1015 eight

The main ideas from this information are: - Life-threatening bleeds should be treated before airway in some cases. - The story of a de-gloving injury and how it was treated. - Control blood loss with direct pressure and consider spinal stabilization. - Consider the need for transport in cases of airway and breathing problems or significant bleeding. - Signs of hypoperfusion indicate the need for rapid transport. - Treat drivers involved in significant accidents with the same urgency as other passengers. - Be alert for injury-specific signs and symptoms and use the DTF, DTLS approach. - Don't remove impaled objects unless they impair CPR or ventilation. - Start evaluating the eyes from the outer aspect and work your way in. - Assess vital signs and immobilize patients with facial and throat injuries. - Control bleeding and provide psychological support. - Document all findings and interventions. I'm saying you should treat life-threatening bleeds even before airway. Like if I saw a life-threatening bleed, put a glove hand on it right away. Stop it right away before you do anything else. How has something like that been happening? Like that's in the middle of a surgery or something. Yeah, that's in the middle of a surgery, but that's a de-gloving right there. I had, I'll tell you the story. I did a call one time for a guy. It was an older car. Years ago, when they had the visors, they were metal. And they were covered with a piece of vinyl. Right? And so the vinyl had been ripped off, so he had a metal visor. And it was kind of, it must have been kind of a little bit down, and he got into a car accident. Head on. And his head hit it and scalped his skin. It shaved his skin right off. Flapped it right back. It's called a de-gloving. Right? It's, what do they call that? It reflected it back. So what do we do? We came, we put it back in anatomical position, and bandaged it, and they stitched it on. Not a big deal. But it looks pretty, it looks pretty graphic, right? And his blood, I mean, it bled like a suck bait. But it's just skin. They just sewed it back on. That's just skin. Injuries may be very obvious or hidden, especially like traumatic brain injuries and things. Control blood loss with direct pressure. Consider the need for spinal stabilization. And check your, obviously check your responsiveness. Ensure a clear and painted airway. Have suction available. You can use, if altered, consider an OPA or maybe an IHL. Would we use an NPA on these patients? No. Because they are head trauma patients. Very good. Check airway adequacy. Use DCAP, BTLS. We covered that, right? You went over that? Deformities, contusions, abrasions, pump support abrasions, burns, damage, flush abrasions. Know it, learn it, live it. Splinting or otherwise restricting chest wall motion is kind of indicated. We're going to talk about that. We don't wrap chest walls anymore. We don't bandage it. What I do, though, is I'll have a patient take a pillow, or maybe a bath blanket, and I'll have them put it over the injury and hold it with their arm. So when they breathe, it kind of stabilizes the bone, so the bone's not going in. Restricting chest wall movement is just making you feel a little better. And I'm still letting patients get pain meds. Circulation. You're going to check all your vital signs. Significant bleeding is an immediate life-threatening number. They could be bleeding internally. So the external bleeding is having a potentiating effect. It's adding to it. So I can't necessarily stop the internal bleeding, but I can stop the external. So stop all external bleeding. And one of the best ways to stop internal bleeding is a mobilization. Just tell the patient, sir, don't move. Because when they move, they break clots. So if I keep you immobilized and stop all external bleeding, we will slow bleeding down. And then you can call out ALS. If you have internal bleeding, we can give you a medication called TXA, transometric acid. And what that does is that stops the body from breaking down clots, so the clots that build up will stay. And so it causes clotting faster. It increases clotting. So transport decision. Consider quickly transporting patients with airway and breathing problems or with significant bleeding. When in doubt, transport. You're never going to go wrong with head and neck injuries to transport high priority. Call ALS. They might not be available, but call anyway as soon as you recognize it. A patient with internal bleeding must be transported to a trauma center. So if the patient is stable, I'm going to UMass. If the patient is unstable, I'll go to the closest appropriate facility. But the patient with internal bleeding needs surgical intervention. They need a trauma surgeon. So signs of hypoperfusion imply the need for rapid transport. Hypoperfusion, the other word for that? It's a dirty five-letter word to answer that. Charge. A patient with a significant mechanism injury, you might have a patient whose motor vehicle crashed, passenger's dead or seriously injured, but the driver isn't. I would treat the driver with the same urgency as the patient. Even though the driver may not have any signs of, I'm fine, I'm fine, but he was subjected to the same forces as everybody in that car. So if there's one death or serious injury in the vehicle, then they're all subjected to the same forces. So they would get the same high-priority transport, even without signs and symptoms of injury. A significant blood on the face or throat should increase your suspicion of a spinal or brain injury. Get a medical history, your sample history, obviously. Be alert for injury-specific signs and symptoms in your pertinent negatives. Remember we talked about pertinent negatives? A pertinent positive supports your differential diagnosis and a pertinent negative detracts from it. So I'm having chest pain. So that's a pertinent positive for cardiac. But now I ask you to breathe deeply and that hurts. So that's a pertinent positive for pleuretic chest pain, pain on inspiration, and that's a pertinent negative for cardiac, because cardiac pain will not cause pain when you breathe in. It'll be there all the time. So a pertinent positive supports your differential diagnosis. A pertinent negative detracts from it. Is that because it's involuntary? Is it because it's involuntary that we will feel it? No, it's because pleuretic chest pain is irritation of the nerve endings within the lungs when you breathe. Cardiac pain is in the heart. When I breathe deeply, it's not going to affect the heart one way or the other. So you'll have no pain there. So get a sample history if you can, and then use DTF, DTLS. For an isolated injury where the patient's a good historian and it was a non-significant injury, we can do a focused assessment. But if you're in doubt, you're not sure, your patient's a poor historian, untouched and unresponsive, cut the clothes off, do it as you tell. Even if the patient is complaining of no complaints, and they have a high severity mechanism, I'm going to do a head-to-toe anyway. Because maybe there's so much endorphins flowing through their body they don't realize the injury. Amped up, they don't realize the injury. Ensure that control of breathing is maintained. Make sure you note all injury locations. Inspect open wounds for foreign matter and stabilize impaled objects. We never remove an impaled object. If you have an object that's impaled, it may be in a blood vessel but tamponading off blood flow. If I pull it out, now the patient's going to bleed. Or I might cut blood vessels as I remove it. They should only be removed surgically. The only two times you remove an impaled object is if the object impairs CPR or ventilation. If it affects airway or affects CPR, then I can remove it. But otherwise, I leave it in place and stabilize it. You can take a roll of roller gauze and you roll it up to make like a donut and you put it around the item and tape it in place and stabilize it. Well, if the knife is impaired, I do CPR here. So if the knife's here, no, I'm going to leave it in place. But if the knife is here, I pull it out. If you've got a knife sticking in your chest and I'm going to do CPR on you because you're in cardiac arrest, you're probably not going to make it anyway. So I put an occlusive dressing over it. I take the knife out, occlusive dressing, and do CPR and hope for the best. It's possible, people. Do you know who did that? Steve Irwin. Really? Steve Irwin, when he got hit with a... When he died? He died. And that's why... No, yeah, I know he died. He died and that's why he died. He pulled it out and it was a rupture of his myocardium and it bled out from there. If he had left it in, he may have survived. But it was his first reaction. And you're right. I mean, I've done that. It's like, oh, jeez. You know, you don't even think about it. What about if they're in danger? Like, they're in a car and it's on fire and they've got an impalement and you've got to remove the impalement to get them out. Is that... I mean, does that count? Well, yes. But if you were going to try and pull the patient out and they're impaled, I would probably... I'd try and put the fire out. But if there was no way to put the fire out, it was growing, I would probably remove the patient by unimpaling them. But, you know, that would be one of those things where that's one in a million. Cars don't explode like they do on TV anyway. I'm sorry. When evaluating the eyes, when evaluating the eyes, start with the outer aspect and work your way in to the center. Examine the eye for obvious foreign matter. Visual acuity is a vital sign of the eye. That's why we do the eight points of conjugate gaze and check for peripheral vision because that is a vital sign of the eye. Look for discoloration, bleeding, redness, eye symmetry, and pearls. Assess vital signs to obtain a baseline. You must be concerned with visual bleeding and unseen bleeding. Remember, I can exsanguinate between my abdomen and my pelvis. I can lose four liters of blood, two liters of my pelvis, two liters of my abdomen. Facial and throat injuries, baseline information is very important. And you can use appropriate monitoring devices. Repeat your primary assessment. Repeat your vital signs. And immobilization, immobilize them. Seat collar, bandage. You know, they can go. Patients can stand right up and sit down on the stretcher, but make sure you strap them down on the stretcher and try to tell them not to move. Maintain an open airway, suction, maybe put an OVA if they'll accept it. Control visual bleeding. If the patient shows signs of hypoperfusion, treat aggressively for shock and rapid transport. Keep them warm. Elevate the legs over the whole stretcher. Call air last, high flow oxygen. Stop the bleeding. Psychological support. Psychological medicine. Document, you want to describe the mechanism of injury, the position you found the patient, the forces applied to the patient, and the parts of the body that were injured. You want to do a full explanation, right? Diarrhea of the keyboard or pen. Treat soft tissue injuries to the face and neck the same as you would soft tissues of the body anywhere else. Stop the bleeding. Bandage, secure it. Make sure you've got a good pain airway. Avoid moving the neck. Always approach the patient from the front. Ma'am, please don't move your head. Somebody's going to come behind you. Grab your head. We're going to put a collar on you just in case you have a spinal cord injury. Okay? Never approach from the back. Control bleeding by applying direct manual pressure. Gloved hands. And then apply a dry, sterile dressing. Use roller gauze. You're going to wrap it around the head. You're going to put like a 2x2 or 4x4 or a trauma dressing and then wrap it with roller gauze. There are two types. You have Curlex. Curlex is almost like a cotton gauze that's rolled up. And Perforate looks like cheesecloth. You can unroll it. You can use that as a dressing or roll up. Or you can pack with that. And then you also have roller gauze which is like elastic. And you can roll it up. And that can act as a dressing too. Do not apply excessive pressure to skull fractures. Yes, I want to stop the bleeding. No, I don't want to put too much pressure. Cover exposed brain, eye, or other structures with moist, sterile dressing. Any tissue that's moist, cover it with a moist, sterile dressing. We don't want it to dry out like the eviscerations for the abdomen. Apply ice to local injuries that do not break the skin. Do not put ice or cold compresses on an open wound. Yes, it will stop the blood bleeding because it will constrict the blood vessels. But what will happen is once the tissue warms up, you're going to bleed like a stuck pig because blood that is cool does not clot. It loses its clotting capability. So therefore, it will just bleed, bleed, bleed. So we don't put ice on open wounds, only closed wounds. Soft tissue injuries around the mouth and cheek, check for bleeding inside the mouth. Sometimes doctors can graft a piece of a bald skin back into position. So the rule of thumb is the rule of thumb. If you have a piece of tissue that's smaller than the patient's thumb, don't bother. They can't put it back in. Unless it's the thumb. Then we bring the thumb. If it's greater than the thumb, put it in a plastic bag, keep it cool, not directly on ice because that will freeze it and they can hopefully reattach it. And make sure you label it and bring it with the patient to the hospital. Don't bring it to a St. V's and the patient to a memorial because that's not going to work. If you happen to have, like I talked about, that debloving, that flap of skin, put it back in the anatomical position, bandage it and transport it. If it's grossly contaminated with dirt and debris, rinse it off. Otherwise, just put it back in position. Eye injuries are common, especially in sports, that can produce lifelong complications including blindness. After an injury, pupil reaction and shape of the eye can be disturbed. Sometimes patients can develop, remember we talked about disconjugate gaze, when people this way and some people over here. I'm not a chameleon. My pupils don't move independently. So, if they're in different positions, there's a problem. Two things can cause that. A bad thing is a neurological injury. Like I told you, that patient at Holy Cross, at Holy Cross, that step is drunk. 18 year old and went head first and he had disconjugate gaze. That was a neurological condition. But you can also have a blowout fracture. An orbital blowout fracture. Your eye is rooted or anchored inside your socket by muscles. And those muscles allow you to turn your eyes. If I fracture a bone, that no longer acts as an anchor. So, the muscles that are anchored will pull the eye in that direction. So, if I have a lower orbit fracture, my eye will pull up. If I have an upper fracture, my eye will pull down. So, that can cause a disconjugate gaze. They call it a blowout fracture. Treatment always starts... Treatment starts with a thorough examination. Always use gloves, goggles and masks. Do not aggravate any problem. Do not force the eye open. Look for abnormalities or conditions that suggest the nature of the injury. Foreign objects. Orbit protects the eye from penetration of large objects. But smaller objects can get in. You can try and rinse it off. Rinse it out. This is a nasal cannula. You put it over the nose. Open up the eyes. And you use a 60cc syringe and you spray sterile water or normal saline. And it rinses out the eye. It works pretty well. That's a pretty good way of doing it. You do not... When you rinse, you do not want to rinse for the unaffected eye. Because you don't want to get the debris from here in here. So, I would rinse this way. God bless you. Lost it twice. A foreign body will leave a small abrasion on the conjunctiva or the cornea. And it will feel like, even if you get it out, the patient is going to feel like I saw something in my eye. And it will be like that for a couple of days. Gentle irrigation may not wash out foreign bodies. So, if it's stuck to the cornea or stuck to the conjunctiva, don't try and pick it out. Foreign bodies may be impaled in the eye. It's important to understand that, again, I'm not a chameleon. So, let's say I've got somebody... I've got a pencil in my eye, right here, right? So, as I turn my eye, it's going to do this, right? So, I want to stabilize this. So, I put... Like, I roll up roller guards and I kind of stabilize it so it doesn't move. And then I bandage it. But I leave this eye open. What's going to happen when I look around? I've got to bandage both eyes. And I'm going to tell the patient, I'm going to put bandage on both your eyes. Please keep your eyes still. Do not move them because you have to protect those objects. Right? And hold the bandage. Burns of the eyes stop the burning and prevent further damage. So, if it's a fire burn or a thermal burn, the eye instinctively closes the eyelid, the eyelashes, the eyebrows, the carpet, protects the eye, but it gets burned. Make sure you put out the fire. Put out the... You know, cool it. Moistural dressings, but do not force the eye open. If it's a chemical burn, force the eye open and irrigate it. You must irrigate it. Because, like, if it's acid, acid's produced like a surface scarring. It'll burn the surface of the skin. But alkali will actually, bleach and things will actually cause aliquification necrosis. And it'll destroy the eye. You've got to rinse. So, if it's like, if it's a patient with a chemical burn to the eye, I'm going to rinse until it stops burning. So, I'm going to rinse, rinse, rinse for 20 minutes and then I'm going to stop and say, does that burn? Yeah, it still burns. Okay, another 20 minutes. So, these patients are not load and go. These are one of the times where I'll stay in play. I will stay on scene until the burning stops. Because if I drive to the hospital and it's still burning, by the time I get to the hospital again, it's permanent. So, I've got to rinse it right away. These are different ways. This is the nasal cannula. This is the eye wash station. This is forcing it open and pouring water in it. And this is bobbing for apples. I don't recommend this. I don't think anybody's going to stand there unless you shove their face in a bowl of water. Again, chemical burns, we're going to irrigate, clean, dress, and transport. And again, we're going to irrigate until it stops. Eye wash station until it stops. Thermal burns, do not try and force it do not try and force the eyelids open. Sometimes it will burn and fuse shut. Rinse the eye, bandage, and transport to the hospital. We have these special eye shields that you can put on the eye, especially for burns that seal up the eye and you can moisten them and they won't stick to the skin. Light burns. Infrared light, laser light, bright beams can cause significant damage. Looking at a solar eclipse, what happens is the moon passes in front of the sun and it hyper-focuses the infrared light and infrared rays and you look at it directly it will burn your eyes and it will burn your retina. Looking at a laser directly or looking at an arc welder when it tells it where the the hood and it can burn your eyes. So what happens is you get retinal damage. You might not notice it right now boy that was a cool solar eclipse. And then like an hour or two later you're like, oh my eyes hurt. And you start getting massive conjunctivitis. Your eyes start swelling and all of a sudden you start seeing black spots and that's the permanent damage to your retina. Lacerations require very careful repair to restore the appearance and function of the eye. Plastic surgeons, surgical ophthalmologists they're worth their weight in gold because it's very fine surgery to do those repairs. And a lot of times they have to wait for swelling to go down before they can do it. If there is a laceration to the globe of the eye apply no pressure. Manage it very lightly with moist sterile dressing and treatment tools. Especially if you see vitreous humor coming out of that jelly. On rare occasions the eyeball may be displaced in the socket. It doesn't hang down here. It kind of just pops out kind of hangs out a little bit. Moist sterile dressing keep it in place is very important also. They'll actually pop it back in place. But don't use it. Have the patient like Supine bandage both eyes. If you have injury if you want to immobilize one eye you must bandage both. What is the reaction when you see something like that? You're like ooooh like that. Kind of ooooh. They're kind of like ooooh. I mean we don't say that to the patient. We go ooooh. You know but you think that. Oh my god. Worst thing you can say to a patient when you're like oh my god. That's not going to do anything. I believe that's not going to do anything. Well I did that one time. I told you I had that woman with the elbow injury and she and I moved her elbow and I felt decrepitus and I must have made a face because she looked and said oh that didn't hurt. I must have gone ooooh. Hyphema we talked about that that's a lot in the aqueous humor. The orbit fracture can cause a blowout fracture or can fracture the pore or the roof of the orbit of the eye. So signs and symptoms of possible brain injury one pupil larger than the other without the history of a blast eye. Eyes not moving together disconjugate case failure of both eyes to follow your finger bleeding onto the conjunctiva or protrusion or bulging of the eye. That could be the sign of intracranial pressure causing a bulging of the eye because the brain is right behind the eye. Blast injuries there are four blast injury patterns. You have primary secondary tertiary and quadranary. Primary is the concussion wave the secondary is the or the tertiary the secondary is the shrapnel. Most eye injuries come from the shrapnel. When something explodes it sprays shit out and you can't get it in your eyes. That's most of the time when you're going to get the injuries during a blast. Contact lenses I'm not a big fan of removing contact lenses. I don't like playing with eyes. If it's a soft contact you can pinch it and use some sterile saline to get it out. If it's a hard contact you're supposed to have a suction device. We don't have that in the ambulance so if you've got a hard contact I'm just going to irritate the best I can. I'm not going to try to remove it. But if there's a chemical in your eye I've got to remove it because that may fuse to the eye if I don't. Nosebleeds we call it epistaxis is a common problem. The number one cause of epistaxis is a little trauma like a nose. Everybody ever seen a Seinfeld episode? I was scratching. Anterior there are two types. There's the anterior and posterior nosebleeds. The anterior nosebleeds is from using one nostril it's a mild bleed and it stops very quickly. A posterior nosebleed is from larger blood vessels in the back of the nose bleeds for both nostrils. Patients will taste the blood if they swallow it and it's very difficult to stop. My son gets those especially in the winter time in the heat and he gets really bad nosebleeds. Generally to stop those there are four things you can do to stop 99% of nosebleeds. Have the patient put their head forward so they don't aspirate the blood they don't even swallow it because it will cause them to vomit. Have them ice pack or bag of peas or carrots frozen on the forehead that cold causes constriction of blood vessels in the maxilla and then take a pen or roller gauze lift up the upper lip put it under the air and rub it. Stimulation of the tissues of the maxilla will further constrict blood vessels. That will stop 99% of nosebleeds.