Patients With Traumatic

Injuries
Condell Medical Center
EMS System
August 2008 CE
Site code #10-7200E1208

Prepared by: Sharon Hopkins, RN, BSN, EMT-P

Objectives
Upon successful completion of this

module, the EMS provider should be

able to:
Identify the differences between a Category
I, II and III trauma patient
State transport decisions for trauma
patients based on Region X guidelines
Understand what the mechanism of injury is
and the information it provides
Understand the difference between the
index of suspicion and the general
impression

Objectives contd
Describe assessment and treatment
appropriate for the patient with traumatic
insult based on Region X SOPs
Burns, tension pneumothorax, sucking chest
wound, flail chest, pericardial tamponade,
eviscerated organs
Successfully calculate the GCS and RTS given
the patients parameters
Identify and appropriately state interventions
for a variety of EKG rhythms
Identify ST elevation on a 12 lead EKG
Successfully identify the landmark and perform
chest needle decompression
Actively participate in trauma scenario
discussion
Successfully complete the quiz with a score of
80% or better

Leading Causes of Death

In the age groups from 1 to 44, unintentional
injury is the leading cause of death
45 and over, the leading causes of death are
disease
cardiovascular disease and cancers
These statistics point to a financial burden
placed on the patient as well as society for
unintentional injuries
Source: National Vital Statistics System, National Center for
Health Statistics, CDC

Level I Trauma Centers

Prepared and committed to handle all

types of specialty trauma 24/7

Provides leadership and resources to
other levels of trauma care in the
Region
Participates in data collection, research,
continuing education, and public
education programs
Level I: Evanston Hospital, St. Francis in
Evanston
Level I non-Region X: Advocate Lutheran
General, Froedtert (Wisconsin)

Level II Trauma Centers

Increased commitment to trauma care for
the most common trauma emergencies
with surgical capability available 24/7
Participates in data collection, continuing
education, and public education
programs
Level II: Condell, Glenbrook, Highland
Park, Lake Forest, Rush North Shore, Vista
Medical Center East (VMH)

Additional Level II Trauma

Centers
- Not
Geographically In Region X
Centegra McHenry, Illinois
Good Shepherd Hospital (GSH)
Barrington, Illinois
Northwest Community Hospital
(NWCH) Arlington Heights

Region X SOP -Trauma

Transport
Systolic B/P < 90 on 2

consecutive readings (or peds

< 80)
Transport to the highest level
Trauma Center within 25
minutes
25 minute clock starts from the
time of injury

Region X SOP Trauma

Transport
Traumatic arrest, isolated burns >20%
Transport to the closest Trauma
Center

No airway
Transport to the closest
Emergency Department

Region X SOP Trauma

Transport
Category I Trauma Patient
Unstable vital signs
Based on anatomy of the injury
Transport to the highest level
Trauma Center within 25 minutes
25 minute clock starts from the
time of injury

Region X SOP Trauma

Transport

Category II Trauma Patient

Based on mechanism of injury

High potential for injury but patient is

stable for now

Based on existence of co-morbid factors
that increase the risk of complications to
recovery
Transport to the closest Trauma Center

Region X SOP Trauma

Transport
Category III Trauma Patient

All other traumatic injuries and

routine care is being provided
Isolated traumatic injury (generally
GCS >10)
Isolated fractures
Minor burns
Lacerations
Transport the patient to the closest
Trauma Center

Mechanism of Injury
The process and forces that cause

trauma
Mentally recreate the incident from the
evidence noted
Identify strength of forces involved
Identify direction forces came from
Identify areas of the patients body
most likely affected by the forces
Start to identify the mechanism of injury
during the scene size-up

Injury Patterns Pedestrians

Adults

Generally turn away & present lateral

surfaces
Anatomically, impact is low on the body
Injuries to tibia, fibula, femur, knee, lateral
chest, upper extremity, then head & neck
Pediatrics
Generally turn and face the vehicle
Injuries anatomically higher on the body than
adults
Injuries to femur, pelvis and then those
sustained when run over or pushed aside by
the vehicle

Injury Patterns Motor

Vehicle

Rotational (38% of MVC)

Injuries similar to frontal & lateral

Deceleration is usually more gradual &
injuries less serious although the vehicles
look worse
Frontal (32% of MVC)
Up and over pathway
Femur fractures
Blunt abdominal injury via compression
Lower chest injuries after steering wheel
impact
Head & neck injuries with windshield
impact

Injury Patterns Motor

Vehicle
Down and under pathway
Lower leg injuries from sliding under the
dash
Chest injuries with steering wheel impact
Collapsed lungs from breath holding at
time of impact
Ejection
27% of fatalities
2 impacts with interior vehicle & then the
objects outside the car (ground, trees,
fences, etc)

Injury Patterns Motor

Vehicle
Lateral impact (15% of MVC; 22% of all MVC
fatalities)

Much less structural steel for protection between

victim and impact site
Vehicle damage may not look severe but internal
injury potential is high
Upper & lower extremity fractures on impact side
Lateral compression with a large amount of
internal injury to chest & abdominal organs
Unrestrained passengers are missiles and add to
injuries other passengers already sustained

Injury Patterns Motor

Vehicle
Rear end (9% of MVC)
Head rotates backward and then snaps
forward
Less neck injury if the head rest is in place

Rollover (6% of MVC)

Occupant experiences impact every time

vehicle impacts a point on the ground
Vehicle sides and roof provide less crumple
zones for absorbing impact forces
Ejection is common in unrestrained persons

Index of Suspicion
Your anticipation of injury to a

body, region, organ, or structure

based on identification of the
mechanism of injury
Your index of suspicion is honed
from experience and time on the
job

General impression

Formed from mechanism of

injury and index of suspicion

Will guide the EMS provider
regarding a direction on how
to proceed in caring for this
patient and be a guideline on
choosing which SOP to follow

Documentation To Include of
The Complaint

O - onset
P provocation/palliation
Q - quality
R - radiation
S severity (0 10)
T timing when did it start

Documentation
Provide answers to:
Who (the patient youre caring for)
What (happened)
When (did it happen)
Where (which body part)
How (did it occur)

Trauma Care Amputated

Parts
Routine trauma care
To remove gross contamination, gently rinse

with normal saline

DO NOT use distilled water to irrigate open
wounds
Normal saline is isotonic and less harmful to
tissue
Cover stump with damp (normal saline) sterile
dressing and ace wrap
Ace provides uniform pressure to stump
Cover wounds with sterile dressing

Care of Amputated Parts

Place part in a plastic zip

lock bag
Place bag in larger bag or
container over ice and water
Do not ice the part alone

Pain Management Including for

Adult Burns
Morphine for pain control
2 mg slow IVP over 2 minutes
May repeat every 2 minutes as
needed to a maximum of 10 mg
Watch for respiratory depression
Monitor for a drop in blood
pressure due to vasodilation
from the medication

Adult Burns - Electrical

Immobilize the patient
High potential for traumatic injury
Muscle spasms during contact
with source
Thrown when power source cut
Assess for dysrhythmia place on
cardiac monitor
Assess distal neurovascular status of
affected part
Cover wounds with dry sterile
dressings

Adult Burns - Inhalation

High risk for airway compromise
Note presence of wheezing,

hoarseness, stridor, carbonaceous

sputum, singed nasal hair
High flow oxygen via non-rebreather
mask
Monitor for need of advanced airway
device
ETT
Combitube if trained and approved

Adult Burns - Chemical

Consider need for HAZ-MAT involvement
If powdered chemical, first brush away

excess dry material

Remove clothing if possible
Flush burned area with sterile saline
If eye involvement, remove contact lenses
and flush continuously with sterile saline
Avoid contamination of noninvolved areas

Adult Burns - Thermal

Superficial 1st degree
Cool burned area with saline
<20% BSA involved, apply sterile
saline soaked dressings
>20% BSA, apply dry sterile dressing
Do not overcool major burns or apply
ice directly to burned areas

Adult Burns - Thermal

Partial or full thickness (2nd or 3rd degree)
Wear sterile gloves and mask while burn areas
are exposed
Cover burn wound with dry sterile dressings
Preventing air flow over exposed burn areas
reduces pain levels
Place patient on clean sheet on stretcher
Cover patient with dry clean sheets and blanket
protect from hypothermia

Infant differences:
back 13%,
each buttocks
2.5%, each entire
leg 14%

Case Study #1
Adult patient who reached over a charcoal grill
just as the match was thrown onto the soaked
coals
Injury is restricted to the right arm

What type of burn is this?

Using the Rule of Nines, what is the TSBA
burned?
What type of care is appropriate?
How can the pain be managed?
What does the documentation look like?

Case Study #1 Patient with

Burns

Case Study #1
Combination of superficial and partial thickness burns

approx 4.5% TSBA (circumferential around forearm)

Evidence of redness with a blistered area although
blister is broken
Appropriate care includes cooling burn, applying sterile
saline soaked dressing (<20% TBSA)
Additional helpful care
Elevation of arm, removal of ring before fingers swell
For pain control
Morphine 2 mg slow IVP; can repeat 2 mg in 2
minutes up to 10 mg

Case Study #1 Documentation

What, when, where, how
Our 52 year-old patient received superficial
and partial thickness burns approximately
20 minutes ago to her right forearm when
reaching across flames from a charcoal
grill.
Detailed description of injury
Description of intervention prior to EMS &
that which EMS provided
Response to intervention

Chest Injuries Traumatic

Arrest Category I Trauma
Begin CPR
Transport to closest Trauma Center
A hospital on by-pass must take a
patient in life threatening condition if
they are the closest appropriate hospital
Perform bilateral chest decompression
Use common sense does your scene
size up, evaluation of mechanism of
injury and general impression indicate a
potential chest wall injury?

Chest Injuries Tension

Pneumothorax Category I
Trauma

History of injury to the chest wall

Diminished breath sounds
Hyperresonance if percussion done
Severe dyspnea
Hyperinflation of chest
Jugular vein distention
Tachycardia
Hypotension

Needle Decompression
Landmarks anterior approach
2nd intercostal space in the midline of
the clavicles
Place prepared flutter valve needle
over the top of the rib
Avoids potential injury to vessels
and nerves that run along the
bottom of the rib

Quick Way to Find 2

nd

ICS

Feel for the top of the sternum

Roll your finger tip to the anterior surface at
the top of the sternum
Feel the little bump near the top of the
sternum
This bump is the Angle of Louis

From the Angle of Louis slide your fingers

angled slightly downward toward the affected

side following the rib space
You are automatically in the 2nd ICS

Identify the midline of the clavicle

The midline is more lateral than persons realize
and usually runs in line with the nipple

Alternate Method to Find 2nd

Intercostal Space
Palpate the clavicle and find the midline
The midline is farther out (more lateral) from
the sternum than most persons realize

Move your finger tips under the clavicle

into the 1st intercostal space

1st rib is under the clavicle and is not palpated

Spaces identified for the numbered rib above
the space

Feel for the firm 2nd rib and palpate the

soft space below the rib
This is the 2nd ICS

Needle Decompression
Find your own 2nd ICS
Now find your neighbors 2nd ICS
Use both methods to find the landmark
and decide which is easiest for you

Documentation

To include signs and symptoms

Size of needle used (length and gauge)
Site needle inserted into
Response from the patient

Equipment
Long needle (preferably 2-3 inch) and large
bore needle (preferably 12-14G)
Flutter valve
Cleanser to prepare skin overlying the site
Method to secure needle in place

Skin will most likely be diaphoretic

Tape may not stick
May need to maintain manual control of needle

Skin Preparation
Midline of
clavicle
2nd ICS
Angle of
Louis

Inserting the
Needle
Remove proximal end cap

from

needle
Will be able to hear trapped air escaping
Needle inserted over top of rib
Once hiss of air heard continue to advance
catheter while withdrawing stylet
Stabilize catheter as best as possible
Patient should symptomatically improve
Do not expect to hear improved breath sounds;
takes time for the lung to reexpand

Case Study #2
EMS is called to the scene for a 52 year-old

male with c/o sudden onset dyspnea with

pain between his shoulder blades while
watching TV at home. The patient is agitated,
short of breath, with increased respiratory
rate and SaO2 of 89%.
Further assessment reveals decreased breath
sounds on the right and clear on the left
Vital signs: 98/62; HR 118; RR 32 and shallow
Your impression & intervention plan?

Case Study #2
Spontaneous tension pneumothorax
They dont all develop from trauma

Begin supplemental oxygen support via

non-rebreather, cardiac monitor,

preparation for IV
BUT
Quickly prepare for needle decompression
while the above are being prepared
Patients with a tension pneumothorax cant
wait and will deteriorate without needle
decompression

Sucking Chest Wound

Category I Trauma

Most common with penetrating wounds

Free passage of air between the
atmosphere and pleural space if the
open wound is at least 2/3rd the size of
the diameter of the trachea
Size of trachea about the size of pts 5th
finger

Air is drawn into the chest cavity

Air replaces lung tissue
Lung collapses

Sucking Chest Wound

Severe dyspnea
Open chest wound
Check anterior, posterior, axilla areas

Frothy blood at wound opening

Sucking sound as air moves in and
out
Tachycardia with hypovolemia

Treatment Sucking Chest

Wound
Immediate treatment is to seal the
opening

May start by placing a gloved hand over the

wound
When able, place an occlusive dressing,
taped on 3 sides, over the wound

Wound now converted to a closed

pneumothorax
Monitor for signs of tension
pneumothorax

May need to lift a corner of the dressing to

release trapped air via burping dressing

Flail Chest Category I

Trauma

3 or more adjacent ribs broken in 2 or

more places

Segment becomes free with pardoxical chest

wall motion during respirations
Paradoxical movement more evident after the
muscles splinting the flail segment fatigue

Usually takes a tremendous amount of

blunt trauma to cause a flail chest

Often present will be associated severe
underlying injury (ie: pulmonary contusion)
Respiratory volume reduced and
respiratory effort increased

Treatment Flail Chest

Place patient on the injured side (may not be

possible to do this in the field based on mechanism of

injury)

High flow oxygen nonrebreather mask

Monitor for need to assist ventilations via BVM
to deliver positive pressure ventilations
Evidence of underlying pulmonary injury
Effort and fatigue
Pulse oximetry
EKG monitoring
Tremendous amount of force is delivered to the
chest wall and cardiac injury is highly likely as a
result

Pericardial Tamponade
Category I Trauma
Blood or other fluid fills the pericardial sac
restricting cardiac filling & contractility
Most often related to penetrating trauma
Venous return to the heart is restricted
Decreased cardiac output
Pressure on the coronary arteries restricts
blood flow to the myocardium

Pericardial Tamponade Signs &

Symptoms
Usually history of penetrating trauma
Agitated patient
Diminished strength of pulses (weak and thready)

with tachycardia
Narrowing pulse pressure
Diastolic & systolic numbers moving closer together
Distended neck veins (JVD)
Diaphoretic and pale
Muffled, distant heart tones
Hypotension

Treatment Pericardial
Tamponade
Treatment in the field is limited to

being supportive
Patient requires high index of
suspicion and/or rapid identification
with rapid transport
In ED will perform needle thoracentesis
and then transfer the patient to the OR
for open heart surgery

General Assessment Pearls

Restlessness and agitation
You must consider hypoxia,
shock, influence of alcohol
and/or drugs
This is one time you need to assess
for all reasons of restlessness and
not just stop when you discovered
one cause there may be more than
one pathology going on at a time

Evaluation Pearls Low

SaO2

SaO2 reading may be inaccurate in the presence

of:
Hemorrhagic shock with delayed capillary refill
Hypothermia
Lung damage
Evaluate all parameters together to get the best
overall picture in ventilated patient
What does the ETCO2 indicate?
Are you able to ventilate the patient?
Are there extenuating circumstances where
the circulation is affected and would affect the
pulse ox reading like those listed above?

More
Case
Studies

Case Study #3
Your 34 year-old

patient received a
GSW to the right
upper abdomen.
They are conscious
and alert; B/P 90/62;
HR 120; RR 28;
bleeding is minimal
Category trauma?
What are your
interventions?

Case Study #3 Category I

Trauma

Make sure the scene is secured

Consider need for spinal immobilization
During assessment of wound, consider

thoracic injury in addition to abdominal

injury depending on the angle of the GSW.
Examine for an exit wound
Check the back and the axilla

Prepare for the worst assume the patient

will deteriorate before ED arrival
Repeat VS: B/P 80/; HR 140; RR 32,
remains conscious and in pain
Transport to the highest level Trauma
Center within 25 minutes

Case Study #3 - Treatment

Routine trauma care
Question is this an isolated abdominal

wound or is it a combination abdominal/ chest

wound?
Need to treat patient for potential injuries of
both body cavities
EMS cannot determine in the field the angle
of the trajectory
Cover the wound and watch for evisceration
Fluid resuscitation keep B/P at low levels;
the higher the B/P the faster the patient
bleeds out

Case Study #3 Documentation

If patient states anything, put it in quotes

If information available, add angle patient shot
from (ie: above, below) and distance from
weapon
If known, list type of weapon used
Include results of inspection, auscultation,
palpation

Location of entrance and exit wound

Size of wound(s)
Assessment of the general area (ie: contusions,
bleeding, swelling/distention, pain, powder marks)

Preserve evidence as much as possible

Case Study #4
Your 10 year-old

patient
has a
penetrating
injury to
the right leg
above the
knee while
playing in
his backyard
Initial VS: B/P 90/70;
HR; 130; RR 32; no
active bleeding
Category trauma? Field
interventions?

Case Study #4 Category III

Next VS: B/P 92/64; HR 110; RR 20.
Stabilize foreign body in place
Obtain distal neurovascular status

Distal pulses
Movement can you wiggle your toes?
Sensation close your eyes and tell me
which toe I am touching

Document distal neurovascular

status and describe how the foreign

object is stabilized in place

Case Study #5
Your 62 year-old patient had abdominal
surgery 1 week ago. Today at home he
sneezed hard and felt a tearing
sensation in his
abdomen and
called EMS.
VS: B/P 100/60;
HR 110; RR 24
No active
bleeding
What
interventions
are appropriate?

Case Study #5 Interventions

Immediately cover the wound

Need to minimize contamination

Need to prevent more organs from protruding
Need to prevent loss of fluids

Place a saline moistened dressing over the

exposed tissue
Place dry gauze over the saline dressings
Can place light manual control over the
organs to prevent further evisceration
especially during movement, coughing,
sneezing, deep breaths

Case Study #6
21 year-old drove into a metal fence. Upon

EMS arrival, there is obvious external chest

injury with bleeding. Coming closer to the
patient, EMS can hear a sucking sound from
the chest wound.
Patient is alert, in pain, severe dyspnea
VS: B/P 90/62; HR 130; RR 34; GCS 15
Breath sounds L > R
Look at the injury what is your impression
and what interventions are necessary?

MVC Into Metal Fencing

Case Study #6 Category I

An adequate dressing will be difficult to
achieve with such an extensive wound

A gloved hand just wont be enough to get

started

This patient may be a candidate for

conscious sedation and intubation to

provide positive pressure ventilation
Reassessment VS: B/P 80/56; HR 140;
RR 36 GCS remains 15
Transport is to highest level trauma
center within 25 minutes

Case Study #6 - Treatment

Open chest wounds need to be covered

ASAP with a non-occlusive dressing

Carefully monitor if the treatment of the
open chest wound converts the injury into a
tension pneumothorax
Carefully monitor the patient for the need
for more aggressive airway control (ie:
supportive ventilation via BVM or intubation)
Initially can start O2 therapy with a nonrebreather mask

Case Study #6 Documentation

What cause of the injury (penetration,
MVC, pedestrian, etc)
When the injury occurred
Where by body location

quadrant refers to the abdomen

Chest injuries uses reference such as
anterior/ posterior, nipple line, upper/lower
chest wall

How the injury occurred

Expand and give detail description of the
injury, treatment rendered, pt response

Case Study #7
Your 45 year-old patient is a

construction worker who was

accidentally shot in the head with a
nail gun
Upon arrival, the patient is awake,
alert, talking (GCS 15)
VS: B/P 132/78; HR 96; RR 20;
complains of a minor headache;
minimal bleeding at a few puncture
wounds noted on the occipital area of
the scalp (patient has thick hair).

X-ray
from
ED
No
deficit
s
noted

Case Study #7 - Treatment

Consider any injury above the level of the

clavicles to include a c-spine injury until proven

otherwise and immobilize the patient
Control bleeding
The face and scalp have such a rich blood supply
small wounds tend to bleed heavily

Protect from further contamination

The open wound may be in direct contact with the
brain

Document neurological evaluation to establish

baseline for comparison (AVPU, GCS, movement)

Case Study #8
You are called to the scene for a 10 year-old
female who has been run over by a bus
As patient exited bus, she bent down to tie
her shoe and was caught under the wheels
of the bus
Upon your arrival, you note a large amount
of avulsed tissue with bleeding from the left
hip, left buttock, and left upper thigh area
The patient is screaming in pain
VS: B/P 110/70; HR 110; RR 26 GCS 15
What is your impression?
What is your treatment plan?

10 y/o run over by bus

Case Study #8 Category I or

II?
General impression

Category II minimally pedestrian run-over

Category I trauma if unstable pelvis or 2 or
more long bones (proximal bones) fractured
and vital signs unstable
Potential problems to consider & address
Massive hemorrhage & control of hemorrhage
Spinal injury
Additional injuries
Airway control
Equipment to fit a 10 year-old
Further wound contamination

1 year F/U with skin grafts

Glasgow Coma Scale - GSC

Tool used to evaluate and monitor a

patients condition
Evaluates
Best eye opening
Best verbal response
Best motor response
Serves as an indicator/predictor of survival
To be performed on all EMS patients

GCS
Possible total score 3 (lowest) 15 (highest)
13 15
Minor head injury patient scores
Moderate head injury patient scores 9 12
Severe head injury patient scores <8
Significant mortality risk

GCS Pearls
The change in the GCS is more important

than the absolute score

Check for associated injuries
Manage a head injury as a multiple injured
patient until other injuries ruled out
Stabilize the neck for any head injury
Dont assume the level of consciousness is
altered just because of ETOH and/or drugs
Is there an occult (hidden) injury present?
Provide accurate, clear, detailed
documentation

GCS Eye Opening 1-4

Points
Spontaneous (4) eyes open; may or may not focus

To voice (3) prior to touching the patient, eyes will open to

sounds around them or EMS calling/yelling to them to open

eyes
Often difficult to accurately assess due to EMS gaining
immediate c-spine control so difficult at times to
determine if patient responded to voice or touch (pain)
To pain (2) doesnt necessarily imply you must apply
painful stimulus, could be just to touch
Flutter of eyelids is scored as 2
None (1) eyes remain closed with no eyelid flutter or other
eye movement; eyes do not open

GCS Verbal Response 1-5

Points
Oriented (5)
Confused (4)

Words may be appropriate to situation but pt does

not respond to questions
Inappropriate words (3)
Words are spoken and understood but nonsensical
to the situation (over there)
Incomprehensible words (2)
Includes mumbling, unintelligible speech, moaning
None (1)

GCS Motor Response 1-6

Points
Obeys command (6)
Localizes pain (5)

Patient who pulls equipment off; pushes your

hands away; purposeful movement
This patient knows where the obnoxious stimuli is
contacting his body

Withdraws to pain (4)

Pt cannot isolate where they feel the noxious

stimuli so just pulls back/withdraws

Flexion (3) arms bent towards midline when

stimulated
Extension (2) arms extended when
stimulated
None (1) remains flaccid

GCS Pearls
Give the patient the best score
possible

If the patient moves the right side of their

body but no movement on their left, score
them for the movement they currently
exhibit on the right
If patient deteriorates, easier to see the
drop or change in the GCS score

When testing for responses, watch

even for minimal activity like eyelid

flutter or a grimace

GCS Pearls
Acceptable noxious stimuli
Armpit pinch or nailbed pressure
Sternal rub, pinching web space
between fingers, pinching shoulder
muscle (trapezius)
Earlobe pinch is out of favor
Can cause movement of head &
neck in response to the pain

RTS Scoring 0 12 points

GCS & RTS Practice #1

Patient eyes are open and they watch you

during the examination

The patient is confused; they dont
remember how they got hurt and cant
remember the day of the week
When you ask the patient to show me 2
fingers, they respond but are slow to do so
VS: B/P 120/70; HR 88; RR 18
Total GCS?
Total RTS?

GCS & RTS Practice #2

The patient does not open their eyes
The patient groans when pinched or
an injured body part is touched
The patient does not follow
commands and will push your hands
away when you touch them
VS: B/P 96/68; HR 102; RR 22
Total GCS?
Total RTS?

GCS & RTS Practice #3

The patients eyes are open
When asked what month is this?,

the patient responds, he, umm, he

my jacket. I dont ..
If touched or pinched, the patient
pulls away from the contact
VS: B/P 132/72; HR 96; RR 16
Total GCS?
Total RTS?

GCS & RTS Practice #4

Your patients eyes are closed but they

open wide if the patients injury is

touched
The patient yells dont or stop when
there are pinched but does not answer
questions or speak in sentences
The patient will push your hands away
when you touch them
VS: B/P 108/64; HR 102; RR 18
Total GCS?
Total RTS?

GCS & RTS Practice #5

The patients eyes are closed but the

eyelids flutter when you loudly call out

their name
The patient does not answer questions
but will groan when touched but not say
recognizable words
The patient does not follow commands
but will push away your hands when
touched
VS: B/P 80/52; HR 112; RR 12
Total GCS?
Total RTS?

GSC & RTS Practice #6

The patients eyes are closed but will open

when the patient is touched

The patient says leave me alone and
what are you doing? and goes back to
sleep. When eyes are open they respond I
dont know to questions
They do not follow command and will push
your hands away when touched
VS: B/P 110/68; HR 88; RR 20
Total GCS?
Total RTS?

GCS/RTS Practice Answers

#1 GCS 14 (4, 4, 6)

RTS 12 (GCS 4; RR 4; B/P 4)

#2 GCS 8 (1, 2, 5)
RTS 10 (GCS 2; RR 4; B/P 4)
#3 GCS 11 (4, 3, 4)
RTS 11 (GCS 3; RR 4; B/P 4)
#4 GCS 11 (2, 4, 5)
RTS 11 (GCS 3; RR 4; B/P 4)
#5 GCS 10 (3, 2, 5)
RTS 10 (GCS 3; RR 4; B/P 3)
#6 GCS 11 (2, 4, 5)
RTS 11 (GCS 3; RR 4; B/P 4)

Identify Rhythm Strip #1

Treatment Symptomatic
Bradycardia

Bradycardia or Type I Wenckebach

Atropine 0.5 mg rapid IVP

May repeat every 3-5 minutes to total of 3mg
If ineffective, begin pacing

Type II or 3rd degree heart block

Begin TCP
Valium 2 mg slow IVP for discomfort
May repeat 2 mg IVP every 2 minutes to max 10 mg
TCP set at rate 80/minute and start at lowest mA
Watch for capture
If TCP not effective, give Atropine 0.5 mg rapid IVP
May repeat Atropine 0.5 mg every 3-5 minutes; max
3mg

Identify Rhythm Strip #2

6 second strip

Treatment Sinus Rhythm

No treatment necessary for the rhythm
Treat the patients complaint
IF ACS, then

Aspirin 324 mg chewed (faster absorption)

Nitroglycerin 0.4 mg sl
May repeat in 5 minutes; watch B/P
Morphine if 2nd NTG dose not effective
2 mg slow IVP
May repeat every 2 minutes to max 10 mg
Screen for recent Viagra type drug usage

Identify Rhythm Strip #3

6 second strip

Treatment Rapid Atrial

Fibrillation
Stable patient with B/P >100 mmHg
Verapamil 5mg SLOW IVP over 2+ minutes
If no response in 15 minutes & B/P stable,
repeat 5mg SLOW IVP over 2+ minutes

Unstable patient with B/P <100 mmHg

Contact Medical Control for direction

Afib patients at increased risk for atrial

clots dislodging and migrating to the
brain and the patient having an
ischemic stroke

Rhythm Strip Identification

Strip #1 Second degree Type I Wenckebach (drops one)

Strip #2 Normal sinus rhythm

Strip #3 Atrial fibrillation controlled

#1 Identify ST Elevation

#2 Identify ST
elevation

#3 Identify ST Elevation

ST Elevation Answer Key

EKG #1 Leads V 1 - 4
EKG #2 Leads V 2 - 5
EKG #3 Leads II, III, aVF

Bibliography
Bledsoe, B., Porter, R., Cherry, R. Paramedic

Care Principles & Practices 2nd Edition

Brady.
2006.
ITLS Bulletin. Case Study: ITLS Patient ETCO 2.
June 2008.
Region X SOPs Eff date March 1, 2007;
Revised January
2008.
www.chems.alaska.gov/ems/document/GCS
www.merck.com
www.swsahs.nsw.gov.au/