Section 5 Trauma

arterial bleeding

Arterial bleeding can sometimes be recognized by its bright red color. (Blood coming from the heart is generally well oxygenated; the iron atoms in hemoglobin turn bright red when they bind with oxygen.) Often bleeding from an artery can be seen spurting with each beat of the heart. Keep in mind, however, that as pressure decreases in the cardiovascular system, spurting will decrease and may not be noticeable. massive hemorrhage

patient care for thermal burns

As an EMT, you will have to care for thermal burns caused by scalding liquids, steam, contact with hot objects, flames, flaming liquids, and gases. Sunburn can also be severe in infants and young children, who may have other heat-related injuries. The steps for basic care of thermal burns are given in Table 26-5. The standing orders for burn care are determined by your EMS Medical Director and the regional EMS system. Some EMS systems state that all partial thickness and full thickness burns are to be wrapped with dry sterile dressing or a burn sheet, whereas other burn centers recommend moist dressings for partial thickness burns to less than 10 percent of the body and dry dressings for more severe cases. The latter protocol is now being adopted by most EMS systems. Stop the burning process!/Cool the burned area. Flame—Wet down, smother, then remove any affected clothing. Semi-solid (grease, tar, wax)—Cool with water. Do not remove the substance. Ensure an open airway. Assess breathing. Look for signs of airway injury: hoarse voice, stridor, soot deposits, burned nasal hair, facial burns. Complete the primary assessment. Treat for shock. Provide high-concentration oxygen. Treat serious injuries. Evaluate burns by depth (see below), extent (rule of nines or rule of palm), and severity. Do not clear debris. Remove clothing and jewelry. Wrap with dry sterile dressing. Burns to hands or feet—Remove the patient's rings or jewelry that may constrict blood flow with swelling. Separate fingers or toes with sterile gauze pads. Burns to the eyes—Do not open the patient's eyelids if burned. Be certain the burn is thermal, not chemical. Apply sterile gauze pads to both eyes to prevent sympathetic movement. (Some local protocols recommend covering only the injured eye. Follow your local protocols.) If the burn is chemical, flush the eyes for 20 minutes en route to the hospital. Never apply ointments, sprays, or butter (which would trap the heat against the burn site and have to be scraped off by the hospital staff). Do not break blisters. Do not apply ice to any burn (as it can cause tissue damage). Keep the burn site clean to prevent infection. Keep the patient warm, as the temperature regulation function of the skin may be affected by the burn.

electrical injury

Electric current, including lightning, can cause severe damage to the body. In these cases the skin is burned where the energy enters the body and where it flows into a ground. Along the path of this flow, tissues are damaged due to heat and forceful contraction of muscle tissue. In addition, significant chemical changes take place in the nerves, heart, and muscles, and body processes are disrupted or may completely shut down.

blast injuries

Besides the high-velocity penetrating trauma caused by flying objects launched by the bomb, most explosions release high-velocity winds and overpressure waves (waves of pressure greater than normal atmospheric pressure). These forces can cause significant blunt-force trauma and in many cases will result in closed injuries. In contrast to more common direct-force trauma, the potential for massive internal damage from blast trauma is much higher. The most common closed injuries associated with blast trauma are the rupture of hollow organs. Air-filled organs such as the lungs and the eardrums will commonly burst when struck by the high pressure of a blast. Liquid-filled organs such as the stomach, intestine, and urinary bladder are also at high risk with these type of injuries. Blast injuries can also cause more traditional mechanical damage to the areas hit by the blast winds and overpressure. Beneath the skin, bones can be broken, organs crushed, and blood vessels lacerated. The largest concern with blast injuries is that they frequently will not be evident just by viewing the external surface of the skin. These injuries must be anticipated based on the type of force that caused them.

assessment for bleeding patient

Not all bleeding may be obvious, though, and clothing can soak up a great deal of blood, particularly if the patient is wearing bulky or many layers of clothing. The ground or carpeting beneath the patient can also soak up a lot of blood. In those cases use a gloved hand to assess void spaces and detect bleeding. In low light, rapidly "feeling for the wet spots" with your gloved hands is an important assessment technique. If you recognize life-threatening hemorrhage, you must take immediate steps to correct it before you perform any other assessment or treatment. Continue the rest of the primary assessment only after you have controlled massive bleeding. If massive bleeding is difficult to control, you may find that you are unable to complete any other steps before transferring care to a higher level.

The goal for on-scene time when caring for a trauma or shock patient

been stated as a maximum of 10 minutes (unless lengthy extrication is required). This time limit is often called the platinum 10 minutes. Like the golden hour, there is no research that proves 10 minutes is the ideal on-scene time. The best rule is simply to take as little time as possible at the scene. In patients showing signs of shock, or a mechanism of injury that suggests that possibility, some elements of patient assessment, such as detailed exams and treatments, are best done in the ambulance en route to the hospital. On-scene assessment and care should consist of the ABCs with spinal precautions, a rapid trauma exam, immobilization, and moving the patient to the ambulance.

decompensated shock

begins at the point when the body can no longer compensate for the low blood volume or lack of perfusion. Late signs of shock, such as falling blood pressure, develop. If untreated, decompensated shock will lead to irreparable damage to vital organs (such as the kidneys) and death.

Blood volume

adult: 5000 cc child: 2500 cc infant: 800 cc

superficial burn

involves only the epidermis (the outer layer of the skin). It is characterized by reddening of the skin and perhaps some swelling. An example is a sunburn. The patient will usually complain about pain (sometimes severe) at the site. Typically the burn will heal of its own accord, without scarring. Superficial burns are also called first-degree burns.

laceration

is a cut. It may be smooth or jagged (Figure 26-6). This type of wound is often caused by an object with a sharp edge, such as a razor blade, broken glass, or a jagged piece of metal. However, a laceration can also result from a severe blow or impact with a blunt object. If the laceration has rough edges, it may tend to fall together and obstruct the view as you try to determine the wound depth. It is usually impossible to look at the outside of a laceration and determine the extent of the damage to underlying tissues. If significant blood vessels have been torn, bleeding will be considerable. Sometimes the bleeding is partially controlled when blood vessels are stretched and torn. This is due to the natural retraction and constriction of the cut ends that aid in rapid clot formation.

hypovolemic shock

is most commonly seen by EMTs. When it is caused by uncontrolled bleeding, or hemorrhage, it can be called hemorrhagic shock. The bleeding can be internal, external, or a combination of both. Hypovolemic shock may also be caused by burns or crush injuries, where plasma is lost, or by severe dehydration.

skin

it is the largest organ of the human body. The skin's total surface area is more than twenty square feet for an average adult. Its major functions are: PROTECTION. The skin is a barrier that keeps out microorganisms (germs), debris, and unwanted chemicals. Underlying tissues and organs are protected from environmental contact. The surface of the skin also provides a home to millions of microorganisms designed to defend against unwanted germs. This population of helpful bacteria compete and balance against an overpopulation of harmful organisms. WATER BALANCE. The skin helps prevent water loss and stops environmental water from entering the body. This helps preserve the chemical balance of body fluids and tissues. TEMPERATURE REGULATION. Blood vessels in the skin can dilate (increase in diameter) to carry more blood to the skin, allowing heat to radiate away from the body. When the body needs to conserve heat, these vessels constrict (decrease in diameter) to prevent heat loss. The sweat glands found in the skin produce perspiration, which will evaporate and help cool the body. The fat that is part of the skin serves as a thermal insulator. EXCRETION. Salts, carbon dioxide, and excess water can be released through the skin. SHOCK (IMPACT) ABSORPTION. The skin and its layers of fat help protect the underlying organs from minor impacts and pressures.

cardiogenic shock

may develop in patients suffering a myocardial infarction, or heart attack. It develops from the inadequate pumping of blood by the heart. The strength of the heart's contractions may be decreased because of the damage to the heart muscle. Alternatively the heart's electrical system may be malfunctioning, causing a heartbeat that is too slow, too fast, or irregular. Other cardiac problems, such as congestive heart failure, may also cause shock. You must watch for low blood pressure, edema in the feet and ankles, and other signs of heart failure.

chemical burns to eyes patient care

A corrosive chemical can burn the globe of a person's eye before he can react and close the eyelid. Even with the lid shut, chemicals can seep through onto the globe. To care for chemical burns to the eye, you should take the following steps: Immediately flood the eyes with water. Often the burn will involve areas of the face as well as the eye. When this is the case, flood the entire area. Avoid washing chemicals back into the eye or into an unaffected eye (Figure 26-27). Keep running water from a faucet, low-pressure hose, bucket, cup, bottle, rubber bulb syringe, IV setup, or other such source flowing into the burned eye. The flow should be from the medial (nasal) corner of the eye to the lateral corner. Since the patient's natural reaction will be to keep the eyes tightly shut, you may have to hold the eyelids open. Start transport and continue washing the eye for at least 20 minutes or until the patient's arrival at the medical facility. After washing the eye, cover both eyes with moistened pads. Wash the patient's eyes for 5 more minutes if he begins to complain about renewed burning sensations or irritation.

open crush injuries

crush injuries also can be open wounds. An open crush injury can result when an extremity is caught between heavy items, such as pieces of machinery. Blood vessels, nerves, and muscles are involved, and swelling may be a major problem with resulting loss of blood supply distally. Bones are fractured and may protrude through the wound site. Soft tissues and internal organs can be crushed to produce profuse bleeding, both externally and internally (Figure 26-10).

Object impaled in cheek

A dangerous situation exists when the cheek has been penetrated by a foreign object. First the object may go into the oral cavity and create an airway obstruction, or it may stay impaled in the cheek wall but work its way free and enter the oral cavity later. Second, when the cheek wall is perforated, bleeding into the mouth and throat can be profuse and interfere with breathing, or it may make the patient nauseated and induce vomiting. External wound care will not stop the flow of blood into the mouth. Examine the wound site. Gently inspect both the external cheek and the inside of the mouth. Use your penlight and look into the patient's mouth. If need be, carefully use your gloved fingers to probe the inside cheek to determine if the object has passed through the cheek wall. This is best done with a dressing pad used to protect your fingers and any wound you touch. Remove the object if you find perforation and you can see both ends of the object. Pull it out in the direction that it entered the cheek. If this cannot be easily done, leave the object in place. Do not twist the object. If you find perforation but the tip of the object is also impaled into a deeper structure (e.g., the palate), stabilize the object. Do not try to remove it. Position the patient. Make certain that you allow for drainage (the possibility of spine injuries may require you to immobilize the head, neck, and spine first then tilt the patient and the spine board as a unit). Monitor the patient's airway once the object is removed or stabilized. Be prepared to suction as necessary. Keep in mind that an object penetrating the cheek wall also may have caused teeth or dentures to break, creating potential airway obstruction. Pay close attention, especially if the patient is not alert. Blood in the patient's mouth can compromise the airway. Dress the outside of the wound using a pressure dressing and bandage or apply a sterile dressing and use direct hand pressure to control the bleeding. You may be able to place gauze on the inside of the cheek to help control bleeding into the mouth but only if the patient is alert and cooperative. Monitor the patient's mental status closely, and make sure the dressing does not work its way into the airway. Consider the need for oxygen and care for shock. You may have to use a nasal cannula if constant suctioning is required. If any dressing materials are placed in the patient's mouth, use of standard face masks can be dangerous unless you leave 3 to 4 inches of the dressing outside of the patient's mouth.

airway burns

A special consideration in thermal burns must be made for burns, or potential burns, to the airway. In addition to causing immediate damage to the mouth, trachea and lungs, airway burns can be a very real long-term threat as damaged tissues can swell and occlude the airway even hours later. Any evaluation of a burn patient should include special attention to the possibility of this type of injury. First consider the mechanism. Was the airway at risk? Steam and vapor injuries are considered high-probability mechanisms. Burns that occur in enclosed spaces also have a considerable likelihood to include the airway. Second, is there any evidence of airway involvement? Findings such as burns to the mouth and nose, soot in sputum or mucus, singed eyebrows or nose hairs, and difficulty speaking are all potentially dangerous findings. The development of a hoarse voice, particularly in a short-term setting, is especially ominous. If an airway burn is found, you should initiate rapid transport to an appropriate destination and consider an intercept with Advanced Life Support to offer higher-level airway management techniques. Airway-related burns can also expose patients to potentially harmful chemicals such as carbon monoxide and hydrogen cyanide. In general, any patient who has a potential airway burn or exposure to inhaled by-products of combustion should be monitored for the possibility of carbon monoxide and cyanide poisoning. At a minimum, these patients should be moved to fresh air and treated with high-concentration oxygen via nonrebreather mask. If your protocols allow, the application of humidified oxygen may slow down the swelling process. Safety of the rescuers on scene must always be a first priority when hazardous materials are expected.

cold application

A traditional method of controlling bleeding is the application of ice or a cold pack to the injury. The cold minimizes swelling and reduces the bleeding by constricting the blood vessels. Application of cold should not be used alone but rather in conjunction with other manual techniques. Application of cold will also reduce pain at the injury site. Never apply ice or cold packs directly to the skin. This can cause frostbite and further damage to the tissue. Always wrap ice or a cold pack in a cloth or towel before applying it to the skin. Do not leave it in place for longer than 20 minutes at a time.

patient assessment shock

ALTERED MENTAL STATUS. The brain is very sensitive to any decrease in oxygen supply. When the brain is deprived of oxygen, even slightly, mental and behavioral changes may be seen. These may include anxiety, restlessness, and combativeness. PALE, COOL, AND CLAMMY SKIN. When the body senses inadequate tissue perfusion, it attempts to correct the problem by diverting, or shunting, blood from nonvital areas to the vital organs. Blood is quickly directed away from the skin and sent to organs such as the heart and brain. This results in loss of skin color, abnormally cool skin temperature, and development of moist skin (also known as diaphoresis). Infants and young children may have a capillary refill time of greater than 2 seconds. (Delayed capillary refill time is considered an unreliable sign of shock in patients over the age of five when capillary refill time can more readily be influenced by other factors.) Note that in neurogenic shock (rare) the skin is typically warm, flushed, and dry because the circulatory system has lost the ability to constrict blood vessels in the skin. NAUSEA AND VOMITING. In the body's efforts to direct blood to the vital organs, blood is diverted from the digestive system, resulting in nausea and sometimes vomiting. VITAL SIGN CHANGES. The first vital signs to change are the respiratory and pulse rates: The pulse will increase in an attempt to pump more blood. As it continues to increase and blood loss worsens, the pulse becomes weak and thready. Respirations increase in an attempt to raise the oxygen saturation of the blood left in the system. As shock progresses, respirations become more rapid, labored, shallow, and sometimes irregular. Blood pressure drops because the body's compensating mechanisms can no longer keep up with the decrease in perfusion or blood loss. Decreased blood pressure is a late sign of shock. By the time the blood pressure drops, the patient is in a truly life-threatening condition. Pulse oximetry might not be accurate in patients with shock. Oximeters rely on adequate perfusion to get an accurate reading. Patients with shock may not be adequately perfusing their extremities. OTHER SIGNS. Late signs of shock include thirst, dilated pupils, and sometimes cyanosis around the lips and nail beds.

patient assessment open wounds

Airway, breathing, circulation, and severe bleeding are identified and treated in the primary assessment. Once the primary assessment and the appropriate physical examination have been completed, care for the individual wounds begins.

signs of shock

Altered mental status: Altered mental status occurs because the brain is not receiving enough oxygen. The brain is very sensitive to oxygen deficiencies. When it is deprived of oxygen, even slightly, behavioral changes may be noted. These changes may begin as anxiety and progress to restlessness and sometimes combativeness. Pale, cool, and clammy skin: When the body senses low blood volume, natural mechanisms take over in an attempt to correct the problem. One of these mechanisms is to divert blood from nonvital areas to vital organs. Blood is quickly directed away from the skin to such organs as the brain and heart. This results in the loss of color and temperature in the skin. Infants and children may exhibit capillary refill times of greater than 2 seconds. NOTE: In anaphylactic and neurogenic shock (rare), the skin is typically warm, flushed, and dry because the circulatory system has lost the ability to constrict blood vessels in the skin. Nausea and vomiting: In the body's continuing effort to keep blood perfusing the vital organs, blood is diverted from the digestive system. This causes feelings of nausea and occasionally vomiting. Vital sign changes The first vital signs to change are the pulse and respirations: The pulse will increase in an attempt to pump more blood. As the pulse gradually increases, it becomes weak and thready. Most patients will become tachycardic with significant blood loss; however, a significant number do not, so you cannot rely solely on this sign. Respirations also increase in an attempt to increase the amount of oxygen in the blood. The respirations will become shallower and labored as shock progresses. Blood pressure is one of the last signs to change. When blood pressure drops, the patient is clearly in a state of serious, life-threatening shock. A narrowing of the pulse pressure may also occur. This means that the difference between the systolic and diastolic pressures will decrease (become closer together). Late signs of shock that you may encounter include thirst, dilated pupils, and in some cases cyanosis around the lips and nail beds. No matter how small blood loss appears to be, if the patient shows any signs or symptoms of shock, the bleeding must be considered serious

bite wounds

Although for the most part they are assessed and treated like any other open wound, you should be aware that infection rates tend to be higher in these types of injuries, and human bites may be considered a sign of abuse or assault. In general, these injuries, although most commonly not life threatening, should be taken seriously and evaluated by a physician.

amputation

Amputated fingers, toes, hands, feet, or limbs are completely cut through or torn off (Figure 26-9). Jagged skin and bone edges can sometimes be observed. There may be massive bleeding; or the force that amputates a limb may close off torn blood vessels, limiting the amount of bleeding. Often blood vessels collapse, or they retract and constrict, which limits bleeding from the wound site.

High pressure injection injuries

An uncommon but important injury can occur when a patient is working with a machine that injects grease, paint, air, or some other substance under high pressure. If the nozzle injects the substance into the patient, typically the finger, rather than the object it was intended for, this can lead to significant injury. These machines may use pressures of thousands of pounds per square inch, which results in a wound that is much worse than it looks. There is typically very little (or even no) injury apparent on inspection. The real damage is not visible because it is under the skin. When the high-pressure device injects its solution, it can travel a significant distance; for example, moving through most or all of a limb. The injected solution causes extensive tissue damage, both from the force of the pressure and from the toxic nature of some solutions. Over the course of the next few hours, tissue begins to die. If the patient does not get the appropriate treatment early enough, there is a high probability that at least part, and perhaps all, of the patient's limb will have to be amputated. EMT treatment for high-pressure injection includes elevating and splinting the limb. Although the patient may complain of severe pain, do not apply cold. This causes vasoconstriction and can lead to further tissue damage and death from lack of perfusion. If the incident occurred just before your arrival, the patient may not have any pain and may not wish to go to an emergency department. It is nonetheless vital that you persuade the patient to be evaluated in an ED as soon as possible. If the patient delays treatment, he may end up losing his hand or forearm.

steps of direct pressure

Apply firm pressure with the palm of your hand (or fingers for a smaller wound). In the case of junctional hemorrhage, you may need to lean into the wound and apply body weight to enhance the pressure. The amount of pressure that should be used can be gauged to the severity of the wound. Minor bleeding can often be controlled with gentle pressure. If the bleeding is mild, use a sterile dressing between your gloved hand and the wound. If the bleeding is severe or spurting, immediately place your gloved hand directly on the wound. Do not waste time trying to find a dressing (Figure 25-4). Consider aiming your direct pressure toward a bone. If the wound can be compressed between your hand and a bone, bleeding control will be more effective. Hold the pressure firmly until the bleeding is controlled. Remember, your goal is limiting additional blood loss. Once the bleeding has been controlled, bandage a dressing firmly in place to form a pressure dressing (see the following explanation). Do not remove a dressing once it has been placed on the wound. Removal of a dressing may destroy clots or cause further injury to the site. If a dressing becomes blood soaked, apply additional dressings on top of it and hold them firmly in place. Keep in mind, however, that bleeding through a dressing is a sign that what you are doing is ineffective. If the wound continues to bleed in this manner, you should consider other, more aggressive methods, such as a hemostatic dressing or a tourniquet. Remember also that adding more padding to the wound may impede your ability to apply effective direct pressure. The best pressure is applied directly to the ends of the bleeding vessels. If you use a lot of dressing material for a small wound, you may end up spreading and dissipating the force over a larger area, which will have the counterproductive effect of reducing the pressure on the bleeding vessels.

injury in blast

As previously discussed, primary injuries occur because of the intense high pressure (pressure wave; overpressure) and blast winds that hit the patient. Injuries can include damage to any air- or fluid-filled body organ or cavity, especially pressure injury to the lungs. Secondary injury is the result of projectiles (shrapnel) such as debris hitting the patient (blast wave), leading to open and penetrating wounds. Tertiary (third level) injuries occur if the patient is thrown by the blast. Tertiary injuries occur both from the force of the blast and as a result of the violent landing after being thrown. These injuries can include not just soft-tissue injuries but also fractures, avulsions, and amputations. Finally, the patient may sustain additional injuries such as exposure to chemicals or toxins, burns, and crush injuries. These are sometimes referred to as quaternary (fourth level) injuries.

splinting

Bleeding associated with a musculoskeletal injury may be controlled by proper splinting of the injury. Since the sharp ends of broken bones may cause tissue and vessel injury, stabilizing them and preventing further movement of the bone ends prevents additional damage. There are several types of splints used for stabilizing injured extremities. Inflatable splints, also called air splints, may be used to control internal and external bleeding from an extremity. This type of splint may be used to control bleeding even if there is no suspected bone injury. The splint produces a form of direct pressure. Air splints are useful if there are several wounds to the extremity or one that extends over the length of the extremity. Air splints are most effective for venous and capillary bleeding. However, they are not usually effective for the high-pressure bleeding caused by an injured artery—at least not until the arterial pressure has decreased below that of the splint. However, you may use an air splint to maintain pressure on a bleeding wound after other manual methods, such as a pressure dressing, have already controlled the bleeding.

patient assessment closed wounds

Bruising may be an indication of internal injuries and related internal bleeding (Table 26-1). In addition, consider the possibility of closed soft-tissue injuries whenever there is swelling, pain, or deformity, as well as a mechanism of blunt trauma. Internal damage can also be demonstrated by bleeding from the ears and nose. Occasionally patients will also report vaginal or rectal bleeding and, potentially, blood in their urine. Look for the presence of blood in their eyes and even in the sputum that they cough up. Always consider the mechanism of injury (MOI) when you examine a patient with a closed wound. Crush injuries may be difficult or impossible to identify during assessment, so you must rely on the MOI. Patients with a significant MOI should be considered to have internal bleeding and shock until they are ruled out in the emergency department.

Classifying Burns by Agent and Source

Burns can be classified according to the agent causing the burn (e.g., chemicals or electricity). Noting the source of the burn (e.g., dry lime or alternating current) can make the classification more specific. You should report the agent and also, when practical, the source of the agent (Table 26-2). For example, a burn can be reported as "chemical burns from contact with dry lime Never assume the agent or source of the burn. What may appear to be a thermal burn could, in fact, be caused by radiation. You may find minor thermal burns on the patient's face and forget to consider light burns to the eyes. Always gather information from your observations of the scene, bystanders' reports, and the patient interview.

Classifying Burns by Depth

Burns involving the skin are classified as superficial, partial thickness, and full thickness burns (Figure 26-19). These classifications are also sometimes called first-degree, second-degree, and third-degree burns, with first-degree burns corresponding to superficial burns and so on, as described next.

pediatric classification of burn severity

Burns pose greater risks to infants and children than to adults. This is because their body surface area is greater in relation to their total body size. This results in greater fluid and heat loss than would occur in an adult patient. Infants have a higher risk of shock, airway problems, and hypothermia from burns. In addition, the classification of burn severity differs in patients less than five years of age, as shown in Table 26-4. When a child has been burned, consider the possibility of child abuse. Classifications of Burn Severity: Children Less than Five Years of Age CLASSIFICATIONS BY THICKNESS AND PERCENT OF BODY SURFACE AREA Minor Burns Partial thickness burns of less than 10 percent of the body surface Moderate Burns Partial thickness burns of 10 to 20 percent of the body surface Critical Burns Full thickness burns of any extent or partial thickness burns of more than 20 percent of the body surface

treating genital injuries

Care for a patient with a genital injury includes these steps: Control bleeding as you would for other soft-tissue injuries. Preserve any avulsed parts as described in your local protocols. Consider whether the injury you see suggests another, possibly more serious, injury (e.g., blood at the meatus suggesting pelvic trauma). Display a calm, professional manner to maintain the patient's dignity. Although treatment is usually the same as for other soft-tissue injuries, the modest patient may need more reassurance. If the patient is a child or other possibly vulnerable person, inquire in a nonthreatening way whether sexual abuse was involved. Dress and bandage the wound in accordance with the principles of bandaging (covered later in this chapter). Consider the possibility of sexual assault. Although not all genital injuries are caused by sexual assault, this mechanism of injury is a common cause. You should always consider this possibility and involve appropriate resources (law enforcement, sexual assault advocacy, etc.) in times of high suspicion.

patient care shock

Care for shock is similar to the care for bleeding described earlier. Remember Standard Precautions when caring for any patient who is bleeding externally. The emergency care steps for shock (Scan 25-2) are as follows: Maintain an open airway and assess respirations. Address inadequate breathing immediately and aggressively. If bleeding is significant, there are signs of hypoxia, or the patient's vital signs indicate or suggest the potential for shock, administer oxygen. Control any external bleeding. If a pelvic fracture is suspected, use a pelvic binding device as discussed in the "Musculoskeletal Trauma" chapter. Splint any suspected bone injuries or joint injuries. However, if your patient is in shock, do not use your valuable on-scene time for this. Splints should be applied en route to the hospital. Do not take time to individually splint multiple injuries. You can splint the entire body by securing the patient to a long spine board. This will adequately stabilize the injuries until further care can be given. Prevent loss of body heat by covering the patient with a blanket or turning up the heat in the ambulance's patient compartment. In either case remove wet clothing. Transport the patient immediately. Detailed exams and care procedures should be done en route to the hospital. Notify the receiving hospital as soon as possible. Give them information on the patient's injuries and condition. Contact medical direction if necessary. If your on-scene time is extended due to extrication or your transport time to the hospital is lengthy, request an ALS intercept if available. This may be a ground ambulance or a helicopter service. If you have the patient loaded in your ambulance, begin transport and ask that the ALS unit intercept your unit en route. Time is of the essence. If the patient is conscious, speak calmly and reassuringly throughout your assessment, care, and transport. Fear increases the body's work and worsens developing shock. Research has shown that the traditional practice of elevating the legs as a treatment for shock may not be helpful. However, if elevating the legs is part of your local protocols, it will do no harm if there is no possibility of spine injury.

patient care internal bleeding

Care for the patient with internal bleeding centers on the prevention and treatment of shock (hypoperfusion). Definitive treatment for internal bleeding can only take place in the hospital. Patients with suspected internal bleeding must be considered serious and warrant immediate transport to the hospital. Unnecessary treatment for internal injuries will not harm the patient; however, death may result from not treating a patient who needs it. As with all patients, your first priority is the standard ABCs; that is, ensure an open airway, adequate breathing, and circulation. Patients with internal bleeding may deteriorate quickly. Monitor the ABCs and vital signs often. Be prepared to maintain the patient's airway, to provide or assist ventilations, or to administer CPR as needed. Maintain the ABCs and provide support as needed. Control any external bleeding. If bleeding is significant, there are signs of hypoxia, or the patient's vital signs indicate or suggest the potential for shock, administer oxygen. If you suspect internal bleeding in an injured extremity, apply an appropriate splint. Take steps to preserve body temperature. Provide prompt transport to an appropriate medical facility. Internal bleeding must often be controlled in an operating room.

patient care chemical burns

Chemical burns require immediate care, and in an ideal situation, people at the scene will begin this care before you arrive. At many industrial sites, workers and Emergency Medical Responders are trained to provide initial care for incidents involving the chemicals in use at that facility. Most major industries have emergency deluge-type safety showers to wash dangerous chemicals from the body. However, this will not always be the case. Be prepared for situations in which nothing has been done and there is no running water near the scene. As always, take care to protect yourself from chemical injury. Use specialized response teams if the scene is not secure. Take care when coming into contact with contaminated clothing or with the patient if chemicals are still present. Emergency care for a patient with chemical burns includes the following: The primary care procedure is to wash away the chemical with flowing water. If a dry chemical is involved, brush away as much of the chemical as possible; then flush the skin (Figure 26-26). Simply wetting the burn site is not enough. Continuous flooding of the affected area is required, using a copious but gentle flow of water. Avoid hard sprays that may damage badly burned tissues. Continue to wash the area for at least 20 minutes, and continue the process en route to the hospital. Take steps as needed to avoid contaminating yourself with the chemical agent. Remove the patient's contaminated clothing, shoes, socks, and jewelry as you apply the wash. Do not contaminate skin that has not been in contact with the chemical. Apply a sterile dressing or burn sheet. Treat for shock. Transport. alkali burns should be irrigated longer Because a strong alkali liquefies dead tissue, the alkali is able to eat into the tissue much farther than an acid can. There is a well-known exception to the principle of acids causing limited damage. Hydrofluoric acid not only causes burns like any other acid, but it also penetrates much more deeply If you encounter a patient with a hydrofluoric acid exposure, you must irrigate copiously and for as long as you can or until medical direction tells you to stop. Hydrofluoric acid burns can cause great tissue damage with few external signs, so do your best to persuade a reluctant patient to go to the emergency department for further treatment.

elevation of extremity

Elevation of an injured extremity has never been proven to decrease bleeding, but if it can be done quickly and easily, it makes sense to employ this method at the same time you apply direct pressure. When you elevate an injury above the level of the heart, gravity helps reduce the blood pressure in the extremity, slowing bleeding. However, do not use this method if you suspect possible musculoskeletal injuries, impaled objects in the extremity, or spine injury as the movement of broken bone ends or penetrating objects can further damage the tissues. To use elevation in controlling external bleeding, first apply direct pressure to the injury site; then elevate the injured extremity, keeping the injury site above the level of the heart.

Treating Avulsions

Emergency care for avulsions requires the application of large, bulky pressure dressings. In addition, you should make every effort to preserve any avulsed parts and transport them to the medical facility along with the patient. It may be possible to surgically restore the part or to use it for skin grafts. In cases in which flaps of skin have been torn loose but not off, follow these steps: Clean the wound surface. Fold the skin back to its normal position as gently as possible. Control bleeding and dress the wound using bulky pressure dressings. If skin or another body part is torn from the body, control bleeding and dress the wound using a bulky pressure dressing. Save the avulsed part and wrap it in a sterile dressing kept moist with sterile saline. Make certain that you label the avulsed part with what it is, the patient's name, and the date and time the part was wrapped and bagged. Your records should show the approximate time of the avulsion. Be sure to keep the part as cool as possible, without freezing it, by placing it in a cooler or any other available container so it is on top of a cold pack or a sealed bag of ice. Do not use dry ice. Do not immerse the avulsed part in ice, cooled water, or saline. Label the container the same as the label used for the saved part.

emergency care for shock

Emergency care for the patient in shock includes airway maintenance, the administration of oxygen, and preserving body temperature. Remember that transportation is an intervention. Your most significant treatment for the shock patient may be early recognition of the problem and prompt transportation to a hospital where the patient will receive definitive care. The term golden hour has been used to describe the optimal time from the infliction of a traumatic injury until the patient receives definitive treatment in a hospital—usually surgery. However, trauma programs and experts have ceased using the term golden hour because there is no research that clearly identifies the optimal time between injury and definitive care. Furthermore, EMTs should never consider an hour the ideal time if less time can be taken. Perhaps a better statement is that every minute between the time of injury and the patient's getting to an operating suite is, in fact, like gold to the patient—and to his chances of survival.

external bleeding

External bleeding, or hemorrhage, is bleeding that occurs outside the body. It is typically visible on the surface of the skin. It occurs after force penetrates the skin and lacerates or destroys underlying blood vessels. How much a person bleeds is a function of several factors. The size and severity of a wound are major considerations. The amount of bleeding is also a function of the size and pressure of the blood vessel that has been ruptured (Figure 25-3) as well as the person's ability to clot and stop the bleeding.

treating specific types of burns

First and foremost, take precautions to keep yourself safe. Burn injuries pose very significant scene safety threats. What burned the patient could burn you! Be sure the burning process has stopped, and use specialized resources (fire, HAZMAT teams, and so on) if it has not. Do not approach a burn patient if there is a risk of electricity or a chemical/radiological threat. Once the scene is safe, your immediate care will be especially important to the long-term outcome of the burn patient. There are special approaches to the care of thermal burns, general chemical burns, and chemical burns to the eyes

Patient Care: Electrical Injuries

Follow these steps to provide emergency care to a patient with electrical injuries: Provide airway and breathing care. Electrical shock may cause severe swelling along the airway and can cause respiratory failure. Be prepared to provide positive pressure ventilations. Provide basic cardiac life support as required. Since cardiac rhythm disturbances are common, be prepared to perform defibrillation if necessary. Care for shock and administer high-concentration oxygen. Care for spine injuries, head injuries, and severe fractures. All serious electrical shock patients should be fully immobilized because electrical current can cause severe muscular contraction. Also, the patient may have been thrown by a high-voltage current. In either case there is the possibility of a spinal injury that requires immobilization. Evaluate electrical burns, looking for at least two external burn sites: contact with the energy source and contact with a ground. Cool the burn areas and smoldering clothing the same as you would for a flame burn. Apply dry sterile dressings to the burn sites. Transport as soon as possible. Some problems have a slow onset. If there are burns, there also may be more serious hidden problems. In any case of electrical shock, heart problems may develop. Remember that the major problem caused by electrical shock is usually not the burn. Respiratory and cardiac arrest are real possibilities. Be prepared to provide basic cardiac life support measures with automated defibrillation.

The amount of skin surface involved can be calculated quickly by using the rule of nines

For an adult, each of the following areas represents 9 percent of the body surface: head and neck, each upper extremity, chest, abdomen, upper back, lower back and buttocks, the front of each lower extremity, and the back of each lower extremity. These make up 99 percent of the body's surface. The remaining 1 percent is assigned to the genital region. In the rule of nines, the percentages are modified for infants and young children, whose heads are much larger in relationship to the rest of the body. An infant's or young child's head and neck are counted as 18 percent; each upper extremity as 9 percent; chest and abdomen as 18 percent; the entire back as 18 percent; each lower extremity as 14 percent; and the genital region as 1 percent. (This adds up to 101 percent, but it is used to give only a rough determination. Some systems count each lower limb as 13.5 percent to achieve an even 100 percent.)

closed crush injuries

Force can be transmitted from the body's exterior to its internal structures, even when the skin remains intact and the only indication of injury is a simple bruise. This force can cause the internal organs to be crushed or ruptured, causing internal bleeding. This is called a crush injury. Solid organs such as the liver and spleen normally contain considerable amounts of blood. When crushed, they bleed severely and cause shock. Contents of hollow organs, such as digested food or urine, can leak into the body cavities, causing severe inflammation and tissue damage.

treating amputations

In many cases the amputation may itself be less dangerous than the serious bleeding caused by the injury process. Always take steps to control hemorrhage immediately. Apply direct pressure first, and use a tourniquet if direct pressure fails or if direct pressure is not possible. Consider the use of a pressure dressing over the site of the amputation. Care for the amputated part (Figure 26-17). When possible, wrap it in a sterile dressing, and secure the dressing with a self-adhesive gauze bandage. Wrap or bag the amputated part in a plastic bag, and keep it cool by cold packs. Do not immerse the amputated part directly in water or saline. In addition, do not let the part come in direct contact with ice, or it may freeze. Never complete an amputation.

Treating abrasions and lacerations

In treating abrasions take care to reduce wound contamination. Although bleeding from a long, deep laceration may be difficult to control, direct pressure over a dressing usually works well. Do not pull apart the edges of a laceration in an effort to see into the wound. Most lacerations can be cared for by bandaging a dressing in place. Some EMS systems recommend using special wound-closure strips for minor lacerations. (A butterfly bandage is made up of thin strips of adhesive bandaging and is designed to bring the sides of a laceration together.) Bandage a gauze dressing over the butterfly strip. Do not underestimate the effects of a laceration. When evaluating a laceration, check the pulse as well as motor and sensory function distal to the injury. The patient may need stitches, plastic surgery, antibiotics, or a tetanus shot at the hospital, so do not put on bandages and leave the patient at the scene. Serious infection or scarring could result.

pediatric shock

Infants and children present a special problem when assessing for shock. They have such efficient compensating mechanisms that they can maintain a normal blood pressure until half of their blood volume is gone. By the time their blood pressure drops, they are already near death. The potential for shock must be considered and cared for early. Do not wait for signs of shock to appear.

genital injuries

Injuries to the genitals are not very common, but they often bleed heavily and cause significant anxiety in patients. The genitals are very vascular (contain lots of blood vessels), so when they are injured, they bleed heavily. Because they are also part of the reproductive system, injuries in this area can affect a patient's ability to have children. Males tend to sustain trauma to the genitals more frequently than females because of the less-protected position of male genitalia, but anyone can sustain a genital injury. Specific injuries that occur to the genitals are: Lacerations, contusions, and abrasions, which can result from either blunt or penetrating trauma (Figure 26-18A). Avulsions, including a degloving injury of the penis (Figure 26-18B), in which the skin and tissue are pulled off and torn in the same way as a degloving injury to the hand, as described earlier. Blunt trauma, including straddle injuries in which the patient injures the perineum by landing heavily on a narrow structure. Zipper injuries, which are especially common in uncircumcised boys. The foreskin may get caught in the zipper of the patient's pants. Foreign bodies and impaled objects in the vagina or penis. Blood at the meatus (the external opening for urine flow) (Figure 26-18C), which is often an indication of a disruption of the urethra. In patients who have sustained blunt trauma, the cause of the urethral injury may be a fracture of the pelvis, which will be further discussed in the chapter "Musculoskeletal Trauma."

Internal bleeding

Internal bleeding is bleeding that occurs inside the body. The bleeding itself is not visible, but many of the signs and symptoms are very apparent. There are several reasons internal bleeding can be very serious: Damage to the internal organs and large blood vessels can result in loss of a large quantity of blood in a short period of time. Blood loss cannot be seen. External bleeding is easy to identify, but internal bleeding is hidden. Patients may die of blood loss without having any external bleeding. Severe internal blood loss may even occur from injuries to the extremities. Sharp bone ends of a fractured femur can cause enough tissue and blood vessel damage to cause shock (hypoperfusion).

massive hemorrhage

Massive hemorrhage occurs when extensive wounds open up large blood vessels or many smaller blood vessels Massive bleeding can occur in many places on the body, but some large blood vessels are particularly vulnerable to trauma. Junctional hemorrhage occurs where the appendages of the body connect to the trunk. In these locations large arteries and veins tend to be less well protected and particularly vulnerable to traumatic forces. The neck, both armpits, and both sides of the groin are sites where massive bleeding is likely.

Signs of Internal Bleeding

Many of the signs of internal bleeding that you will see are also signs of shock (hypoperfusion). These signs have developed as a result of uncontrolled internal bleeding. They are late signs, indicating that a life-threatening condition has already developed. If you wait until signs of internal bleeding or shock develop before beginning treatment, you have waited too long. Signs of internal bleeding are: Injuries to the surface of the body, which could indicate underlying injuries. Bruising (Figure 25-12), swelling, or tenderness over vital organs (especially in the chest and abdomen). Basic knowledge of anatomy is important for this reason. Painful, swollen, or deformed extremities. Bleeding from the mouth, rectum, vagina, or other body orifice. A tender, rigid, or distended abdomen. Vomiting a coffee-grounds-like substance or bright red vomitus, indicating the presence of blood. (Red blood is usually from an active, current, "new" bleeding. Dark blood is usually "old.") Dark, tarry stools or bright red blood in the stool. Signs and symptoms of shock. Remember that some of the signs listed in Table 25-1 are late signs. They will appear only after internal bleeding has already resulted in significant blood loss.

if minor bleeding

Massive external bleeding in civilian life is rare. Most of the bleeding you will see in your career as an EMT will be nonmassive and far less imminently life threatening. In this setting proceed through the primary assessment as normal. Airway will be first and most important. Ensuring adequate breathing will be next. Finally, bleeding will be addressed in "C," the circulation phase, only after assessing and treating the prior elements. Remember always to seek out bleeding in clothing and surroundings and use a gloved hand to detect blood in void spaces. Sometimes external blood loss can be examined by looking at the amount of blood lost on the ground. This assessment technique is notoriously inaccurate, however, and usually useful only for differentiating "a lot" from "a little" external blood loss.

patient care external bleeding

Most external hemorrhage is compressible, and as an EMT, you will use compression techniques to control almost all of the bleeding you encounter After ensuring that the scene is safe and donning appropriate personal protective equipment, determine how aggressive you need to be with bleeding control. Is the bleeding massive, and should it be your first priority? If not, continue through the airway and breathing steps, and correct those problems first. If the bleeding is massive, however, move immediately to the bleeding control steps listed next. For any patient with significant bleeding or signs of shock, in addition to controlling external bleeding, consider the need to administer oxygen The major methods of controlling external bleeding are: direct pressure: can be applied with a sterile gauze pad, sterile dressing, or gloved hands pushing against wound, hold uninterrupted with steady pressure for approx. 5 min. if bleeding stops wrap dressing and check distal pulse to check if it is too tight, if bleeding seeps through dressing add bulkier dressing but do not remove initial dressing. If bleeding continues: elevation of a limb: above level of heart with direct pressure to wound. don't elevate if broken bone suspected. if fails to stop bleeding: hemostatic agent: apply hemostatic dressing or gauze. for gauze put on side of gauze into wound and pack it and wrap remaining around limb to initiate clotting process. after applying dressing, hold manual pressure for 4-5 min tourniquet: used if ALL means of hemorrhage control fail, this is last resort. primary means for hemorrhage control for complete or partial amputation of extremity. Brands include MAT, CAT, Delfi, etc. may be improvised using ambulance equipment like a cravat: make improvised tourniquet at least 2 inches wide and place 2 inches above injury. wrap arounf extremity and tie one knot on the anterior surface of the extremity. place rigid object like a stick over the knot and tie ends of bandage over knot. twist object till bleeding stops. before securing object, reassess limb for bleeding then secure object with tape or bandages Precautions: never put tourniquet over joint or clothing do not loosen or release tourniquet after its been applied leaving in place for too long can lead to tissue damage tourniquets too loose can worsen bleeding if a stump: apply dressing over the stump and tape the tourniquet down RECORD DATE AND TIME OF TOURNIQUET APPLICATION Other methods include splinting and cold application.

nosebleed

Nosebleeds, also called epistaxis, may be caused by direct trauma to the nose. However, tiny capillaries in the nose may burst because of increased blood pressure (hypertension), sinus infection, or digital trauma (nose picking). Controlling bleeding from the nose is sometimes more difficult if the patient is taking certain medications, such as an anticoagulant such as warfarin (Coumadin). To stop a nosebleed, follow these steps: Have the patient sit down and lean forward. Apply or instruct the patient to apply direct pressure to the fleshy portion around the nostrils. Keep the patient calm and quiet. Do not let the patient lean back. This can allow blood to flow down the esophagus to the stomach as the patient swallows, resulting in nausea and vomiting. If the patient becomes unconscious or is unable to control his own airway, place the patient in the recovery position (on his side), and be prepared to provide suction and aggressive airway management.

hypothermia, acidosis, coagulopathy

Preventing heat loss prevents hypothermia, a condition that not only can deplete the body's energy stores but can also reduce the blood's ability to clot. Preventing further blood loss and oxygenating the patient prevent acidosis, a condition that occurs when cells receive insufficient oxygen and generate acidic waste products that accumulate in the blood. Your treatment also prevents coagulopathy, an impaired ability to clot. All three of these problems—hypothermia, acidosis, and coagulopathy—are the subject of trauma research that is going on right now

radiological burn

Radiation can be extremely harmful, and contact with either the source of radiation or with a patient contaminated with radiological materials can pose a serious risk to your well-being. You should not approach a radiological injury without the proper protective equipment and specialized training. You may be called, however, to treat a patient with radiological injuries after that patient had been decontaminated. In the immediate setting, most radiological injuries will present like thermal injuries with damage to the various layers of the soft tissue. Care would be similar in these cases and consist of covering the burns and transport to an appropriate facility. Know that radiation can also cause many other potentially harmful effects and any patient with this type of injury should be carefully assessed and monitored for airway and breathing problems.

3 main components of circulatory system

Recall that the heart, blood vessels, and blood are the three main components of the circulatory system. These components may be likened to a pump, pipes, and fluid in the pipes. For the circulatory system to function properly, all three components must function properly. If any component fails, or "leaks," the body will try in various ways to compensate and maintain adequate perfusion. However, if the problem is not corrected and the condition quickly reverses, adequate perfusion cannot be maintained, and shock (hypoperfusion) will result.

To properly apply a tourniquet, follow these steps:

Select an appropriate site, following local protocols. The tourniquet should always be between the wound and the heart. If using a commercial tourniquet, follow the manufacturer's instructions. In general, you should place the strap around the limb, pull the free end through the buckle or catch, and tighten this end over the pad. Tighten to the point where bleeding is controlled. There should be no distal pulse palpable, but this may be a result of damage to an artery, not an the effect of the tourniquet itself, so observe the wound to make sure it is no longer bleeding. If you cannot be sure that the bleeding has stopped (some of these wounds are quite large), you should tighten the device until it cannot be tightened any further. Be aware that tightening a tourniquet causes great pain. You may need to prepare the patient for this and address the emotional aspects as the pain increases. If you are using cravats or triangular bandages as tourniquets, wrap the material around the injured limb and tie a knot over the pad. Slip a rigid device such as a pair of scissors into the knot and rotate to tighten the tourniquet. Resist the temptation to use a pencil, pen, or other fragile device as these will frequently break when the tourniquet is tightened. Tighten to the point where a distal pulse can no longer be felt or until the tourniquet cannot be tightened any further. Secure the device in place with tape or by tying with the ends of the cravat. Attach a notation to the patient to alert other rescuers and hospital staff that a tourniquet has been applied, and indicate the time of the application. Note this on your prehospital care report as well. Do not cover the extremity. You must visually monitor the wound site and the effectiveness of the tourniquet. Leave the tourniquet in open view. Advise hospital staff of the application of a tourniquet during your radio report and in person upon your arrival at the emergency department. You may arrive at a scene to find that well-meaning bystanders have already applied a tourniquet to an injury, which may or may not have been necessary. If the EMT determines that the bleeding is not severe and other means would control it, medical direction may be contacted about removing the tourniquet. Always follow your local protocols for this situation. If you are directed to remove the tourniquet, have another rescuer apply direct pressure to the wound while you release the tourniquet. If you find that the "tourniquet" applied by a layperson has not stopped the bleeding, immediately apply direct pressure and remove it. Proceed to control the bleeding as you normally would.

pressure dressing

Several types of dressings may be used to control external bleeding (Figure 25-5). A pressure dressing will control most external bleeding. Place several gauze pads on the wound. Hold the dressings in place with a self-adhering roller bandage wrapped tightly over the dressings and above and below the wound site. You must create enough pressure to control the bleeding. Take care that the pressure dressing you are applying does not cut off blood flow and become a tourniquet. A pressure dressing should be snug to accomplish its goal of applying pressure to the wound, but it should not cut off distal circulation.

hemorrhage

Severe bleeding, or hemorrhage, is the major cause of shock (hypoperfusion) in trauma. The cells and tissues of the brain, the spinal cord, and the kidneys are the most sensitive to inadequate perfusion. Bleeding, or hemorrhage, is classified as either external or internal and can be either minor or severe

patient assessment internal bleeding

Since internal bleeding is not visible and may not be obvious, you must identify patients who may have internal bleeding by performing a thorough history and physical exam. Suspicion of internal bleeding and estimates of its severity should be based on the mechanism of injury as well as clinical signs and symptoms. If a patient has a mechanism of injury that suggests the possibility of internal bleeding, treat as though the patient has internal bleeding. Blunt trauma is the leading cause of internal injuries and bleeding. Mechanisms of blunt trauma that may cause internal bleeding are: Falls Motor-vehicle or motorcycle crashes Auto-pedestrian collisions Blast injuries Penetrating trauma is also a common cause of internal injuries and bleeding. It is often difficult to judge the severity of the wound even when the size and length of the penetrating object are known. Always assess your patient for exit wounds. Mechanisms of penetrating trauma are: Gunshot wounds Stab wounds from a knife, ice pick, screwdriver, or similar object Impaled objects

capillary bleeding

Superficial wounds to the surface of the skin often produce capillary bleeding. This bleeding is under very low pressure and produces only a slow ooze from the wound. It typically ceases without any intervention at all. However, this type of bleeding sometimes occurs over large areas, so the risk of infection is high. Nonmassive bleeding can also come from veins and even small arteries.

blood functions

TRANSPORTATION OF GASES. Blood picks up inhaled oxygen at the alveoli in the lungs and carries it to the body's cells. In a similar fashion, the blood picks up carbon dioxide at the body's cells and carries it back to the alveoli, where it is offloaded then exhaled. NUTRITION. Blood circulates nutrients from the intestines or storage tissues (such as fatty tissue, the liver, and muscle cells) to the other body cells. EXCRETION. Blood carries waste products from the cells to organs, such as the kidneys, that excrete (eliminate) them from the body. PROTECTION. Blood carries antibodies and white blood cells, which help fight disease and infection. Blood also contains platelets and clotting factors that work to control bleeding from damaged blood vessels by forming blood clots. REGULATION. Blood carries substances that control the body's functions, such as hormones, water, salt, enzymes, and chemicals. Blood also plays an important role in regulating body temperature by carrying body heat to the lungs and skin surface, where it is dissipated. Dilation (expansion) of blood vessels increases blood flow to the skin, which increases heat loss from the skin surface. Conversely, constriction (narrowing) of blood vessels decreases blood flow to the skin, which decreases heat loss so core temperature can be preserved.

patient care closed wounds

Take the appropriate Standard Precautions and follow these steps for emergency care of a patient with closed wounds: Manage the patient's airway, breathing, and circulation. Consider the need for high-concentration oxygen by nonrebreather mask. Manage as if there is internal bleeding and provide care for shock if you believe that there is any possibility of internal injuries. Splint extremities that are painful, swollen, or deformed. Stay alert in case the patient vomits. Continue to monitor the patient for the development of shock and transport as soon as possible. Apply cold packs to isolated injuries (avoid direct contact with skin) to manage pain and swelling.

abrasion

The classification of abrasion includes simple scrapes and scratches in which the outer layer of the skin is damaged but not all the layers are penetrated. Abrasions can range in severity (Figure 26-5). Skinned elbows and knees, road rash, mat burns, rug burns, and brush burns are examples of abrasions. With abrasions, there may be no detectable bleeding or only the minor ooze of blood from the capillary beds. The patient may be experiencing great pain, even if the injury is minor. Because of dirt or other substances ground into the skin, the opportunity for infection is great.

patient care open wounds

The following steps are general guidelines for emergency care of open wounds. Steps for specific kinds of open wounds appear on the following pages. Be sure to take appropriate Standard Precautions when performing these steps. Expose the wound. Clothing that covers a soft-tissue injury must be lifted, cut, or split away. For some articles of clothing, this is best done with scissors or a seam cutter. Do not attempt to remove clothing in the usual manner, which can aggravate existing injuries and cause additional damage and pain. Take care in removing clothing if blood or debris has adhered it to the wound. Clean the wound surface. Do not try to pick embedded particles and debris from the wound. Simply remove large pieces of foreign matter from the surface. When possible, use a piece of sterile dressing to brush away large debris while protecting the wound from contact with your soiled gloves. Do not spend much time cleaning the wound. Control of bleeding is the priority. Control bleeding. Start with direct pressure or direct pressure and elevation. When necessary, apply a tourniquet. It may be important to remember that direct pressure may not be possible in certain crush-type injuries or amputations. Damage may be too widespread or bone ends may interfere with the ability to apply direct pressure. If direct pressure to an extremity is not appropriate or possible, move directly to the placement of a tourniquet (see the chapter "Bleeding and Shock"). Remember also that with penetrating trauma and puncture wounds, bleeding may be occurring internally without its being visible on the surface of the skin. For all serious wounds, provide care for shock, including administration of high-concentration oxygen (see the chapter "Bleeding and Shock"). Prevent further contamination. Use a sterile dressing. When none is available, use the cleanest cloth material at the scene. Bandage the dressing in place after you have controlled the bleeding. If an extremity is involved, check for a distal pulse to make certain that circulation has not been interrupted by the application of a tight bandage. With the exception of a pressure dressing, bleeding must be controlled before bandaging is started. Periodically recheck the bandage to make certain that bleeding has not restarted. Keep the patient lying still. Any movement will increase circulation and could restart bleeding. Reassure the patient. This will help ease the patient's emotional response and perhaps lower his pulse rate and blood pressure. In some cases this may help to reduce the bleeding rate. Also, a patient who feels reassured will usually be more willing to lie still, reducing the chances of restarting bleeding.

Treating Impaled Objects

The object may be a knife, a fence post or guard rail, a shard of glass, or even a wooden stick—or part of any of these that has broken off in the wound (Figure 26-13), piercing any part of the body. Even though it is rare, you may be confronted with an impaled object that is long enough to make transport impossible unless the object is shortened. In such cases contact the emergency department physician for specific directions. Usually someone must hold the object, keeping it very stable, while you gently cut through it at the desired length. A fine-toothed saw with rigid blade support (e.g., a hacksaw or reciprocating saw) should be used. In some cases, you may need to leave the object in place as found. The challenge in these cases is stabilization of the object. In general when caring for a patient with a puncture wound involving an impaled object, do not remove the impaled object Expose the wound area. Cut away clothing, taking great care not to disturb the object. Do not attempt to lift clothing over the object as you may accidentally move it. Long impaled objects may have to be stabilized by hand during exposure, bleeding control, and dressing. Control profuse bleeding by direct pressure, if possible. Be careful to position your gloved hands on either side of the object and exert pressure downward. Do not put pressure on the object. Apply pressure with great care if the object has a cutting edge, such as a knife or a shard of glass; otherwise, you may cause additional injury to the patient. Be careful not to injure your hands or damage your gloves. While you continue to stabilize the object and control bleeding, have another trained rescuer place several layers of bulky dressing around the injury site so the dressings surround the object on all sides (Figure 26-14). Manual stabilization must continue until the stabilizing dressings are secured in place. Have the other rescuer begin by placing folded universal pads or some other bulky dressing material on opposite sides of the object. For long or large objects, folded towels, blankets, or pillows may have to be used in place of dressing pads. Remove your hands from under the pads. Place them on top, and apply pressure as each layer is placed in position. The next layer of pads should be placed on opposite sides of the object, perpendicular to the first layer. Continue this process until as much of the object as possible has been stabilized. Once bandaged in place, the dressings will stabilize the object and exert downward pressure on bleeding vessels. Keep in mind that there is a limited amount of time that can be given to stabilizing an impaled object. Stay in contact with the Medical Director for directions and recommendations. Secure the dressings in place. Although adhesive strips may hold the dressings in place, blood around the wound site, sweat, and body movements may not allow you to use tape. Triangular bandages folded into strips (cravats) can be applied by tying one above and one below the impaled object. The cravats should be wide (no less than 4 inches in width once folded). A thin rigid splint can be used to push the cravats under the patient's back when they are needed to care for objects impaled in the trunk of the body. Care for shock. Provide oxygen at the highest possible flow and concentration. When appropriate, oxygen administration and heat conservation measures should be accomplished as soon as possible. When working by yourself, these may have to be delayed while you attempt to control bleeding. Keep the patient at rest. Position the patient for minimum stress. If possible, immobilize the affected area—for example, with a splint or a spine board. Provide emotional support. Transport the patient carefully and as soon as possible. Avoid any movement that may jar, loosen, or dislodge the object. If the object was removed by bystanders before you arrived, bring it to the hospital for examination. Reassure the patient throughout all aspects of care. An alert patient who is afflicted with an impaled object is usually very frightened.

An alternative way to estimate the extent of a burn is the rule of palm, also known as the palmar method or the rule of ones, which uses the patient's own hand to approximate the surface area.

The rule of palm can be applied to any patient—infant, child, or adult. Since the palm and fingers of the hand equal about 1 percent of the body's surface area, mentally compare the patient's palm and fingers with the size of the burn to estimate its extent. (For example, a burn the size of five palms and fingers equals approximately 5 percent of the body.) The rule of palm may be easier to apply to smaller or localized burns, whereas the rule of nines may be easier for larger or more widespread burns.

Classifying Burns by Severity

The severity of burns must be classified to determine the order and type of care, to determine the order of transport, and to provide maximum information to the emergency department. In some cases the severity of the burn may determine if the patient is to be taken directly to a hospital with special burn-care facilities. CLASSIFICATIONS BY THICKNESS, PERCENT OF BODY SURFACE AREA, AND COMPLICATING FACTORS Minor Burns Full thickness burns of less than 2 percent of the body surface, excluding the face, hands, feet, genitalia, or respiratory tract Partial thickness burns of less than 15 percent of the body surface Superficial burns of 50 percent of the body surface or less Moderate Burns Full thickness burns of 2 to 10 percent of the body surface, excluding the face, hands, feet, genitalia, or respiratory tract Partial thickness burns of 15 to 30 percent of the body surface Superficial burns that involve more than 50 percent of the body surface Critical Burns All burns complicated by injuries of the respiratory tract, other soft-tissue injuries, and injuries of the bones Partial thickness or full thickness burns involving the face, hands, feet, genitalia, or respiratory tract Full thickness burns of more than 10 percent Partial thickness burns of more than 30 percent Burns complicated by musculoskeletal injuries Circumferential burns Geriatric Note Note that burns usually classified as moderate are considered critical in adults over fifty-five years of age.

skin anatomy

The skin has three major layers: the epidermis, the dermis, and the subcutaneous layer. The outer layer of the skin is the epidermis. The outermost epidermis is composed of dead cells, which are rubbed off or sloughed off and replaced. The pigment granules of the skin and living cells are found deeper in the epidermis. The cells of the innermost portion are actively dividing, replacing the dead cells of the outer layers. The epidermis contains no blood vessels or nerves. Except for certain types of burns and injuries due to cold, injuries of the epidermis present few problems in EMT-level care. The layer of skin below the epidermis is the dermis. This layer is rich with blood vessels, nerves, and specialized structures such as sweat glands, sebaceous (oil) glands, and hair follicles. Specialized nerve endings in the dermis are involved with the senses of touch, cold, heat, and pain. Once the dermis is opened to the outside world, contamination and infection become major problems. Such wounds can be serious, especially when accompanied by profuse bleeding and intense pain. The layers of fat and soft tissue below the dermis are called the subcutaneous layers. Shock absorption and insulation are major functions of this layer. Again, when these layers are injured, there are problems of tissue and bloodstream contamination, bleeding, and pain.

soft tissues

The soft tissues of the body include the skin, fatty tissues, muscles, blood vessels, connective tissues, membranes (tissues that line or cover organs), glands, and nerves (Figure 26-1). Teeth, bones, and cartilage are considered hard tissues. Soft-tissue injuries are generally classified as closed wounds or open wounds. The skin and its layers of soft tissue can be damaged in a variety of ways. Most commonly mechanical force from trauma rips, crushes, stretches, and otherwise injures these relatively delicate cells. Soft tissue can also be injured chemically, thermally, and even electrically. In a broad sense, soft-tissue injuries can be categorized by type and by the cause of the injury.

patient assessment electrical injuries

The victim of an electrical accident may have any or all of the following signs and symptoms (Figure 26-28): Burns where the energy enters and exits the body Disrupted nerve pathways displayed as paralysis Muscle tenderness, with or without muscular twitching Respiratory difficulties or respiratory arrest Irregular heartbeat or cardiac arrest Elevated blood pressure or low blood pressure with the signs and symptoms of shock Restlessness or irritability if conscious or loss of consciousness Visual difficulties Fractured bones and dislocations from severe muscle contractions or from falling (can include the spinal column) Seizures (in severe cases)

tourniquet

There are several situations in which direct pressure is not appropriate. Severe trauma to an extremity can cause multiple lacerations, penetrations, and anatomic destruction that may lead to bleeding in more than one area. Protruding broken bone ends and crush-type amputations can also prevent the ability to apply direct pressure. In addition, sometimes direct pressure simply does not work. This will be evident when an extremity continues to bleed severely despite attempts at controlling the bleeding with direct pressure and hemostatic agents. Obvious bleeding and rapid soaking through of dressings are key indicators that your direct-pressure efforts have failed. In these cases you must rapidly move to the next level of intervention, which is a tourniquet. Previously believed to be an extreme last resort, tourniquets have moved into mainstream care for patients with severe bleeding that can't be controlled by direct pressure. At one point it was believed that the use of a tourniquet was a "life or limb" decision. It was felt that with blood flow cut off, the tissue of the limb would die and an amputation would be necessary. This is no longer assumed. In combat situations in Iraq and Afghanistan, many tourniquets have been placed without leading to amputations. Tourniquets are used on only extremity injuries. In addition, do not apply the tourniquet directly over a joint (elbow or knee). Place the tourniquet approximately two inches above the bleeding wound. Most experts would agree that a commercially designed tourniquet is superior to an improvised device, so if possible, a commercial device should be used. Tourniquets improvised from materials such as this should be at least two inches wide and several layers thick. Never use narrow material such as a rope or wire that could cut into the skin. A blood pressure cuff may also be used as a tourniquet (Figure 25-10). If a blood pressure cuff is used, monitor the pressure to be sure the cuff does not gradually deflate. Once a tourniquet has been applied, do not remove or loosen it unless ordered by medical direction

head injury

Traumatic injuries resulting in a fractured skull may cause bleeding or loss of cerebrospinal fluid (CSF) from the ears or nose. However, this fluid loss is not due to direct trauma to the ears or nose. Instead, the head injury results in increased pressure within the skull, which forces fluid out of the cranial cavity. You should not attempt to stop this bleeding or fluid loss as doing so may increase the pressure in the skull. Do not apply pressure to the ears or nose. Allow the drainage to flow freely, using a gauze pad to collect it.

Puncture Wound or Object Impaled in the Eye

Use loose dressings for a puncture wound to the eye with no impaled object. If you find an object impaled in the eye, you should (Figure 26-16): Stabilize the object. Place a roll of 3-inch gauze bandage or folded 4 × 4s on either side of the object, along the vertical axis of the head, in a manner that will stabilize the object. Apply rigid protection. Fit a disposable paper drinking cup or paper cone over the impaled object, and allow it to come to rest on the dressing rolls. Do not allow it to touch the object. Do not use a Styrofoam cup, which can flake. Have another rescuer stabilize the dressings and cup while you secure them in place with a self-adherent roller bandage or with a wrapping of gauze. Do not secure the bandage on top of the cup. Dress and bandage the uninjured eye. This will help to reduce sympathetic eye movements. Consider the need for oxygen and care for shock. Reassure the patient and provide emotional support. In some EMS systems, step 4 is not part of the recommended treatment for an injured eye. Covering both eyes often makes a patient anxious. Furthermore, covering the uninjured eye seems to make little, if any, difference in patient outcome. However, you should follow your local protocols. An alternative to the previous method calls for the rescuer to make a thick dressing with several layers of sterile gauze pads or universal dressings. A hole approximately the size of the impaled object is cut in the center of this pad. The rescuer then carefully passes this dressing over the impaled object and positions the pad so the impaled object is centered in the opening. The rest of the procedure remains the same as previously described. If your EMS system instructs you to use this technique, remember that you must take great care not to touch the object as the dressing is set in place.

hypothermia

We also know that hypothermia (reduced body temperature) also affects the body's ability to clot. The colder a patient gets, the more likely coagulopathy, or impaired ability to clot, will be a concern. Keep in mind that as patients become hypoperfused, their ability to generate heat through metabolism and their ability to conserve heat through blood flow can be affected. Hypothermia, therefore, must be an immediate and ongoing concern in any patient with bleeding.

Treating Penetrating Trauma

What appears at first to be a simple, shallow puncture wound may be only part of the problem. There also could be a severe exit wound that requires immediate care, so be sure to search for one. . If the bullet has penetrated the body, you must assume that there is considerable internal injury. Close-range shootings often have burns around the entry wound (Figure 26-12D). Remember that any gunshot wound to the face, no matter how minor, can create airway problems. Air guns fired at close range can cause serious damage by injecting air into the tissues.All stab wounds should be considered serious, especially when they involve the head, neck, chest, abdomen, or groin or are inflicted proximal to the knee or elbow. Care for a patient with a moderate or serious puncture wound includes these steps: Reassure the alert patient. Such wounds can be frightening. Search for additional penetrations, including exit wounds, especially in the case of a gunshot wound. Control bleeding and provide adequate wound treatment to both the entry and exit wounds. Assess the need for basic life support whenever there is a gunshot wound. Care for shock, administering high-concentration oxygen. Follow your local protocols with regard to immobilizing the spine when the patient's head, neck, or torso is involved. (See the chapter "Trauma to the Head, Neck, and Spine.") There is evidence to suggest that you should not immobilize a patient with penetrating trauma to the torso unless there is neurological deficit. Doing so can harm the patient's ability to breathe and has proven to be of little value in the vast majority of cases. As always, follow your local protocols. Transport the patient. If the object that caused the puncture wound is available, and if the scene of the emergency is not a crime scene, take the object to the emergency department for examination as well.

septic shock

When an infection spreads throughout the body via the bloodstream, sepsis (formerly called "blood poisoning") is present. Toxins produced by this condition can lead to dilation of the blood vessels and loss of integrity ("leakiness") of the blood vessels, causing septic shock. This is often the result of a urinary infection, postsurgical infection, or pneumonia. Two special parts of the treatment for this condition are intravenous fluid and early notification of the hospital. If ALS is available, it is very important that you call for it so aggressive IV fluid resuscitation can be initiated. In some EMS systems, you may be required to notify hospitals that you are en route with a patient with evident shock who meets criteria for a "sepsis alert." Signs of sepsis can include the patient's temperature being high or low; tachycardia, tachypnea, and hypotension are present; there is reason to suspect an infection; and the patient has an altered mental status or a worsening of a preexisting altered mental status. Follow your local protocols.

puncture wound

When an object passes through the skin or other tissue, penetrating trauma occurs. A puncture wound results from the penetration of the skin. Typically puncture wounds are caused by objects such as bullets, nails, ice picks, splinters, or knives (Figure 26-7). Blast injury can also cause penetrating trauma by launching high-velocity shrapnel (objects thrown by the blast, including bomb materials and debris)Penetrating trauma violates the skin and soft tissues by pushing objects through them. Often there is no severe external bleeding, although internal bleeding may be profuse. Common puncture wounds are relatively small and insignificant to look at but, depending on the depth of penetration, may cause devastating injuries. Your assessment may find only tiny external wounds on the surface of the skin, but the damage may prove to be deadly. Always consider a puncture wound a serious injury. The threat of contamination and subsequent infection is high.

Determining the Severity of Burns

When determining the severity of a burn, consider the following factors: Agent or source of the burn Body regions burned Depth of the burn Extent of the burn Age of the patient Other illnesses and injuries The agent or source of the burn can be significant in terms of patient assessment. A burn caused by electrical current may cause only small areas of skin injury but pose a great risk of severe internal injuries. Chemical burns are of special concern since the chemical may remain on the skin and continue to burn for hours or even days, eventually entering the bloodstream. This is sometimes the case with certain alkaline chemicals. When you are considering the body regions burned, keep in mind that any burn to the face is of special concern since it may involve injury to the airway or the eyes (Figure 26-23). The hands and feet also are areas of concern because scarring may cause loss of movement of fingers or toes. Special care is required to avoid aggravation to these injury sites when moving the patient and to prevent the damaged tissues from sticking to one another. When the groin, genitalia, buttocks, or medial thighs are burned, potential bacterial contamination can be far more serious than the initial damage to the tissues. Note that circumferential burns (burns that encircle the body or a body part) can be very serious because they constrict the skin. When they occur to an extremity, they can interrupt circulation to the distal tissues. When they occur around the chest, they can restrict breathing by limiting chest wall movement. In addition, the burn healing process can be very complicated. This is particularly true when circumferential burns occur to joints, the chest, and the abdomen where the encircling scarring tends to limit normal functions. The depth of the burn is important to determine its severity. In partial thickness and full thickness burns, the outer layer of the skin is penetrated. This can lead to contamination of exposed tissues and the invasion of harmful chemicals and microorganisms into the circulatory system. You also will need to roughly estimate the extent of the burn area. The patient's age is a major factor in considering the severity of burns. Infants, children under age five, and adults over age fifty-five, because of their anatomy and physiology, have the most severe responses to burns and the greatest risk of death. They also have different healing patterns than other age groups. Patients with respiratory ailments, heart disease, or diabetes will react more severely to burn damage.

treating specific chemical burns

When possible, find out the exact chemical or mixture of chemicals that were involved in the incident. Most industrial sites will have a material safety data sheet (MSDS) that provides specific emergency information about the chemical agents being used. Some special chemical burns require specific care procedures. MIXED OR STRONG ACIDS OR UNIDENTIFIED SUBSTANCES. Many of the chemicals used in industrial processes are mixed acids, whose combined action can be immediate and severe. The pain produced from the initial chemical burn may mask any pain being caused by renewed burning due to small concentrations left on the skin. When the chemical is a strong acid (e.g., hydrochloric acid or sulfuric acid), a combination of acids, or an unknown, play it safe and continue washing even after the patient claims he is no longer experiencing pain. DRY LIME. If dry lime is the burn agent, do not wash the burn site with water. To do so will create a corrosive liquid. Brush the dry lime from the patient's skin, hair, and clothing. Make certain that you do not contaminate the patient's eyes or airway. Use water only after the lime has been brushed from the body, contaminated clothing and jewelry have been removed, and the process of washing can be done quickly and continuously with running water. CARBOLIC ACID (PHENOL). Carbolic acid does not mix with water. When available, use alcohol for the initial wash of unbroken skin, followed by a long steady wash with water. (Follow local protocols.) SULFURIC ACID. Heat is produced when water is added to concentrated sulfuric acid, but it is still preferable to wash rather than leave the contaminant on the skin. HYDROFLUORIC ACID. This acid is used for etching glass as well as many other manufacturing processes. Burns from it may be delayed, so treat all patients who may have come into contact with the chemical, even if burns are not in evidence. Flood the affected area with water. Do not delay care and transport to find neutralizing agents. (Follow local protocols.) INHALED VAPORS. Whenever a patient is exposed to a caustic chemical and may have inhaled the vapors, provide high-concentration oxygen (humidified, if available) and transport as soon as possible. This is very important when the chemical is an acid that is known to vaporize at standard environmental temperatures. (Examples include hydrochloric acid and sulfuric acid.)

patient assessment burns

When your patient has been burned, patient assessment involves classifying, then evaluating, the burns. Burns can be classified and evaluated in three ways: By agent and source By depth By severity All three are important in deciding the urgency and the kind of emergency care the burn requires. These classifications are discussed in detail in the following text. Note Patient assessment should not be neglected to begin immediate burn care.

PPE for external hemorrhage

Whenever bleeding is anticipated or discovered, you must use Standard Precautions to avoid exposure of your skin and mucous membranes. Blood and open wounds pose a risk of infection to the EMT. Therefore, you must wear protective gloves when caring for any bleeding patient. You should also wear a mask and protective eyewear if there is a chance of encountering splattered blood. In addition, you should wear a mask when assisting a patient suffering from profuse or spurting (arterial) bleeding, or one who is spitting or coughing up blood. Consider wearing a gown if clothing may become contaminated.

venous bleeding

Wounds to large veins, such as the jugular veins in the neck, can also cause massive bleeding. Although venous bleeding has less pressure behind it than arterial bleeding, the sheer volume of blood carried by some veins is enough to create immediately life-threatening hemorrhage in some patients. Venous bleeding can sometimes be differentiated from arterial bleeding as it tends to be darker in color and to flow steadily from a wound rather than spurt. massive hemorrhage

contusion

a bruise, the most frequently encountered type of closed wound (Figure 26-4). In a contusion the epidermis remains intact, but cells and blood vessels in the dermis are damaged. A variable amount of internal bleeding occurs at the time of injury and may continue for a few hours. Pain, swelling, and discoloration occur at the wound site. Swelling and discoloration may occur immediately or may be delayed as much as forty-eight hours.

full thickness burn

all the layers of the skin are damaged. Some full thickness burns are difficult to tell apart from partial thickness burns; however, there are usually areas that are charred black or brown or areas that are dry and white. The patient may complain of severe pain or, if enough nerves have been damaged, may not feel any pain at all (except at the periphery of the burn, where adjoining partial thickness burns may be causing pain). This type of burn may require skin grafting. As these burns heal, dense scars form. Full thickness burns damage all layers of the skin and may damage subcutaneous tissue, muscle, bone, and underlying organs. These burns are sometimes called third-degree burns.

open wound

an injury in which the skin is interrupted, or broken, exposing the tissues underneath. The interruption can come from the outside, as a laceration, or from the inside when a fractured bone end breaks the skin. There are numerous types of open wounds, including abrasions, lacerations, punctures, avulsions, amputations, crush injuries, blast injuries, and high-pressure injection injuries.

closed wound

an internal injury; that is, there is no open pathway from the outside to the injured site. In a closed wound, the skin can be damaged, but it remains intact. These wounds usually result from the impact of a blunt object. Although the skin itself may not be broken, there may be extensively crushed tissues beneath it. Closed wounds can be simple bruises, internal lacerations (cuts), and internal punctures caused by fractured bones, crushing forces, or the rupture (bursting open) of internal organs (Figure 26-3). Internal bleeding from a closed wound can range from minor to life threatening. There are three types of closed wounds: contusions, hematomas, and crush injuries.

dressing

any material applied to a wound in an effort to control bleeding and prevent further contamination. Dressings should be sterile.

avulsion

flaps of skin and tissues are torn loose or pulled off completely. When the tip of the nose is cut or torn off, this is an example of an avulsion. The same applies to the external ear (Figure 26-8A). A degloving avulsion occurs when the hand is caught in a roller. In this type of incident, the skin is stripped off like a glove (Figure 26-8B). An eye pulled from its socket (extruded) is also a form of avulsion. The term avulsed is used in reporting the wound, as in "an avulsed eye" or "an avulsed ear." When tissue is avulsed, it is cut off from its oxygen supply and will soon die.

neurogenic shock

may result from the uncontrolled dilation of blood vessels from nerve paralysis caused by spinal cord injuries. Although there is no actual blood loss, the dilation of the blood vessels increases the circulatory system's capacity to the point where the available blood can no longer adequately fill it. Neurogenic shock is rarely seen in the field. However, sepsis (massive infection) or an anaphylactic (severe allergic) reaction may also result in vasodilation that may cause shock.

hematoma

occurs when blood collects at the site of an injury. A hematoma differs from a contusion in that hematomas involve a larger amount of tissue damage, including damage to larger blood vessels with greater internal blood loss. Where a contusion may cause some minor injury to small blood vessels, a hematoma is characterized by much more severe internal bleeding and the collection of a larger volume of blood beneath the skin. In fact, as much as a liter of blood may accumulate in a hematoma.

hemostatic agents

products designed to enhance direct pressure's ability to control bleeding. Although a wide variety of agents may be used in these products, they generally work by applying a material designed to absorb the liquid portion of the blood and leave the larger formed elements to clot. Essentially this absorption enhances the blood's ability to form a clot. Hemostatic agents originated as powders poured into wounds but have now evolved into dressings (Figure 25-6) and gauze bandages (Figure 25-7) impregnated with absorbent product that can be applied directly onto a wound. To use these dressings, open the package and follow the manufacturer's directions. Some dressings must be placed into a wound in a specific orientation. It is important to remember that hemostatic agents aid direct pressure but do not replace it. Once the dressing or gauze is applied, you must apply direct pressure over the wound. Hemostatic agents are particularly useful if a large cavity has been formed by trauma. Applying direct pressure over a cavity is typically not effective as the tissue within the cavity continues to bleed and is not usually effectively compressed. This situation can be addressed by filling the cavity with dressings or unrolled bandages. Once the space of the cavity has been occupied, direct pressure can be applied over that space. Hemostatic gauze is particularly useful in this regard as it offers both the wound packing property and the hemostatic agent. You should not push dressings or bandaging materials into an internal wound such as penetrating trauma to the abdomen or chest

Light (typically involving the eyes) agent

source: Intense light sources; ultraviolet light can also be considered a source of radiation burns

chemical agent

source: Various acids, bases, and caustics

Radiological agent

source:Usually from nuclear sources; ultraviolet light can also be considered a source of radiation burns

thermal agent

sources: Flame; radiation; excessive heat from fire, steam, hot liquids, and hot objects

Electricity agent

sources:Alternating current, direct current, and lightning

compensated shock

the body senses the decrease in perfusion and attempts to compensate for it. For a time the body's compensating mechanisms work, and the patient maintains his blood pressure. Some early signs of shock are actually caused by the body's compensating mechanisms at work. You will note an increased heart rate (to increase blood flow) and increased respirations (to increase oxygenation of the blood). Constriction of the peripheral circulation (to redirect blood to the vital core organs) results in pale, cool skin and, in infants and children, increased capillary refill time.

partial thickness burn

the epidermis is burned through and the dermis (the second layer of the skin) is damaged, but the burn does not pass through to underlying tissues. There will be deep, intense pain; noticeable reddening; blisters; and a mottled (spotted) appearance to the skin. Burns of this type cause swelling and blistering for 48 hours after the injury, as plasma and tissue fluids are released and rise to the top layer of skin. When treated with reasonable care, partial thickness burns will heal themselves, producing very little or no scarring. Partial thickness burns are also called second-degree burns.

blood thinners

these medications are commonly prescribed to patients with a history of stroke, irregular heartbeat (atrial fibrillation), heart attack, or artificial heart valves. These medications—which include aspirin, warfarin (Coumadin), clopidogrel (Plavix), Pradaxa (dabigatran), and Xarelto (rivaroxaban)—act to prevent strokes or heart attacks, but in the setting of external or internal bleeding can result in life-threatening bleeding from injuries that might be relatively minor for a patient who is not on one of these medications