Trauma Studies For Paramedics - Critical Thinking - Assessment Answer

November 03, 2018
Author : Ashley Simons

Solution Code:1EBD

Question:Trauma Studies For Paramedics

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Assignment Task

Answer both of the questions below.

 Question 1:

You have a patient with a suspected spinal injury after they were 'dumped' in shallow water by a large, powerful wave at your local surf beach. Compare Queensland Ambulance Service (QAS) current spinal injury management with two other Ambulance service guidelines and discuss the current evidence surrounding the recent change in Australian Resuscitation Council Guideline 9.1.6 - Management of a suspected spinal injury in relation to the use of hard collars and backboards for immobilisation, extrication and transport.

Question 2:

On reassessment of a patient with severe chest injuries following an assault with a baseball bat you have a high index of suspicion that the patient has developed a tension pneumothorax. Using current evidence, discuss your pre-hospital management of this condition.

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Solution:

Introduction

Over the last few decades there has been tremendous change in the presentation of injuries in accidents occurring on the roads or on the sports field and even at work sites. The spinal and chest injuries have been studied in particular and found to need specialized handling right at the location where the injury occurs. This would mean that the pre-hospitalisation care would, to a large extent, be translated into the outcome of the recovery of the patient (Armstrong, Simpson, Crouch 2007).

Whether the patient would ever walk again or have the use of his or her lower limbs effectively or even be afflicted with paralysis of some part of the body would all depend on how the patient had been handled while being lifted from the place where the injury had taken place or wherever the patient had fallen or was found. It would also be determined if the spinal injury management was taken care of effectively and efficiently at the pre-hospitalisation stage itself.

The Australian Resuscitation Council Guidelines 9.1.6.

The Australian Resuscitation Council Guideline 9.1.6 has recommended certain procedures for handling patients having Spinal injuries. These guidelines are quite a change from the previously held motions on handling such patients. The guidelines advise against total immobilization of the patient or it may be counter indicative and cause unwarranted delay.

Another total change is the advice against using survival collars. This is because they do more harm than good. The adverse impact can be listed as follows:

  1. Sizing and fitting of the collar can cause unnecessary and unwarranted movement of neck and head. It can result in much discomfort and pain as well as causing pressure on the veins of the neck and raising the intra-cranial pressures.

The collar may also unnecessarily restrict the movement of the jaw for opening the mouth and even in swallowing (Benner, Brauning, Green, Caldwell, Borloz, Brady 2006). There is also the threat of choking in instances of vomiting. The air passages may get compromised and endanger the survival of the patient. Thus, the collar has been discarded as life-threatening in several cases. Its disuse has been strongly recommended by the ANZCOR Guideline 9.1.6.

Similarly rigid spinal boards have put the victim at further risk. Earlier than use was recommended and enthusiastically pursued by first aid and ambulance personnel alike. However, current research has highlighted the fact that even a healthy person left on a spine board tends to develop all forms of aches and pains in the region of the neck, the head, the lover back as well as the shoulder blades.

On a rigid board patient may attempt to find a comfortable position and try to move around in the attempt to do so. This could be potentially dangerous as there is scope of the injury getting. This form of prone stance can also result in patient of spinal injury suffering from a high risk of pressure neurosis.

The situation could be worse in patients who are unconscious. Thus, it has been reported that unconscious patients are exposed to greater risk in cases of stepping. This is because breathing is restricted and the patient’s life could be compromised (Crosby, 2006).

The ANZCOR 9.1.6 guidelines recommend the usage of air mattress, bead filled vacuum mattress or padded spine board. Most of these are usually available in the ambulance.

Comparison

There are well equipped ambulance services that have been trained and maintained by various states of Australia. The Queensland Ambulance service with its statewide presence of 298 response centre contributing to 15 Ambulance Service Networks and seven centres of operations has the distinction of being the top ambulance service in Australia as compared to the New South Wales or even the Victoria Ambulance Services. The Queensland Ambulance Service [QAS] has a large dedicated team of paramedics, Emergency Medical Dispatchers, Patient Transport Officers, Volunteer First Responders and well-knit, trained and managed Local Ambulance Committees. QAS has excellent aero-medical services coordination and is skilled in the management of multi-casualty trauma incidences as well as disasters either man made or natural. The services provided are transparent, efficient and medically well managed. This makes QAS one of the leading ambulances services in the world.

All three ambulance services are well equipped and have trained manpower. However, in the case of spinal injuries the QAS is well advanced. Their revised standard Operating Procedures comprise ensuring that the patient does not make any unnecessary movements. The head and neck are maintained in a neutral position with no flexion of the head.

However, the advise the use of a cervical collar and spine board. Yet they warm against use of spine board for transportation. For long distances they have recommended that special care is given to the pressure area.the Ambulance Victoria Services also uses the cervical collar and spinal board. This is counter-indicated according to the ANZCOR Guideline 9.1.6. They do give a number of criteria like age of patient, state of consciousness, evidence of injury etc to advice use of the two restrictive measures.

Conclusion

Comparing all three ambulance services for their procedures in dealing with spinal injuries it was observed that only QAS had endeavoured to follow the latest guidelines while the others continued to flout them. QAS did not use cervical collars and spinal boards. They were informed on the latest procedures

 Pre-hospital Management of severe Chest Injuries

Introduction

Tension pneumothorax is a common chest injury that presents in one out of 250 instances of chest injuries on an average. While chest injuries contribute significantly to fatal mortality there is a comparatively small incidence of life threatening chest injuries of which a larger part is the occurrence of Tension pneumothorax. It is on the early pre-hospital management on which depends the survival and recovery of the patient (Hood, Considine 2015).

There are strict guidelines for the pre-hospital management of chest injuries based on the consensus of experts in the field just about a decade ago.

Best Practices in Pre-hospitalisation care for chest injuries

These were some of the best practices that had been observed and practiced  by experts in the field all over the world. Some of the primary steps, according to these guidelines,  in the pre-hospitalisation care are delineated as follows:

  1. It is essential that high flow of oxygen be maintained for the patient from the very commencement of care. The target range of oxygen saturation should be maintained at 94 to 98 per cent at all times for all the patients who have suffered such major trauma. Breathing may or may not be strained but the target range of oxygen should be kept steady.
  2. The best position for aiding  breathing and for optimal gas exchange is the sitting up position or ideally with the ‘healthy lung down’ position of laying the patient down ion his or her side. However, this is difficult to attain in patients who may have also had spinal fractures and are hypovolaemic. This is also true for those patients who sustain some form of airway bleed on suffering a lung injury . This is a crucial stage for management while affecting the transfer of the patient with the greatest precaution and safety (Zideman, Singletary, Buck, 2015)
  3. In most cases effective handling of pain may be essential for providing immediate relief to the patient. If at the outset some effective analgesic is administered to the patient suffering from mild or severe pain then there may be little reason to go in for any form of invasive pre-hospital interventions on the thorax. Once the patient is out of pain it may be easier to have the transfer process conducted efficiently.
  4. Many a times it is very difficult to diagnose tension pneumothorax in patients suffering from chest injuries. Most ventilated patients may rapidly present with falling oxygen saturation levels as well as decreased levels of cardiac output. They may also exhibit increased inflation pressures  in the thoracic cavity. If this situation is not diagnosed rapidly there is every chance of the patient suffering cardiac arrest. Thus, tension pneumothorax can be seen to occur in instances of positive pressure ventilation in the patients suffering from chest injuries.
  5. In patients that are breathing spontaneously there is a marked level of difficulty in arriving at a diagnosis of tension pneumothorax. While the universal symptom of chest pain persists the decompensation occurs progressively. Along with the onset of respiratory distress there is the threat of other problems like tachycardia, ipsilateral decreased entry of air into the air passages which is observed in almost 50 per cent to 75 per cent of the patients (Ramasamy, Midwinter, Mahoney, Clasper, 2009).
  6. An effective tool that should be used at the early part of the diagnosis stage is the ultrasound. It can verify the diagnosis of a tension pneumothorax in a more accurate manner than the conventional form of radiographs of the chest.

Conclusion

It can be seen, therefore that the basic knowledge on the handling of chest injuries has undergone much  change in the last two decades. What were earlier thought to be the best practices in providing immediate relief to the patient have been re-examined in a fresh light. As newer systems of management have been evolved for the early management of chest injuries it is essential to have them in place. The pre- hospitalization care is initiated from the point where the patient is picked up at the site of the accident to the handing over of the patient to the hospital authorities. This form of pre-hospitalization care makes a major difference between life and death or even permanent injury and complete recovery for the patient. In fact it is the astute management of the immediate medical needs of the injured patient right from the site of the infliction of injury, all though the journey and finally to the nearest trauma centre (Ramasamy, Midwinter, Mahoney, Clasper, 2009).

The quality of pre-hospitalization care determines the final outcome of the overall treatment process. Thus, it can be concluded that effective, efficient, high quality and timely delivered, pre-hospital  management  and care at the pre-hospitalization stage is the key to preventing long term injury and in many cases even death in most presentations of severe chest injuries.

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