The Neighborhood Emergency Trauma Bag HR Bohman, MD, FACS CAPT, MC, USN (Ret) Jefferson Healthcare Surgical Associates (Ret) The Neighborhood Emergency Trauma Bag Why we put together the Neighborhood Emergency Trauma Bag designed for individuals who have little or no medical training but who may be called upon as immediate responders to provide initial trauma care and bleeding control to a victim of traumatic injury prior to the arrival of emergency medical services (EMS) or in an austere environment Trauma is an epidemic in the US Intentional mass casualty incidents and natural disasters are on the rise 20% of trauma deaths are preventable with optimal emergency and trauma care
Death due to bleeding can occur in minutes The American College of Surgeons is committed to the Zero Preventable Deaths and Stop the Bleed campaigns The Neighborhood Emergency Trauma Bag Purpose Initial stabilizing care of significant life-threatening injury Discussion of injuries for which this is beneficial Explanation of: Acute life-threatening airway and respiratory problems Types of shock and its treatment in a resource limited environment Review of contents of bag and how to use Documentation of treatment given
Platinum 10 Minutes Proper lifesaving care within the first few minutes following injury significantly increases the survivability of those who incur these traumatic injuries (7 major injuries) 1) Uncontrolled hemorrhage severe, heavy bleeding that doesnt stop without treatment 2) Airway obstruction something blocking the airway so that air cant get to the lungs (usually the tongue) 3) Open sucking chest wound penetrating injury puts a hole in the chest that allows air to enter the chest cavity through the hole (often creating a sucking sound) and results in collapsed lung and inadequate oxygenation 4) Tension pneumothorax air is trapped in the chest cavity outside the lung and doesnt allow the lung to expand with each breath which results in collapsed lung with increased pressure in chest and ultimate obstruction of blood return to heart 5) Massive hemothorax large amount of blood is trapped in the chest cavity outside the lung which doesnt allow
the lung to expand and results in collapsed lung and shock from loss of blood 6) Flail chest multiple rib fractures that dont allow the chest to expand evenly thus making breathing difficult 7) Pericardial tamponade blood builds up in the sac that surrounds the heart and ultimately prevents the heart from pumping blood Definition of Shock THE MANIFESTATION OF THE RUDE UNHINIGING OF THE MACHINERY OF LIFE. Gross, 1872 A clinical condition marked by inadequate organ perfusion and tissue oxygenation Shock Disorder of the Circulatory System
Pathophysiology of Shock In shock, there is progressive failure of the circulatory system There is something wrong with the pump (heart), the pipes (blood vessels), the fluid (blood volume), or it becomes obstructed (impedes blood flow) Shock is not a single specific clinical condition. Shock results in hypoperfusion at the cellular level with resultant cellular hypoxia. (cells run out of energy) The body attempts to compensate by a progression of physiologic mechanisms to correct the cellular hypoxia / hypoperfusion. Pathophysiology of Shock In trauma the most common cause of shock is
blood loss in which the vascular space is depleted and cannot recover fluid from the interstitial space decreased venous return decreased CO compensation with increased SVR increased tissue hypoxia Overcoming the Triangle of Death Rapid Surgical Intervention & IV Resuscitation _
_ _ _ 107 degree ORs Warm IV Fluids Hot Pockets Bair Huggers Whole Blood Factor VIIa Pathophysiology of Shock
Mechanisms for inadequate tissue blood flow (perfusion) include: Volume loss Pump failure Vasodilatation Obstruction Basis for classification of types of shock Classifications of Shock
Classifications based on major underlying cause of shock. More than one type of shock may exist in a given patient. Treatment of shock state based on treating the underlying cause or causes. Classifications of Shock Hypovolemic Shock Loss of fluid from the vascular space Makes up 75% of all cases of shock 2 different types: Loss of whole blood hemorrhage Loss of plasma volume dehydration Burns, diarrhea, heat exhaustion, 3rd spacing, etc.
Classifications of Shock Cardiogenic Shock Failure of the heart to adequately pump blood Makes up 15% of cases of shock 2 different types: Coronary blockage of blood flow to heart causing ischemia or infarction of heart muscle. Non-coronary failure of heart to pump not related to blood flow to heart muscle Arrhythmias, ruptured valve, cardiomyopathy, etc. Classifications of Shock Distributive Shock Caused by an inappropriate redistribution of blood flow to the tissues Makes up 8% of cases of shock
3 different types: Neurogenic loss of peripheral vasomotor tone with pooling Septic inflammatory mediated microvascular injury with capillary permeability and mismatched blood flow Anaphylactic histamine induced vasodilatation and vascular permeability Classifications of Shock Obstructive Shock Impedes flow of blood through vascular system Makes up only 2% of shock cases 2 different types: Occlusive Pulmonary Embolus blood clot blocks pulmonary artery Air Embolus air blocks right ventricle
Compressive Tension Pneumothorax compresses great veins and blood return to heart Cardiac Tamponade compresses cardiac chambers and prevents filling of ventricles Clinical Features of Shock Hypovolemic Shock Most common type of shock in trauma
Due to hemorrhage until proven otherwise Clinical manifestations related to amount of circulating blood volume lost Normal blood volume is 7% of body weight in Kg Average blood volume in 70 Kg man is 5 liters Clinical Features of Shock Classes of Hypovolemic Shock Class I loss of up to 15% blood volume
Up to 750 cc blood loss No clinical signs or symptoms Equivalent to donating 1-1 units of blood Heart rate, blood pressure and capillary refill normal Replace with crystalloid or oral fluids Clinical Features of Shock Classes of Hypovolemic Shock Class II loss of 15%-30% blood volume
750 1500 cc blood loss Mild tachycardia Decreased pulse pressure Systolic pressure unchanged Mild tachypnea Decreased urinary output (20-30 cc/h) Anxious, hostile, or frightened Replace with crystalloid, possible blood Clinical Features of Shock
Classes of Hypovolemic Shock Class III loss of 30% - 40% blood volume 1500 2000 cc blood loss Marked tachycardia Marked tachypnea Decreased BP
Oliguria Confusion, apathy Replace with crystalloid and blood Clinical Features of Shock Classes of Hypovolemic Shock Class IV loss of > 40% blood volume
> 2000 cc blood loss Life-threatening exsanguination Significant tachycardia Marked tachypnea Significant depression BP Narrow pulse pressure or unobtainable diastolic Cold and pale skin Lethargic to comatose Urine output negligible Require rapid infusion blood and crystalloid
Clinical Features of Shock Manifestations:Tachycardia, hypotension, tachypnea and cutaneous vasoconstriction any injuries patient who is cool and tachycardic is in shock until proven otherwise. ATLS 6th ed Decreased urine output Narrowed pulse pressure Decreased mental status Clinical Features of Shock Cardiogenic Shock
Failure of the pump Irregular heart beat Tachycardia, PSVT, A. Fib, PVCs, V. Tach, V. Fib Tachypnea, Shortness of Breath Skin cool and clammy Peripheral and central cyanosis Decreased urine output
Engorged neck veins Clinical Features of Shock Distributive Shock Loss of autoregulation of blood distribution Neurogenic Hypotension and bradycardia Neurologic changes paralysis, sensory deficits Normal capillary refill Septic Tachycardia, late hypotension Skin pink, warm and dry Fever or hypothermia
Anaphylactic Tachycardia and hypotension Wheezing, stridor, hives Vomiting, abdominal cramps, diarrhea Clinical Features of Shock Obstructive Shock ( Impedes blood flow) Occlusive Pulmonary Embolus Sudden severe hypoxia
Underlying risk factors Air Embolus Murmur washing machine in heat Air entry site Penetrating chest trauma with open pneumothorax Open central lines Compressive Tension pneumothorax
Time is of the essence All trauma patients are in hypovolemic shock till proven otherwise Common things occur commonly, but If you never think of a diagnosis you will never make it Management Plan Stop life-threatening external hemorrhage ! Assure a secure airway if unconscious Head tilt - Chin lift Jaw-thrust with neck stabilization if suspected neck injury
Nasopharyngeal or oral airway Treat breathing issues Vent a tension pneumothorax Cover a sucking chest wound Support ventilation if needed (Ambu bag, oxygen) Management Plan External Bleeding Management Plan External Hemorrhage Place a tourniquet Management Plan Airway Obstruction Assure a secure airway if
unconscious Head tilt - Chin lift Jaw-thrust with neck stabilization if suspected neck injury Nasopharyngeal or oral airway Management Plan Airway Obstruction Management Plan Breathing Issues Treat breathing issues Vent a tension pneumothorax Cover a sucking chest wound Support ventilation if needed (Ambu bag, oxygen)
Management Plan After ABCs Secure vascular access Hypotensive resuscitation if bleeding not controlled Splint fractures
Treat and cover open wounds Prevent Hypothermia Monitor and re-triage Document the care given Transport to definitive care ASAP Management Plan Documentation Care Triage Triage The Neighborhood Emergency Trauma Bag Contents
1 Body Bag (hypothermia prevention) Hand & Body Warmers 18hrs 3 Silk Tape Rolls Hand Sanitizer 3 oz. Chest Decompression Needle 10 gauge, 3.25 long Blue Nitrile Exam Gloves size large 100/box Penlight LED Medical Alcohol Pads 200/box Fingertip Pulse Oximeter Blood O2 Sat. Monitor Stethescope & Blood Pressure Cuff Manual Adult SAM Splint XL 5.5X36 Rolled Safety Goggles
Betadine Solution 4 oz. bottle If your neighborhood has medically trained personnel, please consider adding: 1 Emergency Cricothyrotomy Kit 3 1 Nasopharyngeal 9pc (20F-36F) Airway Kit 1 Russell Pneumo Fix Chest Decompression Device w/needle 1 Ambu Bag w/ mask
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