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PHTLS
PREPARATION
PACKET
th
Edition
Note: This packet contains the latest trauma guidelines, review information and pre-test. It is mandatory that participants review the textbook, complete the pre-test and be familiar with the PHTLS assessment and management criteria prior to the course. A pre-test score of 76% is required for this course. Feel free to contact our office should you have any questions The pre-test will be collected at the beginning of the class.
Ó 2023
Shaun Fix
Florida’s Premier Provider Of Quality Medical Training Programs
Nationally Accredited and OSHA Programs
CEU Provider
Since 1988
Pre-Hospital Trauma Life Support_10th^ edition
60 min Lesson^6 (Secondary Survey)
10 min BREAK
60 min Lesson^ 7A^ (Disability-Traumatic Brain Injury)
10 min BREAK
60 min Lesson^ 7B^ (Disability-^ Spinal Injury)
60 min LUNCH
60 min Lesson^8 (Special Considerations)
Stations 1-3 are found
in Day 1
Final Scenario Evaluations- 45 minutes each
(Each student is team leader in 1 case)
Station 4 :
Student led scenarios
Skills Case
Review Rapid
Extrication
Circulation Case 3
Circulation Case 4
Special Case 16
Special Case 22
Station 5 :
Student led scenarios
Skills Case
Review IO for
Trauma
Circulation Case 1
eXsanguinating Case 1
Multisystem Case 2
Circulation Case 2
Station 6 :
Student led scenarios
Skills Case
Review Traction
Splint
Review Pelvic
Binder
eXsanguinating Case 3
Exposure Case 4
Disability Case 5
Special Case 16
60 min Written Exam
Day 2
End of Day 2
Prehospital External Hemorrhage Control Protocol Spine Board Debate
It is agreed that the long board is an appropriate device for extrication and patient movement on scene and to a
stretcher, but 2015 brought about documented controversy as to its effectiveness at truly immobilizing the spine
and its benefits; Key Issues:
- There are no documented studies to support that straight rigid board immobilization with a collar is
beneficial.
- Some patients’ anatomy actually flexes the head forward while others hyperextend the head when placed on
a board.
- Patients will all begin to complain of neck and back pain if left on a hard board.
- Skin breakdown can occur at points that contact the board.
- Obese patients are at risk for positional asphyxia
- Emergency airway procedures are more difficult to perform on immobilized patients
The lack of supporting benefit and the growing potential for detrimental side effects has led many areas to decrease
or completely remove the use of spine boards for anything more than extrication or movement. Instead opting for
placing a collar on the patient and lying the spine on the stretcher.
*Some protocols for ruling “in” or “out” the use of spinal immobilization are still utilized.
Apply direct pressure/pressure dressing to injury Direct pressure effective (hemorrhage controlled) Direct pressure ineffective or impractical (hemorrhage not controlled) Wound amenable to tourniquet placement (e.g. extremity injury) Wound not amenable to tourniquet placement (e.g. junctional injury) Apply a tourniquet* Apply a^ topical hemostatic agent with direct pressure# Pack wound if necessary
PHTLS Shock
Classification of Hemorrhagic Shock Class I Class II Class III Class IV Blood loss (mL) Up to 750 750 - 1500 1500 - 2000 > Blood loss (% vol) Up to 15% 15%-30% 30%-40% >40% Pulse rate <100 100 - 120 120 - 140 > Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or increased Decreased Decreased Decreased Respiratory rate 14 - 20 20 - 30 30 - 40 > Urine output (mL/hr) >30 20 - 30 5 - 15 Negligible CNS/ mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Signs Associated with Types of Shock Vital Sign Hypovolemic Neurogenic Septic Cardiogenic Skin temperature Cool, clammy Warm, dry Cool, clammy Cool, clammy Skin color Pale, cyanotic Pink Pale, mottled Pale, cyanotic Blood pressure Drops Drops Drops Drops Level of consciousness Altered Lucid Altered Altered Capillary refilling time Slowed Normal Slowed Slowed Type of Fracture Blood Loss Potential Rib 125 mL Radius or ulna 250 - 500 mL Humerus 500 - 750 mL Tibia or fibula 500 - 1000 mL Femur 1000 - 2000 mL Pelvis 1000 - unlimited mL There are three types of shock:
- Hypovolemic shock
- Vascular volume smaller than normal vascular size
- Loss of fluid and electrolytes
- Loss of blood and fluid
- Distributive shock
- Vascular space is larger than normal
- Neurogenic “shock” (hypotension)
- Psychogenic shock
- Septic shock
- Anaphylactic shock
- Cardiogenic shock
- Pump failure Shock Assessment Vital Sign Compensated Decompensated Pulse Increased; tachycardia Greatly increased; marked tachycardia that can progress to bradycardia Skin White, cool, moist White, cold waxy Blood pressure range Normal Decreased Level of consciousness Unaltered Altered, ranging from disoriented to coma Management
- Ensure oxygenation and ventilation
- Control hemorrhage (external or internal)
- External- direct pressure or tourniquet or homeostatic agent
- Internal-direct pressure (extremity immobilization/ PASG for pelvis/ low abd.) - Move toward a definitive facility
- Control body temp (lower the pt)
- Fluid replacement for Class II, III, or IV shock
- Isotonic crystalloids (lactated Ringers preferred; warm if possible)
- Ideally blood or packed RBC’s (now being used prehospital)
- Controllable bleeds- 1 - 2 liters (adult) (20 mL/kg peds) – Titrated to SBP 80-90 mmHg
- Uncontrolled (internal) bleeds- the least amount of fluid required to maintain SBP 80-90 mmHg
Copyright 202 I 0 National Association of Emergency Medical Technicians (NAEMT). *Course materials are developed by NAEMT for the sole purpose of conducting NAEMT education courses and may not be utilized for any other Instructor Information This skill station involves a skier who lost control while skiing. The patient’s LOC is altered and he requires airway management and rapid transport. Follow the written scenario, and provide information to all team members as the scenario progresses or as the team members ask. Patient Information Moulage: Pale and diaphoretic, cyanotic lips and nails, multiple body abrasions, blood at mouth Position: Laying on his side in a basket stretcher Actions: Eyes open to pain, incoherent moaning, and withdraws from pain Dispatch Information You and your partner work for a rural emergency medical service. Your ambulance has been dispatched to a local ski resort for a skiing accident in a remote section of your response area. It is noontime in late winter, clear sky with 17°F (–8°C). The closest hospital with an emergency department is 40 minutes away by ground; the closest level I trauma center is a 60-minute ride by ground or 15 minutes by air ambulance. Primary Survey 31 - year-old male, approximately 270 lb (122 kg); patient dressed in heavy winter clothing and ski boots X: No major external hemorrhage A: Partially obstructed—gurgling B: Rapid and shallow C: Fast radial pulse, skin pale and clammy D: 8 (E-2, V-2, M-4), PERRLA, moves all four extremities E: Various small abrasions on hands, knees where the ski suit ripped, blood at mouth Scene Assessment/General impression Resort staff direct you to the first aid building. There you find three members of the ski patrol and the patient’s wife. The ski patrol packaged the patient and moved him to the aid station at the base of the hill. No interventions have occurred. The ski patrol reports the patient lost control and tumbled into trees. They arrived 5 minutes after the accident and his condition has not changed. The accident happened 20 minutes ago. *Treatments/Critical Actions Note: ★ icon indicates a Critical Action
- Spinal motion restriction ★
- Manual opening of the airway with suctioning of the oropharynx ★
- Insert NPA and assist ventilations with high-flow oxygen and bag mask ★
- Drug assisted intubation if within scope of practice ★
- Rapid transport to trauma center, request air medical transport ★
- Maintain body heat
- IV during transport to maintain BP at 90 mm Hg systolic Initial Patient Impression: Critical/Rapid Transport BP: 112/72 (MAP 85) GCS: 8 (E-2, V-2, M-4) Temp: 98.8°F (37.1°C) Sample Scenario Evaluation Skill Station
Head: Obvious deformity and bleeding from jaw Neck: Unremarkable Chest: Equal, bilateral breath sounds and shallow Abdomen: Soft, nontender Pelvis: Stable Extremities: Abrasion of hands and knees, scant bleeding Back: Unremarkable Reassessment Vital Signs Critical actions done Critical actions NOT done BP: 126/74 (MAP 91) BP: 92/60 (MAP 71) P: 130, weak P: 150, weak, rapid, irregular R: 20, assisted R: 8, irregular Skin: Pale, cool, clammy Skin: Cyanosed, cool, clammy Spo 2 : 94%/O 2 Spo 2 : 90%/O 2 GCS: 8 (E-2, V-2, M-4) GCS: 4 (E-1, V-1, M-3) Glucose: 90 mg/dl (5 mmol/l) Glucose: 90 mg/dl (5 mmol/l) etco 2 : 38 mm Hg etco 2 : 60 mm Hg Pain: Unable to obtain Pain: Unable to obtain Temp: 98.8°F (37.1°C) Temp: 98.8°F (37.1°C) Sample Signs/symptoms: Reduced LOC Allergies: Penicillin (per wife) Medications: None Past medical history: Back surgery 8 years ago (per wife) Last oral intake: Breakfast, 3 hours ago Event leading to incident: Skiing Sample Scenario Evaluation Skill Station
Transport and Destination
Transport Timing: Emergent/Rapid transport Destination: Trauma center
Discussion Points
- What are the basic and advanced methods to maintain an airway?
- Are there any perceived complications with the cold winter gear the patient is wearing?
NAME: This answer sheet will be collected
COURSE: PHTLS 10 th^ Edition Mandatory Pre-Test
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Grade Scale
- 1= 97.
- 2= 95.
- 3= 93.
- 4= 91.
- 5= 89
- 6= 86.
- 7= 84.
- 8=82.
- 9= 80.
- 10= 78
- 11=75.
- 12=73.
- You are attending to a 22 year-old man who was involved in a street fight. He sustained some direct punches to his head. Although initially unconscious; he is now awake but responds very slowly and now seems confused. What do you initially suspect? a. Epidural hematoma b. Hypoglycemia c. Subdural hematoma d. CVA
- A 30 year-old woman fell from a galloping horse and has obvious facial trauma. She has a respiratory rate of 8 and is not responding to verbal stimuli. You note gurgling type noises coming from her airway. How would you proceed? a. Insert a Laryngeal Mask Airway b. Apply a rigid c-collar c. Do a comprehensive neurological exam. d. Perform a modified jaw thrust
- You are responding to the local deli shop where the new kid has just amputated half of his thumb on the meat slicer. After hemorrhage control, what is your initial treatment plan? a. Place the thumb in the freezer b. Put the severed part in isopropyl alcohol. c. Wrap the thumb in moistened gauze d. Place the severed part in a baggie for transport.
- When multisystem trauma is suspected the focus shifts to? a. Controlling significant external hemorrhage b. Inserting an oral airway c. Obtaining a Glasgow Coma score d. Immobilizing fractures
- A 20 year-old who hit the steering wheel during a MVA is complaining of shortness of breath and pain to the chest. He is experiencing crepitus to the area and difficulty taking a deep breath. What is the current priority? a. Assisting his respirations with a bag valve mask b. Inserting a chest tube for drainage. c. Administer high flow oxygen. d. Preform a pericardiocentesis.
- What is the initial priority when a patient has an obvious open fracture of an extremity with severe bleeding from the wound? a. Splint with an air splint to provide pressure to the wound while immobilizing. b. Apply direct pressure to the wound. c. Apply a tourniquet to the area above the fracture to control blood loss. d. Utilize an occlusive dressing to control the bleeding.
- What can decrease the fall risk for an elderly individual? a. Walking barefoot b. Adding throw rugs along hallways and other open floor areas. c. Eating a diet rich in antioxidants. d. Regular visual screenings to maintain/assist with visual acuity.
- One of the key points to consider when administering fluids to patients in shock is? a. Fluids should be titrated to obtain a systolic blood pressure >120mmHg. b. Transport should be delayed to secure 2 large bore IV’s for fluid resuscitation. c. Ideally, IV fluids should be warmed: not room temperature or cold. d. Synthetic colloid solutions such as dextran should be administered ASAP in the prehospital setting.
- Distributive shock includes which of the following? a. Neurogenic and Anaphylactic b. Spinal and Obstructive c. Anaphylactic and Spinal d. Cardiogenic and Obstructive
- Which of the following regarding helmet removal is important to know? a. Two trained rescuers are necessary to preform helmet removal. b. Helmet removal ensures that no hidden bleeding is occurring into the posterior helmet. c. It is necessary to assess and manage the airway. d. All of the above.
- A 6 year-old child was thrown from a roller coaster at a local amusement park. He has a traumatic avulsion to his left lower calf area, and the bleeding has not been controlled by direct pressure. What is your next action? a. Apply a tourniquet b. Pack a hemostatic agent dressing firmly into the wound. c. Place an abdominal binder to slow blood flow to the legs. d. Start an intraosseous IV to obtain rapid vascular access for fluid replacement.
- Hitting the steering wheel during a violent head on collision often results in which type of injury? a. Traumatic brain injury b. Cardiac contusion c. Pelvic fracture d. Open femur fracture
- Which of the following symptoms might you see with a Basilar skull fracture? a. ‘Raccoon eyes’ – discoloration around the eyes. b. Leakage of cerebrospinal fluid from the nose or ears. c. Blood behind the eardrum visualized via otoscope. d. All of the above
- When placing a pregnant patient on spinal motion restriction, which of the following will help to minimize hypotension. a. Place her on her left side and stack pillows for comfort. b. On her left side; by elevating the right side of a backboard. c. In a modified Trendelenburg d. Supine
- Which best describes a full thickness burn? a. Painful blisters b. Red painful areas that are oozing clear fluids c. Thick dry white leathery burns. d. None of the above.
- Principles of physics suggest that when a solid object collides with a human body, a transfer of significant energy occurs. Which of the following characteristics determine damage severity? a. Density of the moving object b. The contact area of the impact c. The cavitation that is created by the impact d. All of the above
- A difficult intubation should be anticipated for which individual? a. A 12 year old drowning victim b. A 29 year old burn victim with a weak cry and inspiratory stridor. c. A 56 year old with an abdominal gunshot wound d. An 85 year old stroke patient
- A teenager was thrown from the back of a pickup truck and is complaining of severe pain in her right chest area. Vital signs are stable, and she is alert, orientated and crying from pain. What would you do to specifically address the pain? a. Administer 20 mg of Morphine sublingually. b. Administer 100 mcg of Fentanyl. c. Administer 800 mg of Ibuprofen PO. d. Administer 25 mcg of Ketamine.
- A 45 yo man was pulled from a burning truck. Burns are noted to his entire left arm & hand as well as the entire posterior surface of his torso. What is your estimation for body surface that is affected by these burns? a. 28% b. 40% c. 15% d. 60%
- You have responded to a nursing home where a 94 y.o. woman slipped and fell in the hallway and is slow to respond to verbal stimuli; responsive to pain. Bleeding to the scalp is controlled. Glascow Coma Scale is 5, BP 160/90, P 50, R 28 (irreg), Glucose 144. What should you consider next? a. Administer Fentanyl for pain. b. Place in a hard c-collar. c. Ask if the patient has a MOLST form or advanced directives. d. Preform a head tilt chin-lift maneuver and insert an oral airway.
- A 63 y.o. has been pulled from a high speed train accident. She does not have obvious signs of bleeding but appears disoriented, pale, diaphoretic. Her BP is 74/52, P 134, R24. What type of shock do you suspect? a. Cardiogenic b. Anaphylactic c. Hemorrhagic d. Neurogenic
- The safety of the EMS team cannot be stressed enough. Which of the following events causes the majority of deaths to EMS personnel? a. Fire related injuries b. Gun violence c. Hazardous materials d. Vehicle collisions (on scene or in an EMS unit)
- A 14 y.o. fell from a high jump at the skateboard park. He is complaining of abrasions to his left hip, knee and arm and hands. There was no loss of consciousness. Vitals are all stable. What action should you take next? a. Start an IV and administer meds for pain control. b. Complete a primary and secondary survey. c. Clean the abrasions with saline and apply dry bandages. d. Apply oxygen via a nasal cannula.
- When is rapid extrication indicated? a. The patient has a life-threatening condition that cannot be corrected where the patient is found. b. The scene is unsafe for the EMS personnel and patient. c. The patient needs to be moved rapidly to access other patients. d. All of the above
- A primary concern when a patient has an obvious traumatic facial injury is? a. Altered mental status b. Obstruction of the airway c. How the patient will be able to communicate effectively d. Depressed skull fracture
- An explosion at a local warehouse has left a 50 y.o. man with back injuries from an impact. He has sensation and movement to this lower legs. BP 140/92, P 108, R 28. His chief complaint is excruciating back pain and guarding of the rib area. What pain medication would be indicated? a. high dose NSAID b. Ketamine c. Propofol d. No pain meds until neuro can evaluate.
- What should you do first if a burn victim with stridor suddenly stops breathing during the initial assessment? a. Insert an oropharyngeal airway and assist respirations. b. Apply 100% O2 with a non-rebreather mask. c. Suction with saline lavage to clear the airway. d. Preform a needle cricothyrotomy.
- Critical thinking on the scene is essential for optimizing patient outcomes. Which of the following is utilized in the PHTLS primary surveys to assess the trauma patient? a. PHTLS secondary assessment b. XABCDE Assessment c. The Golden Hour Review d. MOLST Evaluation
- The time to obtain the SAMPLER information is: a. During the Primary Assessment b. Upon scene arrival to determine the need for additional resources. c. During the secondary survey, after life threatening conditions have been ruled out. d. During the hospital hand off of patient care.
