Welcome to the ITLS Instructor Update to the 7e of the textbook. This is a self directed, self paced update. At the top of each page is a slide with key points or “triggers”, the notes below the slide provide expanded content. In some instances, in the notes, you will have the opportunity to “click on” or copy the link into your browser, a hyperlink that will direct you to videos, downloads or other websites, all of which are intended to enhance your understanding even more. At the conclusion of this self directed module you will need to successfully complete an online quiz to to complete the update Objectives: Upon completion of this update the participant should be able to define or describe the following: v  Golden Period v  “Fix It” v  Hyperventilation v  Mechanisms of injury from an explosion v  Location of chest decompression v  EtCO2 and how it can help in assessment v  Management of head injury v  CAB versus ABC assessment v  Additional assessment tools v  Airway management v  Bleeding control v  Course resources v  Alternative course delivery options

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To view Dr. John Campbell’s introduction of the 7e please click on the following link

http://www.youtube.com/watch?v=hc_DREjCpOo

When completed return to this point to continue update

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In the fall of 2010 the American Heart Association, European Resuscitation Council, International Liaison Committee on Resuscitation released their recommendations and guidelines for cardiac and stroke resuscitation. These guidelines have been included in the 7e of the ITLS textbook. It has been suggested that we now call the prehospital period the “Golden Period” because it may be longer or shorter than an hour. Each chapter has a new section called “key terms”, which will refer you to a specific page number for an explanation of the term. New case presentations, photos and illustrations give the 7e a fresh look

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Personal watercraft injuries section has been expanded because of the increase use of them and data on injuries is more available There is an increase number of incidents of terrorism, in the civilian setting, across the globe more awareness is necessary. More data on injuries is also available

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Battlefield experience has proven that controlling serious external hemorrhage must be done immediately. A patient can rapidly die from major blood loss. This is not to be confused with AHA/ERC/ILCOR recommendations of providing circulation before opening the airway and breathing. “Fix It” is the term that describes interventions performed based on patient needs, resources available and time it will take to execute. Performed by team members during the assessment phase without causing interruptions of the assessment. Emphasizes the team concept. The use of finger-stick serum lactate levels and prehospital abdominal ultrasound exams are mentioned as areas of current study to better identify patients that may be in early shock.

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Key Chapter Points 1.  Correctly perform the ITLS Primary Survey. 2.  Identify within two minutes which patients require load and go. 3.  Describe when to perform critical interventions. 4.  Correctly perform the Ongoing (reassessment) Exam. 5.  Correctly perform the Secondary Survey. 6.  Describe when to perform critical interventions. 7.  Demonstrate proper communications with medical direction. 8.  Demonstrate the proper sequence of rapid assessment and the management of the

multiple-trauma patient.

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The use of wave form capnography is stressed as the standard for confirming and monitoring endotracheal tube placement , assessing ventilation status and monitor for shock. Hypoventilation and hyperventilation do not refer to oxygenation but to the amount of carbon dioxide retained. The use of ELM (external larynx manipulation) is introduced as a means of improving glottic visualization.. In Appendix A - Optional Skills, Drug Assisted Intubation is discussed. The use of benzodiazepines and opiates in combination, with or without a paralytic, may be administered to achieve intubating conditions. To better reflect the various pharmacologic approaches to facilitate intubation the practice of Drug Assisted Intubation (DAI) replaces Rapid Sequence Induction/Intubation (RSI)

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Cyanide poisoning prevents the cells from using oxygen to make energy. Because the body is using no oxygen, the circulating blood will usually be 95–100% saturated. Conditions that may make a pulse oximeter reading unreliable are: • Poor peripheral perfusion • Severe anemia or exsanguinating hemorrhage • Hypothermia • Excessive patient movement • High ambient light • Nail polish or a dirty fingernail • Carbon monoxide poisoning • Cyanide poisoning A “face-to-face” approach (also called the “tomahawk method”) has been described and used successfully. While c-spine is maintained the intubator holds the laryngoscope in his hand, with the blade end of the handle emerging from the thumb side of the fist, so the blade can “hook” the tongue. External Laryngeal Manipulation (ELM) a broader more inclusive term Some of today’s new systems use a variant of the optical scopes, which allows direct visualization. Other systems make use of miniature video cameras that have the image projected on a screen that is either attached to the scope or adjacent to it. At this time, these should not be considered a standard for the pre-hospital setting.

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With the increase in terrorism, understanding blast injury is important. The magnitude of the blast wave depends on the size of the explosion and the environment in which it occurs. Closed spaces, such as buses, produce highly lethal blast injury. The mechanism of injury by explosions is due to 3-5 factors Primary. This is the initial air blast. A primary blast injury is caused solely by the direct effect of blast overpressure on tissue. Secondary. The patient is being struck by material (shrapnel) propelled by the blast force. Tertiary. The patient’s body is being thrown by the pressure wave and impacting the ground or another object. Quaternary. This is the thermal burns from the explosion or radiation Quinary. This is reported as a hyperinflamatory state caused by chemicals used in making a bomb or added to the bomb (a form of dirty bomb).

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For many years needle decompression of a tension pneumothorax has been advocated as a lifesaving procedure and the anterior approach (second or third intercostal space, mid-clavicular line) has been most commonly used by prehospital providers. In the last few years the lateral (4th or 5th intercostal space mid-axillary line) approach has become popular with the military, who favor it because it can be used to decompress the chest without removing a soldier’s body armor (“x” marked on picture above is for educational purposes only). Multiple studies also have been published showing the catheters being used were too short to decompress the chest in many patients. It is recommended that for the anterior approach the catheter needle must be a large bore (8 French or about 14 gauge) and 6 to 9 cm long Examples of catheters long enough to decompress a tension pneumothorax: (A)  Turkel Safety needle. (B)  ARS needle for decompression. (C)  Cook pneumothorax needle

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Patients in shock have decreased oxygen being supplied to their cells. Thus, if you are monitoring a patient either in shock or at risk of going into shock, monitor the level of exhaled CO2 as part of your overall care. A level of exhaled CO2 that falls much under 35—especially if it falls into the 20s or below—may be an indication of circulatory collapse and thus can be an additional warning sign of worsening shock In some situations there may be life-threatening external hemorrhage that you cannot control with direct pressure. In these extreme circumstances you should not hesitate to apply a tourniquet. A tourniquet is rarely needed, but when it is needed, it should be applied quickly. If you cannot stop severe bleeding hemostatic agents may be used in conjunction with direct pressure and tourniquets or when tourniquets can not be used (groin, axilla, neck, face, scalp). More information on this later in the update.

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Indications for the use of IO infusion include: - The pediatric or adult patient who is in cardiac arrest and in whom you cannot quickly

obtain peripheral venous access -  The patient with hypovolemic shock and difficult intravenous placement. -  The patient who needs drugs or fluids within five minutes, when a peripheral

intravenous cannula cannot be placed in two attempts or 90 seconds. The EZ IO use is described in the textbook and is a safe, easy, fast way of gaining IO access. There are three sizes of needles (peds, adult and "big boy"); Vidacare describes them as 15mm (3-39 kg), 25mm (40 kg and greater) and 45mm (excessive tissue.) To view Vidacare’s training aids click on the link below http://www.vidacare.com/EZ-IO/Index.aspx

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Key Chapter Points 1. Cover the anatomy. 2. Cover the physiology of the brain and explain why hyperventilation is no longer

recommended except in cases of herniation syndrome. 3. Emphasize the control of the airway in the patient with an altered level of

consciousness. Stress that suction must be available at all times. 4. Stress that a patient with a serious head injury (Glasgow Coma Score of 8 or less)

will not tolerate hypoxia or hypotension. In this situation a blood pressure of at least 110-120 systolic must be maintained

5.  Mention that prehospital providers tend to inadvertently hyperventilate head-injured patients. Stress that, if possible, capnography should be used to prevent inadvertent hyperventilation.

6. Mention the aspects of the Glasgow Coma Score and that each part should be recorded, not just the total score. This score should always be recorded if there is altered mental status.

7.  Stress limited indications for hyperventilation. 8. Check glucose level

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There have been no large clinical trials that compare methods of spinal motion restriction. Thus, there is no Class I evidence and no formal standards of care. There are a growing number of studies that raise concerns about the complications of SMR, particularly in victims of penetrating trauma to the trunk. The complications with the most potential danger are those related to the patient’s ability to maintain an airway and breathe effectively. The information presented in this chapter represents general guidelines for the management of patients who may experience spinal trauma. Remember, various mechanisms of injury require SMR, and this procedure is associated with potential complications for the patient and EMS providers.

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The procedure for use of a short backboard was moved to “Resource Central” and photo scans of performing SMR for standing patients were added. The “Resource Central” topic will be described later in this update The X-Collar is a cervical device which facilitates motion restriction of the head and neck in the position found For supplemental training material follow the X-Collar link below http://www.training.xcollar.com/

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Deciding which patient should be taken to a local community hospital and which should be taken directly to a trauma center can be a difficult decision, with only a patient history, a scene size-up, and a patient assessment to guide it. Better tools are needed to distinguish between patients who have injuries that are either not severe or not time critical and will remain stable, and those with a significant mechanism of injury who appear stable initially, and then decompensate later, requiring emergent transfer to a trauma center. Tests performed quickly in the ambulance or on scene that could help predict which apparently stable patient might deteriorate would be very helpful. Current studies using finger-stick serum lactate levels and studies using abdominal ultrasound in the field, Focused Assessment with Sonography for Trauma (F.A.S.T. exam) show some promise. Studies are listed at the end of Chapter 2

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When direct pressure TO THE SOURCE OF BLEEDING is insufficient in controlling external hemorrhage from wounds to the extremities, the use of a tourniquet as an adjunct is well documented in improving survival and outcomes. •  Ability to salvage the limb decreases with time – ideally, limit tourniquet application

to 2 hours or less. Contact medical command for directions/ assistance with re-perfusion procedures.

•  Use of commercial tourniquets is advantageous over improvised ones, as better distribution of pressure to limit tissue damage is provided.

•  Note the time applied and communicate when one has been applied. Expedite transport to trauma center following application.

Hemostatic agents may be used in conjunction with tourniquets placed on an extremity or independently (neck, axilla, groin) following inability to control external hemorrhage. •  Hemostatic agent MUST be applied directly to the source of bleeding! 33% of

failure to control bleeding is caused by inappropriate application (Brown, 2007) •  Adequate training with the specific hemostatic agent being utilized is warranted •  Direct pressure with the hemostatic agent for a minimum of two (2) minutes is

required – even if bleeding appears to be controlled. •  Dress wound after control of bleeding is achieved. •  To ensure continual effectiveness, reassessment of wound for recurrence of

bleeding is necessary. •  Hemostatic agents are not to be utilized in open chest or abdominal wounds.

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To increase understanding and effectiveness of devices and agents it is recommended multiple examples of tourniquets and hemostatic agents be made available. Use of an IV training arm works well to demonstrate and for practice of tourniquet application. While impractical to demonstrate live use of hemostatic agents, students should be able to handle various agents available for use. Emphasis on correct placement with direct pressure to SOURCE of bleeding. ChitoGauze video demo http://youtu.be/daC3PtePtmE Celox video demos Gauze: http://youtu.be/hhaJMZcywzo Pre-filled syringe: http://youtu.be/q1mxoiZOjl4 QuickClot video demo http://youtu.be/e9xvIbKBJn4

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It is important to recognize impaired respiratory function, early management of potential infection and pain Circumferential constriction of the chest wall will impair respiration and facilitate hypoventilation. •  Advanced airway management with rapid transportation to the closest appropriate

receiving facility is warranted. •  Escharotomy of the chest should be performed at the hospital or by personnel

authorized to perform in the out-of-hospital setting (e.g. flight crew’s). Dressings containing small particles of metallic silver exhibit pronounced antibacterial activity against a wide range of gram-positive, gram-negative bacteria, yeasts and fungi. The management of pain is an important component of patient care. Consultation with medical direction will facilitate optimal implementation.

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While endotracheal intubation remains the gold standard for securing an airway, studies have demonstrated no difference or poorer outcomes when initiated in the out-of-hospital setting. •  Use of a supraglottic airway device should be considered as an alternative to quickly

gaining access for provision of adequate ventilation.

•  Should not be utilized in the presence of airway swelling secondary to burns or anaphylaxis

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Key Chapter Points 1. Review pathophysiology of aging by systems. 2. Stress that when doing field triage, geriatric patients have more injuries and worse

outcomes than younger patients who are subjected to the same mechanisms. 3. Review patient assessment, and relate how aging affects assessment and

interventions. 4. Discuss potential problems with spinal motion restriction in elderly patients.

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Key Chapter Points 1. Cover the general information included in the lecture slides, including the information

associated with the various trimesters. 2. Note should be made that the status of the fetus generally depends on the well-being

of the mother. Therefore, if the mother has adequate blood volume, blood pressure, and circulation, then the fetus will do well. Use the quote: “Death of the fetus in the trauma situation is most often associated with the death of the mother.”

3. Mention that the treatment of shock is the same for pregnant patients as for other patients.

4. Emphasize that the physiologic changes of pregnancy may cause delay in the diagnosis of the shock state in the mother.

5. Stress that uterine obstruction of venous blood flow may cause hypotension in the supine patient (“supine hypotension syndrome”), and thus must be prevented by rolling the patient or backboard to the left.

6. Note that there is an increased rate of fetal demise minute or 3 days following major trauma to the mother.

7. Mention that short backboard-type device may be ineffective as an SMR device in the pregnant patient because of the difficulty with adequately securing the straps. This concern also applies to the very obese patient.

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Key Chapter Points 1.  Review commonly abused drugs and their common signs and symptoms. 2.  Review clues of drug use by the patient. 3.  Review the pertinent history you should obtain when managing a patient who may be

under the influence of drugs. 4.  Explain how to interact with a patient who is under the influence of drugs. 5.  Explain how to manage the patient who is injured, under the influence, and

uncooperative. Be familiar with and discuss your local laws regarding restraining a patient.

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Patients without a palpable pulse who present with sinus rhythm and non-dilated pupils (< 4 mm) may survive. Those presenting with asystole, agonal rhythm, V-fib or V-tach are not likely to survive. • Must consider survivability versus the risk to pre-hospital providers and the public at

large. • Guidelines for withholding or terminating resuscitation of Pre-hospital Traumatic

Cardiopulmonary Arrest (TCPA) are well defined (Table 21-1) through the joint position statement of NAEMSP and ACS Committee on Trauma.

• Review causes of TCPA thoroughly. • Pediatric patients requiring CPR have demonstrated up to a 25% survival rate. As

such, aggressive resuscitation is warranted. •  Initiate compressions immediately if patient is pulseless and resuscitative measures

are warranted. •  Increasing EtCO2 during TCPA resuscitative measures indicates an improvement in

cellular respiration.

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This section will Increase awareness and update current practices related to exposures Methicillin-resistant Staphylococcus aureus (MRSA) is increasing in transmission outside of the hospital-associated infection category. Specifically, community acquired or CA-MRSA, is of concern when appropriate precautions are not exercised. •  Good hand-washing, use of intact gloves, immunizations, cleanliness of equipment,

and surfaces serve to protect patients and providers. Hepitis B (HB) vaccine, alone or in combination with hepatitis B immune globulin (HBIG), might be useful for post-exposure prophylaxis. Studies have shown that response to HB vaccine is not impaired by concurrent administration of HBIG and that the combination of HB vaccine and one dose of HBIG produces immediate and sustained high levels of protective antibody to the hepatitis B surface antigen (anti-HBs).

Szmuness W, Stevens CE, Oleszko WR, Goodman A. Passive-active immuni- sation against hepatitis B: immunogenicity studies in adult Americans. Lancet 1981;I:575-7.

HIV post exposure prophylaxis consists of two to three antiretroviral medications administered within 24 hours of exposure. Serious side effects from taking the medication often inhibit compliance to the entire regime.

•  No guarantee prophylaxis regime will prevent the acquiring HIV. Reporting of an exposure to the designated officer (DO) is required by United States federal law. •  Determination if exposure occurred •  Serves as liaison with medical facility •  Written report required via the confidential exposure report form •  Local laws determine if informed consent is required to obtain serologic status of the

source.

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•  In addition to the convention printed text, this text is available in two electronic delivery options.

• CourseSmart is a subscription (rental) of the textbook that is internet based. Students can search key concepts, easily navigate to a page number, chapter or bookmark. Pages can also be printed for offline reading.

• Nook and the Kindle versions are available, for purchase, through Amazon.com Barnsandnoble.com, and other retail outlets.

www.amazon.com www.barnsandnoble.com

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The slide set has a fresh new look and have been updated to reflect the changes in the 7e Resource Central is an online resource that offers a wealth of tools to help student learning and comprehension, including quizzes, audio glossary, videos and animations of key concepts, appendices, and more. It is also a full suite of supplements just for instructors including Instructor Guide, curricula and Power Point slides. All you need for learning and teaching success is found inside Resource Central. The Course Management System is not part of Resource Central it is managed by ITLS not the publisher. For an electronic walkthrough of the textbook and resources click the link below http://www.pearsonhighered.com/showtell/ITLS_0132818116/web

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ITLS contracted with the Platinum Education Group to create updated advanced and basic pretests, advanced and basic post tests and advanced and basic retests for the 7e. The new exams will all have 50 multiple choice items (questions) on them and referenced to specific objectives in the textbook. The tests and items will go through a process to ensure they are valid, reliable, the cut score (passing score) is appropriate and beta tested with the results analyzed For additional information on Platinum Educational Group click on the link below http://www.platinumed.com/

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An electronic grade sheet application is in development for grading practical scenarios. This may be used in place of the traditional hard copy grade sheet, providing electronic storage of performance

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The TRAUMAassessment DVD takes the practical segment of the ITLS provider course out of the classroom and into real-time on DVD. This easy-to-follow simulation demonstrates ITLS’ complete patient assessment procedures for a targeted visual review of textbook material. The simulation takes you step-by-step through ITLS methods for a structured trauma assessment and rapid transport to the hospital. Learn how to determine the equipment and resources required in the field trauma setting, and become skilled at establishing patient care priorities in order to maximize patient outcome from scene to surgery. After you have the basics down, watch the demonstration in real-time for a comprehensive overview of how the ITLS assessment should be performed in the field. To view a sample of the TRAUMAassessment DVD click on the link below http://www.youtube.com/watch?v=SzB9EhYB6go

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ITLS eTrauma is an 8-hour course taking trauma training online – making it accessible and affordable for all, and providing the flexibility to fit the busy lifestyle of trauma care providers. The course covers the didactic portion of the Provider course and includes 13 multimedia interactive modules. eTrauma is accredited by CECBEMS to provide 8 hours of CE The ITLS Completer Course is an 8-hour course designed to be used in conjunction with the ITLS eTrauma: Taking Trauma Training Online course, During the Completer Course participants will participate in the standard skill stations (Patient Assessment, Spinal, Airway, Extrication) and standard testing (written and practical). Upon successful completion a provider card is issued The eTrauma Cost Calculator is an interactive tool you can download that will allow you to compare the cost of presenting the ITLS Provider course as the traditional 2-day model versus utilizing ITLS eTrauma in conjunction with a 1-day Completer Course. To download Instructions for Launching Demo click on link below http://dl.dropbox.com/u/30968655/To_Launch_eTrauma_Demo_Lesson.pdf To download Lesson 2 Demo of eTrauma click on the link below http://dl.dropbox.com/u/30968655/FTK14_Lesson-02.zip To download Cost comparison calculator click on link below http://dl.dropbox.com/u/30968655/ITLSe_Trauma_Comparison_Calculator.xls

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Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) is the national accrediting body for EMS continuing education courses and course providers. CECBEMS accredited programs have met CECBEMS' standards for accreditation. These standards require sound educational offerings determined by a review of its objectives, teaching plan, faculty, and program evaluation process. ITLS’ accreditation with CECBEMS was reapproved through January 2014 One of the greatest resources ITLS has is the instructors. Additional tools (e.g. Resource Central) are available to enhance your ability to deliver the ITLS message. Additional professional education development modules are being developed (e.g. enhancing inter-rater reliability, use of multimedia in the classroom, understanding test development). In addition to these modules the annual ITLS conference continues to offer opportunities to enhance your skills and knowledge.

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This concludes the self directed 7e ITLS Instructor update. To access the the online quiz click on the link below. Results of your quiz will be forwarded to your Chapter Coordinator and they will issue your new Instructor card

www.itrauma.org/7eupdatequiz

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