PERCOMONLINE - AEMT/PARAMEDIC 1

Homework Assignment: Trauma Scenarios

Updated 22 April 2017 Gandy; 23 January 2020 Klopper

Instructor: Student Name:Grading: Date:

Content: 90Research: 5Critical Thinking: 5Grade:

Instructor Comments:

INSTRUCTIONSTHIS IS A RESEARCH PAPER!

1. Review the case studies below and answer all questions relating to each.2. Read the entire case study and familiarize yourself with each of the questions first. 3. Sources of research may include, but are not limited to:

o Prescribed textbook and other textbookso Reputable online resources such as National Library of Medicine, Centers for Disease Control and

Prevention, American Heart Association, Journal of Emergency Medical Services and so on. o PERCOMOnline course material.

4. Ensure that all references are current and preferably not more than five years old5. Do not use your textbook alone - Work that is not based on a variety of different sources is unacceptable.6. If you directly quote a source the quoted portion must be in enclosing quotation marks and the source must be

cited. Try to limit the number of quotes and rather use your own words.7. Your answers must be comprehensive. Short answers will not be accepted. You must discuss in detail the

reasons for your answers. If, for example, you are asked “what body systems are involved, “it is not sufficient to simply say, “respiratory, endocrine, and nervous.” You must explain WHY you have determined that these systems are involved and HOW they are involved.

8. If there are multiple parts to a question, you must answer each part. 9. Write your answers in the blue text boxes provided. Every box must contain an answer. Do not use the size of

the text box to determine how much should be written – write as much as needed. The text box will grow to accommodate your answer.

10. The key words for this paper are WHAT, WHY, AND HOW! Cover those bases and you will do well.11. Demonstrate your critical thinking skills as fully as possible. There may or may not be “right” answers to all

questions. Look for plausible answers and explain your reasons. 12. Justify your answers with WHAT, WHY, AND HOW explanations. 13. The more complete your discussion is, the better your grade will be. You will have an opportunity to revise your

paper before a final grade is issued. Feel free to contact your instructor for advice and help at any time. 14. When finished, email to your course instructor. Expect to have your paper evaluated and sent back for further

work. This process may continue until both you and your instructor are satisfied that you have a comprehensive and clear understanding of the issues. Upload the Word document to https://www.percomonline.com (DO NOT upload PDF or any other document types).

To confirm that you have read and understand the instructions printed above, type “YES” into the cell to the right.

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ContentsINSTRUCTIONS

Case Study 1 – One-Car Rollover (Cliff)

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

Question 10

Question 11

Question 12

Question 13

Question 14

Question 15

Question 16

Question 17

Question 18

Question 19

Case Study 2 – Motorcycle vs. Car Collision (Toby)

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

Question 10

Question 11

Question 12

Question 13

Question 14 Page 2 of 2

Case Study 3 – Burn Patient (Dale)

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

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Case Study 1 – One-Car Rollover (Cliff)Scene Survey

You are sent to a one-car rollover. There is one patient pinned under the wreckage. On arrival, you see a SUV in a ditch, lying on its top. A young male, Cliff, is pinned under the roof at mid-chest, halfway in and halfway out of the vehicle at the driver’s door.

As you approach, Cliff opens his eyes and says, “I….can’t…….breathe.” His lips are cyanotic.

He is extricated by first responders onto a long spineboard, and as soon as your stretcher is at his side, he is placed on your stretcher and the spineboard removed.

Question 1a. What are your scene considerations?

b. Where is the best place to park your ambulance if there are no other rescuers or law enforcement on scene?

c. The road is straight and flat at this location. There is one fire engine on scene, and two police cars. They have blocked off the scene. In view of this, where is the best place to park your ambulance?

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Question 2Initial Impression

You observe that he opens his eyes when you speak to him, is verbally responsive, but his speech is confused, and he does not obey commands.

His airway is open, but he has bloody saliva. He is breathing at a rate of 22 breaths per minute, and his chest excursion appears to be shallow. His SpO2 is 87%.

His skin looks pale. It is cool and clammy to the touch. He has cyanosis around his lips.

He has a weak carotid pulse at a rate of 116 and regular.

He has a large amount of blood around his right knee. When your partner cuts his pants open, you observe an avulsion to the anterior surface of the knee which has bled a lot but is no longer bleeding.

a. What actions should you take immediately?

Focused Physical Examination

LOC Patient opens his eyes when you speak to him; speech is intact but confused. Does not follow commands.

HEENT Scalp is intact with no signs of trauma; facial bones are intact with no signs of trauma; pupils are 5 mm, round, equal, and react to light sluggishly. No raccoon's eyes or Battle’s sign are present; mouth is clear without trauma to the tongue or teeth; neck is supple and non-tender to palpation. Jugular veins are flat in the supine position; trachea is midline by palpation. There is no visible or palpable trauma to the neck.

CHEST Contusions across the sternum, right chest, and upper abdomen. No surgical scars or penetrating trauma. Right chest is painful to palpation in region of ribs 7-12. Breath sounds are diminished in the right middle and lower lobes. Heart sounds are S1 and S2.

ABDOMEN Bruising in the right upper quadrant. No surgical scars. No penetrating trauma. Tender to palpation in the right upper quadrant. Non-distended, non-guarded.

PELVIS Stable to palpation.LEGS Large avulsion to right anterior knee. Skin hanging off to side. Bleeding has stopped. No signs of

trauma otherwise. No distal pulses in lower extremities. ARMS Patient is moving arms spontaneously and movement is not purposeful.BACK Bruising in the posterior axillary line at the base of the right scapula. No other signs of trauma. Spine is

non-tender to palpation and there are no deformities.

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b. What is Cliff’s chief complaint?

c. Were all the bases covered in the summary of the assessment above? If not, what would you add?

d. Why did you and the first responders remove the spineboard from beneath him as soon as he was on your ambulance stretcher?

Question 3Additional Information

A bystander volunteers this information: He observed Cliff driving at a high rate of speed. Cliff passed him a half-mile before the accident. He observed Cliff’s SUV swerve to miss a deer in the road and then roll approximately three times.

Given what you know, what injuries do you suspect?

Question 4WHAT immediate treatments will you provide?

Question 5Does Cliff have any potential injuries that are immediately life threatening?

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Question 6Additional Information

As your treatment progresses, you note that Cliff’s cyanosis is increasing. He is complaining of increasing pain in his right upper abdomen, and he is now saying “I can’t breathe.”

How will you assess Cliff further to try to determine the cause of his increased cyanosis and difficulty breathing?

Question 7What injuries do Cliff’s upper right quadrant pain and his pain around his right lower rib cage?

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Question 8Patient Update

1. Eight minutes into your scene time, Cliff becomes unresponsive.

2. He has no detectable blood pressure. 3. His carotid pulse is 166. 4. His breath sounds on the left are clear and

vesicular, but there are no breath sounds on the right.

5. His skin is cold and clammy and gray. 6. His abdomen is tense and guarded.

What are the probable reasons for each of these findings? Explain each one fully.

Cliff becomes unresponsive.

No detectable blood pressure.

Carotid pulse is 166.

Breath sounds on the left are clear and vesicular, but there are no breath sounds on the right. Skin is cold and clammy and gray.

Abdomen is tense and guarded.

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Question 9Is there a recognizable pattern of signs and symptoms being displayed? If so, what are they, and what do they signal?

Question 10a. Why do you think Cliff’s jugular veins are flat when he is supine? EXPLAIN.

b. Are jugular veins normally flat when supine? EXPLAIN.

c. WHAT, if anything, is the significance of contusions across his sternum, lower right ribcage and right upper abdominal quadrant? EXPLAIN.

d. What can a medic learn from observing jugular veins and inspecting the chest for contusions in a patient with this history? EXPLAIN.

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Question 11a. What are the signs of cardiac tamponade?

b. Does Cliff exhibit any of those signs?

Question 12How can one, through physical assessment, distinguish between a tension pneumothorax and a hemothorax? EXPLAIN.

Question 13a. If Cliff has a tension pneumothorax, HOW would you treat it? Explain fully and include anatomical details about how you would do it.

b. HOW would you assess your patient to see if your intervention helped?

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Question 14a. If Cliff has a cardiac tamponade, HOW would you treat him for it in the prehospital setting?

b. WHAT is the definitive treatment for pericardial tamponade?

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Question 15Patient Update

Cliff’s latest vital signs are: BP 60/40; RR 60; Pulse 166. Pulse SpO2 is now 76. Monitor shows sinus tachycardia with

frequent PVCs.

WHAT immediate interventions should you do? EXPLAIN. Assume that you have the scope of practice and pharmacology to do whatever paramedic interventions you deem necessary, regardless of state or local protocols.

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Question 16IMPORTANT: Show your calculations

a. What is Cliff’s MAP?

Additional InformationCliff’s ICP is 8 mmHg

b. What is his CPP?

c. How will knowing his MAP and CPP affect your treatments?

d. What are your concerns about his CPP and why is CPP important?

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Question 17Patient Update

Cliff’s abdomen is becoming distended and rigid.

What do these findings suggest

Question 18Summarize your findings and treatment of Cliff.

a. WHAT are his probable injuries?

b. WHY did you treat him as you did?

c. WHAT do you expect your treatments to accomplish?

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Question 19Discuss your hospital destination decisions in terms of: (HINT: American Trauma Society Trauma Levels)

a. A rural system where the nearest Level IV hospital is 25 miles away, the nearest Level III hospitals are 40 miles away, and the nearest Level I trauma center is 125 miles away.

b. A suburban system where a Level III hospital is 8 miles away, and a Level 1 trauma center is 15 miles away.

c. An urban system where you are 10-15 minutes from a Level 1 trauma center anywhere in the city.

d. Discuss the role of helicopter transport in each of these situations.

e. What will be your transport mode for Cliff? No lights and siren, lights only, or lights and siren. Discuss each in terms of how it would affect Cliff’s ultimate outcome.

No lights and siren

Lights only

Lights and siren

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Case Study 2 – Motorcycle vs. Car Collision (Toby)Scene Survey

You arrive at the scene of a motorcycle vs. car collision. The motorcycle is embedded in the front of a compact car. There is a dent in the top of the roof of the car, the windshield is shattered from an outside impact, and there is one patient, Toby, lying supine about 30 feet from the vehicle. The driver of the car, a young female, is outside the car, walking around, and without any apparent trauma, but crying and very upset.

A firefighter first responder is talking to her and says that she’s “OK” but you need to look at the motorcycle rider.

Toby is wearing a full-face motorcycle helmet and a leather jacket and leather chaps.

Initial ImpressionYou approach him and identify yourself and ask him what happened. He says, “I can’t breathe, and I can’t feel anything.”

Question 1a. What does his response suggest to you immediately?

b. What should your first intervention be?

Patient UpdateAs you continue to talk to him you see that his eyes are open and he is talking, but with difficulty. He seems very short of breath. He responds to you with what you think are appropriate responses. He tells you that he was riding, and that the car suddenly made a left turn in front of him, and that he could not avoid hitting it. His helmet is intact with extensive scuffing on the left side and top.

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Question 2What do his responses tell you about his level of consciousness and his airway status?

Question 3a. What transport decisions would you make at this time?

Patient Update

As you continue to talk to him, you see that his breathing is labored, with reduced tidal volume and chest rise; he is using accessory muscles in his neck to breathe; his abdomen demonstrates diaphragmatic or abdominal breathing; he is talking in one-word responses, and he is frightened. His skin is pale, but warm and dry. He has a radial pulse of 60.

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Question 4What conclusions can you draw from these findings? Explain each in detail.

a. Reduced tidal volume and chest rise.

b. Use of accessory muscles in neck

c. Diaphragmatic breathing (exaggerated diaphragmatic movement)

d. One-word responses

e. Fear

f. Pink skin, but warm and dry

g. Radial pulse of 60

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Question 5What is Toby’s chief complaint?

Question 6Focused Physical Examination

HEENT Helmet in place. CHEST A mid-sternal bruise about the size of a

grapefruit is noted. There are no lacerations or penetrations and no other signs of trauma. No pain on palpation. No surgical scars. No chest rise and fall is seen. Breath sounds are clear and equal but diminished bilaterally. Percussion reveals no dullness or tympany.

ABDOMEN The abdomen is negative for surgical scars and contusions, lacerations, or penetrations. It is soft, non-tender, and non-distended. Exaggerated diaphragmatic movement is noted, synchronized with respiratory efforts.

LEGS There are bilateral anterior contusions and lacerations extending from the knee down the tibia about 4 inches (10 cm) and they are not bleeding.

ARMS There are no signs of trauma to the arms other than some minor contusions.

BACK There is a laceration to the left hip area, extending to the left buttock, which has bled profusely and is still bleeding.

VITAL SIGNS Pulse 60, RR 24, BP 86/64, pulse oximeter 92.

Based on these findings, answer the following:

a. WHAT immediate actions will you take?

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b. WHY did you take each action?

Question 7Motorcycle helmets must be removed before placing a patient on a flat surface because if they are not removed, once placed supine, the helmet will cause the patient’s neck to flex forward. Describe the steps in removing a motorcycle helmet safely.

Question 8a. Given Toby’s (1) lack of chest rise and (2) exaggerated diaphragmatic movement, heart rate of 60, warm, dry skin, and dyspnea, what specific injury do you think is causing this? (Justify your answer with anatomical and physiological rational)

b. Which spinal nerves innervate the diaphragm?

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c. Which spinal nerves innervate the intercostal muscles of the rib cage?

Question 9What is your PRIMARY CONCERN with Toby? Explain fully, stating WHAT and WHY.

WHAT is your primary concern?

WHY?

Patient Update

En route to the hospital, as you are gaining more information and doing your SAMPLE survey, Toby tells you that he is an insulin dependent diabetic.

Question 10Will this information change your treatment? If not, why not. If so, why, what, and how?

Yes, it will because:

No, it won’t because:

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Question 11What level hospital will your hospital destination for Toby be? Explain your answers fully. Hint: What services will he need?

Question 12Discuss:

a. Fluid resuscitation for Toby. WHAT, WHY, and HOW?

What fluid and Why?

How much?

b. Oxygen therapy for Toby. Keep in mind that studies show no benefit to trauma patients from oxygen therapy unless they are hypoxic, and that hyperoxygenation creates oxygen free radicals that are harmful.

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c. Considering the Triad of Death (if you are not familiar with this term, search for it in any browser and you should easily find the definition and description), what additional measures should you take in treating Toby?

Recommended Reading: http://www.emsworld.com/article/10728872/hypothermia-complications

Patient Update

Toby’s blood glucose is 340 mg/dL

Question 13

Does Toby’s blood glucose reading change your treatment at all?

Yes, because:

No, because:

Question 14Discuss current thinking with regard to the use of C-collars and long spine boards with emphasis on The Maine Protocols for spinal restrictions. Are there any problems or flaws in the Maine Protocols that concern you? Why or why not?

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Case Study 3 – Burn Patient (Dale)Scene Survey

You are sent to an industrial facility for a burn patient. Dale, age 55, is an electrician. He was working on a piece of machinery when he received a shock. There was a considerable amount of grease on the machine he was working on, and there was a flash explosion which happened at face level.

Dale is sitting in a chair in the company nurse’s office at the facility. It appears that no treatment has been given. Dale appears somewhat dazed, but he can talk to you and answer questions appropriately. You immediately notice that his face is black with soot, and his eyebrows and hair on the front of his head have been burned away.

Dale tells you that he just does not know what happened. He says that in his 30 years as an electrician he has never had an accident like this. He seems more concerned about losing his job than anything.

Question 1a. Based upon these facts and Dale’s appearance and behavior, what conclusions can you draw about his condition?

b. What assessment questions would you like to ask him at this time?

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Focused Physical Examination

LOC Dale is awake and able to answer questions about the accident appropriately. However, he seems preoccupied with whether or not he is going to lose his job. He is not complaining of much pain.

HEENT There is black soot covering his face. His eyebrows and eyelashes and the hair at the front of his head are burned away. His skin appears to be charred in some places. At other places there appears to be a gray crust. His voice is hoarse. Pupils are PEARLA. His ears are red, with blisters on the pinnae. There is black soot in his nose and mouth.

Neck is supple and non-tender to palpation, but Dale complains of pain from burns to the front of his neck, which appear to be partial thickness. Jugular veins are flat, trachea is midline.

CHEST There are no apparent surgical scars. There is a partial-thickness burn extending from the neck to about the 5th dermatome. Dale’s shirt has been partially burned away.Chest excursion appears normal. Breath sounds are equal, but there are rhonchi heard in the bronchi. Respiratory rate is 36 breaths per minute. Heart sounds are S1 and S2.

ABDOMEN No surgical scars, abdomen is soft, non-distended, and non-tender to palpation. Bowel sounds not assessed.

PELVIS Pelvis is stable.LEGS No deformity, lacerations, abrasions,

contusions, or deformities. Pedal pulses are present bilaterally.

ARMS There are partial- and full-thickness burns to both arms from the mid-humeral area to the fingers. Dale says there is no pain in his hands and fingers; as a matter of fact, he cannot feel them.

BACK There is no tenderness nor deformity or signs of trauma to the back.

VITAL SIGNS BP 110/70; Pulse 108; Respirations 36, becoming noisy and labored; BGL 86. Temp 98.4 F. Pulse oximetry: 90% on room air.

Question 2a. What is your first priority and most important concern for this patient? Explain in detail.

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b. What immediate treatments will you give Dale? Why?

I would do this:

Because:

c. How will you manage his burns in terms of dressing and bandaging?

d. What hospital destination is most appropriate for Dale?

e. What mode of transport is most appropriate for Dale?

f. What continuing treatments should be given to Dale during transport?

g. How do you evaluate Dale’s condition? Critical, potentially critical, non-critical, routine. Explain your answer.

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Question 3You have determined that Dale needs advanced airway interventions!

What advanced airway intervention will you perform? Describe in detail, step-by-step, your management of Dale's airway.

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Question 4Using the Rule of Nines, what percent of Dale’s body is burned?

IMPORTANT: Show your calculations

Question 5a. Explain the Consensus Formula (previously Parkland Formula) and why it is used. Include information about fluid shifts in burn patients. (HINT: Review the Advanced Burn Life Support Manual)

b. If Dale weighs 100 kg, Apply the Consensus Formula to Dale’s case and explain your treatments, based upon it.

IMPORTANT: Show your calculations

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Question 6Discuss the characteristics of flash burns vs. flame burns vs. steam burns vs. chemical burns. Explain fully.

Flash Burns:

Flame Burns:

Steam Burns:

Chemical Burns:

Question 7a. What are the greatest immediate risks facing Dale?

b. What are the greatest delayed risks facing Dale?

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Question 8What body systems are involved with Dale’s injury? Explain your answers.

Question 9a. Discuss myoglobinemia in burn patients.

b. Discuss rhabdomyolysis in burn patients

c. Discuss hyperkalemia in burn patients.

d. Discuss infection in burn patients.

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