PHTLS: Prehospital Trauma Life Support

742 Pages·2014·30.98 MB·English

by  coll.

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Library of Congress Cataloging-in-Publication Data
PHTLS (1986)
PHTLS : prehospital trauma life support I 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. -Eighth edition.
p.;cm.
Prehospital trauma life support
Includes bibliographical references and index.
ISBN 978-1-284-0417 3-6
I. National Association of Emergency Medical Technicians (U.S.). Pre-Hospital Trauma Life Support Committee, author. II. American College of
Surgeons. Committee on Trauma, author. m. Title. IV. Title: Prehospital trauma life support.
[DNLM: 1. Wounds and Injuries-therapy. 2. Emergencies. 3. Emergency Medical Services. 4. First Aid-methods. 5. Traumatology. WO 700]
RC86.7
616.02'5--dc23 2014027414
6048
Printed in the United States of America
18 17 16 15 14 10 9 8 7 6 5 4 3 2 1
Brief Table of Contents
DIVISION 1 Introduction ............... 1 CHAPTER 15 Burn Injuries ....... 406
CHAPTER 1 PHTLS: Past, CHAPTER 16 Pediatric
Present, and Future ...................... 1 Trauma ................................... 428
CHAPTER 2 Injury Prevention ...... 1 4 CHAPTER 17 Geriatric
Trauma ................................... 456
DIVISION 2 Assessment and
Management .............................. 32 DIVISION 4 Summary ............... 475
CHAPTER 3 The Science, CHAPTER 1 B Golden Principles
Art, and Ethics of Prehospital of Prehospital Trauma Care ........ 4 75
Care: Principles, Preferences,
and Critical Thinking .................... 32 DIVISION 5 Mass Casualt ies
and Terrorism .......................... 487
CHAPTER 4 Physiology of
Life and Death ............................ 48 CHAPTER 19 Disaster
Management ............................ 487
CHAPTER 5 Kinematics of
Trauma ..................................... 70 CHAPTER 20 Explosions and
Weapons of Mass Destruction .... 508
CHAPTER 6 Scene Assessment 1 1 4
DIVISION 6 Special
CHAPTER 7 Patient Assessment
Considerations ......................... 542
and Management ...................... 1 36
CHAPTER 21 Environmental
CHAPTER B Airway and
Trauma I: Heat and Cold ............ 542
Ventilation ............................... 1 63
CHAPTER 22 Environmental
CHAPTER 9 Shock .................. 21 7
Trauma II: Lightning, D rowning,
Diving, and Altitude ................... 588
DIVISION 3 Specific Injuries ....... 25B
CHAPTER 23 Wilderness
CHAPTER 10 Head Trauma ...... 25B
Trauma Care ............................ 635
CHAPTER 11 Spinal Trauma ..... 288
CHAPTER 24 Civilian Tactical
CHAPTER 12 Thoracic Emergency Medical Support
Trauma ................................... 334 CTEMSJ .................................... 655
CHAPTER 13 Abdominal Glossary ...................................... 669
Trauma ................................... 362
lndex ........................................... 687
CHAPTER 14 Musculoskeletal
Trauma ................................... 378
Table of Contents
DIVISION 1 Introduct ion ............... 1 Concepts of Injury Prevention ................................. 23
Goal ....................................................................................... 23
~ CHAPTER 1 PHTLS: Opportunities for Intervention .............................................. 23
Potential Strategies ............................................................... 23
.., ~,) Past, Present, and
Strategy Implementation ....................................................... 23
- Future ...................... 1 Public Health Approach ......................................................... 26
Evolving Role of EMS in Injury Prevention ............ 27
Introduction ................................................................ 2
One-on-One Interventions ..................................................... 27
Philosophy of PHTLS ................................................... 2 Community-Wide Interventions. ............................................ 28
The Problem ............................................................................. 2 Injury Prevention for EMS Providers ..................................... 28
The Phases of Trauma Care ........................................ 3 Summary ................................................................... 29
Pre-event Phase ....................................................................... 4 Scenario Recap ......................................................... 30
Event Phase ............................................................................. 5
Scenario Solution ..................................................... 30
Postevent Phase. ...................................................................... 5
References ................................................................. 30
History of Trauma Care in Emergency
Suggested Reading .................................................. 31
Medical Services ......................................................... 7
Ancient Period ......................................................................... 7
Larrey Period (Late 1700s to Approximately 1950) ................. 7 DIVISION 2 Assessment and
Farrington Era (Approximately 1950 to 1970) ......................... 8 Managem ent .............................. 32
Modern Era of Prehospital Care (Approximately
1970 to Today) ..................................................................... 8
~ CHAPTER 3 The
PHTLS-Past, Present, Future .................................... 9
.., ~J Science, Art, and
Advanced Trauma Life Support ................................................ 9
PHTLS ..................................................................................... 10 · · Ethics of Prehospital
PHTLS in the Military ............................................................. 11 Care: Principles, Preferences,
International PHTLS ............................................................... 11
and Critical Thinking ......... 32
Vision for the Future .............................................................. 11
Summary ................................................................... 12
Scenario ..................................................................... 33
References ................................................................. 12
Introduction .............................................................. 33
Suggested Reading .................................................. 13
Principles and Preferences ...................................... 34
Situation ................................................................................ 35
f i
Condition of the Patient ........................................................ 36
CHAPTER 2 Injury Fund of Knowledge of the Prehospital
.., J
~, Prevention .............. 1 4 Care Provider ..................................................................... 36
Equipment Available .............................................................. 36
Critical Thinking ........................................................ 37
Scenario ..................................................................... 15
Using Critical Thinking to Control Biases .............................. 39
Introduction .............................................................. 15
Using Critical Thinking in Rapid Decision Making ................. 39
Concepts of Injury .................................................... 16
Using Critical Thinking in Data Analysis ................................ 39
Definition of Injury ................................................................ 16 Using Critical Thinking Throughout the Phases
Injury as a Disease ................................................................. 16 of Patient Care ................................................................... 40
Haddon Matrix ....................................................................... 17
Ethics .........................................................................4 0
Swiss Cheese Model .............................................................. 18
Ethical Principles ................................................................... 40
Classification of Injury ........................................................... 19
Autonomy .............................................................................. 41
Scope of the Problem ............................................... 19
Nonmaleficence ..................................................................... 42
Injury to EMS Personnel. ........................................................ 22 Beneficence ............................................................................ 42
Prevention as the Solution ...................................... 22 Justice .................................................................................... 43
Research .................................................................... 43 Scenario Recap ......................................................... 68
Reading the EMS Literature. .................................................. 43 Scenario Solution ..................................................... 68
Types of Evidence .................................................................. 43
References .................................................................6 9
Steps in Evaluation ................................................................ 44
Suggested Reading ..................................................6 9
Summary ................................................................... 46
Scenario Recap ......................................................... 46
~ CHAPTERS
Scenario Solution ..................................................... 47
,, ~,) Kinematics of Trauma .. 70
References ................................................................. 47
Suggested Reading .................................................. 48
Scenario ..................................................................... 71
'fi
Introduction .............................................................. 71
CHAPTER 4 Physiology
General Principles ..................................................... 72
,, J
~, of Life and Death ..... 49 Pre-event ............................................................................... 72
Event ...................................................................................... 72
Scenario ..................................................................... 50 Postevent ............................................................................... 72
Introduction .............................................................. 50 Energy ........................................................................ 72
Laws of Energy and Motion ................................................... 73
Airway and Respiratory System .............................. 50
Energy Exchange Between a Solid Object and the
Oxygenation and Ventilation of the
Human Body ....................................................................... 75
Trauma Patient ................................................................... 51
Blunt Trauma ............................................................. 79
Pathophysiology .................................................................... 54
Mechanical Principles ............................................................ 79
Circulatory System ................................................... 54
Motor Vehicle Crashes ........................................................... 79
Circulation and Oxygenation ................................................. 54
Motorcycle Crashes ................................................................ 88
Pathophysiology .................................................................... 54
Pedestrian Injuries ................................................................. 90
Shock ......................................................................... 54
Falls ........................................................................................ 92
Definition of Shock ................................................................ 55 Sports Injuries. ....................................................................... 93
Physiology of Shock ................................................. 55 Regional Effects of Blunt Trauma .......................................... 94
Metabolism: The Human Motor ............................................. 55 Penetrating Trauma .................................................. 98
The Fick Principle. .................................................................. 56
Physics of Penetrating Trauma ............................................... 98
Cellular Perfusion and Shock ................................................. 57 Damage and Energy Levels .................................................. 100
Anatomy and Pathophysiology of Shock ............... 57 Anatomy .............................................................................. 102
Cardiovascular Response ....................................................... 57 Regional Effects of Penetrating Trauma .............................. 103
Hemodynamic Response ........................................................ 59 Shotgun Wounds .................................................................. 105
Endocrine Response ............................................................... 61 Blast Injuries ........................................................... 107
Types of Shock .......................................................... 61 Injury From Explosions ........................................................ 107
Hypovolemic Shock ................................................................ 61 Physics of Blast .................................................................... 108
Hemorrhagic Shock ................................................................ 61 Interaction of Blast Waves With
Distributive (Vasogenic) Shock .............................................. 63 the Body ........................................................................... 108
Cardiogenic Shock ................................................................. 64 Explosion-Related Injuries ................................................... 108
Complications of Shock ........................................... 65 Injury From Fragments. ........................................................ 109
Acute Renal Failure ................................................................ 66 Multi-etiology Injury ............................................................ 110
Acute Respiratory Distress Syndrome ................................... 66 Using Kinematics in Assessment ........................... 110
Hematologic Failure ............................................................... 66 Summary ................................................................. 110
Hepatic Failure ....................................................................... 67
Blunt Trauma ........................................................................ 110
Overwhelming Infection ........................................................ 67 Falls ...................................................................................... 111
Multiple Organ Failure ........................................................... 67 Penetrating Trauma .............................................................. 111
Summary ................................................................... 68 Blasts ................................................................................... 111
Table of Contents vii
Scenario Recap ....................................................... 111 Establishing Priorities ............................................ 138
Scenario Solution ................................................... 112 Primary Assessment ............................................... 138
References ............................................................... 112 General Impression .............................................................. 139
Step A-Airway Management and Cervical Spine
Suggested Reading ................................................ 113
Stabilization ..................................................................... 139
Step B-Breathing (Ventilation) .......................................... 140
Step (-Circulation and Bleeding (Perfusion
' ~ CHAPTER 6 Scene and Hemorrhage) ............................................................. 141
_ J Step D-Disability ............................................................... 143
~· ~ Assessment .......... 1 1 4 Step E-Expose/Environment .............................................. 144
Simultaneous Evaluation and
Scenario ................................................................... 115 Management .................................................................... 145
Introduction ............................................................ 115 Adjuncts to Primary Assessment ......................................... 145
Resuscitation ........................................................... 145
Scene Assessment ................................................... 115
Transport .............................................................................. 146
Safety ................................................................................... 116
Fluid Therapy ....................................................................... 146
Situation .............................................................................. 116
Basic Versus Advanced Prehospital Care
Safety Issues ........................................................... 116
Provider Levels ................................................................ 146
Traffic Safety ........................................................................ 116
Secondary Assessment ........................................... 146
Mitigation Strategies. .......................................................... 117
Vital Signs ............................................................................ 149
Violence ............................................................................... 118
SAMPLE History ................................................................... 149
Hazardous Materials ............................................................ 119
Assessing Anatomic Regions ............................................... 149
Situation lssues ....................................................... 121
Neurologic Examination ...................................................... 152
Crime Scenes ....................................................................... 121
Definitive Care in the Field .................................... 152
Weapons of Mass Destruction ............................................. 122
Preparation for Transport .................................................... 153
Scene Control Zones ............................................................ 123
Transport .............................................................................. 153
Decontamination ................................................................. 123
Field Triage of Injured Patients ............................................ 153
Secondary Devices ............................................................... 123
Duration of Transport .......................................................... 154
Command Structure ............................................................. 125
Method of Transport ............................................................ 154
Incident Action Plans ........................................................... 126
Bloodborne Pathogens ........................................................ 128 Monitoring and Reassessment
Patient Assessment and {Ongoing Assessment) ........................................... 156
Triage ............................................................................... 130 Communication ....................................................... 156
Summary ................................................................. 135 Special Considerations ........................................... 156
Scenario Recap ....................................................... 135 Traumatic Cardiopulmonary
Scenario Solution ................................................... 135 Arrest ............................................................................... 156
Pain Management ................................................................ 158
References ............................................................... 135
Abuse ................................................................................... 158
Suggested Reading ................................................ 135
Prolonged Transport ............................................... 158
Patient Issues ....................................................................... 159
Crew Issues .......................................................................... 159
-~ CHAPTER 7 Patient Equipment Issues ................................................................. 159
_ J Summary ................................................................. 160
~· ~ Assessment and
Management ......... 1 36 Scenario Recap ....................................................... 160
Scenario Solution ................................................... 161
Scenario ................................................................... 137 References ............................................................... 161
Introduction ............................................................ 137 Suggested Reading ................................................ 162
viii Table of Contents
'fi
References ............................................................... 194
CHAPTER B Airway
..,. ~;f'J and Ventilation ....... 1 63 Suggested Reading ................................................ 194
~ CHAPTERS
Scenario ................................................................... 164
..,. _
Introduction ............................................................ 164 ~J Shock ................... 217
Anatomy .................................................................. 164
Scenario ................................................................... 218
Upper Airway ....................................................................... 164
Introduction ............................................................ 218
Lower Airway ....................................................................... 164
Physiology ............................................................... 166 Physiology of Shock ............................................... 218
Oxygenation and Ventilation of the Trauma Patient.. .......... 168 Metabolism .......................................................................... 218
Pathophysiology ..................................................... 169 Definition of Shock ................................................. 219
Decreased Neurologic Function ........................................... 169 Classification of Traumatic Shock ......................... 219
Hyperventilation .................................................................. 170 Types of Traumatic Shock ...................................... 219
Assessment of the Airway and Ventilation .......... 170 Hypovolemic Shock .............................................................. 219
Position of the Airway and Patient ...................................... 170 Distributive (Vasogenic) Shock ............................................ 221
Upper Airway Sounds .......................................................... 171 Cardiogenic Shock ............................................................... 223
Examine the Airway for Obstructions .................................. 171 Assessment .............................................................. 224
Look for Chest Rise .............................................................. 171 Primary Assessment ............................................................. 225
Management ........................................................... 171 Secondary Assessment.. ....................................................... 229
Airway Control ..................................................................... 171 Musculoskeletal Injuries ...................................................... 230
Essential Skills ..................................................................... 171 Confounding Factors ............................................................ 230
Manual Clearing of the Airway ............................. 175 Management ........................................................... 231
Manual Maneuvers .............................................................. 175 Airway. ................................................................................. 232
Suctioning ............................................................................ 175 Breathing ............................................................................. 232
Selection of Adjunctive Device ............................. 176 Circulation: Hemorrhage Control. ........................................ 232
Disability .............................................................................. 237
Simple Adjuncts ...................................................... 177
Expose/Environment ............................................................ 237
Oropharyngeal Airway ......................................................... 177
Patient Transport .................................................................. 237
Nasopharyngeal Airway ....................................................... 177
Vascular Access .................................................................... 237
Complex Airways .................................................... 177
Volume Resuscitation .......................................................... 238
Supraglottic Airways. ........................................................... 177
Prolonged Transport ............................................... 244
Endotracheal Intubation ...................................................... 178
Summary ................................................................. 245
Continuous Quality lmprovement. ........................ 188
Scenario Recap ....................................................... 246
Ventilatory Devices ................................................ 188
Scenario Solution ................................................... 246
Pocket Masks ....................................................................... 188
Bag-Mask Device ................................................................. 188 References ............................................................... 246
Manually Triggered (Oxygen-Powered) Devices .................. 188 Suggested Reading ................................................ 247
Positive-Pressure Ventilators ............................................... 189
Evaluation ............................................................... 190 DIVISION 3 Specific Injuries ....... 258
Pulse Oximetry ..................................................................... 190
Capnography. ....................................................................... 191 ~ CHAPTER ., 0
Prolonged Transport ............................................... 192 .,, ~J Head Trauma ......... 258
Summary ................................................................. 193
Scenario Recap ....................................................... 193 Scenario ................................................................... 259
Scenario Solution ................................................... 193 Introduction ............................................................ 259
Table of Contents ix