. While en route, the patient tells the paramedics he was stabbed with an ice pick.

2. Was this a high-velocity or low-velocity wound?

3. If the ice pick were still in the patient’s back, should the paramedics remove it? Why or why not?

4. If the patient’s injury had been caused by a bullet, what sort of signs might the paramedics have seen near the site of the wound?

5. Was the paramedics’ decision to transport the patient rather than provide field treatment the correct choice?

6. What types of injuries might the patient have sustained?

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HANDOUT 2-5 REINFORCEMENT

CHAPTER 2 REVIEW 1 Write the word or words that best complete the following sentences in the space(s) provided.

1.

trauma to the head is the MOST common cause of trauma death related to vehicle collisions.

2.

is the branch of physics that deals with objects in motion, and energy exchanges that occur.

3.

The tendency of an object to remain at rest or remain in motion unless acted on by an external force is called .

4.

The energy of motion is transformed into heat

5.

The

energy

an

object

has

6.

while it energy.

. is

in

motion

is

called

is the rate of motion in a particular direction in relation to time.

7. describes the actual injury process.

8.

injury occurs as blunt impact abruptly halts a portion of the body while inertia causes the remaining anatomy to continue in motion.

9.

Injuries that occur along edges of the impacting force or at organ attachments are called injuries.

10.

Analysis of the impact types and the events associated with vehicle collisions help you arrive at a(n) .

11. The five types of vehicle impacts are , , and

.

12. The five events of vehicle collision are collision,

collision,

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, ,

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collisions,

collision, and

carriers when a

in the passenger

impacts.

13. Parents

should

secure

child seat

system is in place.

14. Mechanisms associated with frontal impacts include —and—

pathway, pathway,

—and— pathway,

and

.

15. The pathway accounts for a large proportion of unrestrained passenger vehicular deaths.

16. The syndrome results from compression of the chest against the steering column.

17. While ejection from a vehicle may occur with other types of impact, it is MOST commonly associated with impact and the vehicle occupant.

18. The region of a vehicle designed to absorb the energy of impact is called the .

19. Lateral impacts account for only of all auto collisions, yet they are responsible for a percentage of vehicular fatalities.

20.

Rear-impact collisions usually result in limited injuries, especially if the is positioned properly.

21. The four major types of motorcycle impacts are , and .

22. In

pedestrian

versus

children tend to turn 23.

and

,

,

automobile crashes, adults tend to turn from the oncoming vehicle, whereas it. are added risks with personal watercraft use.

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24.

Trauma resulting from a fall is dependent on the .

25.

A severe fall occurs when an adult falls more than child falls more than feet.

and the feet, and a small

26. Explosions create several mechanisms of injury including a(n) , , , of persons near the blast, and .

27. The three blast injury phases are , and

, .

28.

injuries are the MOST common lifethreatening trauma associated with explosions.

29.

are well-prepared allied health professionals who are a valuable resource when responding to an athletic field injury requiring patient transport.

30. With severe and prolonged crush injury entrapment, prehospital care may include the administration of and other mediations.

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HANDOUT 2-6 REINFORCEMENT

CHAPTER 2 REVIEW 2 Write the word or words that best complete the following sentences in the space(s) provided. bullet’s kinetic energy is three to nine times that of a bullet.

1. A high-energy medium-energy

2. The law of explains why a projectile’s kinetic energy is transformed into damage as it slows.

3. The path a projectile follows is its

.

4. When a bullet travels through air, it meets wind resistance, or

.

5 The formation of a shock wave and subsequent cavity within a semifluid medium is called .

6. The is the portion of the bullet you would see if you looked at it as it traveled straight toward you.

7. The expressed in hundredths of an inch.

8.

of a bullet is its diameter is the swing or wobble around the

axis of a projectile’s travel.

9. The

location

of

a

bullet’s

center .

of

mass

affects

its

10. Projectiles also may increase their profile and their by deforming when they strike a medium that is denser than air.

11. Bullet deformity caused by body armor may increase the rate, but the reduction in bullet and lost overall injury potential.

exchange reduce

12. Knives, swords, arrows, and other slow-moving penetrating objects cause -velocity, -energy wounds.

13. When the tip of a bullet impacts tissue, it pushes the tissue the along the pathway of its travel. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

and to

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14.

is the damage done as a penetrating object strikes tissue, and that tissue, and pushes it out of the way.

15. When a high-velocity high-energy projectile strikes human tissue, it creates a .

16. Hemorrhage associated with projectile damage to a severe.

is often

17. The filling of the pericardial sac with fluid is called pericardial 18. The organs.

19.

.

is the largest body cavity and contains MOST of the internal can absorb much of the cavitational energy while sustaining injury itself.

20. Since the pressure wave that causes cavitation moves forward and outward, the exit wound may have a appearance.

21.

is the surgical incision to provide an emergency airway, and perforate the membrane between the thyroid and cricoid cartilages.

22. Seal open chest wounds with a(n) dressing.

23. Remove only impaled objects that are lodged in the that interfere with the airway.

24. Penetrating injuries, especially those associated with a high mortality.

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,

, or

wounds, carry

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HANDOUT 2-7 REINFORCEMENT

BLUNT TRAUMA LISTS 1.

List the events of a vehicle collision and give a brief definition of each.

2.

List the types of vehicle impact and give a brief definition of each.

3.

List the four pathway mechanisms associated with frontal impacts.

4.

List the six mechanisms associated with blasts.

5.

List the three blast injury phases.

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HANDOUT 2-8 REINFORCEMENT

PENETRATING TRAUMA TRUE OR FALSE Indicate whether the following statements are true or false by writing T or F in the space provided.

1.

Wounds from handguns are just as lethal as those from rifles.

2.

Bullets follow a curved path once fired from a gun.

3.

To prevent tumbling, bullets are sent spinning through the air by the gun barrel’s rifling.

4.

When bullets mushroom, their profile, energy exchange rate, and damage potential increase.

5.

Handguns and weapons.

rifles

are

considered

medium-velocity

6. The damage caused by high-energy bullets rarely extends beyond the actual track of the projectile.

7.

Low-velocity projectiles do NOT produce either a pressure shock wave or cavitation.

8.

The pressure shock wave is the damage done as the projectile strikes tissue, contuses and tears that tissue, and pushes the tissue out of its way.

9.

Damage caused by low-velocity wounds is limited to the object’s path of travel.

10. Muscles, the skin, and other connective tissues are dense, elastic, and very well held together.

11.

Solid organs have the same density and resiliency as muscle.

12.

Penetrating injury to lung tissue is generally less extensive than can be expected with any other body tissue.

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13.

The passage of a projectile through the abdominal cavity does NOT produce a significant cavitational wave.

14.

Impaled objects in the chest should be removed and an occlusive dressing applied.

15.

Entrance wounds will often have a “blown-out” appearance.

16.

If you arrive at the scene of a shooting or stabbing before law enforcement, make every effort to secure the scene.

17.

The presence of frothy blood from a gunshot wound to the chest may indicate a developing tension pneumothorax.

18.

Seal open chest wounds with a moist, sterile dressing.

19.

An impaled object may obstruct blood vessels, thereby restricting blood loss.

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Chapter 2 Answer Key Handout 2-1: Chapter 2 Quiz 1 1. c

6. b

11. b

16. b

2. a

7. c

12. c

17. a

3. b

8. b

13. b

18. a

4. d

9. c

14. a

19. c

5. a

10. a

15. c

20. c

Handout 2-2: Chapter 2 Quiz 2 1. a

5. a

9. b

13. c

2. c

6. c

10. a

14. b

3. b

7. b

11. d

15. b

4. b

8. a

12. c

16. b

Handout 2-3: Chapter 2 Scenario 1 1. Frontal and lateral.

2. Knowing the approximate speed of the sports car when it struck the station wagon would be useful because impacts at speeds greater than 20 miles per hour are significant mechanisms of injury.

3. Because the vehicle deformity indicated the likelihood of severe internal trauma, initiation of the IVs should have been attempted en route.

4. Possible injuries include myocardial contusion, flail chest, aortic tear, pneumothorax, and cervical spine injury. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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5. Expected injuries might include cervical spine injury; internal head injuries; clavicle, pelvis, and femur fractures; diaphragmatic rupture; and aortic tear.

Handout 2-4: Chapter 2 Scenario 2 1. “What caused the wound?”

2. Low-velocity.

3. Except in the case of an object lodged in a cheek, impaled objects should not be removed because removal may cause further injury.

4. Residue from the blast, powder burns (tattooing), abrasions from muzzle exhaust.

5. Yes. Penetrating wounds either anterior or posterior have a high mortality rate. Remember the Golden Period.

6. Possibilities include spinal cord injury, pulmonary contusion, pneumothorax, pericardial tamponade, hemothorax.

Handout 2-5: Chapter 2 Review 1 1. Blunt 2. Kinetics 3. inertia 4. energy 5. kinetic 6. Velocity 7. Biomechanics of trauma 8. Compression 9. shear 10. index of suspicion 11. vehicle, body, organ, secondary, additional 12. vehicle, body, organ, secondary, additional 13. back, air bag ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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14. restrained, up-and-over, down-and-under, ejection 15. up-and-over 16. paper bag 17. frontal, unrestrained 18. crumple zone 19. 1/4, higher 20. head rest 21. frontal, angular, sliding, ejection 22. away, toward 23. drowning, hypothermia 24. contact area, energy transmission pathway 25. 20, 10 26. pressure wave, blast wind, projectiles, displacement, heat 27. primary, secondary, tertiary 28. Lung 29. Athletic trainers 30. sodium bicarbonate

Handout 2-6: Chapter 2 Review 2 1. rifle, handgun 2. conservation of energy 3. trajectory 4. drag ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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5. cavitation 6. profile 7. caliber 8. Yaw 9. stability 10. energy exchange rate 11. energy, velocity, kinetic energy 12. low, low 13. forward, side 14. Direct injury, contuses, tears 15. pressure wave 16. solid organ 17. tamponade 18. abdomen 19. Lung tissue, limited 20. blown-out 21. Cricothyrotomy 22. occlusive 23. cheek, neck, trachea 24. gunshot

Handout 2-7: Blunt Trauma Lists 1. Vehicle collision—auto strikes an object; body collision—vehicle occupant strikes the vehicle’s interior; organ collision—tissues behind contacting surface collide as the body halts; secondary collisions—vehicle occupant ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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impacted by objects within auto; additional impacts—vehicle receives a second impact.

2. FRONTAL - mechanisms associated with frontal impact include the restrained pathway, up-and-over pathway, down-and-under pathway and ejection LATERAL - occupants present a different profile (turned 90 degrees) to the collision forces, the physical space and amount of structural steel between the impact site and the vehicle interior (the crumple zone) is also greatly reduced OBLIQUE - the auto is struck at an angle rather than directly to the front, side, or rear REAR END - the collision force pushes the auto forward. Within the vehicle, the energy of the collision propels the occupant forward ROLLOVER - as the vehicle rolls, it impacts the ground at various points, and the occupant experiences a collision with each vehicle impact

3. restrained pathway, ejection

up-and-over pathway,

down-and-under pathway,

4. pressure wave, blast wind, projectiles, personnel displacement, confined spaces and structural collapses, burns 5. primary, secondary, tertiary

Handout 2-8: Penetrating Trauma True or False 1. F 2. T 3. T 4. T 5. F

6. F 7. T 8. F 9. T 10. T

11. F 12. T 13. F 14. F 15. F

16. F 17. T 18. F 19. T

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Chapter 3 Hemorrhage and Shock

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HANDOUT 3-1 EVALUATION

CHAPTER 3 QUIZ Write the letter of the best answer in the space provided.

1. The population MOST at risk for trauma and trauma death is the: a. young adult female. c. infant. b. young adult male. d. elderly.

2. The sympathetic nervous system is the division of the autonomic nervous system that: a. controls vegetative functions. c. increases heart rate. b. regulates sleeping patterns. d. regulates the digestive system.

3. Stroke volume is predicated by: a. preload, afterload, and blood pressure. b. preload, afterload, and cardiac contractility. c. preload, afterload, and end diastolic pressure. d. preload, afterload, and heart rate.

4. Starling’s law of the heart is: a. the conduction of electrical stimuli causing the heart to contract. b. the process by which arteries contract or dilate, depending on the needs of cells for oxygenated blood and waste product removal. c. the process by which an increase in cardiac output occurs in proportion to the diastolic stretch of the heart muscle fibers. d. the process by which arteries contract in response to a drop in blood pressure caused, for example, by severe hemorrhage.

5. Blood volume moved by the heart in one minute is referred to as: a. minute volume. b. stroke volume. c. cardiac output. d. end diastolic volume.

6. The vascular system consists of three types of vessels. Which of the following statements is TRUE regarding arteries? a. Arteries are relatively large, normally twice the size of veins. b. Arteries carry only oxygenated blood. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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c. Arteries carry blood from the heart to the body tissues. d. Arteries contain about 64 percent of the total blood volume.

7. The layer of an artery that controls the vessel lumen size is the: a. tunica adventitia. c. tunica arteriole. b. tunica media. d. tunica intima.

8. The vessels that are only one cell thick, and allow efficient gas and metabolic substrate movement into and out of the interstitial space are called: a. arterioles. c. venules. b. capillaries. d. veins.

9. The blood vessels that are called the “capacitance system” are the: a. veins. c. capillaries. b. arteries. d. arterioles.

10. The molecule in the blood to which oxygen attaches is: a. cytoplasm. c. hemoglobin. b. serotonin. d. globulin.

11. Platelets are: a. important for clotting and blood vessel repair. b. one of the red blood cells. c. one of the fragments of cytoplasm that circulates in the blood. d. iron-based cells that bind with oxygen.

12. Venous bleeding is usually: a. bright red and spurting in nature. c. oozing and quick clotting. b. dark red and flowing. d. dark red, forming droplets on the skin.

13. The step in the clotting process in which the smooth blood vessel muscle contracts, reducing the vessel lumen, is called the: a. platelet phase. c. coagulation phase. b. vascular phase. d. aggregate phase.

14. The network of fibers that stick together, form a strong protein mesh, and entrap red blood cells, to form a stronger, more durable clot is: a. platelets. c. fibrin. b. hemoglobin. d. plasma.

15. One of the factors that can hinder the clotting process is: a. immobilization. c. fever. b. dehydration. d. medications such as aspirin. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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16. The first step used to control external bleeding is: a. a tourniquet. c. direct pressure. b. pulse pressure points. d. elevation.

17. If a decision is made to use a tourniquet to stop external hemorrhage, an important point to remember is that: a. the accumulation of lactic acid, potassium, and anaerobic metabolites can occur with tourniquet use. b. the tourniquet should be released every 10 minutes to maintain circulation. c. you should use a thin or narrow constricting device to avoid tissue damage. d. you should apply the tourniquet properly so that arterial blood flow remains intact.

18. Recent evidence suggests that may NOT be as good an injury severity predictor as once thought. a. a decrease in blood pressure c. the patient’s capillary refill time b. the mechanism of injury d. unconsciousness 19. Patients with epistaxis should be placed: a. with their feet elevated to compensate for decreased blood pressure. b. in a supine position. c. in the recovery position. d. in a prone position.

20. Your patient has lost approximately 20 percent of his total blood volume. He is anxious, restless, and has cool, clammy skin. In which stage of hemorrhage is he? a. Stage 1 c. Stage 3 b. Stage 2 d. Stage 4 21. During Stage 2 hemorrhage, the patient’s pulse pressure will: a. remain constant. b. be noticeably narrower. c. be noticeably wider. d. widen briefly, but return to normal.

22. The blood volume of an infant or young child is proportionally: a. about 20 percent greater than that of an adult. b. about 20 percent less than that of an adult. c. about the same as that of an adult. d. variable from 10 to 20 percent less than that of an adult. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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23. A patient with a tension pneumothorax is in what type of shock? a. Hypovolemic shock b. Respiratory shock c. Obstructive shock d. Cardiogenic shock

24. The ultimate killer of all trauma victims is: a. penetrating trauma. b. cerebral hypoxia. c. blood loss. d. shock.

25. When ventilating a patient each breath should move a tidal volume of mL. a. 250 c. 750 b. 500 d. 1000 26. The measure of peripheral vascular resistance is the: a. pulse pressure. b. systolic blood pressure. c. diastolic blood pressure. d. mean arterial pressure.

27. Precapillary sphincters dilate and permit blood flow through capillaries during times of low oxygen and carbon dioxide build up in the cells because of the release of which chemical? a. Histamine b. Epinephrine c. Dopamine d. Antihistamine 28. Cutaneous vasoconstriction in the shock victim contributes to: A. precapillary sphincter constriction. c. hypothermia. b. bronchoconstriction. d. organ vasodilation.

29. Toxin release that adversely affects the vascular system’s ability to control blood vessels results in: a. neurogenic shock. b. septic shock. c. positive dromotropy. d. sensitization.

30. Once in irreversible shock, if aggressive resusitation restores the pulse and blood pressure: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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a. the body can regain homeostasis. b. hypoxia will resolve over days. c. death still occurs. d. peripheral vasodilation will stave off hypothermia.

31. A precipitous drop in blood pressure signals which stage of shock? a. Initial c. Decompensated b. Compensated d. Irreversible

32. Which of the following medical conditions will NOT cause a patient to experience distributive shock? a. Cardiac tamponade c. Sepsis b. Anaphylaxis d. All of the above can cause distributive shock 33. Tension pneumothorax and pulmonary emboli can cause which type of shock? a. Cardiogenic c. Respiratory b. Obstructive d. Distributive 34. Cardiogenic shock: a. is rarely fatal. b. has a high mortality rate. c. is due to increased cardiac output. d. is most often caused by trauma.

35. High-concentration oxygen as needed should be applied to assure an oxygen saturation of at least: a. 100 percent. c.

96 percent. b. 90 percent. d.

85 percent.

36. Normal expiratory CO2 levels in the head-injured patient who is intubated, should NOT drop below: a. 45 mmHg. c.

35 mmHg. b. 40 mmHg. d.

30 mmHg. 37. When establishing patient priorities, using the CUPS acronym, the “P” stands for: a. possibly unresponsive. c. potentially unstable. b. permanent damage. d. priority transport.

38. When a normovolemic patient is placed in the supine position, the jugular veins should be: a. flat. c. partially distended. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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b. fully distended.

d.

bulging.

39. Pericardial tamponade presents with distended jugular veins, tachycardia, hypotension, and: a. muffled heart tones. c. irregular heart tones. b. amplified heart tones. d. bounding heart tones.

40. If you suspect a pelvic fracture in your patient, you should: a. compress the pelvis lateral to medial, and anterior to posterior to confirm a fracture. b. rock the pelvis to confirm a fracture. c. ask the patient to raise each leg independently to confirm a fracture. d. not compress or otherwise manipulate the pelvis.

41. If a patient’s blood pressure decreases when he is moved from a supine to a seated position, he is said to have: a. postural vitals. c. orthostatic hypotension. b. supine hypotension. d. a “negative” tilt test.

42. Reassessment of the trauma patient should occur every minutes for the critical, unstable or potentially unstable patient, and every minutes for the stable patient. a. 10, 20 c.

15, 5 b. 20, 10 d.

5, 15 43. When using a blood pressure cuff as a tourniquet, you should place the cuff: a. distal to the hemorrhage and inflate to 20 to 30 mmHg above the systolic blood pressure. b. proximal to the hemorrhage and inflate to 20 to 30 mmHg above the systolic blood pressure. c. distal to the hemorrhage and inflate to 30 to 40 mmHg above the systolic blood pressure. d. proximal to the hemorrhage and inflate to 30 to 40 mmHg above the systolic blood pressure.

44. One of the reasons that the use of whole blood or packed red blood cells is impractical in the field is the: a. inability to gain a patient’s consent for use. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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b. short shelf life. c. type of tubing required for administration of blood. d. inability to carry enough blood volume to be effective.

45. Which of the following statements is TRUE regarding the use of the PASG? a. Inflation of the PASG returns about 1 liter of blood to the central circulation. b. The PASG has been found not to increase peripheral vascular resistance. c. Inflation of the PASG reduces venous capacitance by as much as 1 liter. d. Inflation of the PASG pressurizes the abdominal cavity and may reduce chest excursion.

46. Pharmacological intervention in patients in hypovolemic shock: a. is generally limited. b. should include dopamine along with a fluid challenge. c. should occur as soon as IV lines are placed. d. should be given through an IV line of normal saline, not lactated Ringer’s solution.

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HANDOUT 3-2 EVALUATION

CHAPTER 3 SCENARIO Review the following real-life situation. Then answer the questions that follow.

Late on Thursday night, Medic 6 is returning to quarters after transporting a patient with chest pain to the hospital. It has been raining heavily and the roads are very slick. Wendi, the driver, has slowed and is proceeding cautiously along a twisty stretch of Kuna Road when Mark, her partner, yells, “Slow down!”

Up ahead, a stretch of guardrail is missing at a point where the land falls away sharply toward a creek. Wendi turns on the warning flashers and pulls to a stop.

Mark gets out and reports that a car has gone off the road.

The vehicle did not get very far. It hit a large oak just beyond the guardrail and is badly damaged. Wendi notifies dispatch, while Mark gathers the gear.

After a scene size-up, the crew decides it is safe to approach the car. Once there, they find only one person, a male about 25 years old who appears to have been ejected when the car door flew open on impact. He is unconscious, with difficulty breathing.

Wendi maintains cervical spinal immobilization, while Mark completes the primary assessment. He discovers an airway partially obstructed with blood and teeth. The airway is suctioned and secured. The rest of the initial assessment reveals the following: respirations, 44 and labored; no radial pulse but a carotid pulse rate of 132; capillary refill time of 4 seconds; responsive only to pain; a large laceration on the patient’s forehead; skin turgor is good, skin is pale, cool, diaphoretic. The patient’s weight is estimated to be 175 pounds.

1. What immediate problems should the crew suspect with this patient?

2. What should their next actions be?

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HANDOUT 3-3 REINFORCEMENT

CHAPTER 3 REVIEW Write the word or words that best complete the following sentences in the space(s) provided.

1. The loss of blood from the vascular space is called .

2. The circulatory system has three basic components: the , and the .

3. The rate through

, the

nervous system slows heart nerve stimulation.

4. The heart rate through

nervous system increases stimulation.

5. The stroke volume is predicated on three factors: , and .

6. from the heart, whereas toward the heart.

,

are vessels that carry blood away carry blood

7. The is the blood vessel in which oxygen is diffused into the body tissue and products of metabolism enter the bloodstream.

8. The three phases of the clotting process are the phase, the phase, and .

9.

are strong protein fibers that form a durable clot.

10. The first step to control external bleeding is by applying firm on the wound.

11. During the absence of perfusion, , metabolites accumulate in the stagnant blood.

12.

, and other

may NOT be as good an injury severity predictor as was once thought.

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13. Bleeding from the nose is called

.

14. During stage 2 hemorrhage, pulse pressure begins to strength .

, and pulse

15. Infants and young children have a blood volume about 20 percent than an adult.

16. Tension pneumothorax is a type of 17. A

shock.

cut in a blood vessel causes the vessel to open.

18. One of the earliest signs of shock is a rising 19.

and as shock sets in.

are catecholamines released by the body

20. In a Class 2 hemorrhage the patient has lost circulating blood volume.

21. A

.

to

percent of their

in blood pressure is a sign of decompensated shock.

22. Cardiogenic shock may present with the signs and symptoms of or .

23. The CUPS acronym, used to establish patient priorities, stands for: , , , or .

24. In a supine, normovolemic patient, the jugular veins should be .

25. If a patient becomes dizzy or has a syncopal episode when moving from a supine to a sitting or standing position, that is known as a positive .

26. Stable trauma patients should be reassessed every minutes, and unstable or potentially unstable patients should be reassessed every minutes.

27. When using a blood pressure cuff as a tourniquet, it should be inflated to a pressure to mmHg greater than the blood pressure.

28. Using blood in the field is impractical because it has a(n) and is .

29. Inflating the abdominal compartment of the PASG can reduce . ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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HANDOUT 3-4 REINFORCEMENT

SHOCK MATCHING Write the letter of the term in the space provided next to the appropriate description. a. Hemorrhage k. Homeostasis b. Shock l. Stroke volume c. Preload m. Tranexamic acid d. Frank-Starling mechanism n. Afterload e. Tunica media o. Tunica adventitia f. Clotting p. Aggregate g. Fibrin q. Anaerobic h. Epistaxis r. Hematoma i. Coagulopathy s. Erythropoietin j. Ischemia t. Thready 1. The middle, muscular layer of the blood vessels that controls lumen size.

2.

Bleeding from the nose resulting from injury, disease, or environmental factors.

3.

Resistance a contraction of the heart must overcome in order to eject blood.

4.

An abnormal internal or external discharge of blood.

5.

Protein fibers that trap red blood cells as part of the clotting process.

6.

Able to live without oxygen.

7.

Outer fibrous layer of the blood vessels.

8.

The amount of blood ejected by the heart in one cardiac contraction.

9.

The body’s response to stop the loss of blood.

10.

A state of inadequate tissue perfusion.

11.

To cluster or come together.

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12.

An increase in cardiac output in proportion to the diastolic stretch of the heart.

13.

A protein that spurs production of red blood cells in the bone marrow.

14.

The pressure within the ventricles at the end of diastole.

15.

A blockage in the delivery of oxygenated blood to the cells.

16.

The tendency of the body to maintain a steady, normal internal environment.

17.

A condition in which the blood’s ability to clot is impaired.

18.

The drug that appears to play a beneficial role in the management of trauma and hemorrhagic shock.

19.

Blood accumulation in the interstitial spaces, resulting in a contusion or being forced between tissue layers (fascia) forming a pocket of blood.

20.

A weak pulse.

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Chapter 3 Answer Key Handout 3-1: Chapter 3 Quiz 1. b

13. b

24. d

35. c

2. c

14. c

25. b

36. d

3. b

15. d

26. d

37. c

4. c

16. c

27. a

38. b

5. c

17. a

28. c

39. a

6. c

18. b

29. b

40. d

7. b

19. c

30. c

41. c

8. b

20. b

31. c

42. d

9. a

21. b

32. a

43. b

10. c

22. a

33. b

44. b

11. a

23. c

34. b

45. d

12. b

46. a

Handout 3-2: Chapter 3 Scenario 1. Immediate problems to be dealt with include airway compromise, shock, and cardiorespiratory collapse.

2. The crew should act to maintain ABCs, provide positive-pressure ventilation with 100 percent oxygen, provide full spinal immobilization, and provide rapid transport to a trauma center. En route, they can initiate large-bore IVs with NS or LR run wide open.

Handout 3-3: Chapter 3 Review 1. hemorrhage 2. heart, blood vessels, blood 3. parasympathetic, vagus 4. sympathetic, vasomotor center 5. preload, cardiac contractility, afterload 6. Arteries, veins 7. capillary ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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8. vascular, platelet, coagulation 9. Fibrin 10. direct pressure 11. lactic acid, potassium, anaerobic 12. Mechanism of injury 13. epistaxis 14. narrow, diminishes 15. greater 16. obstructive 17. longitudinal 18. diastolic blood pressure 19. Epinephrine, norepinephrine 20. 15, 30 21. precipitous drop 22. myocardial infarction, pulmonary edema 23. critical, unstable, potentially unstable, stable 24. fully distended 25. tilt test 26. 15, 5 27. 20, 30, systolic 28. short, costly 29. chest excursion Handout 3-4: Shock Matching 1. e

6. q

11. p

16. k

2. h

7. o

12. d

17. i

3. n

8. l

13. s

18. m

4. a

9. f

14. c

19. r

5. g

10. b

15. j

20. t

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Chapter 8 Abdominal and Pelvic Trauma

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HANDOUT 8-1 EVALUATION

CHAPTER 8 QUIZ Write the letter of the best answer in the space provided.

1. The abdominal cavity is bound superiorly by the: a. ribs. c. diaphragm. b. pelvis. d. back muscles.

2. The division of the abdominal cavity containing organs or portions of organs covered by the peritoneum is called the: a. peritoneal space. c. pelvic space. b. retroperitoneal space. d. endoperitoneal space.

3. The left upper abdominal quadrant contains: A. the gallbladder. c. the spleen. b. most of the liver. d. portions of the urinary bladder.

4. The small bowel is composed of the: a. colon, rectum, and anus. b. duodenum, jejunum, and ileum. c. stomach, colon, and duodenum. d. waste products of digestion eliminated through the anus.

5. The largest organ in the abdomen is the: a. liver. c. spleen. b. stomach. d. uterus.

6. Accessory organs in the digestive system include the: a. stomach. c. small bowel. b. pancreas. d. rectum.

7. The organ responsible for detoxifying the blood, removing damaged erythrocytes, and storing glycogen is the: a. liver. c. pancreas. b. gallbladder. d. spleen.

8. An abdominal organ that is NOT an accessory organ of digestion, but a part of the immune system is the: a. gallbladder. c. pancreas. b. liver. d. spleen.

9. The dynamics of pregnancy greatly affect the anatomy of the female abdominal cavity. An example is the fact that: a. during the first and second trimesters, there is little change in the size of the uterus and little displacement of the other abdominal organs. b. by 32 weeks the uterus fills the abdominal cavity to the level of the lower rib margin. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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c. during the last trimester, intraabdominal pressure increases and tidal volume decreases. d. by the third trimester, circulatory volume and cardiac output both rise by about 20 percent.

10. The abdominal vasculature consists of all of the following EXCEPT the: a. abdominal aorta. c. superior vena cava. b. iliac arteries. d. femoral arteries.

11. The fine fibrous tissue surrounding the interior of MOST of the abdominal cavity and covering MOST of the small bowel and some of the abdominal organs is called the: a. mesentery. c. duodenum. b. retroperitoneum. d. peritoneum.

12. When considering the pathophysiology of abdominal injury, remember that: a. the abdomen is bound by muscles rather than skeletal structures. b. the majority of penetrating abdominal injuries affect the large bowel. c. blunt trauma to the abdomen produces the most visible signs of injury. d. blast injuries involve only blunt trauma caused by the pressure wave generated by the explosion.

13. Hollow organs may rupture with compression from blunt forces, especially is the organ is full and distended. Hollow organs include the: a. spleen. c. pancreas. b. kidneys. d. gallbladder.

14. Which of the following is TRUE regarding the liver? a. It is a retroperitoneal organ. b. It is not as firm as the spleen and pancreas. c. It is restrained from forward motion by the ligamentum teres. d. It is the second-largest single organ within the abdomen, being smaller than the stomach.

15. Peritonitis is: a. the release of bowel contents into the abdomen. b. inflammation of the peritoneum. c. evisceration of the peritoneum. d. protective tensing of abdominal muscles as a result of pain.

16. The number one killer of pregnant females is: a. toxicity. c. complications of pregnancy. b. trauma. d. infection.

17. Detachment of the placenta from the uterine wall during pregnancy is called: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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a. abruptio placentae. c. placenta prolapse. b. placenta previa. d. placenta premature.

18. Children compensate very well for blood loss and do NOT show any signs or symptoms until they have lost over of their blood volume. a. one third c. two thirds b. one half d. three quarters 19. During your initial assessment of a patient with an abdominal injury, remember: a. that level of consciousness and orientation are not reliable indicators of the patient’s condition. b. to ask the patient to move from a supine position to a seated or standing position to assess for dizziness or lightheadedness. c. that limited chest movement may be a result of the pain of peritonitis or blood irritating the diaphragm. d. that rapid, shallow respirations, diminished pulse pressure, and a rapid pulse are all late signs of shock not often seen in the prehospital setting.

20. The principles of managing the abdominal injury patient include: a. placing the patient in the prone position for relief of pain. b. anticipating shock based only on the mechanism of injury. c. controlling all external bleeding prior to transport. d. initiating a large-bore IV line with 5 percent dextrose in water.

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HANDOUT 8-2 EVALUATION

CHAPTER 8 SCENARIO Review the following real-life situation. Then answer the questions that follow.

“My boyfriend’s been cut in his stomach by a knife! We need an ambulance!” The dispatcher attempts to calm the excited caller, then dispatches law enforcement and Medic 12, with paramedics Rachel and Damon, to the parking lot of a local tavern known as a “bikers’ bar.” The ambulance is advised to proceed with caution until the scene is secured by law enforcement. As the paramedics arrive, they see three police cars on scene. An officer motions for the ambulance to proceed in and directs the paramedics to a large motorcycle.

Lying across the seat of the motorcycle is an adult male, in obvious distress, holding a bloody leather jacket over his abdomen.

1.

What should Rachel and Damon do next?

The patient removes his jacket. The paramedics see protruding bowel.

2.

What is the name of this kind of penetrating injury? What are the paramedics’ immediate concerns? What is the MOST common protruding viscera?

3.

How should Rachel and Damon conduct an assessment of this patient?

During the assessment, the patient tries to push the bowel back through the wound.

4.

How should the paramedics manage this patient? Should they replace the bowel? Should they use the PASG?

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HANDOUT 8-3 REINFORCEMENT

CHAPTER 8 REVIEW Write the word or words that best complete the following sentences in the space(s) provided.

1.

The abdominal cavity is divided into three spaces. The division containing those organs or portions of organs covered by the peritoneum is called the space.

2.

The division containing those organs posterior to the peritoneal lining is called the space.

3.

The division containing those organs located within the pelvis is the space.

4.

The abdomen is divided into four subregions by vertical and horizontal lines. The gallbladder, MOST of the liver, and a small portion of the pancreas are located in the quadrant.

5.

The stomach, spleen, MOST of the pancreas, and transverse and descending colon are located in the quadrant.

6.

The appendix, and portions of the ascending colon, rectum, and female genitalia are located in the quadrant.

7.

The sigmoid colon and portions of the urinary bladder, small bowel, descending colon, and rectum are located in the quadrant.

8.

The is the internal passageway that begins at the mouth and ends at the anus.

9.

The , of the small intestine.

10. The

, and

is the largest organ in the abdomen.

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11. The three accessory organs to the digestive system are the , , and the .

12. By 32 weeks and until the end of the pregnancy, the uterus fills the abdominal cavity to the level of the margin.

13. The abdominal aorta bifurcates into two large arteries.

14. Many abdominal organs are covered by a serous membrane called the .

15. The double fold of peritoneum that prevents the digestive tract from tangling is called the .

16. The abdomen is bound by than

rather structures.

17. 40 percent of penetrating abdominal trauma affects the .

18.

trauma to the abdomen produces the LEAST visible signs of injury.

19. Blunt trauma causes trauma through three mechanisms: , , and .

20. With trauma to the abdomen, the discoloration of and noticeable require several hours to develop.

21. The liver, spleen, pancreas, and kidneys are considered organs, whereas the stomach and bowels are considered organs.

22. Liver injury often presents with pain in the upper right as blood accumulates against the diaphragm.

23. Inflammation of the peritoneum is called . ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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24.

is the protective tensing of the anterior abdominal muscles as a result of pain.

25. Trauma is the number one killer of females.

26. Premature separation of the placenta from the uterine wall is known as .

27. Children compensate well for blood loss and may NOT show any signs or symptoms until they have lost over of their blood volume.

28. For the patient who has sustained abdominal injury, the analysis of the

is the MOST important element of the scene size-up.

29. Any decrease in the level of orientation or consciousness should alert you to the need to maintain a for abdominal injury.

30. Grey-Turner’s sign is the discoloration of the

region.

31. Each abdominal quadrant should be palpated individually, leaving any quadrant with anticipated injury or patient complaint of pain for .

32. Blood loss in a pregnant patient can exceed percent before the normal signs and symptoms of hypovolemia reveal themselves.

33. Prehospital IV infusion is usually limited to

mL of fluid.

34. Titrate your administration rate of IV fluids to maintain a systolic blood pressure of .

35. Place the late-term mother, when possible, in the

position.

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Student’s Name

HANDOUT 8-4 REINFORCEMENT

ABDOMINAL TRAUMA MATCHING Write the letter of the term in the space provided next to the appropriate description. a. Peritoneal space b. Retroperitoneal space c. Pelvic space d. Digestive tract e. Flank pain f. Evisceration g. Liver h. Pancreas i. Spleen j. Gallbladder k. Right upper quadrant l. Inferior vena cava m. Peritoneum n. Mesentery o. Peritonitis p. Guarding q. Abruptio placentae r. Left upper quadrant s. Right lower quadrant t. Hematuria ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

A penetrating abdominal injury that causes part of the abdominal contents to protrude through the wound.

The fine, fibrous tissue surrounding the interior of MOST of the abdominal cavity and covering MOST of the small bowel and some of the abdominal organs.

Inflammation of the peritoneum.

A condition in which the placenta separates from the uterine wall.

Division of the abdominal cavity containing those organs posterior to the peritoneal lining.

Renal injury may cause blood in the urine as well as .

Structure that restrains and prevents the digestive tract from tangling.

A part of the immune system; the organ that performs some immunological functions and stores a large volume of blood.

Division of the abdominal cavity containing those organs located within the pelvis.

Internal passageway that begins at the mouth and ends at the anus.

The abdominal quadrant that contains the gallbladder, right kidney, MOST of the liver, some small bowel, a portion of the ascending and transverse colon, and a small portion of the pancreas.

The division of the abdominal cavity containing those organs or portions of organs covered by the peritoneum.

The small hollow organ that receives bile from the liver and stores it until it is needed.

Blood in the urine.

Protective tensing of the abdominal muscles by a patient suffering abdominal pain.

The abdominal quadrant that contains the stomach, spleen, left kidney, MOST of the pancreas, and a portion of the liver, small bowel, and transverse and descending colon.

The accessory organ of the digestive system responsible for detoxifying the blood, removing damaged or aged erythrocytes, and storing glycogen.

The accessory organ of the digestive system responsible for the production of glucagon and insulin.

Located along the spinal column, it collects venous blood from the lower extremities and the abdomen, returning it to the heart.

The abdominal quadrant that contains the appendix, and portions of the urinary bladder, small bowel, ascending colon, rectum, and female genitalia.

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Chapter 8 Answer Key Handout 8-1: Chapter 8 Quiz 1. c

6. b

11. d

16. b

2. a

7. a

12. a

17. a

3. c

8. d

13. d

18. b

4. b

9. b

14. c

19. c

5. a

10. c

15. b

20. b

Handout 8-2: Chapter 8 Scenario 1. Determine the mechanism of injury and extent of injury by asking the patient to remove the jacket. (Depending on the circumstances, it may still be a good idea to have the police stay close by to ensure that the scene remains safe.)

2. This type of injury is an evisceration. The paramedics should be concerned about shock, occluded blood supply to the bowel, and bowel contamination.

The small bowel is the most common protruding viscera.

3. Though the mechanism of injury may appear obvious, Rachel or Damon should confirm the mechanism of injury by questioning the patient and bystanders. However, this patient needs surgery. The patient should be prepared for immediate transport. With any abdominal trauma, paramedics should suspect cervical spine injury. The patient should be immobilized, and the paramedics should perform a rapid initial assessment. A rapid trauma assessment should then be performed.

4. As mentioned previously, this patient needs definitive surgical care. The paramedics should administer 100 percent oxygen by nonrebreather mask.

The bowel should not be replaced. The open wound should be covered with a wet sterile dressing, then an occlusive dressing. The patient’s hands may need to be restrained to prevent them from manipulating the bowel. While en route, the paramedics should insert two large-bore IVs. The use of the PASG is controversial for eviscerations. The paramedics should consult medical direction, which may advise them to inflate only the leg sections.

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Handout 8-3: Chapter 8 Review 1. peritoneal 2. retroperitoneal 3. pelvic 4. right upper 5. left upper 6. right lower 7. left lower 8. digestive tract 9. Duodenum, jejunum, and ileum 10. liver 11. liver, gallbladder, pancreas 12. lower rib 13. iliac 14. peritoneum 15. mesentery 16. muscles, skeletal 17. liver 18. Blunt 19. deceleration, compression, shear 20. ecchymosis, swelling 21. solid, hollow 22. shoulder 23. peritonitis ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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24. Guarding 25. pregnant 26. abruptio placentae 27. half 28. mechanism of injury 29. higher index of suspicion 30. flank 31. last 32. 30 33. 3,000 34. 80 mmHg 35. left lateral recumbent

Handout 8-4: Abdominal Trauma Matching 1. f 2. m 3. o 4. q 5. b 6. e 7. n 8. i 9. c 10. d ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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11. k 12. a 13. j 14. t 15. p 16. r 17. g 18. h 19. l 20. S

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Chapter 9 Orthopedic Trauma

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Student’s Name

HANDOUT 9-1 SKILLS

FIXATION SPLINTING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently SKILL/BEHAVIOR 1. Takes Standard Precautions.

2. Assesses pulse, temperature, color, sensation, and capillary refill of distal extremity.

3. Protects open wounds.

4. Directs application of manipulation/manual stabilization.

5. Prepares splint.

6. Applies splint.

7. Immobilizes joint above and below the fracture site.

8. Secures entire injured extremity.

9. Reassesses pulse, temperature, color, sensation, and capillary refill.

Comments:

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Student’s Name

HANDOUT 9-2 SKILLS

TRACTION SPLINTING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently SKILL/BEHAVIOR 1. Takes Standard Precautions.

2. Assesses pulse, temperature, color, sensation, and capillary refill of distal extremity.

3. Applies ankle hitch device.

4. Directs manual manipulation/stabilization of injured leg.

5. Directs application of manual traction.

6. Prepares and adjusts splint to proper length.

7. Positions splint at injured leg.

8. Applies securing device.

9. Applies mechanical traction.

10. Positions and secures supporting straps.

11. Reassesses pulse, temperature, color, sensation, and capillary refill of distal extremity.

12. Immobilizes hip joint on long board.

13. Secures splint on long board.

Comments:

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Student’s Name

HANDOUT 9-3 EVALUATION

CHAPTER 9 QUIZ Write the letter of the best answer in the space provided.

1. Functions of the skeleton include: a. temperature regulation. b. storage of salts and other materials for metabolism. c. production of white blood cells. d. protection from pathogens and debris.

2. Small perforations of the long bones through which the blood vessels and nerves travel into the bone itself are called: a. perforating canals. c. haversian canals. b. diaphysis. d. osteoclasts.

3. The end of a long bone, including the growth plate and supporting structures underlying the joint, is called the: a. cancellous. c. metaphysis. b. epiphyseal. d. epiphysis.

4. The cavity within a bone that contains the yellow marrow is called the: a. periosteum. c. epiphyseal. b. haversian canal. d. medullary canal.

5. Cartilage is the tissue that: a. provides the articular surfaces of the skeletal system. b. is responsible for the production of erythrocytes. c. stores fat in semiliquid form within the internal cavities of a bone. d. forms in a tendon.

6. Joints that do NOT permit movement are called: a. synovials. c. synarthroses. b. amphiarthroses. d. diarthroses.

7. Examples of a triaxial joint include: a. the hip and shoulder. c. the carpal bones of the wrist. b. the bases of the thumbs. d. the knees and elbows.

8. The joint that allows articulation between the atlas and the axis of the spine is called a(n): a. pivot joint. c. condyloid joint. b. hinge joint. d. ellipsoidal joint.

9. The hip and shoulder are examples of: a. pivot joints. c. ball-and-socket joints. b. hinge joints. d. saddle joints.

10. Connective tissue that connects bone to bone and holds joints together is called a: a. tendon. c. joint. b. ligament. d. bursa.

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11. Bones of the head, thorax, and spine are known as the: a. appendicular skeleton. c. axial skeleton. b. peripheral skeleton. d. central skeleton.

12. The single bone of the proximal upper extremity is the: a. femur. c. ulna.

B. humerus.

D. radius.

13. The phalanges are found in the: a. foot. c. skull. b. hand. d. both a. and b.

14. The bone on the thumb side of the forearm is called the: a. humerus. c. radius. b. ulna. d. olecranon.

15. You would find the innominates and the ischial tuberosities in the: a. foot. c. pelvis. b. hand. d. skull.

16. The attachment of a muscle to a bone that moves when the muscle contracts is called the: a. opposition. c. origin. b. insertion. d. fasciculus.

17. Specialized bands of connective tissue that attach muscle to bone at the insertion are known as: a. tendons. c. ligaments. b. joints. d. bursae.

18. Severe trauma that crushes muscles between a blunt force and the skeletal structure beneath, resulting in damage to both the muscle cells and the blood vessels that supply them, is called: a. a muscle strain. c. contusion. b. compartment syndrome. d. concussion.

19. A painful muscle tissue spasm is called a: a. sprain. c. cramp. b. strain. d. fatigue.

20. Grade I, Grade II, and Grade III are used to classify types of: a. fractures. c. sprains. b. strains. d. dislocations.

21. The complete displacement of a bone end from its position in a joint capsule is called a: a. fracture. c. subluxation. b. strain. d. dislocation.

22. A fracture in which a bone is broken into several pieces is known as a(n): a. transverse fracture. c. oblique fracture. b. comminuted fracture. d. fatigue fracture.

23. A break in a bone involving a twisting motion may result in a(n): a. spiral fracture. c. comminuted fracture. b. oblique fracture. d. stress fracture. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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24. Greenstick fractures are usually found in: a. elderly patients. b. patients with chronic medical conditions. c. pediatric patients. d. patients with bleeding disorders, such as hemophilia.

25. Accelerated bone tissue degeneration due to bone mineral loss, is called: a. osteogenesis. c. osteoporosis. b. osteomyelitis. d. osteoarthritis.

26. Pathological fractures result from: a. calcium deficiency. c. genetic conditions. b. onset of menopause. d. cancer.

27. Which of the following does NOT impair the healing process? a. Smoking c. NSAIDS b. Diabetes d. Pregnancy 28. A disruption in the bone-healing process to a degree that two broken bone ends do not rejoin is called: a. a nonunion. c. osteoarthritis. b. a refracture. d. collagen interruption.

29. Internal bleeding from a femoral fracture may result in as much as of blood loss. a. 250 mL c. 1,000 mL b. 500 mL d. 1,500 mL 30. The “six Ps” in evaluating a limb injury include: A. position. c. passivity. b. pallor. d. prognosis.

31. Evaluate the distal extremity for: a. pulse. c. sensation. b. color. d. all of the above.

32. A complication of musculoskeletal injury is compartment syndrome, caused by: a. air trapped in the muscle tissue of the chest wall resulting from a crushing injury. b. bleeding into, or edema within, a muscle mass surrounded by fasciae that do not stretch. c. a comminuted fracture causing multiple internal bleeding sites from sharp bone fragments. d. absence of blood supply, resulting in a buildup of carbon dioxide and waste products in the cells.

33. Immobilization of a sprained ligament results in: a. reduced strain. c. compartment syndrome. b. muscle atrophy. d. neurologic dysfunction.

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34. Generally, you should NOT attempt to align dislocations or fractures within inches of a joint. a. two b. three c. five d. six 35. Guidelines for immobilizing a skeletal injury include: a. immobilizing the bone above and the bone below the injury. b. immobilizing the joint above and the joint below the injury. c. application of traction to the injury prior to immobilization. d. all of the above.

36. It is necessary to check pulses, motor function, and sensation in the distal extremity: a. prior to splinting. c. during splinting. b. after splinting. d. all of the above.

37. Traction splints are applied to injuries to the: a. humerus. c. tibia/fibula. b. femur. d. cervical spine.

38.The MOST frequently fractured bone in the body is the: a. femur. c. clavicle. b. humerus. d. tibia.

39. A fractured humerus is BEST immobilized using a: a. cardboard splint. c. sling and swathe. b. traction splint. d. vacuum splint.

40. A posterior hip dislocation will present with the foot: a. rotated internally c. rotated externally. b. flexed. d. extended.

41. The BEST choice for immobilizing a possible ankle dislocation injury involving a deformity is a(n): a. traction splint. c. elastic bandage. b. padded board splint. d. pillow.

42.When splinting a hand or wrist injury, you should place a roll of bandaging or other material in the patient’s hand to maintain: a. position of rotation. c. position of movement. b. position of function. d. position of curvature.

43. A medication that can be used to premedicate a patient prior to reduction of a dislocation is: a. diazepam. c. oxygen. b. flumazenil. d. atropine.

44.The RICE procedure for strains, sprains, and soft-tissue injuries includes: a. reposition. c. cold. b. ice. d. examination. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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STUDENT’S NAME

HANDOUT 9-4 EVALUATION

CHAPTER 9 SCENARIO Review the following real-life situation. Then answer the questions that follow.

Nathan rounds first base on the way to second. He knows he will need to run faster if he is to beat the throw from the center fielder to second. He runs a little harder and decides to slide into second. As he begins his slide, the cleat in his right shoe digs into the earth and his right ankle suddenly twists. He feels intense pain, but he is safe at second base.

Paramedics George and Elizabeth are on standby at the Placerville Little League baseball game. They both saw Nathan twist his ankle and now see him sitting down, unable to move. The umpire calls time-out and motions for the paramedics to come onto the field to assess Nathan. You and your partner grab the stretcher and several different splints and head toward Nathan.

1. What types of musculoskeletal injuries could Nathan have sustained?

2. What are three types of splints you might bring to manage Nathan’s injury?

You arrive to find Nathan clutching his right ankle. You complete your initial assessment.

3. What steps would you take to perform a musculoskeletal assessment of a lower extremity?

You note that Nathan’s foot has good distal pulses and sensation, but there is swelling, some deformity, and warmth to the medial ankle.

4. What steps would you take to manage Nathan’s injury?

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Student’s Name

HANDOUT 9-5 REINFORCEMENT

CHAPTER 9 REVIEW Write the word or words that best complete the following sentences in the space(s) provided.

1. The single greatest cause of musculoskeletal injuries is/are .

2. Functions of the skeleton include giving the body form, protecting , allowing for efficient , storage of and other materials for metabolism, and the production of blood cells.

3. The small perforations of the long bones through which the blood vessels and nerves travel into the bone itself are called canals.

4. A(n) is a cell that helps in the creation of new bone during growth and bone repair.

5. The

is the central portion or shaft of a long bone.

6. The

is the growth zone of a bone.

7. The tissue within the internal cavity of a bone responsible for the manufacture of erythrocytes is the .

8.

are immovable joints; are joints that allow some very limited movement; and , or , joints permit relatively free movement.

9. The three types of diarthroses are the , and

, .

10. Movement of a body part toward the midline is called Movement of a body part away from the midline is called .

.

11. The connective tissue that connects bone to bone is a(n) .

12. Joints are lubricated by

fluid.

13. The axial skeleton consists of the , , and . The appendicular skeleton consists of the bones of the , , and pelvis (excepting the sacrum).

14. The bone of the proximal upper extremity is the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

, and

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the bones of the forearm are the .

15. The bones of the wrist are the palm are the the .

and

bones, the bones of the , and the bones of the fingers and toes are

16. The large bone of the proximal lower extremity is the 17. The bones of the lower leg are the .

. and the

18. The pairing of muscles that permits extension and flexion of limbs is called .

19. The types of muscular injuries are contusion, syndrome, injury, muscle , muscle .

20. Muscle performance.

, muscle , and muscle

occurs as the muscles reach their limit of

21. A minor and incomplete capsule tear is called a Grade sprain; a significant but incomplete tear is a Grade complete tear is a Grade .

;a

22. The complete displacement of a bone end from its position in a joint capsule is called a(n) .

23. A broken bone in which the bone ends or the forces that caused the fracture do NOT penetrate the skin is called a(n) fracture. A broken bone in which the bone ends or the forces that caused it penetrate the surrounding skin is called a(n) fracture.

24. A fracture in which the bone is broken into several pieces is a(n) fracture.

25. Softening of bone tissue as a result of loss of essential minerals, especially calcium, is known as .

26. A partial fracture of a child’s bone is known as a(n) fracture.

27. A pathological fractures result from or cancer of the bone.

pathologies, such as tumors

28. The healing process can be impaired by conditions such as , or poor health, and and drugs.

29. Each femur fracture may account for as much as ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

,

mL of blood loss.

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30. The “six Ps” in evaluating limb injury are , , , and 31. Evaluate the distal extremity for , 32.

, , . ,

,

, and

refill.

syndrome results from bleeding into, or edema within, a muscle mass surrounded by fasciae that do NOT stretch.

33. Do NOT attempt alignment of dislocations and serious injuries within inches of a joint.

34. When splinting a fracture, immobilize the joint the injury site.

35. Rigid splints require adequate 36. A(n) feet.

and

to lessen patient discomfort.

splint can be used with injuries to the ankles and

37. Begin fracture care by ensuring distal .

38. Kinetic forces necessary to fracture the are likely to produce fractures and

,

, and

are significant and injuries elsewhere.

39. A traction splint is indicated for a patient with an isolated femur fracture that does NOT have concurrent serious , , , or injuries.

40. The

is the MOST frequently fractured bone in the human body.

41. The MOST common hip dislocation is a with the knee and foot rotated

dislocation and presents .

42. When immobilizing the forearm, wrist, hand, or fingers, a wad of dressing material should be placed in the patient’s hand to maintain position of .

43. Medications frequently administered to patients with musculoskeletal injury to relieve pain and to premedicate before relocation of a dislocation include , , and .

44. The acronym RICE, used by athletic trainers, stands for , and .

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,

,

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Student’s Name

HANDOUT 9-6 REINFORCEMENT

MUSCULOSKELETAL TRUE OR FALSE Indicate whether the following statements are true or false by writing T or F in the space provided.

1. A dislocation is a displacement of bones from a joint.

2. The chance of blood vessel damage is much greater with longbone fractures than with injuries to the joint.

3. Pelvic fractures, though painful, seldom result in loss of circulation to the lower extremities.

4. A hip fracture will sometimes present with a lateral rotation of the foot and knee.

5. Fractures of the humerus, pelvis, and femur seldom contribute to hypovolemia.

6. Dislocations of the knee are only rarely accompanied by fractures at the same injury site.

7. Treat any fracture within 3 inches of the knee as you would a dislocation.

8. The fibula is more likely to fracture than the tibia in cases of lowerleg fracture.

9. With an unstable trauma patient, all fractures should be splinted prior to transport.

10. If distal pulses are absent because of a fractured elbow, gently attempt to manipulate the limb to see if a pulse returns.

11. Compartment syndrome occurs MOST often in hip dislocations.

12. You should immobilize a hand injury in the position of comfort.

13. A greenstick fracture disrupts only one side of a long bone.

14. Knee dislocations normally present with the knee at an angle and firmly fixed in place.

15. An anterior shoulder displacement presents with a prominent shoulder and with the arm close to the chest.

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Student’s Name

HANDOUT 9-7 REINFORCEMENT

MUSCULOSKELETAL MATCHING Write the letter of the term in the space provided next to the appropriate description. a. Abduction

k. Insertion

b. Adduction

l. Ligament

c. Articulate

m.Metaphysis

d. Cancellous bone

n. Origin

e. Cartilage

o. Periosteum

f. Diaphysis

p. Pronation

g. Dislocation

q. Subluxation

h. Epiphysis

r. Supination

i. Fracture

s. Synovial

j. Haversian canal

t. Tendon

1.

To join together and permit motion.

2.

Band of connective tissue that attaches muscle to bone.

3.

Having to do with, or relating to, the lubrication of the joint.

4.

Turning of the palm or foot downward.

5.

Displacement of a bone or other structure from its normal anatomical position.

6.

Incomplete dislocation of a joint.

7.

Movement of a body part or extremity toward the midline.

8.

Growth zone of the bone.

9.

Movement of a body part or extremity away from the midline.

10.

Ends of the long bone, including the growth plate.

11.

Turning the palm or foot upward.

12.

Disruption of the bone process.

13.

Hollow shaft of the long bone.

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14. Connective tissue providing the articular surfaces of the skeletal system.

15.

Connective tissue connecting bone to bone.

16.

Tough, hard covering of bone.

17. Spongy bone tissue found at the distal and proximal ends of the long bones.

18. Attachment of a muscle to the bone that does NOT move when the muscle contracts.

19. Attachment of a muscle to the bone that moves when the muscle contracts.

20. Small perforation of the long bone through which blood vessels and nerves travel into the bone.

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Chapter 9 Answer Key Handout 9-3: Chapter 9 Quiz 1. b

15. c

29. d

43. b

2. c

16. b

30. b

44. b

3. d

17. a

31. d

4. d

18. c

32. b

5. a

19. c

33. a

6. c

20. c

34. b

7. a

21. d

35. d

8. a

22. b

36. d

9. c

23. a

37. b

10. b

24. c

38. c

11. c

25. c

39. c

12. b

26. d

40. a

13. d

27. d

41. d

14. c

28. a

42. b

Handout 9-4: Chapter 9 Scenario 1. Possible injuries include ankle sprain, dislocation, tibial and fibular fracture, knee dislocation/fracture, and foot/ankle fracture.

2. Types of splints include full-leg air splint, pillow splint, and vacuum splint.

3. Put on disposable gloves. Gently expose the injury site. Avoid manipulation of the injury site. Look for deformity, discoloration, or other signs of injury.

Question the patient about pain and the ability to move. Palpate for instability, deformity, crepitation. Feel for unusual warmth or coolness over the entire lateral and medial surfaces, then the anterior and posterior surfaces. Assess for presence or absence of distal pedal pulses bilaterally. Check skin for blanching. Evaluate sensation distal to injury site.

4. Administer oxygen, if needed. Apply either a vacuum, air, or pillow splint.

Check for distal pulses, motor function, and sensation before and after the splinting. Apply cold packs to the injury site. Elevate the extremity and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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transport.

Handout 9-5: Chapter 9 Review 1. auto crashes 2. structural, vital organs, movement, salts, red 3. haversian 4. osteoblast 5. diaphysis 6. metaphysis 7. red bone marrow 8. Synarthroses, amphiarthroses, diarthroses, synovial 9. monaxial, biaxial, triaxial 10.

adduction, abduction

11.

ligament

12.

synovial

13.

head, thorax, spine, extremities, shoulder girdle

14.

humerus, radius, ulna

15.

carpal, metacarpals, phalanges

16.

femur

17.

tibia, fibula

18.

opposition

19.

compartment, penetrating, fatigue, cramp, spasm, strain

20.

fatigue

21.

I, II, III

22.

dislocation

23.

closed, open

24.

comminuted

25.

osteoporosis

26.

greenstick

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27.

disease

28.

smoking, infection, diabetes, NSAIDS, immunosuppressive

29.

1,500

30.

pain, pallor, paralysis, paresthesia, pressure, pulses

31.

pulse, temperature, color, sensation, capillary

32.

Compartment

33.

3

34.

above, below

35.

padding

36.

pillow

37.

pulses, sensation, motor function

38.

pelvic ring, internal

39.

pelvic, knee, tibia, foot

40.

clavicle

41.

posterior, flexed, internally

42.

function

43.

diazepam, morphine, fentanyl

44.

rest, ice, compression, elevation

Handout 9-6: Musculoskeletal True or False 1. T

6. F

11. F

2. F

7. T

12. F

3. F

8. F

13. T

4. T

9. F

14. T

5. F

10. T

15. T

Handout 9-7: Musculoskeletal Matching 1. c

8. m

15. l

2. t

9. a

16. o

3. s

10. h

17. d

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4. p

11. r

18. n

5. g

12. i

19. k

6. q

13. f

20. j

7. B

14. E

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Chapter 10 Environmental Trauma

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Student’s Name

HANDOUT 10-1 SKILLS

EMERGENCY CARE FOR HEAT DISORDERS Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently HEAT CRAMPS Procedure 1. Remove patient from hot environment.

2. Place patient in a cool, shaded, or air-conditioned area.

3. Administer oral fluids, if patient is alert and able to swallow, or an IV of normal saline.

1

2

3

HEAT EXHAUSTION Procedure 1. Remove patient from hot environment.

2. Place patient in a cool, shaded, or air-conditioned area.

3. Administer oral fluids, if patient is alert and able to swallow, or an IV of normal saline.

4. Place patient in a supine position.

5. Remove some clothing and fan the patient but do NOT chill the patient.

6. Treat for shock if shock is suspected but do NOT overheat the patient.

1

2

HEATSTROKE Procedure 1. Remove patient from hot environment.

2. Place patient in a cool, shaded, or airconditioned area.

3. Initiate rapid active cooling en route to hospital by: a. Removing patient’s clothing. b. Covering the patient with sheets soaked in ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

1

2

3

3

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tepid water. c. Cooling body temperature to no lower than 102°F/30°C. 4. Administer high-flow oxygen by nonrebreather mask.

5. Administer oral fluids if patient is alert and able to swallow.

6. Begin one or two IVs of normal saline, wide open.

7. Monitor the ECG. 8. Monitor body temperature.

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HANDOUT 10-2

Student’s Name

EVALUATION CHAPTER 10 QUIZ Write the letter of the best answer in the space provided.

1.

A medical condition caused or exacerbated by the weather, terrain, atmospheric pressure, or other local factors is called a(n): a. homeostatic emergency. c. environmental emergency. b. external emergency. d. localized emergency.

2.

All of the following factors can predispose certain individuals to developing environmental illnesses EXCEPT: a. age. c. fatigue. b. complexion. d. medications.

3.

The natural tendency of the body to maintain a steady and normal internal environment is called: a. homeostasis. c. homeopathy. b. stability. d. normostasis.

4.

Thermal gradient is the difference in temperature between the: a. highest and lowest normal body temperature. b. lowest and highest tolerable temperatures. c. hypothermia and hyperthermia. d. environment and the body.

5.

Thermoregulatory thermogenesis is the production of heat resulting from the: a. high environmental temperatures. b. increase in the rate of cellular metabolism. c. exercise of muscles working effectively. d. processing of food and nutrients.

6.

Heat loss from direct contact of the body’s surfaces with another, cooler object is called: a. convection. c. radiation. b. conduction. d. evaporation.

7.

An unclothed person will lose approximately 60 percent of total body heat at room temperature by the mechanism of: a. convection. c. radiation. b. conduction. d. evaporation.

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8.

The portion of the brain responsible for temperature regulation is the: a. pituitary gland. c. hypothalamus. b. sternomastoid. d. pineal gland.

9.

The rate at which the body consumes energy just to maintain stability is called the: a. basal metabolic rate. c. normostatic rate. b. homeostatic rate. d. thermoregulatory rate.

10. The MOST accurate core temperature reading will be obtained by measurement.

A. axillary c. oral b. temporal d. rectal 11. The general signs of thermolysis include all of the following EXCEPT: a. diaphoresis. c. flushing. b. increased skin temperature. d. cyanosis.

12. Treatment for heat exhaustion should NOT include: a. supine positioning. c. administering salt tablets. b. fanning the patient. d. administering sports drink.

13. Your patient has been working in his garden on a very hot, humid day and has NOT been drinking fluids. His body temperature is about 101°F, his skin is cool and clammy with heavy perspiration, his breathing is rapid and shallow, and his pulse is weak. He is conscious and tells you he feels weak. You suspect: A. heat cramps. c. heatstroke. b. heat exhaustion. d. heat shock.

14. Signs and symptoms of heatstroke may include: A. bradycardia initially, tachycardia later. c. hot, dry skin. b. cool, clammy skin. d. hypertension.

15. The FIRST essential step in the treatment of a patient with heatstroke is to: a. initiate rapid active cooling. b. remove him from the hot environment. c. administer high-flow oxygen. d. administer fluid therapy.

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16. Efforts to cool the body temperature of a pediatric patient with a fever should include: a. immersion in cool water. b. rubbing-alcohol sponge bath. c. cold packs in the armpits and groin. d. administration of an antipyretic medication.

17. When the core temperature of the body drops to below individual is considered to be hypothermic. a. 99°F c. 97°F b. 98.6°F d. 95°F

, an

18. The MOST common presenting arrhythmia seen in hypothermia is: a. ventricular fibrillation. b. first-degree av block. c. ventricular tachycardia. d. atrial fibrillation.

19. Guidelines for handling cardiac arrest patients whose core temperature is below 86°F include: a. checking for pulse and respirations for longer periods. b. administrating up to six defibrillation shocks. c. avoiding orotracheal intubation. d. increasing doses of epinephrine.

20. Your patient has been skiing all day and has developed frostbite to both of his feet. Your treatment may include: a. massaging the feet to restore circulation. b. providing analgesia before thawing. c. thawing the feet because refreezing is possible. d. rewarming the feet so the patient can walk away.

21. Which one of the following statements is TRUE? a. Drowning is the leading cause of death in children under the age of five years. b. Drowning is the third most common cause of accidental death in the United States. c. Approximately 85 percent of drowning victims are female. d. Two-thirds of the males who are drowning victims know how to swim.

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22. If the cause of submersion is unknown, you should always suspect: a. suicide. b. cardiac origin. c. trauma. d. foul play.

23. Although the physiology of freshwater and saltwater drownings differs, there is difference in the end metabolic result or in prehospital management. a. no c. somewhat of a b. only a slight d. considerable 24. The mammalian diving reflex EXCEPT to the brain and heart. a. increases b. constricts

blood flow everywhere c. ceases d. dilates

25. If rescue personnel must go into the water to rescue a patient, they should wear protective clothing if water temperature is less than: a. 90°F. c. 83°F. b. 87°F. d. 70°F. 26. One emergency a diver may experience is “nitrogen narcosis.”

Which of the following is TRUE regarding this condition? a. It is commonly called “the bends” and causes severe pain. b. It is caused by the development of nitrogen bubbles within body tissues. c. It is a state of stupor due to nitrogen’s effect on cerebral function. d. The most serious effect is pulmonary overpressure.

27. Patients who complain of joint and abdominal pain, fatigue, paresthesia, and CNS disturbances within 24 hours after a dive are MOST likely suffering from: a. “the squeeze.” c. nitrogen narcosis. b. decompression sickness. d. arterial gas embolism.

28. High-altitude illnesses usually become manifest at altitudes greater than: a. 4,000 feet. c. 8,000 feet. b. 6,000 feet. d. 10,000 feet.

29. Signs and symptoms of high altitude pulmonary edema include: a. coughing producing frothy sputum. c. abdominal pain. b. decreased urine output. d. severe vomiting. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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30. Rapid ascent is the common cause of overpressure accidents, particularly from depths of: a. over 20 feet. b. less than 6 feet. c. 70 to 100 feet. d. over 200 feet.

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Student’s Name

HANDOUT 10-3 EVALUATION

CHAPTER 10 SCENARIO Review the following real-life situation. Then answer the questions that follow.

Your Medic 6 team is dispatched to a track-and-field event. Dispatch informs you that athletic trainers are currently working on a female athlete who collapsed during a 5K run. It is late in the afternoon, and the temperature and humidity are high.

When you arrive, the patient is in the trainer’s tent. She is unresponsive, her skin is hot and dry, her pupils dilated and fixed, and alternating deep and shallow breathing is evident. The athletic training staff has packed the patient in wet towels with ice located at the armpits, knees, groin, wrists, ankles, and neck.

A brief history finds that the athlete has recently had the flu. Her fluid intake during the race was minimal. Following the race, the patient sat down to stretch and became unconscious.

The patient is loaded into the ambulance where cooling is continued. Vitals signs are pulse, 130 and weak; blood pressure, 80/30; and respirations, 26.

Oxygen is administered via nonrebreather mask at 15 liters per minute. Two large-bore IVs are initiated and run wide open with lactated Ringer’s solution.

The ECG monitor shows a sinus tachycardia without ectopy. The patient is transported in emergency status, and the hospital is notified of the patient’s condition en route.

1. What is the athlete’s problem?

2. Describe the physiological events that have led to the athlete’s condition.

3. Why do you think the athlete experienced this episode?

4. How should the paramedics alter treatment if the patient begins to have seizure activity?

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HANDOUT 10-4 REINFORCEMENT

CHAPTER 10 REVIEW Write the word or words that best completes each sentence in the space(s) provided.

1.

A(n) emergency is a medical condition caused or exacerbated by the weather, terrain, atmospheric pressure, or other local factors.

2.

is the natural tendency of the body to maintain a steady and normal internal environment.

3.

The difference in temperature between the environment and the body is called the .

4.

is the production of heat, especially within the body.

5.

Loss of body heat by direct contact with a cooler object or surface is called heat loss by .

6.

Heat loss to air currents passing over the body is called .

7.

is the maintenance or regulation of a particular temperature of the body.

8.

The body temperature of the deep tissues is called the temperature.

9.

The thermostat.

10.

The rate at which the body consumes energy just to maintain stability is called the .

11.

The rate at which the body consumes energy during activity is called the metabolic rate.

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, which is in the brain, is the body’s

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12. while temperature.

is an unusually high core body temperature, is an unusually low core body

13.

The condition characterized by acute painful spasms of the voluntary muscles following strenuous activity in a hot environment without adequate fluid or salt intake is called .

14.

An acute, dangerous reaction to heat exposure, characterized by central nervous system disturbances and a body temperature above 105°F, is called .

15.

When caring for a child with a fever, consider administering an primarily for patient comfort.

16.

A core temperature less than with signs and symptoms of hypothermia is considered severe hypothermia.

17.

Hypothermia patients who experience body temperatures above will usually have a favorable prognosis.

18.

MOST thermometers used in medicine do NOT register below

19.

The ECG deflection associated with hypothermia is called the .

20.

The use of warm blankets and heat packs to treat a hypothermic patient is known as .

21.

The return of cool blood and acids from extremities to the core of a hypothermic patient being rewarmed by the application of heat packs may result in .

22.

The environmentally induced freezing of body tissues causing destruction of cells is called .

23.

Freezing involving epidermal and subcutaneous tissues, resulting in a white appearance, hard feeling on palpation, and loss of sensation is called .

24.

The process of experiencing respiratory impairment as the result of submersion or immersion in a liquid is known as .

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.

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25.

In drowning, some of the alveoli are damaged.

26.

A complex cardiovascular reflex resulting from the submersion of the face and nose in cold water is called the reflex.

27.

The cold-water drowning victim is NOT dead until he is and dead.

28.

law states that the amount of gas dissolved in a given volume of fluid is proportional to the pressure of the gas above it.

29.

is a state of stupor that develops during deep dives due to nitrogen’s effect on cerebral functions; another term for the condition is “ .”

30.

The development of nitrogen bubbles within the tissues due to a rapid reduction of air pressure is called sickness, or “ .”

31.

Patients suffering from severe barotrauma may require treatment in a(n) oxygen chamber.

32.

Signs and symptoms, including a rapid, dramatic onset of sharp, tearing pain within 2 to 10 minutes of ascent from a deep dive, indicate blocked blood flow caused by a(n) .

33.

Increased pulmonary pressure and hypertension caused by changes in blood flow at high altitude is called high-altitude .

34.

Increased fluid in the brain causing a rise in intracranial pressure at high altitudes is known as high-altitude .

35.

Rapid ascent to a height over 6,600 feet by an unacclimatized person may result in .

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is lost when the capillaries

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Student’s Name

HANDOUT 10-5 REINFORCEMENT

WATER EMERGENCIES Describe the physiological processes affecting patients and treatment in each of the following situations.

1. Drowning Process:

Treatment:

2. Saltwater drowning Process:

Treatment:

3. Barotrauma Process:

Treatment:

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4. Nitrogen narcosis Process:

Treatment:

5. Decompression sickness Process:

Treatment:

6. Arterial gas embolism Process:

Treatment:

7. Pulmonary overpressure accidents Process:

Treatment:

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8. Pneumomediastinum Process:

Treatment:

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HANDOUT 10-6 REINFORCEMENT

THERMAL DISORDERS Describe the physiological processes affecting patients and treatment in each of the following situations.

1. Heat cramps Process:

Treatment:

2. Heat exhaustion Process:

Treatment:

3. Heatstroke Process:

Treatment:

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4. Mild hypothermia Process:

Treatment:

5. Severe hypothermia Process:

Treatment:

6. Frostbite Process:

Treatment:

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Chapter 10 Answer Key Handout 10-2: Chapter 10 Quiz 1. c 9. a 2. b 10. d 3. a 11. d 4. d 12. c 5. b 13. b 6. b 14. c 7. c 15. b 8. c 16. d

17.

18.

19.

20.

21.

22.

23.

24.

d d a b b c a b

25.

26.

27.

28.

29.

30.

d c b c a b

Handout 10-3: Chapter 10 Scenario 1. Heatstroke.

2. Temperature regulation has been lost, probably from insufficient water replacement during exertion in the high temperature. This loss of thermoregulation can lead to cell death and physiological collapse.

3. Since the athlete recently was ill with the flu, she probably did not have an ideal fluid/electrolyte balance before beginning the race. During the race, she failed to adequately replace fluids that were being lost, resulting in a loss of temperature regulation.

4. Administration of diazepam would be appropriate.

Handout 10-4: Chapter 10 Review 1. environmental 2. Homeostasis 3. thermal gradient 4. Thermogenesis 5. conduction 6. convection 7. Thermoregulation 8. core 9. hypothalamus 10. basal metabolic rate 11. exertional 12. Hyperthermia, hypothermia 13. heat cramps 14. heatstroke 15. antipyretic 16. 90°F 17. 86°F 18. 95oF ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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19. J wave 20. active rewarming 21. rewarming shock 22. frostbite 23. deep frostbite 24. drowning 25. surfactant 26. mammalian diving 27. warm 28. Henry’s 29. Nitrogen narcosis, raptures of the deep 30. decompression, the bends 31. hyperbaric 32. arterial gas embolism 33. pulmonary edema 34. cerebral edema 35. acute mountain sickness Handout 10-5: Water Emergencies 1. Drowning Process: Apnea causes a rise in PaCO2 and decrease in PaO2. Gasping occurs, resulting in the introduction of water that leads to reflexive laryngospasm and bronchospasm.

Treatment: Symptomatic. In the case of cardiac arrest, follow ACLS protocols, unless the patient is also hypothermic.

2. Saltwater drowning Process: The hypertonic nature of the solution causes fluid to be drawn from the vascular space into the lungs, causing pulmonary edema.

Treatment: The same as for freshwater drowning.

3. Barotrauma (Nonpulmonary) Process: Caused by inability or failure of a diver to equalize the pressure between the nasopharynx and middle ear or sinuses.

Treatment: If the result of failure to equalize sinus or inner ear pressure during descent, returning to the surface should resolve pain.

4. Nitrogen narcosis Process: Caused by nitrogen’s effect on cerebral function. Diver appears intoxicated.

Treatment: Includes decreasing the amount of nitrogen present in the blood.

This condition is self-resolving upon returning to the surface.

5. Decompression sickness Process: Caused by air bubbles forming in the blood and joints due to a rapid ascent to the surface.

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Treatment: Administer continuous high flow oxygen via non-rebreather and transport in supine position. Additional treatment should be simultaneous with transport to a hyperbaric oxygen chamber facility.

6. Arterial gas embolism Process: Air bubbles enter the circulatory system during a rapid ascent because of rupture of small pulmonary vessels.

Treatment: Is same as for decompression sickness.

7. Pulmonary overpressure accidents Process: Lung overinflation due to rapid ascent. Air trapped in the lungs by mucous plugs, bronchospasm, or simple breath holding. With rapid ascent, ambient pressure drops quickly, causing the trapped air to expand.

Treatment: The same as for pneumothorax caused by any other mechanism.

Rest and supplemental oxygen are important, but hyperbaric oxygen is not usually necessary.

8. Pneumomediastinum Process: A release of air through the visceral pleura into the mediastinum and pericardial sac.

Treatment: Includes high-flow oxygen, IV, and rapid transport. Check for, and if necessary, treat pneumothorax.

Handout 10-6: Thermal Disorders 1. Heat cramps Process: Intermittent, painful contractions of various skeletal muscles caused by a rapid change in extracellular fluid osmolarity resulting from sodium and water losses.

Treatment: Includes removing patient from the environment and an increase of fluid and sodium intake. Severe cases may need IV fluid replacement.

2. Heat exhaustion Process: Caused by dehydration and salt loss from exposure to a hot environment. History is important to determine appropriate assessment.

Treatment: Includes removing patient from the environment and replacing fluids with IV normal saline solution. If untreated, may progress to heatstroke.

3. Heatstroke Process: Hypothalamic temperature regulation is lost.

Treatment: Includes removing patient from the environment and rapid patient cooling, oxygen, two large-bore IVs wide open initially, monitoring of core temperature.

4. Mild hypothermia Process: Lowering of body core temperature to between 90°F and 95°F, leading to a lowered metabolic rate and lowered cardiac output and a shift in fluids from the vascular to the extravascular compartment.

Treatment: Includes removing all wet clothing and protecting against heat loss, avoiding rough handling, monitoring core temperature and cardiac ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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rhythm, rewarming patient as able, and giving warm fluids if patient has stopped uncontrolled shivering.

5. Severe hypothermia Process: Core temperature below 90°F, processes described for mild hypothermia continue, leading to cell ischemia and necrosis, eventually resulting in death.

Treatment: Includes everything for mild hypothermia as well as warm IV fluids and warmed oxygen. Avoid medication administration. If vital signs are absent and core temperature is less than 86°F, cardiac arrest medications should be avoided.

6. Frostbite Process: Caused by environmentally induced freezing of body tissues, resulting in ice crystals forming within and water being drawn out of the cells into the extracellular space. Ice crystals expand, causing the destruction of cells.

Treatment: Do not thaw if there is any possibility of refreezing. Do not massage or rub with snow. Administer analgesia prior to thawing. Transport for rewarming by immersion. Cover thawed part with loosely applied, dry, sterile dressings. Elevate and immobilize thawed part. Do not puncture or drain blisters. Do not rewarm frozen feet if they are required for walking out of a hazardous situation.

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Chapter 11 Special Considerations in Trauma

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Student’s Name

HANDOUT 11-1 EVALUATION

CHAPTER 11 QUIZ Write the letter of the best answer in the space provided.

1.Of all the care procedures and advanced interventions available to treat the trauma patient, the MOST promising is: a. rapid IV fluid resuscitation. c. rapid sequence intubation. b. prevention. d. inflation of the PASG. 2.The scene size-up with trauma patients involves four major elements, including: a. accounting for and locating all patients. b. general impression of the patient. c. status of the patient’s ABCs. d. transport decision.

3.The first step in analyzing the mechanism of injury is to: a. ascertain the chief complaint. b. recreate the incident in your mind. c. interview bystanders. d. establish your index of suspicion.

4.Regarding Standard Precautions with the trauma patient, remember: a. that the risk of infection extends to both you and your patient. b. that the risk of bloodborne pathogens is less with trauma patients than with medical patients. c. to wear one pair of gloves, without removing them, throughout the assessment of multiple patients to keep the risk of contamination low. d. that standard PPE when caring for a trauma patient includes gloves, goggles, and a HEPA filter mask.

5.While completing your general impression, you should remember that the mechanism of injury: a. is the most accurate indicator of injury severity. b. may not reflect the actual injury severity. c. will always match the injury patterns. d. is no longer used to determine injury severity.

6.Identify a patient’s level of consciousness by using the mnemonic: a. AEIOU-TIPS. c. DCAP-BTLS. b. AVPU. d. ABCDE. 7.When assessing breathing in the trauma patient: a. you should apply supplemental oxygen via nasal cannula to avoid overoxygenation of remaining red cells. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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b. a dull sound heard on percussion indicates blood in the chest. c. hyperresonance heard on percussion indicates a tension pneumothorax. d. all of the above.

8.Check the radial pulse for strength, regularity, and rate. Shock may be indicated if the pulse is: a. weak and bradycardic. c. weak and thready. b. strong and tachycardic. d. strong and bradycardic.

9.The FINAL step in conducting the initial assessment is: a. the transport decision. b. advanced airway management. c. initiation of large-bore IV lines. d. spinal precautions.

10. Question the patient about any symptoms: a. after the rapid trauma assessment. b. during transport. c. before you inspect or palpate a body region. d. during the initial assessment.

11. General examination techniques include inspecting. This begins with: a. blood pressure measurement. c. the ABCs. b. looking first at skin color. d. palpation of all body regions.

12. Percussion during examination is performed on the: a. abdomen. c. chest. b. back. d. extremities.

13. Use the rapid trauma assessment when: a. you care for any trauma patient. b. you suspect a patient has a serious injury to the body. c. you are caring for multiple patients. d. transport time is more than 10 minutes.

14. The focused exam and history is performed: a. on patients you suspect have limited injuries. b. on all trauma patients. c. on patients you suspect have serious injuries. d. on all unconscious patients.

15. To check eye movement, have the patient: a. blink slowly then rapidly. b. follow your finger as you trace an “H” pattern in front of him. c. hold one eye closed and read from a piece of paper with the other eye, then switch and repeat. d. hold an otoscope while you check for hemorrhage.

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b. supine.

d.

sunken.

17. The “P” in SAMPLE stands for: a. pressure. c. pulse. b. past medical history d. pain 18. All of the following are signs of increasing compensation for blood loss and shock EXCEPT: a. increasing respiratory rate. b. decreasing pulse strength. c. cool, clammy skin. d. increasing pulse pressure.

19. Step 3 of the four-step trauma triage criteria is to: a. recognize special patient who might benefit from a trauma center. b. consider the Glasgow Coma Scale. c. examine anatomical signs of injury. d. look at the mechanism of injury.

20. The revised trauma score is a numeric evaluation of the patient using the elements of the GCS and the patient’s: a. respiratory rate and pulse. b. respiratory rate and systolic blood pressure. c. respiratory rate and diastolic blood pressure. d. respiratory rate and oxygen saturation.

21. Signs of deterioration during reassessment include: a. decreasing pulse rate. b. decreased respiratory rate. c. narrowing pulse pressure. d. decreased capillary refill time.

22. Reassessment of the unstable patient should be performed: a. at 15-minute intervals. b. at 5-minute intervals. c. immediately prior to arrival at the ED. d. continuously.

23. A relatively unappreciated complication of trauma and shock is: a. hypertension. b. seizures. c. hypothermia. d. infection.

24.Splinting must be effective yet done quickly for the seriously injured trauma patient. This is accomplished by: a. rapid immobilization of each individual injury. b. gently aligning all the limbs and securing the entire patient to a ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

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long spine board. c. applying and inflating the PASG. d. splinting each injury site while en route to the hospital.

25. One anatomical/physiological consideration you should keep in mind with infant and child patients is that: a. the child’s head is proportionally smaller than an adult’s head. b. pediatric patients may lose up to 25 percent of their blood volume before any signs appear. c. children have slower heart and respiratory rates than infants. d. a child’s airway widens at the cricoid cartilage.

26. Any pregnant patient in the late stages of pregnancy who is secured to a spineboard should be transported: a. on a spineboard lying supine. b. secured to a spineboard, and tilted 45 degrees. c. secured to a spineboard, and tilted 15 degrees. d. after she is removed from the spineboard.

27. Age-related changes in geriatric patients include: a. loss of brain mass after middle age. b. an increase in renal function. c. up to a 6-inch loss of height. d. an increase in the number of body cells.

28. Standard Precautions at the trauma scene include: a. recapping needles to prevent risk of contamination. b. sticking needles in seat cushions temporarily so they will not get misplaced. c. analyzing the MOI for airway or chest trauma. d. contacting your infection control officer after every incident that involves blood.

29. When deciding if air medical service is warranted remember to: a. allow 3 to 5 minutes for warm-up. b. insure that the cloud ceiling is over 500 feet. c. verify that the pilot has adequate flight hours left. d. take control of the scene during landing.

30. Which of the following has NOT had its effectiveness questioned during the past few years? a. Capillary refill b. Defibrillation c. PSAG d. Rapid infusions of isotonic fluid in trauma

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 11-2 EVALUATION

CHAPTER 11 SCENARIO Review the following real-life situation. Then answer the question that follow.

At a local industrial park, metal parts are created in a machine press. The machine operator accidentally gets his sleeve caught in the machine. Almost immediately he feels searing pain, then nothing. He looks down and his severed arm is on the shop floor.

Alarms set off by the jam in the machine alert the line supervisor, who shuts down production and calls the office of the industrial nurse. The nurse, realizing the severity of the accident, has the trucking dispatcher call up the plant’s first response safety team and then the local EMS. Arriving on the scene minutes after the accident, the nurse finds the line supervisor has released the arm from the machine and is applying direct pressure to the stump in an effort to control bleeding. She quickly assesses the patient for further injuries while instructing the plant safety team to secure the severed limb in a plastic bag placed in cool water. The patient is feeling faint, though the amount of blood lost has been minimal. Placed on the stretcher with oxygen via a nonrebreather mask, he is carried down the stairs to the waiting ambulance, where George and Betty, the paramedics, assume care of the patient.

George performs another assessment and updates the vital signs. IVs are established on the nonaffected side. Due to the extent of injury, and the distance from a trauma center, the paramedic crew decides to have a helicopter dispatched to the scene.

Much to their surprise, dispatch advises that the helicopter was en route back to their base after delivering a high-risk pregnant patient to the regional OB hospital, and has an ETA to their scene of only 10 minutes. With an estimated drive time to the trauma center of 30 minutes, the crew begins packaging the patient for airship transport.

The fire department personnel arrive on-scene, establish a landing zone, and coordinate the landing and take-off of the helicopter.

The patient and his detached arm are rushed to the regional trauma center by air, where a reimplantation team awaits his arrival. After more than four hours of microsurgery, the patient’s arm is reattached.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

1. Describe how this patient’s body compensated for the injury that it experienced.

2. At one point, the patient felt faint. Describe several possible etiologies for this event.

3. What are the treatment priorities?

4. What danger must be guarded against when the paramedics treat the patient?

5. What is important for the paramedics to remember about interacting with the helicopter crew, regarding their safety and the safety of their patient.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 11-3 REINFORCEMENT

CHAPTER 11 REVIEW Write the word or words that best complete the following sentences in the space(s) provided.

1. Of all the care procedures and advanced interventions available to treat the trauma patient, none has more promise for reducing mortality and morbidity than .

2. Key elements of scene size-up include determining the

, identifying scene , accounting for and locating all , and requesting additional .

3. The risks of infection from body substances extends to both your and , especially when dealing with trauma.

4. The may NOT reflect the actual injury severity.

5. Level of consciousness should be identified using the mnemonic.

6. When percussing the chest, a dull sound indicates in the space, while indicates air, under pressure, in the space.

7. A strong tachycardia suggests , while a(n) and pulse suggests shock compensation.

8. Before you inspect or a body region, question the patient about any .

9. When you FIRST begin inspecting your patient, you should look FIRST at the .

10. Percussion involves checking each lobe of the for .

11. The focused trauma assessment is performed on a patient whom you expect has .

12. Check eye movement by having the patient follow your finger as you trace a(n) pattern in front of him.

13. The jugular veins should be in the supine, normovolemic patient and as the patient’s torso and head are raised to a -degree angle.

14. The elements of the SAMPLE history assessment include: and , , , , , and leading up to the incident. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

15. Signs of increasing compensation for blood loss and shock include pulse rate, pulse strength, and a(n) pulse pressure.

16. Step one of the trauma triage criteria considers the and .

17. The revised trauma score is a numeric evaluation of the patient using the GCS and the patient’s and .

18. is a relatively unappreciated complication of serious trauma shock.

19. Standard Precautions at the trauma scene includes contacting your service.

To effectively yet quickly splint the injuries of a seriously injured trauma patient, you should align all the limbs and secure the entire patient to a or stretcher.

20. A pregnant patient in the late stages of pregnancy should be transported in the position, or if secured to a spineboard, tilt the board degrees.

21. The brain loses mass after .

22. It takes to minutes for a helicopter to warm up.

23. The “P” in CUPS stands for .

24. When preparing a patient for helicopter transport, you should establish good IVs, both with catheters.

25. You should completely secure your patient to a(n) or other device approved for use with your local air medical service.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Student’s Name

HANDOUT 11-4 REINFORCEMENT

TRAUMA ASSESSMENT LISTING Compete the following lists.

1. List the circumstances in which you should employ spinal precautions.

2. List basic steps included in shock trauma resuscitation.

3. List signs of deterioration you might encounter during the ongoing assessment.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Chapter 11 Answer Key Handout 11-1: Chapter 11 Quiz 1. b 2. a 3. b 4. a 5. b 6. b 7. b 8. c 9. a 10. c 11. b 12. c 13. b 14. a 15. b 16. c 17. b 18. d 19. d 20. b 21. c 22. b 23. c 24. b 25. c 26. c 27. a 28. c 29. a 30. b Handout 11-2: Chapter 11 Scenario 1. It compensated through constriction of blood vessels at the site of the injury and epinephrine release further vasoconstricting the arterial and venous vasculature.

2. Hypovolemia is a potential cause, but amputations seldom bleed that severely. A psychogenic reaction is a strong possibility also. If the patient is diabetic, metabolic shock is a possibility.

3. The first priority is hemorrhage control, then treatment for shock. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

4. Aggressive fluid resuscitation without hypovolemia can lead to overhydration.

5. Maximal oxygenation and ventilation should be ensured, and oxygen saturation should be maintained above 96 percent. Two large-bore IVs should be established (for this particular patient, both IVs would be established in the uninjured arm) and the patient should be completely secured to a long spine board. The helicopter should only be approached from the front, and only under the direction of the flight crew.

Handout 11-3: Chapter 11 Review 1. prevention 2. mechanism of injury, hazards, patients, resources 3. patient, yourself 4. mechanism of injury 5.

AVPU 6. blood, pleural, hyperresonance, pleural 7. excitement, weak, thready 8. palpate, symptoms 9. skin color 10. chest, resonance 11. limited injuries 12. H 13. distended, flatten, 45 14. signs, symptoms, allergies, medications, past medical history, last oral intake, events 15. increasing, decreasing, decreasing 16. Glasgow Coma Scale score, vital signs 17. respiratory rate, systolic blood pressure 18. Hypothermia 19. gently, firmly, long spine board, orthopedic 20. left lateral recumbent, 15 21. middle age 22. 3, 5 23. potentially unstable 24. two, large-bore 25. long spine board

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.

Test Bank Paramedic Care Principles & Practice, Vols. 4 5th Edition by Bryan Bledsoe

Handout 11-4: Trauma Assessment Listing 1. Mechanism of injury suggests possible spinal injury; suspicion of extremes of flexion/extension, lateral bending, axial loading, distraction, rotation of the spine, or any direct penetrating or blunt forces expressed to the neck or spinal cord; patient with any significant injury above the shoulders; patient with reduced level of consciousness.

2. Provide airway protection; assure adequate oxygenation and ventilations; provide rapid fluid resuscitation; employ the PASG; perform pleural decompression.

3. Increasing pulse rate; decreasing pulse strength; narrowing pulse pressure; increasing respiratory rate; decreasing respiratory volume; increasing capillary refill time; decreasing level of consciousness or orientation; changes in skin color or temperature; increasing anxiety or restlessness.

©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 4, 5th Ed.