Trauma Emergency Care: MOI & Pathophysiology

• Fundamental knowledge is required for emergency care and transport of trauma patients
• Trauma pathophysiology, assessment, and management should be covered
• Trauma scoring, transport decisions, and mode of transport considerations must be included
• Recognize and manage multi-system trauma and blast injuries

Key Trauma Concepts

• Traumatic injuries result from physical forces applied to the body
• Index of suspicion involves awareness of potential serious injuries

Energy and Trauma

• Potential energy represents stored energy based on position
• Kinetic energy relates to the energy of motion, (KE = ½ mass × velocity²)
• Energy of work represents force exerted over a distance

Mechanism of Injury (MOI)

• Nonsignificant injuries involve isolated injuries or falls without loss of consciousness
• Significant injuries include multisystem trauma, falls from height, motor vehicle crashes, car versus pedestrian or bicycle, gunshot wounds, and stabbings

Types of Trauma

• Blunt trauma results from force without penetration, such as falls or vehicle crashes
• Internal injuries should be considered
• Penetrating trauma involves objects piercing the skin, causing internal damage, such as gunshots or stab wounds

Vehicular Crashes

• 3 collisions occur during a crash, the vehicle against an object, the passenger against the interior, and internal organs against solid structures in the body
• MOI considerations include death of occupant, severe vehicle damage, and ejection from the vehicle
• Types of crashes include frontal (airbags, seat belts, contact points), rear-end (whiplash injuries), lateral (side-impact injuries), rollover & rotational (high risk of ejection), and motorcycle crashes (ejection, head-on, angular impacts)

Falls

• Falls over 20 feet (6 meters) are considered significant
• The height, landing surface, and body impact point should be considered

Blast Injuries

• Primary blast injuries result from the pressure wave, affecting hollow organs
• Secondary blast injuries are caused by flying debris
• Tertiary blast injuries result from the victim being thrown into an object
• Quaternary blast injuries consist of burns, inhalation injuries, and crush injuries

Multisystem Trauma

• Affects more than one body system, like head/spine + chest + extremities
• Rapid transport to a trauma center is required

Golden Principles of Prehospital Trauma Care

• Ensure scene safety
• Identify and manage life threats (ABC)
• Limit scene time to < 10 minutes for critical patients
• Obtain SAMPLE history and conduct a secondary assessment
• Consider ALS intercept or air transport

Trauma Center Designations

• Level I trauma centers have comprehensive trauma care, often university-based hospitals
• Level II trauma centers have initial definitive care
• Level III trauma centers have stabilization and transfer capabilities
• Level IV trauma centers are in remote areas, providing advanced life support

Patient Assessment in Trauma

• A rapid trauma assessment should be performed for significant MOI
• Focus should be on the chief complaint for nonsignificant MOI

Common Injury Patterns

• Head trauma includes brain swelling, frequent neuro exams
• Neck/throat injuries include airway compromise, swelling
• Chest injuries include fractured ribs, lung damage, cardiac bruising
• Abdominal injuries include solid organ bleeding, hollow organ rupture

Transport & Destination Decisions

• Scene Time: <10 minutes for critical trauma
• Ground ambulance for stable patients
• Air medical transport if there is prolonged extrication, a remote area, or multiple trauma patients

Soft-Tissue Injuries

• Soft-tissue injuries range from minor abrasions to life-threatening internal damage
• Airway obstruction in trauma patients should not be overlooked
• Soft tissue injuries result from blunt trauma (contusions, crush injuries), penetrating trauma (lacerations, punctures), and burns (thermal, chemical, electrical, radiation)

Anatomy of the Skin

• Epidermis is the outer protective layer
• Dermis is the inner layer containing blood vessels, nerves, and glands
• Functions of the skin include protection against infection, temperature regulation, fluid retention, and sensory perception

Types of Soft-Tissue Injuries

• Contusion represents bruising due to broken blood vessels
• Hematoma involves blood collection within damaged tissue
• Crush injuries can lead to Crush Syndrome if compressed for over 4 hours
• Compartment Syndrome refers to increased pressure in a muscle compartment, leading to ischemia
• Abrasions represent superficial wounds from scraping
• Lacerations involve jagged or smooth cuts
• Avulsions: Skin or soft tissue partially or completely torn away
• Amputations represent complete loss of a limb or body part
• Puncture Wounds: Caused by sharp, pointed objects (risk of internal damage)
• Primary blast injuries represent damage from the blast wave
• Secondary blast injuries represent injuries from flying debris
• Tertiary blast injuries involve a victim being thrown by a blast
• Quaternary blast injuries include burns, inhalation injuries, and crush injuries

Burns

• Superficial (First-degree) burns include red skin, no blisters
• Partial-Thickness (Second-degree) burns include red, blistered skin, severe pain
• Full-Thickness (Third-degree) burns include white or charred skin, nerve damage, no pain at site
• The extent of burn is assessed using the Rule of Nines
• Critical areas: Face, airway, hands, feet, genitalia
• Patient Age: Higher risk for children and elderly
• Presence of other injuries or medical conditions need to be considered
• Thermal burns result from heat exposure (flame, hot surfaces, steam)
• Chemical burns result from strong acids, alkalis, or hazardous substances
• Electrical burns include entry and exit wounds, pose a risk of cardiac arrest
• Radiation burns are caused by exposure to radioactive materials

Emergency Care for Soft-Tissue Injuries

• REST, ICE, COMPRESSION, ELEVATION, SPLINTING (RICES)
• Control bleeding (direct pressure, dressings, tourniquet if necessary) for open injuries
• Prevent contamination (sterile dressings, avoid touching wounds)
• Do not remove impaled objects unless obstructing the airway or CPR
• Cover abdominal eviscerations with a moist sterile dressing and secure with an occlusive dressing
• Apply an occlusive dressing to neck wounds to prevent air embolism

Burn Management

• Stop burning process immediately
• Remove clothing/jewelry from burned area
• Cover with dry, sterile dressing (avoid ointments)
• Chemical burns: Brush off dry chemicals, flush with copious water
• Electrical burns: Be prepared for cardiac arrest, monitor closely
• Radiation burns: Wait for hazmat decontamination before treatment

Assessment and Transport Considerations

• Manage life-threatening bleeding first for the primary assessment
• Assess airway, breathing, circulation (ABCs))
• Rapid transport for shock, severe burns, penetrating trauma
• SAMPLE and OPQRST history during secondary assessment
• Assess for chronic conditions affecting wound healing
• Check for hidden injuries
• Assess for signs of shock (tachycardia, hypotension, pale skin)
• Monitor vital signs frequently and ensure interventions (dressings, splints) remain effective during reassessment

Head and Neck Injuries

• The face and neck are vulnerable to injuries because of their exposed position
• The most common injuries include soft-tissue injuries, fractures, and life-threatening penetrating trauma

Anatomy of the Head, Face, and Neck

• Cranium protects the brain, and is composed of the occiput (posterior), temporal regions (sides), and frontal region (forehead)
• Major bones of the face include the nasal bone, zygomas (cheekbones), maxillae (upper jaw), and mandible (lower jaw)
• Orbit of the eye is composed of the frontal bone, zygoma, maxilla, and nasal bone
• The proximal third of the nose is bone, and the remaining two-thirds is cartilage
• The neck contains vital structures, including the trachea, esophagus, carotid arteries, jugular veins, and larynx (includes Adam's apple, and cricoid cartilage)

Injuries of the Face and Neck

• Facial trauma can cause upper airway obstruction.
• Obstruction sources include blood clots, dislodged teeth/dentures, swelling, or positional obstruction
• High blood flow can cause excessive bleeding in soft-tissue injuries
• Hematomas and deep lacerations require careful management
• Mandible and maxillary fractures are common due to high-energy impacts.
• Signs of jaw fractures include maligned teeth, numb chin, and difficulty opening the mouth
• Foreign objects in the eye should be flushed with sterile saline from the nose side outward
• Chemical burns require continuous irrigation for at least 20 minutes
• Blunt trauma can cause hyphema (bleeding in the eye chamber)
• Retinal detachment requires immediate attention to prevent blindness
• Anterior nosebleeds are mild, and posterior ones are severe. Bleeding should be controlled with direct pressure
• Ear injuries can involve the external, middle, or inner ear
• Tympanic membrane rupture is caused by direct trauma or pressure changes
• Neck injuries include blunt trauma (affecting the airway and great vessels) and penetrating trauma (risk of exsanguination and air embolism)

Emergency Medical Care

• Assess XABCs (Exsanguination, Airway, Breathing, Circulation)
• Control bleeding by applying direct pressure, and avoid excessive pressure on suspected skull fractures
• Stabilize impaled objects
• Rapid transport is necessary for airway compromise, severe bleeding, or head injuries

Open Chest Wounds

• EMTs should respond to a construction site where a worker fell onto a piece of metal, resulting in an open chest wound
• The patient is responsive, but is suffering from shortness of breath and pain

Importance of Sealing Open Chest Wounds

• Open chest wounds should be sealed quickly to prevent air from entering the pleural space, potentially causing a pneumothorax or tension pneumothorax
• Open chest wounds prevent lung collapse and maintain normal breathing mechanics

Possible consequences of chest trauma

• Blunt injury to the heart may cause cardiac contusion, dysrhythmias, or pericardial tamponade
• Penetrating injury may cause pneumothorax, hemothorax, tension pneumothorax, or pericardial tamponade.

Primary Assessment Findings & Immediate Actions

• Look for penetrating wound to the right anterior chest (below the nipple)
• Look for blood bubbling from the wound with breathing

Immediate Actions

• Apply an occlusive dressing (three-sided or vented dressing to prevent air trapping)
• Administer high-flow oxygen via non-rebreather mask (NRB) at 15 L/min
• Monitor for signs of respiratory distress (dyspnea, tachypnea, absent breath sounds)
• Transport quickly to the hospital

Secondary Assessment & Suspected Injuries

• Breath sounds (diminished or absent?) should be assessed
• Chest wall movement (paradoxical motion?) should be assessed
• Subcutaneous emphysema (air under the skin?) should be assessed
• Distended neck veins (JVD – possible tension pneumothorax?) should be assessed
• Look for signs of shock (pale, cool skin, tachycardia, hypotension)
• Suspect pneumothorax (air in pleural space → lung collapse)

Patient Transport & Monitoring

• Vital signs should remain stable in the ambulance
• The patient may develop sounds that are diminished on the right side
• Their breathing may improve
• Breathing should be assisted if breathing rate is abnormal
• Bag-valve mask (BVM) assistance is necessary if breathing rate is less than 12 or greater than 20 breaths/min
• There should be concern for signs of shock (Hemothorax Concern)

Shock

• Symptoms involve hypotension (low BP), tachycardia (fast pulse), cool, clammy skin, and decreased level of consciousness

Key Takeaways

• Pneumothorax is a common complication of penetrating chest trauma
• Tension pneumothorax may develop if air is trapped → Requires lifting one edge of the occlusive dressing to relieve pressure
• Quick assessment and treatment are critical to survival
• Key signs of chest injury include tachypnea, dyspnea, subcutaneous emphysema, crepitus, hemoptysis, paradoxical movement, and pulse pressure narrowing

Abdominal and Genitourinary Injuries

• The abdomen extends from the diaphragm to the pelvis and contains organs of the digestive, urinary, and reproductive systems
• Unrecognized injuries are a leading cause of traumatic death
• Injuries are categorized as blunt or penetrating, and involve solid or hollow organs

Anatomy & Physiology

• Liver, gallbladder, pancreas and duodenum are located in the right upper quadrant (RUQ)
• Stomach and spleen are located in the left upper quadrant (LUQ)
• Appendix, and large and small intestine are located in the right lower quadrant (RLQ)
• Descending colon, left transverse colon are located in the left lower quadrant (LLQ)
• Hollow organs (stomach, intestines, bladder, ureters) can rupture, they spill contents into the peritoneal cavity, causing peritonitis
• Solid organs (liver, spleen, pancreas, kidneys), are highly vascular, and prone to severe bleeding when injured

Types of Abdominal Injuries

• Common MOIs for blunt trauma include car crashes, motorcycle accidents, falls, and blast injuries
• Symptoms of blunt injuries are pain, abdominal distention, bruising, and rigidity
• Seat belt injuries can damage organs if positioned too high
• Open abdominal injuries from penetrating trauma are caused by knives (low velocity), handguns (medium velocity), and rifles (high velocity)
• Evisceration is a protrusion of abdominal organs
• Organs should never be pushed back in; cover with moist, sterile dressing

Specific Abdominal Injuries

• Hollow organ injuries can cause delayed peritonitis
• Liver injury result in severe bleeding, often due to fractured lower ribs or penetrating trauma, and is often associated with referred pain to the right shoulder
• Spleen injuries are common in motorcycle/bicycle accidents and falls, and can result in heavy bleeding
• Kidney injuries can cause blood in urine (hematuria), flank pain, swelling, or bruising

Patient Assessment

• Use standard precautions (gloves, eye protection)
• Look for MOI clues (steering wheel damage, seat belt marks) at the scene
• Primary assessment
  • Ensure airway & breathing are intact
  • Address major bleeding immediately
  • Monitor for signs of shock (rapid pulse, low BP, pale/cool skin)
• Secondary assessment
  • Inspect & palpate abdomen for bruising, rigidity, tenderness
  • Examine back & sides for exit wounds
  • Monitor vital signs: Monitor for tachycardia & hypotension (shock indicators)

Emergency Medical Care

• Monitor and treat signs of shock for both closed and open abdominal injuries
• Administer oxygen and assist with ventilation for both closed and open abdominal injuries
• Cover wounds with a dry, sterile dressing if open
• Stabilize impaled objects if open
• Never. push organs back in for evisceration
  • Cover with moist, sterile dressing during eveisceration
  • Apply occlusive dressing around the injury to retain warmth during evisceration

Genitourinary Injuries

• Suspect kidney injuries if flank bruising, hematuria is present
• Bladder injuries often coincides with pelvic fractures
• External genitalia injuries are painful by not life threatening
• Do not insert anything the vagina if female genitalia injuries are present

Genitourinary Injuries Care

• Control external bleeding with dry, sterile dressings
• Do not remove impaled objects
• Preserve amputation of genital parts in moist, sterile dressing

Sexual Assault Considerations

• Ensure privacy and emotional support
• Never allow patients to shower, change clothes, or urinate (preserve evidence)
• Follow crime scene protocols
• Ensure same gender EMT is present to ensure patient comfort and cooperation

Orthopaedic Injuries

Musculoskeletal System

• Provides form, upright posture, and movement
• Protects vital internal organs
• Consists of bones, muscles, tendons, cartilage, and ligaments

Anatomy & Physiology

• Types of Muscle: Skeletal (voluntary), Smooth (involuntary), and Cardiac
• Skeletal System: There are 206 bones that provide structure and movement, which produce blood cells and store bones, and consist of several structures

Structures of Skeletal System

• The structures consist of the skull, thoracic cage, pectoral girdle, pelvis, and upper/lower extremities

Orthopaedic Injuries

• Fractures (Break in bone) Open (skin broken) vs. Closed (skin intact), as well as other types
• Dislocations: Involves bone displaced from joint
• Sprains (Ligament injury): Common in ankles, knees, and shoulders
• Strains (Muscle/tendon injury): Pain, swelling, and bruising, but no major deformity
• Amputations: Complete or partial severing of a limb, which is high risk for bleeding and shock

Assessment & Management

• Primary Assessment (Life-Threatening Injuries)
  • Follow XABCs
  • Check for shock, responsiveness (AVPU scale), and vital signs
• Secondary Assessment (Specific Injury Examination)
  • Use DCAP-BTLS
  • Use 6 Ps of musculoskeletal injury
• Splinting Techniques
  • Goal is to prevent movement, reduce pain, and protect from further injury
  • Types: Rigid, formable, vacuum, air, and traction splints, as well as using a pelvic binder for pelvic fractures
• Emergency Transport
  • Prioritize patients with suspected vascular injuries or fractures which cause major blood loss
  • Transport quickly to increase survival chances

Common Injuries by Body Part

• Clavicle and scapula fractures should be treated with a sling & swathe
• Humerus fractures should be treated with a swing and swathe while utilizing traction if needed
• Elbow: Immobilize and monitor circulation
• Forearm/Wrist/Hand: Splint, and consider adding an air splint
• Pelvis: Since there is High risk for internal bleeding, use pelvic binder
• Hip Dislocation: Splint as needed, and transport the patient quicky
• Femur and Knee Fractures: Splint in position found
• Ankle should be immobilized, and make sure to check patients circulation

Special Conditions

• Compartment Syndrome: Increased pressure in muscle compartment causes nerve/blood vessel damage. Signs: Extreme pain, pallor, paralysis, and weak pulses require transporting immediatley
• Amputation Care: Preserve amputated part by wrapping in sterile dressing, placing in a bag, and keep it cool

Head and Spine Injuries

Anatomy and Physiology Central Nervous System (CNS) and Peripheral Nervous System (PNS)

• Brain:
  • Cerebrum: Controls voluntary movements, thoughts, and emotions
  • Cerebellum: Coordinates movement and balance
  • Brainstem: Controls vital functions (breathing, heart rate)
• Spinal Cord:
  • Transmits signals between the brain and body
  • Protected by vertebrae and cerebrospinal fluid (CSF)
• Peripheral Nervous System (PNS)
  • Spinal Nerves (31 pairs): Carry motor and sensory information
  • Cranial Nerves (12 pairs): Control facial movements and senses
• Autonomic Nervous System:
  • Sympathetic ("Fight or Flight"): Increases heart rate and blood pressure
  • Parasympathetic ("Rest and Digest"): Slows down body functions

Head Injuries

Types of Head

• Scalp Lacerations: Can lead to significant blood loss
• Skull Fractures: Linear (80%), Depressed, Basilar, and Open can be deadly
• Traumatic Brain Injuries (TBIs): Primary (Direct): Occurs at the moment of impact and Secondary (Indirect): Caused by hypoxia, swelling, or bleeding

Bleeding

• Epidural Hematoma: Arterial bleed; the lucid interval can cause deterioration
• Subdural Hematoma: Venous bleed; slow progression of symptoms
• Intracerebral Hematoma: Bleeding inside brain tissue
• Subarachnoid Hemorrhage: Bloody CSF, irritation, and a sudden headache

Increased Intracranial Pressure (ICP)

• Early Signs include Headaches, nausea, and vomiting
• Late Signs (Cushing's Triad):
  • Hypertension, Bradycardia (Irregular heart rate), and Irregular respirations

Spinal Injuries

Mechanisms and Signs of Injury

Mechanisms of Injury

• Compression Injuries: Falls and diving accidents
• Flexion/Extension: Whiplash in car crashes
• Rotation/Flexion: High-speed crashes
• Distraction Injuries: Hanging or sudden stretching

Signs of Cord Injury

• Pain as well as tenderness or motor dysfunction
• Paralysis (quadriplegia and paraplegia)
• Priapism (erection due to spinal shock)

Patient Assessment

• Assess if MOI High events cause the patient to be irresponsive
• Assess for spinal injuries if the patient is irresponsive
• Airway: Use jaw-thrust maneuver to protect Airway, followed by Breathing
• Circulation: Control scalp bleeding, and make sure to stabilize with a cervical collar

Secondary Assessment

• Glasgow Coma Scale (GCS)
• Conduct Eye, Verbal, and Motor response checks if applicable
• Severe TBI is present if the GCS is less than 8

Emergency Management

• Maintain oxygenation while controlling pressure
• Avoid hyperventilation
• Transport if injury is present or you suspect one Spinal Injuries: Reduce SMR by applying a rigid cervical collar as well as a vacuum backboard
• Logroll when stabilizing