Trauma Lecture Outline PDF

I. Introduction A. Trauma is the primary cause of death and disability in people between ages 1 to 44 years. 1. Basic concepts of mechanics and biomechanics of trauma will help you analyze and manage your patient’s injuries. a. Analyzing a trauma scene is a vital skill. b. Yo...

I. Introduction A. Trauma is the primary cause of death and disability in people between ages 1 to 44 years. 1. Basic concepts of mechanics and biomechanics of trauma will help you analyze and manage your patient’s injuries. a. Analyzing a trauma scene is a vital skill. b. You are the eyes and ears of the emergency department (ED) physicians and/or the trauma team. c. Your documentation is the only source for physicians to understand the events and mechanisms that led to the trauma. II. Trauma, Energy, and Kinetics A. Trauma: Acute physiologic and structural change that occurs when an external source of energy affects the body beyond its ability to sustain and dissipate it 1. Different forms of energy produce different kinds of trauma. a. Mechanical energy i. Energy from motion (kinetic energy [KE]) ii. Energy stored in an object (potential energy) b. Chemical energy i. Energy released as a result of a chemical reaction c. Thermal energy i. Energy transferred from sources that are hotter than the body d. Electrical energy i. Example: Electrocution or lightning strike e. Barometric energy i. Sudden radical changes in pressure 2. Biomechanics: Study of physiology and mechanics of living organisms, using tools of mechanical engineering a. Can be used to help analyze the mechanisms and results of trauma 3. Kinetics: Study of the relationship among speed, mass, direction of force, and physical injury caused by these factors a. Can be used to help predict injury patterns B. Factors affecting types of injury 1. The kind of injury sustained will be determined by the ability of the patient’s body to disperse the energy delivered. 2. External factors that determine types of injury include force and energy. a. Size (or mass) of object delivering force b. Velocity c. Acceleration or deceleration d. Body area affected by application of force  3. Duration and direction are also important factors. a. The larger the area of force dissipation, the more pressure is reduced to a specific spot on the body. b. Blunt trauma: Spreading of impact without breaking the skin i. Difficult to diagnose (a) Often little external damage c. Rapidly applied amounts of energy are less tolerated than the same amount of energy delivered over a longer period of time. d. The position of the trauma victim at the time of the event is another external factor. i. Seat belt use has reduced lethal injuries by occupants in positions less likely to cause fatal injuries. 4. The impact resistance of body parts has a bearing on types of tissue disruption. a. Organs that have gas inside are easily compressed. b. Liquid-containing organs are less compressible. 5. Understanding the effects of forces and energy transfer patterns will help to assess the mechanism of injury (MOI). a. Can help predict most likely type of injury 6. Have a high index of suspicion for injuries that may be undetected. C. Kinetics 1. Velocity (V): Speed at which an object travels per unit of time a. The difference between velocity and speed is that velocity also incorporates the specific direction in which the movement is occurring. 2. Acceleration (a): Rate of change in velocity an object is subjected to 3. Gravity (g): Downward acceleration imparted to any object moving toward Earth a. During each second of a fall, the velocity or speed of the falling object increases by 9.8 m/s². 4. Kinetic energy is associated with the object’s movement. a. Reflects the relationship between the weight (mass) of the object and the velocity at which it is traveling i. Kinetic energy = Mass/2 × Velocity2 b. Velocity has a much greater effect on KE than mass. 5. The KE of a car in motion that stops suddenly must be transformed or applied to another object. a. Modern vehicles have crumple zones to maximize the amount of energy absorbed by deformation before the passenger compartment is involved. 6. Other factors that will affect the amount of energy dissipation in a crash include: a. Vehicle’s angle of impact i. Front impact versus side impact ii. How the patient hits the inside of the automobile b. Differences in sizes of the two vehicles c. Restraint status and protective gear of the occupants 7. Each vehicle involved contributes KE to the crash. 8. Law of conservation of energy: Energy can neither be created nor destroyed; it can only change form.  9. Energy dissipation: Process by which KE is transformed into a form of mechanical energy a. If a car stops slowly, KE is converted to thermal energy. b. If a car crashes, KE is also converted to mechanical energy. i. Mechanical energy is further dissipated in the form of injury. c. Protective devices can manipulate the way in which energy is dissipated. 10. Newton’s first law of motion: A body at rest will remain at rest unless acted on by an outside force. a. Similarly, a body in motion tends to stay in motion unless acted on by an outside force. 11. Newton’s second law of motion: The force an object can exert is the product of its mass (weight) times its acceleration. a. Force = Mass × Acceleration (or Deceleration) b. The greater an object’s mass and/or acceleration, the greater the force needed to make a change of course. c. Deceleration i. Rapid deceleration dissipates tremendous force. d. Deceleration and acceleration can be measured in numbers of g forces. i. One g force = normal acceleration due to gravity ii. Two or three g force = two or three times the force associated with gravity iii. The human limit to deceleration is 30 g. e. In a head-on collision, transferred energy is represented as the sum of both vehicles’ speeds. III. Multisystem Trauma A. Multisystem trauma describes injuries that involve several body systems. 1. Generally caused by events that affect the entire body 2. Often, both blunt and penetrating trauma occurs. B. If you suspect that multiple body systems are affected: 1. Assess the patient’s entire body. 2. Prioritize the treatment of the injuries. 3. Transport patients without delay. IV. Blunt Trauma A. Blunt trauma refers to injuries in which the tissues are not penetrated by external objects. 1. Commonly occurs in: a. Motor vehicle crashes b. Pedestrians hit by vehicle c. Motorcycle crashes d. Falls from heights e. Sports injuries f. Blasts where the pressure wave is the primary cause of injury B. Motor vehicle crashes 1. There are five phases of trauma tied to the effects of progressive deceleration when a vehicle collides with another object. a. Phase 1: Deceleration of the vehicle i. Vehicle strikes another object and is brought to an abrupt stop. ii. Vehicle motion continues until KE is dissipated. b. Phase 2: Deceleration of occupant i. Starts during sudden braking and continues during impact of the crash ii. Results in deceleration, compression, and shear trauma depending on: (a) Mass of each occupant (b) Protective mechanisms in the vehicle (c) Body parts involved (d) Points of impact c. Phase 3: Deceleration of internal organs i. Continue forward momentum until stopped by anatomic restraints ii. May result in tears and shearing injuries d. Phase 4: Secondary collisions i. Occupant hit by objects moving within the vehicle ii. Known to cause severe spine and head trauma e. Phase 5: Additional impacts received by the vehicle i. Vehicle hit by a second vehicle ii. Vehicle deflected into another vehicle, tree, or other object iii. May increase severity of original injuries or cause further injury 2. Impact patterns a. How dented and deformed the vehicle looks is an indication of the forces involved and the degree of deceleration sustained by your patient. b. Frontal or head-on impacts i. The front end of the vehicle distorts as it dissipates KE and decelerates its forward motion. ii. Passengers decelerate at the same rate as the vehicle. iii. Forces applied to the driver will differ based on: (a) Vehicle design (b) Materials (c) Safety features of the vehicle iv. Abrupt deceleration injuries are produced by a sudden stop of a body’s forward motion. (a) Can induce shearing, avulsing, or rupturing of organs (b) Injuries are often invisible during examination. v. The head is vulnerable to deceleration injuries. (a) Can cause the brain to strike the inside of the skull, causing bleeding, bruising, or tearing injuries (1) Will not show up on a physical examination (2) Index of suspicion should be high  vi. The aorta is the most common site of deceleration injury in the chest. (a) Often torn away from its points of fixation in the body (b) Can result in loss of the total blood volume and immediate death vii. Internal organs that continue their motion after the motion of the body stops may result in tearing or shearing injuries. (a) Commonly affected organs include: (1) Liver (2) Kidneys (3) Small intestine (4) Large intestine (5) Pancreas (6) Spleen viii. Crush and compression injuries are the result of forces applied to the body by things external to the body at the time of impact. ix. Compression injuries of the head may result in skull fracture. (a) Often associated with cervical spine injury (b) Assume spinal cord injuries and severe injury to the brain. (c) Brain tissue swells inside the skull. x. Compression injuries of the chest may produce fractured ribs. xi. Compression of the heart may cause dysrhythmias and direct injury to the heart muscle. xii. Compression of the lungs can result in acute respiratory distress syndrome. xiii. Compression against the seat belt may result in: (a) Bowel rupture (b) Urinary bladder rupture (c) Diaphragm tearing (d) Spinal injuries (e) Exsanguination c. Unrestrained occupants usually follow one of two trajectories: i. Down-and-under pathway (a) Occupant slides under the steering column or dash (b) Knees hit the dashboard (c) Energy of deceleration is transmitted up the femurs to the pelvis and the upper torso continues forward until it impacts the vehicle. (d) Look for: (1) Femur fracture (2) Fracture-dislocation of the knee (3) Hip and pelvic fractures (4) Hip dislocation (5) Spinal injuries (6) Rib fractures (7) Pulmonary and cardiovascular injuries ii. Up-and-over pathway  (a) Lead point is the head. (b) Can include significant head and cervical spine trauma (c) Ejection is possible. (d) A dangerous lung injury may occur if your patient reflexively takes a deep breath just before impact. (e) Lower leg fractures could be present. d. Lateral or side impacts i. Impart energy to the near-side occupant directly to the pelvis and chest ii. Seat belts offer little protection. iii. As the passenger compartment deforms, the passenger’s head can strike the impacting vehicle or object. iv. Injury results from: (a) Direct trauma to the affected side (b) Tension developed on the far side v. The shoulder frequently rotates outward and posteriorly, exposing the chest and ribs to injury. (a) May cause rib fractures, lateral flail chest, and lung contusions. vi. The passenger’s body is pushed in one direction, while the head moves toward the impacting object. (a) May result in disruption and dislocation of the spine vii. Passengers travel in opposite directions, colliding with each other. viii. The typical pattern of pelvic injury that occurs is a lateral compression injury (pelvic ring disruption). ix. Death is usually the result of associated torso or head injuries. e. Rear impacts i. Have the most survivors if driver and passengers are properly restrained ii. Whiplash injury iii. Energy is imparted to the front vehicle. f. Rotational or quarter-panel impacts i. Occurs when a lateral crash is off center ii. The point where the vehicle’s greatest loss of speed occurs is where the greatest damage to the occupant will occur. iii. Occupants tend to receive frontal and lateral injuries. iv. Three-point seat belts are effective in preventing injury in angled crashes of up to 45°. g. Rollovers i. Greatest potential for lethal injury (a) Patients may be ejected. (b) Patients may be struck hard against the interior of the vehicle. ii. Ejection increases the chance of death by 91 times. 3. Restrained versus unrestrained occupants a. Seat belts stop the motion of any vehicle’s occupant who is traveling at the same speed as the vehicle.  i. Limit the contact of the occupants with the interior of the vehicle ii. Prevent ejection iii. Distribute deceleration energy over a larger surface iv. Prevent the occupants from violently contacting each other b. Specific injuries associated with seat belt use include cervical fractures and neck sprains. i. Most serious injuries occur because the patient did not use the seat belt correctly. c. Airbags have reportedly reduced deaths in direct frontal MVCs by about 30%. i. Front airbags will not activate in side-impact crashes or impacts to the front quarter panel. ii. Can also result in secondary injuries from direct contact or from the chemicals used to inflate it iii. Small children can be severely injured or killed if airbags inflate while they are in the front seat. C. Motorcycle crashes 1. Any structural protection afforded to victims is derived from protective devices worn by the rider. a. Helmet b. Leather or abrasion-resistant clothing and boots 2. When assessing the scene, attention should be given to: a. Deformity of motorcycle b. Side of most damage c. Distance of skid in road d. Deformity of stationary objects or other vehicles e. Extent and location of deformity in helmet 3. There are four types of motorcycle impact. a. Head-on impact i. Motorcycle strikes another object and stops its forward motion. ii. Rider continues forward until stopped by an outside force. iii. For motorcycles with a low riding seat, the gas tank can act as a wedge on the pelvis. (a) Can result in: (1) Severe anterior-posterior compression injuries (2) Open pelvic fractures b. Angular impact i. Motorcycle strikes an object or another vehicle at an angle. ii. Rider sustains direct crushing injuries to the lower extremity between the object and the motorcycle. iii. May result in: (a) Severe open and comminuted lower extremity injuries (b) Traumatic amputation (c) Severe thoracoabdominal torsion and lateral bending spine injuries (d) Head injury (e) Pelvic trauma  c. Ejection i. Rider will travel at high speed until stopped by a stationary object, by another vehicle, or by contact with the road. d. Laying the bike down i. A technique used to separate the rider from the body of the motorcycle and the object to be hit 4. The helmet should be removed carefully if: a. Airway management techniques cannot be performed with the helmet in place b. Helmet does not fit snugly to the head 5. Assume any dents and abrasions have caused cervical spine fractures until proven otherwise by radiographs. 6. Bicycles and off-road vehicles, such as four-wheelers and snowmobiles, are capable of producing injuries similar to those of motorcycles. D. Pedestrian injuries 1. Almost 85% of pedestrians are struck by a vehicle’s front end. a. Adult injuries are generally lateral and posterior. i. Tend to turn to the side or away from impact ii. Children turn toward the oncoming vehicle. 2. There are three predominant MOIs. a. First impact: Vehicle strikes an adult body with its bumpers. b. Second impact: Adult is thrown on the hood and/or grille of vehicle. c. Third impact: Body strikes the ground or some other object. 3. Pediatric patterns of pedestrian injury are different from patterns in adults. a. Waddell triad refers to pattern of injuries in children and people of short stature: i. The bumper hits the pelvis and femur instead of knees and tibias. ii. The chest and abdomen hit the grille or low on the hood of the vehicle. iii. The head strikes the vehicle and then the ground. E. Falls from heights 1. A fall produces acceleration downward at 9.8 m/s². 2. Severity of injuries affected by: a. Height i. Determines the velocity of the fall. ii. Height plus stopping distance predicts the magnitude of deceleration forces. b. Position i. Will determine the type of injuries sustained and likelihood of survivability ii. Children tend to fall head first. iii. Adults usually try to land on their feet. (a) Don Juan syndrome: Group of potential injuries from a vertical fall to a standing position (1) Foot and lower extremity fractures (2) Hip, acetabular, and pelvic ring and sacral fractures  (3) Vertebral compression and burst fractures (4) Vertical deceleration forces to organs (5) Fractures of the forearm and wrist (Colles fracture) c. Area i. The larger the area of contact, the greater the dissipation of force. d. Surface i. The degree to which the surface can deform under the force of the falling body can help dissipate forces of sudden deceleration. e. Physical condition i. Preexisting medical conditions could influence injuries sustained. (a) Osteoporosis predisposes to fractures even with minimal falls. (b) Hematologic conditions are prone to ruptured spleen in fall. V. Penetrating Trauma A. Penetrating trauma involves a disruption of the skin and underlying tissues in a small, focused area. 1. Classified as low, medium, or high velocity a. Low velocity i. Caused by sharp edges of object moving through body b. Medium and high velocity i. Usually a bullet ii. Path of the object might not be easy to predict because it might flatten out, tumble, or even ricochet within the body 2. In the United States, the most common sources of penetrating injuries are firearms. B. Stab wounds 1. Severity depends on: a. Anatomic area involved b. Depth of penetration c. Blade length d. Angle of penetration 2. May also involve a cutting- or hacking-type force such as in machete wounds 3. Neck wounds can involve critical anatomic structures. 4. Lower chest or upper abdominal wounds have the potential of involving the thoracic and abdominal cavities. 5. The pattern of a stab wound closely relates to the mechanism involved and should be documented in detail. a. Record the direction of the wound. C. Gunshot wounds 1. The severity of a gunshot wound depends on several factors. a. Type of firearm  b. Velocity of projectile c. Physical design and size of projectile d. Distance of the victim from the muzzle of firearm e. Anatomic location of the injury f. Type of structure that is struck 2. Shotguns a. Fire round pellets i. From half a dozen to several dozen at a time b. Shot density is determined by distance traveled. c. Can induce destructive injuries at a very close range 3. Rifles a. Fires single projectile at a very high velocity b. Grooved barrel imparts a spin to the projectile for accuracy 4. Handgun a. Revolver holds 5 to 10 rounds of ammunition. b. Pistol holds 2 to 3 times as many rounds of ammunition as a revolver. c. Rifled barrel imparts spin to bullet, but accuracy is limited. d. Ammunition is generally less powerful than rifles and fires at lower velocity. 5. Ballistics: Study of nonpowered objects in flight a. Most often associated with rifle or handgun bullet travel b. When a bullet leaves the barrel of a gun, gravity begins to pull it toward the earth. i. Trajectory: Curve of a bullet’s travel path related to how fast it falls to the earth after leaving the barrel 6. The most important factor for seriousness of a gunshot wound is the type of tissue through which the projectile passes. a. Tissue of high elasticity (muscle) is better able to tolerate stretch. 7. Entrance wounds are characterized by the effects of the initial contact and implosion. a. Skin and tissues are pushed in, cut, or abraded. b. At close range, tattoo marks from powder burns can occur. c. At closer range, burns can occur from muzzle blast. 8. Deformation and tissue destruction is based on a combination of factors. a. Density b. Compressibility c. Missile velocity d. Missile fragmentation 9. The projectile crushes the tissue during penetration, creating a permanent cavity. a. May be straight line or irregular pathway b. Pathway expansion: Tissue displacement that occurs as the result of low-displacement sonic pressure waves that travel at the speed of sound in tissue c. Bowel, muscle, and the lungs are relatively elastic, resulting in fewer permanent effects of temporary cavitation.  d. Liver, spleen, and brain are relatively inelastic, resulting in more permanent effects of temporary cavity. e. Missile fragmentation: Projectile sends off fragments that create their own separate paths through tissues 10. Exit wounds occur when the projectile’s energy is not entirely dissipated along its trajectory through the body. a. Size depends on the energy dissipated and the degree of cavitation at the point of exit. b. Usually have irregular edges c. May be larger than entry wounds d. Multiple exit wounds may be present if missile fragmentation occurs 11. Shotgun wounds are the result of tissue impact by numerous projectiles. a. The greater the distance from the muzzle to the target, the more dispersion the projectiles will have. b. Severity of an injury depends on: i. Powder charge ii. Size and number of pellets iii. Dispersion of the pellets (a) Determined by: (1) Range at which the weapon was fired (2) Barrel length (3) Type of choke at the end of the barrel 12. Try to obtain the following: a. What kind of weapon was used? b. At what range was it fired? c. What kind of bullet was used? d. How many shots were heard during the shooting? 13. Look for: a. Powder residue around the wound b. Entrance and exit wounds VI. Blast Injuries A. Categories of blast injuries 1. Primary blast injuries a. Damage to the body is caused by the pressure wave generated by the explosion. i. Concentrated pressure results from air displacement and heat originating from the center of the blast. b. Organs generally affected are: i. Lungs ii. Eardrums iii. Other compressible organs c. Close proximity to the origin of the pressure wave carries a high risk of injury or death.  2. Secondary blast injuries a. Result from being struck by flying debris b. A blast wind occurs as the shock wave applies force to air molecules. c. Flying debris may cause blunt and penetrating injuries. 3. Tertiary blast injuries a. Occur when a person is hurled by the force of the explosion (or blast wind) against stationary, rigid objects b. Ground shock: Physical displacement of the body when the body impacts the ground 4. Quaternary (miscellaneous) blast injuries a. Result from the miscellaneous events that occur during an explosion b. May include: i. Burns ii. Respiratory injury iii. Crush injury iv. Entrapment 5. Quinary blast injuries a. Caused by biologic, chemical, or radioactive contaminants that have been added to a traditional explosive device b. Associated with “dirty bombs” B. The physics of an explosion 1. When a substance is detonated, it is converted into large volumes of gas under pressure. a. Propellants are explosives designed to release energy relatively slowly compared with high explosives. 2. Components of blast shock wave a. Blast front: Leading edge of an explosion pressure blast wave b. Positive wave pulse: Phase of the explosion in which there is a pressure front higher than atmospheric pressure c. Shock waves: High-explosive blast waves i. Possess brisance (describes shattering effect of wave and its ability to cause disruption of tissues and structures) ii. Tissue damage depends on the magnitude of the pressure spike and the duration of force. d. Negative wave pulse: Phase in which pressure is less than atmospheric i. Occurs as air displaced by the positive wave pulse returns to fill the space ii. Can lead to high-velocity winds e. The speed, duration, and pressure of the shock wave are affected by: i. Size of the explosive charge (a) The larger the explosion, the faster the shock waves and the longer they will last. ii. Nature of surrounding medium (a) Pressure waves travel more rapidly and are more effective in water. iii. Distance from explosion (a) The farther from the explosion, the slower the shock wave velocity and the longer its duration.  iv. Presence or absence of reflecting surfaces (a) If the pressure wave is reflected off a solid object, its pressure may be multiplied several times. f. An explosion is more damaging in closed spaces. i. Limited dissipation environment ii. Generation of toxic gases and smoke iii. Shock wave is magnified when it comes into contact with a solid surface. C. Tissues at risk 1. Air-containing organs are more susceptible to pressure changes. a. Middle ear b. Heart c. Lungs d. Major blood vessels e. Gastrointestinal tract 2. Junctions between tissues of different densities and exposed tissues are prone as well. 3. The ear is most sensitive to blast injuries. a. The tympanic membrane can rupture. b. Patient may complain of: i. Ringing in the ears ii. Pain in the ears iii. Some loss of hearing iv. Visible blood in the ear canal 4. Primary pulmonary blast injuries occur as contusions and hemorrhages. a. Patient may have: i. Tightness or pain in the chest ii. Tachypnea or other signs of respiratory distress iii. Subcutaneous emphysema over the chest (a) Indicates underlying pneumothorax iv. Pulmonary edema 5. If there is any reason to suspect lung injury in a blast victim, administer oxygen. a. Avoid giving oxygen under positive pressure. b. Intravenous fluids may be poorly tolerated in patients with lung injury. c. Arterial air embolism occurs on alveolar disruption with subsequent air embolization into the pulmonary vasculature. i. One of the most concerning pulmonary blast injuries ii. Even small air bubbles can enter a coronary artery and cause myocardial injury. iii. Can produce disturbances in vision, changes in behavior, changes in level of consciousness, and other neurologic signs 6. Solid organs are relatively protected from shock wave injury but may be injured by secondary missiles or a hurled body. 7. Neurologic injuries and head trauma are the most common causes of death from blast injuries.  a. Subarachnoid and subdural hematomas are often seen. b. Permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism. 8. Extremity injuries, including traumatic amputations, are common. 9. Assessment and management of blast injuries a. Expect significant trauma and multiple patients. b. If the explosion was intentional, examine the area for a secondary device. i. If scene safety cannot be ensured, evacuate until qualified personnel advise you that it is safe to approach the patient. c. Assess the scene for other hazards. d. Assess breath sounds frequently. e. Rapidly examine the patient for open and closed wounds and manage life threats. f. Establish a baseline pulse oximetry value, and reassess frequently. i. Administer high-flow supplemental oxygen even in the presence of a high reading. g. An absence of overt signs of abdominal injury should not lead you to conclude that an injury is not present. h. If the patient reports abdominal pain, then use the OPQRST mnemonic (Onset, Provocation/palliation, Quality, Region/radiation, Severity, Timing). i. Dizziness due to ear injury may lead to vomiting, which can interfere with airway patency and protection. i. Manage any impaled object in your patient’s body according to the guidelines outlined in Chapter 32, Soft-Tissue Trauma and Chapter 34, Face and Neck Trauma. VII. General Assessment of Trauma A. Managing a trauma scene involves more consideration of external factors than a typical medical emergency scene. 1. Your observations are critical to the hospital staff. 2. Very few trauma injuries can be truly stabilized on scene. B. Scene size-up 1. Attention to personal protective equipment is required. a. Gloves b. Protective eyewear c. Masks d. Other PPE may be required based on MOI. 2. Anticipate possible scene hazards while en route. 3. Assess your environment carefully (initially and on an ongoing basis). 4. As you approach your patient(s), determine the number of patients and consider whether you will need additional medical resources. 5. Obtain the following key information: a. If the patient fell, note the height from which the patient fell and type of surface landed on. b. If the incident was an MVC, note the extent of intrusion into the vehicle, the speed of the vehicle, and whether ejection occurred. C. Primary survey 1. Form a general impression. a. Do not make major patient care decisions based strictly on your first impression. b. Keep the MOI in mind as you approach the patient. i. Consider whether spinal motion restriction will be necessary. c. Evaluate the patient using AVPU (Awake and alert, responsive to Verbal stimuli, responsive to Pain, Unresponsive). 2. Next steps follow the order XABCDE: Exsanguination, Airway, Breathing, Circulation, Disability, and Exposure. a. Manage any life-threatening injuries or significant external bleeding. 3. If the patient does not require CPR, next assess airway status. 4. Airway and breathing a. If your patient is unresponsive, ask your partner to open the airway using the jaw-thrust maneuver. i. Consider an oral or nasopharyngeal airway. b. Observe for obvious oral or facial trauma that may contribute to airway obstruction. c. If necessary, remove foreign objects and suction out blood or vomitus. d. If you suspect blockage is due to a foreign object, apply the appropriate manual airway clearing technique. e. Once the airway is clear, assess the patient’s breathing. i. Absence of breathing will require bag-mask ventilation and consideration of a more advanced airway adjunct. ii. If the patient is breathing, note: (a) Rate and quality of respirations (b) Patient’s ability to speak f. Note the skin color. g. Observe chest wall movement with respirations. i. If you observe a sucking chest injury, immediately seal the wound. h. Assess the thorax and neck for: i. Deviated trachea ii. Tension pneumothorax iii. Neck and chest crepitation iv. Broken ribs v. Fractured sternum vi. Other problems that may inhibit breathing i. Determine how best to support your patient’s breathing. 5. Circulation a. Evaluate the patient’s circulation. i. Note rate and quality of the pulse. ii. If there is no pulse, begin CPR. b. Skin signs (color, temperature, and condition) can also be a good indicator of circulation. 6. Assess for disability.  a. Evaluate Glasgow Coma Scale (GCS) score. b. Note pupil size, equality, and reactivity to light. c. Evaluate pulse, motor, and sensation (PMS) in all extremities. 7. Expose the patient for exam. a. Scan quickly for life threats. i. Manage life threats as you find them. 8. Transport decision a. Patients that should be categorized for immediate transport include those with: i. Altered mental status ii. Airway or breathing problems iii. Multisystem trauma iv. Significantly compromised circulation b. If a patient needs immediate transport, continue your assessment en route to the trauma center. i. On-scene time should be limited to 10 minutes or less. (a) Referred to as the “platinum 10 minutes” D. History taking 1. Obtain a SAMPLE history. 2. Medical history should be obtained as soon as possible in case the patient’s level of consciousness deteriorates. 3. If the patient is unresponsive, gather information from bystanders or family members. 4. Important information to obtain includes: a. Patient’s symptoms b. Allergies c. Medications d. Past medical history e. Patient’s last oral intake f. Events leading up to the situation E. Secondary assessment 1. Trauma patients are classified into two major groups: a. Isolated injury i. Allows you to immediately focus on the main problem b. Multisystem trauma i. Find all of the various conditions, and then prioritize them by severity and the order in which you plan to treat them. ii. Think about how each injury or condition relates to the others. 2. Vital signs a. Obtain a full set of initial or baseline vital signs. b. Should include an assessment of: i. Pulse ii. Respirations  iii. Blood pressure iv. Pulse oximetry v. Blood glucose level vi. Cardiac monitoring vii. Automatic blood pressure monitoring, if available 3. Physical examinations a. Most multisystem traumatic injury patients should have a thorough physical exam prior to or during transport. i. Should be done in a systematic manner b. Head and neck i. Palpate and visualize for injuries. (a) Deformities (b) Contusions (c) Abrasions (d) Penetrations (e) Burns (f) Tenderness (g) Lacerations (h) Swelling ii. Check the nose, mouth, and ears for bleeding. iii. Re-examine the pupils for size, equality, and reactivity to light. iv Check for jugular vein distention and tracheal deviation. v. Consider applying a cervical collar while you continue your assessment. c. Chest, abdomen, and pelvis i. Inspect and palpate the chest wall. ii. Look for penetrating injuries and assess for bruising. iii. Use your stethoscope to listen to breath and heart sounds. iv. Palpate the abdomen across the upper and lower quadrants. v. Press the iliac crests down and squeeze them inward to determine pelvic stability. vi. Consider palpation of the pubic symphysis. vii. Examine for signs of incontinence and/or bleeding from the groin area. d. Extremities i. Palpate the legs from top to bottom. ii. Palpate each leg separately, and note any difference. iii. Check both feet for: (a) Distal pulse (b) Motion (c) Sensation iv. Examine the arms in the same manner. v. Check for PMS in the hands and wrists. e. Back  i. While the patient is on his or her side, examine the back for injuries. F. Reassessment 1. While en route to the hospital, perform another rapid full-body scan. 2. Repeat the primary survey (XABCDE). 3. Reevaluate vital signs. a. Every 5 minutes for patients in serious condition 4. Review the status of the interventions you have performed. 5. Notify the hospital staff as quickly as possible. VIII. Trauma Score A. Trauma scoring systems are often used to determine injury severity in the health care profession. 1. There are several different systems. 2. Trauma score is used to determine the likelihood of patient survival. a. Calculated on a scale of 1 to 16 i. 16 is the best possible score. 3. Takes into account: a. Glasgow Coma Scale (GCS) score b. Respiratory rate c. Respiratory expansion d. Systolic blood pressure e. Capillary refill 4. GCS is an evaluation tool used to determine level of consciousness. a. Scores are assigned for eye opening, verbal response, and motor response. b. Can be used to predict patient outcome c. Does not accurately predict survivability in patients with severe head injuries B. Revised Trauma Score (RTS) 1. Physiology score used to assess injury severity in patients with head trauma 2. Heavily weighted to compensate for major head injury without multisystem injury or major physiologic changes 3. Data used to calculate the score include: a. GCS score b. Systolic blood pressure c. Respiratory rate 4. Reliable in predicting survival in patients with severe injuries 5. Highest RTS is 12; the lowest is 0. IX. Management of Trauma A. Management of trauma requires an accurate assessment of the patient and knowledge of the mechanics of injury.  1. During transport, begin any necessary interventions. 2. Unresponsive trauma patients will most likely need an advanced airway placed. a. Should be done before transport, if possible 3. Other treatment should be done en route if the patient is in critical condition. a. Bandaging minor wounds b. Splinting fractured extremities 4. Most patients who are in shock should be: a. Given oxygen b. Kept supine if possible c. Transported rapidly to a trauma center 5. Also consider fluid resuscitation for patients in shock. a. If shock is caused by a large fluid shift, large quantities of fluid may be required. b. If shock is caused by blood loss, too much fluid could dilute the blood and raise blood pressure. c. If shock is caused by vasodilation due to a spinal cord injury, consider administration of medications instead of adding more fluid. d. Consult with medical direction. e. Begin fluid resuscitation at volumes that maintain a minimum blood pressure. 6. Several techniques can be used to treat multisystem trauma. a. Multisystem trauma patients cannot be stabilized in the field. b. Use a team approach to assess and transport your patient. 7. Critical thinking is important when treating a patient with multisystem trauma. B. Trauma lethal triad 1. Hypothermia a. Even mildly hypothermic patients have a lower survival rate than normothermic patients. b. Hypothermia contributes to coagulopathy. 2. Coagulopathy a. Any factor that interferes with blood clotting will cause greater blood loss. b. Results in poor perfusion and, ultimately, death 3. Acidosis a. Often occurs with excessive bleeding and treatments to compensate for it b. Contributes to coagulopathy and complicates treatment 4. Management a. Aggressively seek to control all bleeding to the best of your ability. b. Keep your patients warm. c. Minimize the volume of acidic IV fluid you administered. i. Monitor end-tidal carbon dioxide (ETCO2) and ventilations. ii. Consider administering tranexamic acid (TXA) to help control internal bleeding if protocols allow. C. Criteria for referral to a trauma center 1. The American College of Surgeons Committee on Trauma (ACS-COT) and the Centers for Disease Control and Prevention published a Field Triage Decision Scheme. 2. Physiologic criteria a. If one of the following is present, refer to the highest-level trauma center: i. GCS score of 13 or less ii. Systolic blood pressure of less than 90 mm Hg iii. Respiratory rate of less than 10 or more than 29 breaths/min (more than 20 breaths/min in infants) or need for ventilator support 3. Anatomic criteria a. If one of the following is present, transport to the highest-level trauma center: i. Penetrating trauma to the head, neck, torso, and extremities proximal to elbow or knee ii. Chest wall instability or deformity iii. Two or more proximal long bone fractures iv. Crushed, degloved, mangled, or pulseless extremity v. Amputation proximal to wrist or ankle vi. Pelvic fractures vii. Open or depressed skull fractures viii. Paralysis 4. MOI criteria a. If one of the following is present, and depending on the MOI, transport to the closest appropriate trauma center: i. Adults: Falls more than 20 ft ii. Children: Falls more than 10 ft or two or three times the height of the child iii. High-risk MVC (a) Intrusion into passenger compartment (b) Ejection (partial or complete) from vehicle (c) Death of another occupant in same passenger compartment (d) Vehicle telemetry data consistent with a high risk of injury iv. Pedestrian/bicyclist thrown or run over or vehicle-pedestrian injury with significant impact v. Motorcycle crash at more than 20 mph 5. Special considerations a. If none of above criteria are met, consider transfer to an emergency department or low-level trauma center if: i. Patient’s age is more than 55 years ii. Systolic blood pressure is less than 110 mm Hg in persons older than 65 years iii. Children should be triaged to a pediatric-capable trauma center. iv. Patient uses anticoagulants or has a bleeding disorder v. Patient is pregnant (more than 20 weeks’ gestation) vi. Low-impact mechanism in older adults vii. Burns with other trauma viii. EMS provider judgment  6. The ACS-COT publishes a list of criteria defining four separate levels of trauma centers (Level I, II, III, and IV). 7. It is important to know which hospitals specialize in: a. Neurology b. Burns c. Pediatric trauma d. Cardiac care e. Microsurgery f. Hyperbaric therapy 8. Give the trauma center early notice of the patient’s arrival. D. Mode of transport 1. When making the decision to transport by ground, several factors should be considered. a. Can the appropriate facility be reached within a reasonable time frame? b. What is the extent of injuries? c. If in a congested area, can the patient be transported to a more accessible landing zone for air medical transport? 2. Criteria for the appropriate use of emergency air medical services: a. There is an extended period required to access or extricate a remote or trapped patient that depletes the time frame to get the patient to the trauma center by ground. b. Distance to the trauma center is greater than 20 to 25 miles. c. The patient needs medical care and stabilization at the Advanced Life Support (ALS) level, and there is no ALS-level ground ambulance service available within a reasonable time frame. d. Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center via ground ambulance within the ideal time frame. e. There are multiple patients who will overwhelm resources at the trauma center(s). f. EMS systems require that the patient be brought to the nearest hospital for initial evaluation and stabilization. g. There is a multiple-casualty incident. 3. You should always follow your local protocols when determining what type of transportation is appropriate. 4. When making the transport decision, consider: a. If the patient can be transported by ground within a reasonable amount of time b. Time it will take for the aircraft to lift off, travel, and land c. Terrain E. Research and trauma care 1. The military has done extensive research over many years regarding trauma patient care. a. Civilian research shows that what works well in the military does not always work well in the civilian world. b. Example: Use of pneumatic antishock garments for patients with penetrating wounds to the upper body was found to be harmful in the 1980s, even though they were used for many years in the Vietnam war. 2. Recent military research has shown that the dangers long associated with tourniquet use are not as serious as had once been assumed. a. Greatly increased tourniquet use in the control of extremity bleeding in the civilian population 3. The military also brought the use of tranexamic acid (TXA) to the attention of civilian trauma systems for the control of internal bleeding. 4. Only evidence-based treatments should be adopted for widespread use.