EMCAP and Major Hemorrhage

What is MARCHE?

a trauma care algorithm that prioritizes life-threatening injuries in a specific order

What does the “M” in MARCHE stand for?

massive hemorrhage

What does the “A” in MARCHE stand for?

airway

What does the “R” in MARCHE stand for?

respiratory

What does the “C” in MARCHE stand for?

circulation

What does the “H” in MARCHE stand for?

head injury and/or hypothermia

What does the “E” in MARCHE stand for?

everything else

How do we assess for a massive hemorrhage?

TCCC and/or raking (front and back) of body

How do we assess a patient’s respiratory functioning?

• respiratory rate (RR)

• work of breathing (WOB)

• lung auscultations

• injury assessments (pneumo or hemothorax, flail chest)

• SpO₂

How do we assess a patient’s circulation?

• pulses

• blood pressure

• skin

• level of alertness (LOA)

• BITFT algorithm

  • bones & bleeds

  • IV access

  • TXA (tranexamic acid)

  • fluids

  • tourniquet reassessment

How do we assess a patient for hypothermia?

How can we assess for moderate to severe brain injury?

What does MPHATD in the everything else category stand for?

M — monitoring vitals

P — pain medications

H — head to toe

A — address all wounds

T — tactical evacuation prep (if not already done)

D — documentation (SBAT)

What are pulse sites?

areas where you can compress an artery against a bone

List the different types of pulses you can obtain from a patient.

• temporal

• carotid

• apical

• brachial

• radial

• femoral

• popliteal

• posterior tibial

• dorsalis pedis

Where is the temporal pulse point?

temples (sides of forehead)

Where is the carotid pulse point?

both sides of the neck, right below the jaw

Where is the apical pulse point?

apex of the heart (L side of the chest at the 5th intercostal space at the midclavicular line; bottom of the heart)

Where is the brachial pulse point?

inner elbow

Where is the radial pulse point?

thumb side of the wrist

Where is the femoral pulse point?

groin area between the pubic bone and the anterior iliac crest

Where is the popliteal pulse point

behind the knee

Where is the posterior tibial pulse point?

inner ankle, below the ankle bone

Where is the dorsalis pedis pulse point?

top of the foot between the first and second toes

How is flail chest determined?

• palpate for sternum stability

• observe for paradoxical chest wall motion (flail chest segment)

• observe for chest wall deformity

What are the different levels of respiratory distress?

• mild

• moderate

• severe

• (ventilatory) failure

What are the different levels of oxygenation compromise?

• mild

• moderate

• severe

• (oxygenation) failure

What is EMCAP?

mnemonic for scene assessment (to ensure safety and gather pertinent information)

What does the “E” in EMCAP stand for?

environment

What does the “M” in EMCAP stand for?

mechanism of injury (MOI)

What does the “C” in EMCAP stand for?

casualty count

What does the “A” in EMCAP stand for?

allied agencies

What does the “P” in EMCAP stand for?

PPE

What are the six parts of a scene approach?

1. introduce self and get name and age of patient

2. obtain chief complaint

3. FREI

4. clinical findings

   • peripheral perfusion

   • work of breathing

   • brain perfusion

   • pulse(s)

5. determine sick or less sick (and start CPR if no pulse)

6. delegation to your partner

   • 4 lead ECG

   • blood pressure

   • SpO2

   • respiratory rate (RR)

   • “notify me of any abnormal findings immediately”

note: ensure all other relevant vitals are gathered by end of primary (will depend on patient’s presentation)

What is the first part of a scene approach?

• introduce yourself (name, profession)

• obtain name and age of patient

What is the second part of a scene approach?

obtain chief complaint

What is the third part of a scene approach?

FREI screening

What is the fourth part of a scene approach?

clinical findings

• peripheral perfusion

• work of breathing

• brain perfusion

• pulse(s)

What is the fifth part of a scene approach?

determine sick or less sick (and start CPR if no pulse)

What is the sixth part of a scene approach?

delegation to your partner

• 4 lead ECG

• blood pressure

• SpO2

• respiratory rate (RR)

• “notify me of any abnormal findings immediately”

What vitals must be collected during your primary assessment?

• HR

• BP

• RR

• SpO2

• ETCO2

• pupils

• temp

• 4 or 12 lead ECG

• GCS

• BGL

What are some common hazards present at scenes?

• fire/smoke

• air pollutants/chemicals

• weather

• water

• vehicles

• crimes/assailants/weapons

• animals

• bio-hazards

• bystanders

Why does the MOI matter?

helps predict:

• likely injury patterns

• severity

• required resources

  • extrication

  • ACP

  • trauma centres

What does MOI stand for?

mechanism of injury

What is translational energy?

• injures caused by rapid, linear acceleration (or deceleration) forces

• body moves along a straight line (translates) rather than rotating

• hallmark of high-energy impact (MVCs, falls, etc.)

• severe shearing, stretching, or tearing of tissues

• high risk of spinal cord injuries (SMR)

• high risk of aortic ruptures

• TAI

What is a traumatic axonal injury (TAI)?

• severe form of brain injury caused by shearing forces that damage nerve fibres

• widespread white matter damage caused by rapid acceleration/deceleration

What is rotational energy?

falls or spins leading to twisting forces

What is crush/compression energy?

forces applied over time + area

What must you do regarding identifying hazards during your assessment?

also mention mitigation of the hazard(s), not enough to simply identify the hazard

Why is PPE not considered a mitigation for hazards?

it’s an article of defense (a buffer), not a means of mitigation

e.g., you don’t mitigate traffic hazards by wearing a helmet

What could be a hint to the severity of a call within the calls details, and how can this be applied in the EMCAP?

• trauma triage guideline

• spinal motion restriction standard

• “call details mentioned rollover and ejection, so this patient is likely to meet my trauma bypass and spinal motion restriction (SMR)”

What are deceleration injuries?

rapid loss of velocity —> when the body stops suddenly, organs continue moving at the original velocity until they either:

1) hit something or,

2) tear away from whatever was holding/anchoring them

What are acceleration injuries?

What are contact precautions?

• long sleeve gown

• gloves

• dedicate equipment to patient (or disinfect thoroughly before use with another)

What are droplet precautions?

• long sleeve gown

• gloves

• dedicate equipment to patient (or disinfect thoroughly before use with another)

• mask

• eye protection

What are airbourne precautions?

droplet precautions + N95 mask

What illnesses require droplet precautions?

• pertussis (whooping cough)

• meningococcal disease

• RSV

• influenza

• parainfluenza

• GAS (skin, wound, invasive)

What illnesses require airbourne precautions?

• tuberculosis

• measles (rubeola)

• chickenpox

• shingles

What illnesses require contact precautions?

• RSV

• influenze

• parainfluenza

• GAS (skin, wound, invasive)

• ESBL

• MRSA

• VRE

• clostridium difficile (c-diff)

• norovirus

What is a FREI screening?

• dispatch gives you an initial screening

• new (or worsening cough)

• fever/shakes/chills over last 24 hours

• headache, sore throat, muscle pain, abdominal pain, vomiting, or diarrhea

• must confirm upon patient contact, and adjust PPE accordingly

What is CLAPS-D?

looking for:

C

• contusions

• contaminations

L

• lacerations

A

• abrasions

P

• punctures

• penetrations

• protrusions

S

• swelling

D

• dried blood

• diaphoresis

• deformities

What is TICS-D?

feeling for:

T

• tenderness

I

• instability

C

• crepitus

S

• swelling

D

• deformities

How do we collect clinical findings?

1. looking

2. listening

3. feeling

What are we looking for when assessing peripheral perfusion during our approach?

• paleness

• mottling

• cyanosis

What are we looking for when assessing work of breathing during our approach?

• relaxed breaths

• laboured breaths

• absent

• sounds

What are we looking for when assessing brain perfusion during our approach?

A - alert (*4)

V - verbal (*3)

P - painful (*2)

U - unresponsive (*1)

How are the AVPU brain perfusion check and the GCS related?

AVPU (alert, verbal, pain, unresponsive) = eye section of GCS assessment

What is the purpose of a primary exam?

to find

• life

• limb

• function

threats and indicate the appropriate interventions

What is a bradycardic heart rate?

<50 bpm

What is a tachycardic heart rate?

>100 bpm

How is heart rate calculated?

counting how many beats are felt over 1 minute

• # of beats in 10 seconds x 6

• # of beats in 15 seconds x 4

What are we assessing when taking heart rate?

• rate

• rhythm

• strength

How is respiratory rate calculated?

counting how many respirations are seen over 1 minute

• # of respirations in 10 seconds x 6

• # of respirations in 15 seconds x 4

What is the RR range for bradypnea?

<10 breaths per min

What is the RR range for tachypnea?

>28 breaths per min

What are we assessing when taking respiratory rate?

• rate

• effort

• depth

• pattern

What is systolic blood pressure?

• top number

• pressure in arteries when heart contracts

• reflects cardiac output

• reflects force of contraction

What is diastolic blood pressure?

• bottom number

• pressure in the arteries when the heart relaxes

• reflects vascular tone (systemic vascular resistance)

What can a decrease in systolic blood pressure indicate?

• hypovolemia

• pump problems

What can a decrease in diastolic blood pressure indicate?

• sepsis

• loss of vascular tone (spinal shock)

• severe vasodilation (anaphylaxis)

What is mean arterial pressure (MAP)?

• MAP = DBP + ⅓(SBP-DBP)

• low readings indicate potential organ failure

• target MAP for organs is >65 mmHg

What is a fistula?

surgically created connections between an artery and a vein → provides access to the blood stream for hemodialysis

Why should blood pressure not be taken on the same side of the body as a patient’s masectomy?

lymphnodes are surgically removed during masectomies → taking blood pressure on that side can cause lymphedema since there are no lymph nodes to help with drainage

What is PERRLA?

Pupils Equal, Round, and Reactive to Light and Accommodation

What causes hemorrhagic shock?

rapid blood loss (internal and/or external) leading to inadequate perfusion of tissues and organs

blood volume drops → less oxygen delivery → tissues starve → organ failure → death

In regards to energy transfer, what do we see happen to air-filled tissue (lungs, bowel) during trauma?

tear easily

In regards to energy transfer, what do we see happen to solid organs (liver, spleen) during trauma?

rupture when sheared or compressed

In regards to energy transfer, what do we see happen to bone during trauma?

handles compression well but fails under bending and twisting

In regards to energy transfer, what do we see happen to vascular structures (arteries, veins) during trauma?

fail under sudden stretch

What do high-speed collisions do to the body?

car stops → body keeps moving → body eventually stops → organs keep moving → organs slam into cavity walls → multiple impacts → many layers of damage (complex systemic trauma)

What are compression injuries?

when force is applied directly to tissue, crushing it between two surfaces (e.g., chest vs. steering wheel, abdomen vs. lap belt, head vs. windshield)

In regards to MOI, what 4 questions should be asked?

1. what energy was involved?

2. how did the body decelerate?

3. what was compressed?

4. what can be anticipated to occur next given this information?

“What energy was involved” concerns which factors of MOI?

• velocity

• height

• mass

• surface

“How did the body decelerate” concerns which factors of MOI?

• instant stop

• gradual

• multiple impacts

What are some things that could be anticipated to happen in a patient from only knowing the MOI?

• stabbing → internal hemorrhage

• high-speed collision → organ rupture

• fall from greater than 2m → spinal injury

• electrocuted → enter and exit spots of electrical current

How should amputated/avulsed parts be handled?

• preserve all amputated tissue

• if contaminated → gently rinse with saline

• wrap/cover exposed end with moist, sterile dressing

• place in suitable water-tight container/plastic bag + immerse in cold water

When should a wound be packed?

When should a tourniquet be used to stop a deadly bleed?

What should be done if a deadly wound is located in a hollow space of the skull, chest, or abdomen?

What are common errors seen with tourniquet use?

• not tight enough

• placed over clothes/objects

• placed too low

• stopping when patient screams

• not re-assessing for re-bleeding

• forgetting to document the time