Prehospital Trauma

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					PreHospital Trauma
   Life Support
      th
    6 edition



            Compendium of
              Changes
                             2006


                                    PreHospital Trauma Life Support Committee
           of the National Association of Emergency Medical Technicians
 in cooperation with the Committee on Trauma of the American College of Surgeons
                    General Philosophy of the 6th edition

   Incorporate 2004 changes to the Advanced Trauma Life Support® course (7th
    edition) as taught by the Committee on Trauma of the American College of
    Surgeons.

   Increased emphasis on evidence published in the medical literature
       o section on Reading the medical literature added to chapter 1 (Introduction)
       o include numbered references with citations at the end of each chapter

   Book organized into logical sections

   Add section on Prolonged Transport considerations to most chapters

   Revise algorithms to reflect content changes presented in text

   Skills video now in DVD format for improved functionality

   New chapter scenarios; review questions to be moved to on-line resource


Continued from the 5th edition:

   Continue to be “evidence-based” to the extent possible, demonstrating the science
    behind PHTLS
       o incorporate data from new clinical research on trauma care in the prehospital
          setting
       o incorporate position papers as appropriate from national EMS organizations,
          such as the National Association of EMS Physicians
       o suggested readings provided for most chapters

   Ensure the course focuses on “principles” not protocols to provide prehospital care
    providers with the knowledge base to make reasonable patient care decisions

       o No “official PHTLS” way to perform skills
       o Principle for each skill stated
       o Illustration of one acceptable method of performing the skill that meets the
         principle provided

   Maintain consistency between chapters in terms of terminology, assessment and
    management; assessment sections follow the primary survey (ABCDE approach)

   Include metric weights and measurements for international PHTLS providers

   Term “prehospital care provider” replaces EMT because other health care
    professionals (nurses, physicians, etc) may function in the prehospital setting,
    especially in aeromedical services or internationally
                                                                                          2
SECTION I


   Provider
   Textbook



              3
Textbook layout


Division I- Energy and Injury
       1 Introduction to PHTLS
       2 Injury Prevention
       3 Kinematics of Trauma

Division II- Assessment and Management
       4 Scene
       5 Patient
       6 Airway and Ventilation
       7 Shock

Division III- Specific Injuries
       8 Head Trauma
       9 Spinal Trauma
       10 Thoracic Trauma
       11 Abdominal Trauma
       12 Musculoskeletal Trauma
       13 Burn Trauma
       14 Pediatric Trauma
       15 Geriatric Trauma
       16 Environmental Trauma I: Heat and Cold
       17 Environmental Trauma II: Drowning, Lightning, Diving and Altitude

Division IV- Summary
       18 Golden Principles of Prehospital Trauma Care

Division V- Special Considerations
       19 Disaster Management
       20 Weapons of Mass Destruction
       21 Civilian Tactical Emergency Medical Support
       22 Wilderness Trauma Care


Bold = new chapters and content




                                                                              4
Chapter 1: Introduction to PHTLS


     Statistics updated
     Figure 1-6 revised to better illustrate the time savings of transporting patients to
      facilities with in-house surgeons
     New section on Reading the Medical Literature
         o Discusses levels of evidence
         o Explains steps in evaluation
         o Includes new Box notes:
                   Suggested Journals for review
                   Performing a Computerized Literature Search




                                                                                             5
Chapter 2: Injury Prevention


     Statistics updated in text and tables
     Section on Injury Prevention for EMS Providers expanded
     Footnotes added




                                                                6
Chapter 3: Kinematics of Trauma


     Many new or revised illustrations
     Blast injury
         o New injury definitions
                    Quaternary injuries- injuries imposed by heat or fumes, producing
                     burns, inhalation injury or asphyxiation
                    Quinary injuries- health effects of additives to bombs, including
                     bacteria, radiation or chemicals
         o New chapter devoted to blast injuries in the 6th Edition Military version

     New section: Shotgun Wounds
         o Describes “anatomy” of the typical shotgun shell
         o Range / distance from weapon when discharged is most important
             variable
         o Wounds:
                    Contact wounds- widespread tissue damage; high lethal
                    Close-range wounds- penetrates through fascia; mortality 15 –
                     20%
                    Intermediate range wounds- penetrates into subcutaneous tissue
                     and fascia; mortality 1 – 5%
                    Long range wounds- superficial skin penetration; mortality rate 0%




                                                                                         7
Chapter 4: Scene
     Scene assessment was approximately 2 pages in the 5 th Edition, now it is a
      separate chapter in the Assessment and Management section of the book

     Significantly expanded discussion of all the issues related to assessing and dealing
      with a potentially dangerous scene

     Stress that patient assessment and management only comes after scene safety has
      been assured

     Overview of the process of assessing a scene

     Scene Assessment discussion focused on the 2 major components (which have
      overlap)
         o Safety – primarily focused on personnel safety
         o Situation – primarily focused on the situation confronted
      Each section is presented with clearly defined discussions of the issues that are
      part of each of these components

     Safety Issues
         o Traffic related
                 Weather / light
                 Highway design – reviews high speed limited-access roads versus
                   rural roadway issues
                 Mitigation Strategies
                        Reflective clothing
                        Vehicle Positioning
                        Warning Devices

         o Violence
               Safety suggestions – the use of the “hands-on, hands-off” roles of 2
                 partners
               Safety rules
                     Don’t be there
                     Retreat
                     Diffuse
                     Defend




                                                                                          8
       o Bloodborne Pathogens – includes an expanded discussion of the risks and
         specific diseases encountered along with prevention strategies
             Viral hepatitis (B and C)
             Human Immunodeficiency Virus
             Standard precautions
                     Physical barriers
                          o Gloves
                          o Masks and face shields
                          o Eye protection
                          o Gowns
                          o Resuscitation equipment
                     Handwashing
             Box note: Preventing Sharps injury
             Management of occupational exposure
                     Box note: sample exposure protocol

       o Hazardous Materials – this provides an overview of the issues related to
         responding to a scene involving a hazardous materials release or exposure.

   Situation Related Issues

       o Crime scenes – discussion of the problems and issues faced when
         responding to a scene involving a crime, the police investigation and
         evidence preservation

       o Weapons of Mass Destruction – this section provides an overview of the
         issues related to response to a scene involving a WMD
             o Zones of control
             o Decontamination
             o Secondary devices

       o Scene Command
            o Incident command – overview
            o Unified command
            o National Incident Management System overview
            o Command
            o Incident Action Plans – overview

   Patient Assessment and Triage

       o This section provides a general overview of the patient assessment and
         triage process
             o On-scene resources and what is needed
             o Patient triage – includes a general description of triage as well as the
                START triage method



                                                                                          9
Chapter 5: Patient
     Primary Survey
         o Focus remains “Treat as you go approach”

         o Circulation
               Hemorrhage control:
                       De-emphasizes elevation and pressure points
                       Tourniquets recommended for extremity hemorrhage
                        uncontrollable by direct pressure or pressure dressing (see
                        Chapter 7: Shock)

     Resuscitation
        o Fluid management consistent with Shock chapter

     Algorithm
         o Modified to reflect changes in hemorrhage control and volume resuscitation

     Box note: discusses handling forensic evidence

     Field Triage Scheme
          o Recently revised by American College of Surgeons Committee on Trauma,
             and a panel of experts convened by the Centers for Disease Control and the
             National Highway Transportation Safety Administration

         o Minimal changes to Steps One and Two
               Revised Trauma Score deleted
               Crushed, degloved or mangled extremity added to Step Two
               Burns moved to Step Four

         o Most changes in Steps Three and Four
              Falls > 10 feet for child
              High-risk auto crash
                      Intrusion: > 12 inches occupant site; > 18 inches anywhere
                      Vehicle telemetry data
                      Auto vs. pedestrian/bicyclist thrown, run over or significant (>
                          20 mph) impact
              Children preferentially triaged to pediatric-capable facilities
              Burns with trauma mechanism to trauma center, otherwise to burn
                 facility
              Pregnancy > 20 weeks
              Time-sensitive extremity injury
              EMS provider judgment




                                                                                          10
   Special Considerations
      o Traumatic Cardiopulmonary arrest
              Reorganized
              Section on withholding resuscitation
              Sections on Basic Life Support and Advanced Life Support
              Terminating CPR

   Prolonged Transport
       o Patient Issues
              Safe, warm secure environment
              Security of IV lines, equipment
              Serial assessments
              Medical plan (patient management) and travel plan (route)

       o Crew
             Appropriate safety devices

       o Equipment
             Sufficient supplies for transport (50% more than anticipated)




                                                                              11
Chapter 6: Airway and Ventilation

   Discussion added regarding airway and RSI research conducted since the last
    edition

   Pocket Mask added to section on Ventilatory Devices

   Expanded the discussion of Positive Pressure (Transport) Ventilators with added
    material about the various modes of ventilation

   Discussion of capnography expanded
       o A sudden drop in expired CO2 may result from either a dislodgement of the
         ET tube or decreased perfusion and should prompt a reevaluation of patient
         status and ET tube position

   New section regarding Prolonged Transport
      o Decision making regarding managing the airway during prolonged transport
      o Monitoring of the patient
      o Potential complications en route
      o Use of sedation during prolonged transport

   Algorithm unchanged from 5th edition




                                                                                      12
Chapter 7: Shock


     Anatomy and Pathophysiology
        o Sections significantly edited; reorganized and distilled down

     Management
        o Breathing- maintain SpO2 ≥ 95%
              Over-aggressive ventilation may seriously impair hemodynamics in
                the hypovolemic shock patient by the creation of auto-PEEP
              For an adult, a tidal volume of 350 – 500 mL at a rate of 10 breaths
                per minute is probably satisfactory

        o Circulation
              Hemorrhage control
                      Elevation and pressure points de-emphasized
                          o Elevation of an injured extremity may worsen injuries
                              (convert closed fracture to open)
                          o No data that elevation or pressure points improves
                              outcome of injured trauma patients

                        Tourniquets
                            o Used safely in operating rooms for years
                            o Documented efficacy in recent military applications
                            o Device can be a manufactured tourniquet, a blood
                               pressure cuff or a cravat tied into a “Spanish windlass”
                            o Applied just proximal to the site of hemorrhage, and
                               tightened until bleeding stops
                            o Mark time tourniquet applied on the tourniquet; leave the
                               site exposed for visual monitoring of hemorrhage
                            o Box note on sample tourniquet protocol

                        Topical hemostatic agents
                            o No published studies in civilian environment
                            o HemCon (chitosan) dressing- effective at controlling
                               hemorrhage, recommended by Committee on Tactical
                               Combat Casualty Care
                            o QuikClot- may cause serious burning of healthy tissue
                               because of exothermic reaction; may be lifesaving if
                               other measures fail
                            o TraumaDex- no data to recommend its use
                            o Agents primarily for prolonged transport settings




                                                                                      13
o Resuscitation
         Internal hemorrhage may cease as a result of blood clotting
          mechanisms and hypotension
         Aggressive volume resuscitation may “pop” the clot, resulting in
          recurrent hemorrhage and worsening of the patient’s condition
         Hypovolemic shock resulting from internal should be managed
          differently that that due to external hemorrhage that is easily
          controlled; volume resuscitation should be tailored to the clinical
          setting
                   Uncontrolled hemorrhage- suspected internal hemorrhage in
                    chest, abdomen or retroperitoneum; maintain SBP 80 – 90 mm
                    Hg (mean BP 60 – 65 mm Hg)
                   Suspected Central Nervous System Injuries (brain or spinal
                    cord); risk of hypoperfusion to CNS may outweigh risk of
                    recurrent internal hemorrhage; maintain SBP > 90 mm Hg
                   Controlled hemorrhage- such as that from an extremity; may
                    administer a 1 – 2 liter bolus of crystalloids and volume
                    resuscitate to normal vital signs unless hypotension recurs, in
                    which case one should suspect potential internal hemorrhage
                    and maintain SBP 80 – 90 mm Hg
o Prolonged Transport
         Serial vital signs
         Hemorrhage control- use tourniquet if direct pressure fails or is
          impractical
         If transport time exceeds 2 hrs, may consider removing dressings,
          evacuating obvious blood clot and applying HemCon or QuikClot and
          redressing; consider releasing tourniquet. If hemorrhage recurs,
          reapply tourniquet.
         Rewarm if hypothermic
         Consider urinary and nasogastric catheters
o Shock algorithm modified to reflect content changes


                                                                                      14
Chapter 8: Head Trauma


     Edited by a neurosurgeon (former EMT)
     Physiology- expanded discussion of cerebral blood flow, mean arterial pressure,
      cerebral perfusion pressure and autoregulation
     Pathophysiology
         o Secondary brain injury reorganized
         o New discussion of clinical herniation syndromes
     Specific Injuries
         o Scalp injuries- external hemorrhage the major concern
         o Facial Injuries
                   Mandibular fractures- may result in airway compromise
                   Nasal fractures- often associated with epistaxis
                    Midface fractures
                             LeFort I- maxilla fractures off midface
                             LeFort II- pyramidal fracture through sinuses
                             LeFort III- facial bones fractures off skull
                             Midface fractures may result in airway compromise from either
                              hemorrhage or mechanical obstruction
         o Laryngeal fractures- hoarseness is a common finding, and patients may
             present with extensive subcutaneous air
         o Cervical vessels- injuries to the carotid arteries and jugular veins may result
             in exsanguinating hemorrhage; jugular vein injuries may be associated with
             air embolism
     Management
         o Airway- expanded discussion regarding controversies of airway management
             of brain injured patients
         o Breathing- hyperventilation is associated with worse outcome. Consider both
             tidal volume and ventilatory rate




                                                                                          15
   Prolonged transport
       o Serial exams
       o Prevention of secondary brain injury
       o Interventions suspected increased intracranial hypertension
   Expanded section on Brain death and organ donation
   Algorithm: minimal changes




                                                                       16
Chapter 9: Spinal Trauma


     Limited changes
     Penetrating trauma
         o Ligamentous injuries that result in an unstable spinal column are extremely
            unusual from penetrating trauma to the head, neck or torse
         o Algorithm altered to include head and neck along with penetrating torso
            trauma
     Obese patients
         o Many long backboards only 16 or 18 inches wide with weight limits of 250
            pounds
         o Need for wider, stronger backboards
     Steroids
         o In most circumstances, the administration of steroids is not indicated for
            suspected spinal cord injury in the prehospital setting
     Prolonged transport
         o Appropriate padding
         o Monitor pulmonary status for deterioration
         o Assess for associated injuries
         o Loss of thermoregulation




                                                                                         17
Chapter 10: Thoracic Trauma


     Several new illustrations
     Expanded discussion of physiology, including box on Pulmonary Volumes and
      Relationships
     Expanded section on Pathophysiology, including discussion of how blunt and
      penetrating injuries can affect pulmonary and circulatory function
     Assessment section enhanced
     Specific injuries:
         o Rib fractures- consideration of pain management
         o “Cardiac tamponade” replaces pericardial tamponade”
                    “Cardiac box” introduced; penetrating trauma inside the box should
                     increase suspicion for cardiac injury
         o New: Commotio cordis
                    Sudden cardiac arrest resulting from a sharp blow to the anterior
                     chest; believed to result from injury occurring during a vulnerable
                     period during the cardiac cycle
                    CPR initiated; consider AED / ECG monitor if available
                    Defibrillate and initiate advanced cardiac life support measures
         o Traumatic disruption of the aorta
                    New box not on need to keep mean blood pressure less than 70 mm
                     Hg to prevent rupture
         o New: Traumatic asphyxia
                    Appears dramatic, but discoloration not life-threatening
                    Sign of significant crushing injury to the chest.; be suspicious of
                     underlying injuries
     Prolonged Transport
         o Monitor pulmonary status
         o Avoid aggressive volume resuscitation
         o Manage cardiac dysrhythmias



                                                                                           18
Chapter 11: Abdominal Trauma


     New illustrations and photographs
     Discussion of Assessment significantly expanded
         o New section on Kinematics
         o New section on History
         o New Box note on Peritoneal signs
     New Box note: Focused Assessment with Sonography for Trauma (FAST) exam
     Pregnancy
         o Expanded sections on Assessment and Management
     New section on Genitourinary injuries
         o Emphasis on hemorrhage control




                                                                                19
Chapter 12: Musculoskeletal Trauma


     Extensively reorganized; many new photographs
     Specific musculoskeletal injuries
         o Hemorrhage
         o Instability
                   Fractures
                            Management
                                o Open & closed fractures
                                o Femur fractures
                                o Pelvic Fractures
                            New: Box note on Pelvic Fractures
                                o Rami
                                o Acetabular
                                o Ring
                                         Lateral compression (60 – 70%)
                                         Anterior/posterior compression (15 - 20%)
                                         Vertical shear (5 – 15%)
     Special considerations
         o Critical multisystem trauma patient- emphasis on life threatening issues
         o Expanded: Pain management
                   Morphine
                   Fentanyl
                   Meperidine
         o Amputations
         o Compartment syndrome
                   5 P’s: pain, paresthesias, pallor, pulselessness and paralysis
         o Crush syndrome
                   Compartment syndrome
                   Shock from inflammatory mediators
                   Myoglobinuria


                                                                                      20
       o Mangled extremity- involves extensive damage to two or more of the
          following: skin/soft tissue, tendons, bone, blood vessels, nerves
   Algorithm: changes to reflect content changes
   Prolonged transport
       o Focus on primary survey, life threatening issues
       o Assessment for compartment syndrome
       o Splint instability
       o Irrigate contaminated open wounds




                                                                              21
Chapter 13: Burn Trauma


   The title was changed from Thermal Trauma: Injuries produced by Heat and Cold to

    the current title Burn Trauma

       o This change indicates a more focused discussion of burn related injuries

   A presentation of the various anatomical changes and the clinical features of 1st,

    2nd, 3rd, and 4th degree burns with added artwork

   Burn size estimation

       o Present a modified Parkland resuscitation (2 to 4 mL/kg/ % burn) instead of

           a strict Parkland resuscitation

       o NEW - a Lund-Browder chart for estimation of burn size

       o NEW - a Burn Resuscitation Index or “the rule of ones” for determination of

           burn size as well as fluid resuscitation needs

       o NEW – A discussion of the differences between a burn trauma patient versus

           a trauma patient with blood loss

   Discussion of the initial burn care and assessment is significantly expanded

   Discussion of electrical injuries is significantly expanded

       o Electrolyte changes

       o Myoglobinuria

       o Specific fluid management strategies for electrical injuries

   Discussion of smoke inhalation is expanded

       o Thermal inhaled injury

       o Asphyxiants

                 Carbon monoxide


                                                                                         22
               Hydrogen cyanide

                      Cyanide antidote

               Toxic induced lung injury

   Child abuse section—NEW

      o 20% of all pediatric burn injuries

      o Scald burns

      o Contact burns

   Radiation Burns -NEW

      o Occupational exposure

      o Nuclear attack

      o Hazardous Material Scene

      o Decontamination

      o Acute Radiation Syndrome

      o Fluid resuscitation in mass casualty incident

               Moyer’s solution

               WHO oral rehydration solution

   Chemical Burns – Expanded

      o Scene control

      o Decontamination




                                                        23
       o Specific common chemical injuries

                Cement

                Hydrofluoric acid

                White phosphorus

                Hypochlorite solutions

                Sulfur and nitrogen mustards (chemical weapons)

                Tear gas (chemical weapon)

       o Control of contamination

   Prolonged transport
       o Airway management / inhalation injuries
       o Carbon monoxide poisoning and ventilatory support
       o Decontamination of chemical burns
       o Volume resuscitation
       o Pain control




                                                                   24
Chapter 14: Pediatric Trauma


   Edited by a team of pediatric trauma surgeons
   New illustrations
   New: Common patterns of Injury section and table
   New: Box note on Pediatric injuries associated with seatbelts and air bags
   New: Box note on controversies of pediatric endotracheal intubation
   Specific Injuries
       o Organized in a head-to-toe order
       o New: section on Burns
       o New: section on Pain management
   Prolonged transport section
   New: Pediatric Disaster Triage: JumpSTART
       o Primary and Secondary triage
   New: box on documenting child abuse




                                                                                 25
Chapter 15: Geriatric Trauma


     Reorganized for improved readability and logical flow
     Mention of the role of nutrition in immune function
     New: section on Common medications
         o Discusses how certain medications affect assessment and physiologic
            response to injury
     New: box on reporting suspected elder abuse and neglect
     Prolonged transport
         o Primary survey / management of shock
         o Susceptibility to pressure ulcers and the need for padding
         o Temperature control- prevention of hypothermia




                                                                                 26
Chapter 16: Environmental Trauma: Heat and Cold


   Extensively expanded; only 8 pages on Heat and Cold in 5 th edition
   Thermoregulation and temperature balance
   Heat injury
       o Section and Box on Risk factors: fitness, BMI, age, gender, medical conditions,
          medications
       o Dehydration
       o Minor illnesses:
                 Heat rash
                 Heat edema
                 Heat tetany
                 Heat cramps
       o Major illnesses
                 Heat exhaustion
                 Heat Stroke
                 Exertional hyponatremia
       o Prevention of Heat related illness
       o Prevention of heat illness in prehospital care providers
       o Emergency response rehabilitation


   Cold injury
       o Dehydration
       o Minor illnesses
                 Cutaneous freeze injury
                 Frost nip
                 Cold urticaria
                 Chillblains
                 Solar keratitis




                                                                                       27
       o Major illnesses
                Localized cutaneous cold injury
                Non-freezing cold injury
                Freezing cold injury
                Hypothermia
                Immersion hypothermia
       o Basic and Advanced Cardiac Life Support for Cold Injuries
       o Prevention of cold-related injuries
   Prolonged transport
       o Heat injuries
       o Cold Injuries




                                                                     28
Chapter 17: Environmental Trauma II: Drowning, Lightning, Diving and
       Altitude


   Drowning or near-drowning
       o Epidemiology
       o Submersion factors
       o Mechanism of injury
       o Assessment
       o Management
       o Prevention


   Lightning
       o Epidemiology
       o Mechanism of Injury
       o Injuries from lightning
       o Assessment
       o Management
       o Prevention


   Recreational SCUBA-related injuries
       o Epidemiology
       o Mechanical effects of pressure
       o Diving-related Injuries
                   Barotrauma
                   Decompression sickness
       o Assessment
       o Management
       o Prevention




                                                                       29
   High Altitude
       o Epidemiology
       o Hypobaric hypoxia
       o High-altitude illness
                   Factors related to high-altitude illness
                   Acute Mountain sickness
                   High Altitude cerebral edema (HACE)
                   High Altitude pulmonary edema (HAPE)
       o Prevention
   Prolonged transport
       o Near drowning
       o Lightning
       o Recreational scuba-related injuries
       o High Altitude related illness




                                                               30
   Chapter 18: Golden Principles of Prehospital Trauma Care


       Discussion of hemorrhage control reflects content changes in Chapter 7 : Shock
       Introduces concept of financial harm
           o Investing in costly but unproven technologies / equipment
       Minimal changes from 5th edition:
           o Golden Principles of Prehospital Trauma Care remain the same




                                                                                         31
Chapter 19: Disaster Management


   Introduction
   Disaster cycle
   Mass casualty Incident Management
    o Incident Command System
   Common pitfalls of Disaster Response
    o Communications
    o Scene security
    o Self-dispatched assistance
    o Supply and equipment resources
    o Media
    o Preparedness
   Medical response to Disasters
    o Initial response
    o Search and Rescue
    o Triage
    o Transport
    o Medical Assistance Teams
   The Threat of terrorism and weapons of mass destruction
   Decontamination
   Psychological Response to Disasters
    o Characteristics of disaster that affect mental health
    o Factors impacting psychological response
    o Psychological sequellae of disasters
    o Interventions
    o Worker stress
   Disaster Education and Training




                                                              32
   Chapter 20: Weapons of Mass Destruction

         Introduction
         General Considerations
             o Scene Assessment and the Incident Command System
             o Personal Protective Equipment
             o Patient Triage
             o Principles of Decontamination
         Specific Threats
             o Explosive Agents
                        Categories of Explosives
                        Mechanisms of Injury
                        Injury Patterns
                        Evaluation and Management
                        Transportation Considerations
             o Incendiary Agents
             o Chemical Agents
                        Classification of Chemical Agents
                        Physical Properties of Hazardous Materials
                        Personal Protective Equipment
                        Evaluation and Management
                        Transportation Considerations
                        Selected Specific Agents
                                Cyanides
                                Nerve Agents
                                Lung Toxicants
                                Vesicant Agents
             o Biological Agents
                        Classification of Biological Agents
                        Concentrated Biohazard Agent vs. Infected Patient
                                Contact precautions
                                Droplet precautions
                                                                             33
                Aerosol precautions
         Selected agents
                Anthrax
                Plague
                Smallpox
                Botulinum toxin
o Radiological Disasters
         Medical Effects of Radiation Catastrophes
         Personal protective equipment
         Evaluation and Treatment
         Transportation considerations




                                                      34
Chapter 21: Civilian Tactical Emergency Medical Support

        Scenario

        Definition of TEMS and Protective Medicine

        The TEMS Concept

            o Benefits of TEMS

            o Barriers to Traditional EMS Access

            o Daily Routine Doctrine

        Zones of Care

            o Hot Zone

            o Cold Zone

            o Warm Zone

            o Transit Risk

        Differences between TEMS and EMS

            o Cost-benefit Decisions

            o Airway Management

            o Cardiac Arrest

            o Spinal Immobilization

            o Rapid and Remote Assessment Methodology

            o Noise and Light Discipline




                                                          35
   Medical Counterterrorism Operations

       o Operational and Communications Security

       o Integration

       o Forensic science support

       o Medical intelligence

       o Screening for Incarceration

   Performance Decrement

   Patient Advocacy

   Summary




                                                   36
Chapter 22: Wilderness Trauma Care


       Proper Care Depends on Context

       The Wilderness EMS Context

           o Backcountry injury patterns

           o Safety

           o The Wilderness is Everywhere

       EMS Decision-Making: Balancing the risks and benefits

           o “Clearing” the cervical spine in the wilderness

           o Improvised Evacuations

       Patient Care in the Wilderness

           o Elimination Needs

           o Everyone is Cold, Hungry and Thirsty

           o Backboards Hurt Patients

           o Sun protection

       Specifics of Backcountry EMS

           o Wound Management

           o Hemostasis (stopping bleeding)

           o Antisepsis (Prevention of Infection)

           o Restoration of Function and Cosmesis: Closing backcountry wounds


                                                                                37
       o Dislocations

       o CPR in the Backcountry

                Backcountry Medical arrest and CPR

       o Bites and Stings

                Bee stings

                Snakebite

   The “Wilderness EMS” Context revisited

   Conclusion




                                                      38
SECTION II


   Provider
   Program


              39
Provider Course

Global Changes
       Interactive presentation approach supported by new lesson plan formats
       Increased integration of scenarios throughout lessons
       There is one PHTLS course. There are not basic and advanced courses.

Provider Course Schedules
   Schedules list length of each lesson, rather than prescribing specific program start and
    end times
   There is a preferred schedule, but also an alternative schedule that allows course
    coordinators to schedule baselines and skill teaching stations closer together to
    facilitate skills evaluator/instructor scheduling
   Baseline determinations do not include course pre-test. Pre-test is to be completed by
    participants and provided to the course coordinator prior to the beginning of the course
   Spinal injuries and traumatic brain injuries are covered in a single lesson on CNS
    trauma
   Essential material on abdominal trauma and musculoskeletal trauma are integrated into
    the shock lesson to emphasis the relationship between these injuries and shock




                                                                                          40
Course Plan A (preferred)

        Day One

Course Introduction & Overview              15 minutes
Baseline Determinations (Scenarios only;    45 minutes
written pretest is completed prior to the
course)
Lessons Learned in Trauma Management        20 minutes
(New)
Break                                       10 minutes
Kinematics of Trauma                        60 minutes
Principles of Assessment & Management       45 minutes
Airway, Oxygenation & Ventilation           50 minutes
(Formerly Airway Management and
Ventilation; increased emphasis on tissue
oxygenation)
Lunch                                       45 minutes
Central Nervous System Trauma (Includes 45 minutes
spinal and traumatic brain injury)
Skills Teaching Stations (begins with videos 3 hours, 20 minutes
to uniformly demonstrate skills)
Regroup


        Day Two

Shock (Incorporates key material from            55 minutes
abdominal and musculoskeletal trauma)
Thoracic Trauma                                  45 minutes
Thermal Trauma                                   30 minutes
Break                                            10 minutes
Trauma in Special Patient Populations (Includes 45 minutes
pregnant, pediatric, and geriatric patients)
Skills Teaching Stations (begins with videos to 90 minutes
uniformly demonstrate skills)
Lunch                                           45 minutes
Golden Principles of Prehospital Trauma Care     20 minutes
Final Evaluations (Written & Practical)          3 hours



                                                                   41
Course Plan B (alternative)

        Day One

Course Introduction & Overview                 15 minutes
Lessons Learned in Trauma Management           20 minutes
(New)
Kinematics of Trauma                           60 minutes
Break                                          10 minutes
Principles of Assessment & Management          45 minutes
Airway, Oxygenation & Ventilation (Formerly    50 minutes
Airway Management and Ventilation;
increased emphasis on tissue oxygenation)
Lunch                                          45 minutes
Central Nervous System Trauma (Includes         45 minutes
spinal and traumatic brain injury)
Baseline Assessments (Scenarios only; written 45 minutes
pretest is completed prior to the course)
Skills Teaching Stations (begins with videos to 3 hours, 20 minutes
uniformly demonstrate skills)
Regroup




        Day Two

Shock (Incorporates key material from abdominal 55 minutes
and musculoskeletal trauma)
Thoracic Trauma                                 45 minutes
Thermal Trauma                                    30 minutes
Break                                             10 minutes
Trauma in Special Patient Populations (Includes   45 minutes
pregnant, pediatric, and geriatric patients)
Skills Teaching Stations (begins with videos to   90 minutes
uniformly demonstrate skills)
Lunch                                             45 minutes
Golden Principles of Prehospital Trauma Care      20 minutes
Final Assessments (Written & Practical)            3 hours




                                                                      42
Baseline Determinations

       Motor vehicle collision requiring rapid extrication remains the preferred scenario.
       Alternative scenario of a patient who has fallen, but who has the same management
        priorities, is provided for instances of inclimate weather or other extenuating
        circumstances
       Injuries for both scenarios include:
                       Patient airway
                       Very rapid, shallow ventilations
                       GCS 14
                       Tender left lateral chest wall
                       Pain in upper left quadrant of abdomen, radiating to shoulder
                       Open right tibia/fibula fracture
                       Complaint of neck pain

Scenarios and Teaching Stations

   Rotation schedules for teaching and final evaluation stations list the length of each
    station, rather than prescribing specific rotation start and end times
   No changes to skills or scenarios

Final Skills Evaluation Station

   Rotation schedules for teaching and final evaluation stations list the length of each
    station, rather than prescribing specific rotation start and end times
   No changes to scenarios

Final Written Evaluation

   All new items
   Different items than pre-test, but based on same specifications
   Participants answer all items, regardless of certification/licensure level




                                                                                              43
SECTION III

   Instructor,
   Coordinator
   And
   Refresher
   Programs


                 44
Instructor Program

   Separation of instructor and coordinator components
   Instructor course focuses on ways to achieve interaction with participants and
    adherence to principles versus preferences in skills and final evaluations
   Coordinator functions are covered briefly for familiarity, but in-depth coverage is not
    provided




Course Coordinator Program:

       Instructor/Coordinator is now referred to separately: Instructor and Coordinator
       Coordinator information has been split out from the PHTLS Instructor Course
            o A separate Roles & Responsibilities for Coordinator is listed in the Instructor
                Manual/Policy & Process document
            o   Coordinator is primarily a management/administrative position
       Coordinator Orientation is offered on-line
            o any experienced instructor is eligible to take the Orientation
            o once orientation is complete, submit the associated quiz to State/Provincial
                Coordinator
            o must be monitored during first course being coordinated
       Coordinators can monitor new instructors, as designated by State/Provincial or
        Affiliate




                                                                                              45
Refresher Program

   No current changes
   Revised refresher program will be available to course coordinators via the PHTLS
    website in 2007




                                                                                       46

				
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