Step 2: Immediate Control and Immobilization
Position the patient so that he or she can be cared for safely. In blunt trauma, spine immobilization is needed. Agitated patients must be restrained. The patient is placed on a work surface stationed in a suitable space to give the team members access. After this is accomplished, the team leader is given 5 to 10 seconds of "silence" by the team to mentally take in the scene while making direct contact with the patient.
Please Note: Comments, directions, and instructions specific to pediatric patients are underlined.
Prehospital personnel have often already immobilized patients who are being admitted to the ED. However, out-of-control and even dangerous but critically ill patients may arrive by private car. Emergency situations arising in a hospital setting may be as difficult to control as those that occur away from treatment facilities.
Immobilization and Control
Skeletal immobilization. In trauma situations, address spine immobilization immediately. Long bone and pelvic stabilization may be delayed until the team begins the systematic pathway for trauma.
A. Cervical spine immobilization
1. Removing a helmet is a two-person job. One person stabilizes the patient’s head and neck in neutral position by placing one hand under the patient's occiput and, with the other hand, cupping the patient's chin. The second person releases the helmet chinstrap and spreads the sides of the helmet apart while slipping it over the patient’s head. (A cast cutter may be needed to remove a facemask.)
2. Apply a cervical collar whenever a neck injury is possible. Use rigid collars to provide stabilization. They are available in a variety of sizes (from infant to adult), including no neck and long neck models. Apply without moving the neck. Magill forceps may be used to pull the collar behind the neck with no neck movement.
3. Complete immobilization of the cervical spine requires neck blocks, forehead straps, and a spine board. PEDS: In small children, the backboard may result in neck flexion because of the relatively large posterior skulls of children. Place a pad or folded cloth under the shoulders to keep the neck in a neutral position.
B. Thoracic and lumbar spine immobilization
Logroll the patient to place the long board under the patient’s back using only the degree of rolling necessary. The person stabilizing the head and neck directs the movement.
Physical restraints are frequently needed in emergency situations, even for patients who are cooperative. The urge to pull out ET or gastric tubes is great. When in doubt, apply restraints. They may be attached to the cart rails with brackets at the patient's calf level.
A. Use quick release restraint systems. Wrist restraints must not be tied to the cart with knots. If the patient vomits, he or she must be turned quickly. Boat-cleat type restraints holders (see illustration above) are strong and can be quickly released.
B. Hook and loop fastener straps attached to the resuscitation cart at the level of the ankles, knees, mid thigh, and abdomen are useful.
The out-of-control patient and chemical restraints: A head-injured or intoxicated patient may be so confused and so strong physically that immediate sedation is needed to gain control of the patient, to protect the team, and to protect the patient from excessive intracranial pressure (ICP) rise secondary to struggling. In such cases, it may not be possible to start a reliable IV. Administer ketamine IM 4 mg/kg to allow placement of an IV for subsequent management. Ketamine takes effect in 1 to 2 minutes. The team leader needs to assess whether the potential risk of an increase in ICP with the use of ketamine is worth the benefit from obtaining control of an uncontrollable patient and from the decrease in intracranial pressure that occurs when a patient is not struggling.1
Work
Surfaces/Carts
The
resuscitation cart is highly important. Station the cart
away from
walls. If cables to and from a wall or monitor are unavoidable, arrange
them so that they are in one area only. Access to the patient from the
head of the cart is crucial. Large bore suction is a critical piece of
equipment in airway management, yet it is frequently found on the floor
when it is needed most. This can be avoided by placing a bracket at the
head of the cart to hold the suction tubing in place.
Suction bracket holds suction tubing and other tubing
The brakes on the resuscitation cart must be reliable and should always be set prior to a patient's arrival. The resuscitation cart should have an adjustable backrest. A removable footboard keeps the patient from sliding off of the foot of the cart when the backrest is elevated. Adjustable height and Trendelenburg positioning are important features of a good resuscitation cart. The cart should be easily adjustable to typical operating table height to facilitate patient care. A removable arm board is useful to facilitate chest tube and IV placement.
Larson trauma blocks are 21" x 4" x 4" blocks of plastic or wood that are placed on the cart's cushion so that space is provided between the long board and the cushion for the placement of x-ray cassettes. Three of these blocks are required. They greatly simplify the ability to obtain chest and pelvis x-rays. They are superior to built-in x-ray cassettes because they do not cause magnification of the image. They should be used when a trauma patient is on a long board.
PEDS: Infants and neonates require a special resuscitation table. Equip the table with the following: overhead warming lights with 1 or 2 procedure lights, oxygen tank and oxygen flowmeter, and adjustable oxygen pressure-powered vacuum bottle mounted on the table for tracheal suction. Also mounted on the cart should be a low-pressure meter that may be connected to the infant BVM so that transtracheal pressure can be monitored to avoid producing a pneumothorax by use of excessive pressure.
Pediatric resuscitation cart
An airway cart containing all of the emergency airway equipment needed for both adult and pediatric patients must be situated within arm's reach. See Vol II—AIR SKILLS 1, Aids to Intubation.
10 Seconds of
Silence
In most cases, it is wise for the team to leave hands off the patient
and not talk to the patient during the next 5 to 10 seconds so that the
team leader can
soak in the scene and establish contact with the patient. During these
few seconds,
there is plenty for the team to do: Get the monitor leads ready and
check
lighting (warming lights, etc). In some cases, this brief delay is not
possible.
The patient may be flailing about, or there may be exsanguinating
hemorrhage. The
team leader identifies him- or herself and greets the patient.
Reference
- Caro D. Sedation or induction agents for rapid sequence intubation in adults. February 10, 2011.
http://www.uptodate.com/contents/sedation-or-induction-agents-for-rapid-sequence-intubation-inadults?source=search_result&selected
Title=1~150. Accessed August 20, 2011.