Chapter 22 - EMT (Trauma Overview)

coup-contrecoup brain injury e.g. in motor vehicle accident when passenger's head hits windshield, brain continues to move forward until it strikes inside of skull, resulting in a compression injury (or bruising/contusions) to the anterior portion of the brain and stretching (or tearing) of the posterior portion of the brain

A brain injury that occurs when force is applied to the head and energy transmission through brain tissue causes injury on the opposite side of the original impact

osteoporosis -may cause an elderly patient to sustain a fracture while in a standing position, causing them to fall as a result and possibly sustain additional injuries

A condition in which the musculoskeletal system can fail under relatively low stress because the bones are structurally weakened

Flail chest -when three or more ribs are fractured in two or more places, a free-floating segment (called a flail chest) is created -the detached portion of the ribs moves in the opposite direction of the rest of the chest (paradoxical motion) resulting in painful and ineffective breathing

A life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently.

an open chest wound -as air enters chest cavity, the natural pressure balance is no longer equal and, if left untreated, shock and/or death will result

A penetration or perforation of the integrity of the chest

cavitation Two types: 1. temporary (creates a temporary cavity, caused by the acceleration of the bullet and causes a stretching of the tissues) 2. permanent (creates a permanent cavity, caused by the bullet path and remains once the projectile has passed through the tissue) -the relationship between distance and the severity of injury varies depending on the type of weapon involved, such as a rifle, pistol, or shotgun

A phenomenon in which speed causes a bullet to generate pressure waves, which cause damage distant from the bullet's path

Revised Trauma Score (RTS) -heavily weighted to compensate for major head injury without multisystem injury or major physiologic changes -objective data used to calculate the RTS includes the GCS score, systolic BP, and respiratory rate (RR) -RTS assesses injury severity and has demonstrated reliability in predicting survival in patients with severe injuries -Highest score = 12, lowest = 0

A physiological scoring system used for patients with head trauma

trauma score -relates to the likelihood of patient survival, however, it does NOT accurately predict survivability in patients with severe head injuries because motor and verbal deficits make those criteria difficult to assess --> in its place, the Revised Trauma Score (RTS) is used

A score that relates to the likelihood of patient survival with the exception of a severe head injury. It calculates a number from 1-16, with 16 being the best possible score. It takes into account the GCS score, respiratory rate, respiratory expansion, systolic BP, and capillary refill

arterial air embolism -concerning type of pulmonary blast injury -occurs on alveolar disruption with subsequent air embolization into the pulmonary vasculature -even small air bubbles can enter a coronary artery and cause myocardial injury -air embolisms to cerebrovascular system (blood vessels that supply blood to brain) can produce disturbances in vision, changes in behavior, changes in state of consciousness, and other neurologic signs

Air bubbles in the arterial blood vessels

Glasgow Coma Scale (GCS) score

An evaluation tool used to determine LOC, which evaluates and assigns point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes

Newton's first law e.g. with car --> car and passengers are traveling at 30 mph. When car strikes concrete, passengers will continue to stay in motion at 30 mph until acted on by an external force such as the windshield or steering wheel. Their organs are also traveling at 30 mph and will continue to do so until acted on by the sternum, rib cage, etc.

An object at rest tends to stay at rest and an object in motion tends to stay in motion unless acted on by some force.

projectile -often difficult to determine entrance and exit wounds from projectiles in a prehospital setting

Any object propelled by force, such as a bullet by a weapon

25%

Approximately ___% of all severe injuries to the aorta that occur in motor vehicle crashes are a result of lateral collisions.

pressure waves -there is often additional damage caused by the object moving inside the body and not along the suspected pathway (this = cavitation and can result in serious injury to internal organs distant to the actual path of the bullet) -much like a boat in water, the bullet disrupts not only the tissues that are directly in its path but also those in its wake. Therefore, the area that is damaged by medium- and high-velocity projectiles can be many times larger than the diameter of the projectile itself ^^this is one reason that exit wounds are often many times larger than entrance wounds

Because of a bullet's speed, ______ emanate from the bullet, causing damage remote from its path.

secondary blast injuries -due to objects being propelled by the force of the blast and strike the victim, causing injury -objects can travel great distances and great speeds (up to 3000 mph for military explosives)

Blast injury in which damage to the body results from being struck by flying debris, such as shrapnel from the device or glass or splinters

-lower extremity fractures (knees into dashboard) -flail chest (rib cage into steering wheel) -had trauma (head into windshield) *even if patient is restrained with properly fit seatbelt, injuries can still occur, especially in lateral (t-bone) and rollover impacts

Common passenger injuries in motor vehicle crashes

1. Primary blast injuries - due to blast wave 2. Secondary blast injuries - due to propelled/flying objects 3. Tertiary blast injuries - due to patient being hurled against a stationary object 4. Miscellaneous blast injuries - burns, respiratory injury due to inhalation, crushing injury from building collapse, etc. *most patients who survive an explosion will have some combination of these four types of injury

Four mechanisms of blast injuries (i.e. via military conflict, mines, shipyards, chemical plants, terrorist activities, industrial settings, methamphetamine laboratory explosions)

-solid organs can tear, lacerate, or fracture, causing bleeding into abdomen that can quickly cause death (abdominal pain may be a symptom of abdominal bleeding, as well as worsening vital signs) -hollow organs may rupture and leak acidlike chemicals into abdomen, which can lead to life-threatening infection -blood vessels in this region may rupture or tear and cause serious unseen bleeding *continually reassess abdominal region using DCAP-BTLS

Patient assessment for injuries to the abdomen in trauma patients

tympanic membrane -evolved to detect minor changes in pressure -will rupture at pressures 5-7 pounds per square inch above atmospheric pressure (atm pressure ~ 14.7 pounds per square inch) *the tympanic membranes are a sensitive indicator that you can use to help determine the possible presence of other blast injuries -patient may complain of ringing in the ears, pain in ears, or some loss of hearing, and blood may be visible in the ear canal -dislocation of structural components of the ear, such as the ossicles conforming the inner ear, may occur -Permanent hearing loss is possible

The eardrum; a thin, semitransparent membrane in the middle ear that transmits sound vibrations to the internal ear by means of auditory ossicles Possible signs/injuries?

Kinetic energy -reflects the relationship between the mass (weight) of the object and the velocity (speed) at which it is traveling KE = (1/2)mass x velocity^2 --> velocity has greater impact on injury than mass (since velocity is squared) -the kinetic energy of a speeding car is converted into the work of stopping the car, usually by crushing the car's exterior. The passengers also have kinetic energy since they were moving at the same speed as the vehicle. Their kinetic energy is converted to the work of bringing them to a stop **it is this work on the passengers that results in injury -the amount of kinetic energy that is converted to do work on the body dictates the severity of the injury (high-energy injuries often produce such severe damage that patients require immediate transport)

The energy of a moving object

trajectory

The path a projectile takes once it is propelled

Potential energy --> is converted into KE and results in injury, such as from a fall e.g. if a worker is on a scaffold, he has some potential energy because he is some height above the ground Should he fall, PE is converted into KE and, as the worker hits the ground, KE is converted into work (the work of bringing the body to a stop and thereby fracturing bones and damaging tissues)

The product of mass (weight), force of gravity, and height, and is mostly associated with the energy of falling objects

1. Motor vehicle crashes 2. Falls 3. Poisonings 4. Burns 5. Drowning

The top 5 causes of trauma death

mechanism of injury (MOI)

The way in which traumatic injuries occur; describes the forces (or energy transmission) acting on the body that cause injury

miscellaneous blast injuries

These blast injuries include burns from hot gases or fires started by the blast, respiratory injury from inhaling toxic gases, and crush injury from the collapse of buildings, among others

tertiary blast injuries -a "blast wind" also causes the patient's body to be hurled or thrown, causing further injury -this physical displacement of the body is also referred to as ground shock when the body impacts the ground -in some cases, wind injuries can amputate limbs

These blast injuries occur when the patients is hurled by the force of the explosion against a stationary object

primary blast injuries -when victim is close to blast, the blast wave causes disruption of major blood vessels and rupture of major organs *hollow organs are the most susceptible to the pressure wave

These injuries are due entirely to the blast itself (damage to the body is caused by the pressure wave generated by the explosion)

Level I facility -must be capable of providing every aspect of trauma care from prevention through rehabilitation -a comprehensive regional resource that is a tertiary care facility -has 24-hour in-house coverage by general surgeons -availability of care in specialties such as orthopaedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, and critical care -should also include cardiac, hand, pediatric, and microvascular surgery and hemodialysis -provides leadership in prevention, public education, and continuing education of trauma team members -committed to continued improvement through a comprehensive quality assessment program and organized research to help direct new innovations in trauma care

This level of trauma center is a regional resource center and generally serves large cities or heavily populated areas; most are university-based teaching hospitals

Level IV facility -such a facility may be a clinic urgent care facility with or without a physician -includes basic emergency department facilities to implement ATLS protocols and 24-hour laboratory coverage -Transfer to a higher level trauma centers follows the guidelines outlined in formal transfer agreements -committed to continued improvement of these trauma care activities through a formal quality assessment program -involved in prevention, outreach, and education within its community

This level of trauma center is typically found in remote outlying areas where no higher level of care is available; provide advanced trauma life support (ATLS) prior to transfer to a higher level trauma center

Level II facility -expected to provide initial definitive care for all injured patients, regardless of injury or severity -has 24-hour immediate coverage by general surgeons -availability of care in specialties such as orthopaedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, and critical care -tertiary care needs such as cardiac surgery, hemodialysis, and microvascular surgery may be referred to a Level I trauma center -Committed to trauma prevention and continuing education of trauma team members -Provides continued improvement in trauma care through a comprehensive quality assessment program

This level of trauma center is typically located in less population-dense areas, can be academic institutions or a public/private community facility

Level III facility -must have transfer agreements with a Level I or II trauma center and must have protocols in place to transfer patients whose needs exceed the resources of the facility -has 24-hour immediate coverage by emergency medicine physicians and prompt availability of general surgeons and anesthesiologists -Program dedicated to continued improvement in trauma care through comprehensive quality assessment program -has developed transfer agreements for patients requiring more comprehensive care at a Level I or II trauma center -committed to continuing education of nursing and allied health personnel or the trauma team -must be involved with prevention and have an active outreach program for its referring communities

This level of trauma center serves communities who do not have access to lower level facilities; provide assessment, resuscitation, emergency care, and stabilization

blunt trauma and penetrating trauma -Blunt trauma = the result of force (or energy transmission) to the body that causes injury without penetrating the soft tissues or internal organs e.g. motor vehicle crashes and falls; skin discoloration or complaints of pain may be the only signs -Penetrating trauma = causes injury by objects that primarily pierce and penetrate the surface of the body and cause damage to soft tissues, internal organs, and body cavities

Two categories of traumatic injuries

1. Determine whether passenger was restrained by a full 3-point seatbelt and whether airbag was deployed 2. hip dislocations, internal injuries to abdominal organs, and/or lumbar spine fractures are common when seatbelt is worn improperly (too low or too high) 3. if patient is found lying unconscious against air bag, look for abrasions and/or traction-type injuries on the face, lower part of neck, and chest 4. Contact points are often obvious as you perform a quick evaluation of the interior of the vehicle --> e.g. passenger may have hit dashboard or instrument panel at the knees resulting in hip fracture or dislocation, chest and/or abdomen may hit steering wheel, passenger's face may launch forward and up, hitting the windshield and/or roof header in the area of the visors, causing head and spinal injuries

Understanding the MOI after a frontal collision

1. Death of an occupant in the vehicle 2. Severe deformity of vehicle or intrusion into vehicle 3. Altered mental status 4. Ejection from vehicle ^^any of these findings at a motor vehicle accident should be enough cause for you to consider transporting the patient to a trauma center

What are 4 significant mechanisms of injury for motor vehicle accidents that should be enough cause to consider transporting patient to a trauma center?

look for abrasions and/or traction-type injuries on the face, lower part of the neck, and chest -air bags can cause injury in frontal collisions, specifically abrasions and traction-type injuries the face, neck, and chest

What should you do when you encounter a patient in a motor vehicle accident lying against the air bag, unconscious?

lateral or side impacts (T-bone collisions) -in this type of collision, the car is typically struck above its center of gravity and begins to rock away from the side of impact. This causes a type of lateral whiplash in which the passenger's shoulders and head whip toward the intruding vehicle and hit the doorpost or window *lateral collisions (when car is hit from side) often cause lateral chest and abdomen injuries (esp. when there is substantial intrusion to passenger compartment), possible fractures of lower extremities, pelvis, and ribs, and abdominal organs are at risk due to third collision

What type of collision is known to cause lateral whiplash-type injuries?

rear-end impacts in motor vehicle accidents, particularly when the head/neck is not restrained by an appropriately placed headrest (as body is propelled forward, head and neck stay behind/bent back) *rear-end collisions often cause injury to the cervical spine and surrounding area, as well as acceleration-type injuries to the brain (third collision of brain within skull) -passengers in the back seat wearing only a lap belt may have injuries to thoracic and lumbar spine

What type of collision is known to cause whiplash-type injuries?

car vs. pedestrian collisions -multisystem injuries are common with this type of event *in car vs. bicycle accidents, inspect damage to and position of bike and inspect helmet. If bike helmet is damaged, suspect head and spine injuries -these patients should be assumed to have injury to spinal column until proven otherwise and spinal stabilization must be initiated and maintained -also try to roll patient onto side in order to assess the posterior side of the body

What type of collision often results in patients who have graphic and apparent injuries, such as broken bones, as well as possible unseen injuries to underlying body systems?

Rollover crashes -the most common life-threatening event in a rollover is ejection or partial ejection from the vehicle (nonrestrained patient) --> unpredictable injuries, unrestrained passenger may have sustained multiple strikes as vehicle rolled one or more times -restrained passengers on outboard side of a vehicle that rolls over is at high risk for injury because of the centrifugal force (the patient is pinned against the door of the vehicle) -if patient hits roof, they may sustain a spinal cord injury

What type of collision provides multiple opportunities for second and third collisions and can eject nonrestrained passengers?

rotational collisions (spins) --> rotation of the vehicle as it spins provides opportunities for vehicle to strike objects such as utility poles, causing patient to experience rotational motion as well as lateral impact

What type of collisions are conceptually similar to rollovers?

underwater explosions

What type of explosions result in the most severe abdominal injuries?

the deformity of the motorcycle, the side of the most damage, the distance of skid in the road, the deformity of stationary objects or other vehicles, and the extend and location of deformity in the helmet

When assessing a car vs. motorcycle crash, what should you pay close attention to?

1. Confirmed blood pressure of less than 90 mmHg at any time in adults, and age-specific hypotension in children 2. Respiratory compromise, obstruction, and/or intubation 3. Receiving blood to maintain vital signs 4. Emergency physician's discretion (says so) 5. Glasgow Coma Scale (GCS) score of less than or equal to 8 with mechanism attributed to trauma 6. Gunshot wound to the abdomen, neck, or chest (according to American College of Surgeon's Committee on Trauma)

When one or more of the following criteria are present in the trauma patient, they are classified as a Level I trauma patient (6)

1. Falls of greater than 10' without loss of consciousness 2. Falls of less than 10' with loss of consciousness 3. Medium- to high-speed vehicle collisions (>25 mph) *remember that small children are top-heavy so they tend to land on their heads even from small falls

When your patient is a child, the following constitute a significant MOI (3)

spinal injury

Whenever there is a significant impact to the head, you should also suspect a _____.

-seatbelts are designed to be worn over the iliac crests of the pelvis in order to distribute the force over the bony surface Possible injuries due to improperly worn seatbelts: -hip dislocations (if seatbelt is worn too low) -internal injuries to abdominal organs (when seatbelt is worn too high) -lumbar spine fractures (esp. in elderly patients)

Where is the seatbelt supposed to be worn? What are some injuries associated with seatbelts in motor vehicle accidents?

-when there is an extended period required to access/extricate a remote (i.e. injured hiker, snowmobiler, boater) or trapped patient (i.e. in crashed car) which depletes the time window to get the patient to the trauma center by ground -distance to trauma center is greater than 20-25 miles -patient needs ALS-level medical care and there is no ALS-level ground ambulance service available within a reasonable time frame -traffic conditions or hospital availability make it unlikely that patient will get to a trauma center via ground ambulance within the ideal time frame -there are multiple patients who will overwhelm resources at the trauma center(s) reachable by ground within the time window -EMS systems require bringing a patient to the nearest hospital/facility for initial evaluation and stabilization (which may add delay to definitive surgical care) -There is a mass-casualty incident (MCI) *these are guidelines. You should always follow your local protocols when determining what type of patient transportation is appropriate

Criteria on when to use emergency air medical services for trauma patients (identified by AAMS and MedEvac Foundation International)

1. frontal (head-on) 2. Rear-end 3. Lateral (T-bone) 4. Rollovers 5. Rotational (spins) ^^difference = the direction of the force of impact (with spins and rollovers, there is possibility of multiple impacts)

Five categories of motor vehicle crashes

Newton's third law e.g. if patient's head traveling at 30 mph hit an A-pillar, then really an A-pillar hit the patient's head at 30 mph as well (equal forces acting in opposite directions)

For every action, there is an equal and opposite reaction

A patient who has experienced a significant MOI and patient is considered to be in serious or critical condition should have a rapid full-body scan or rapid head-to-toe examination performed -whereas patients suffering from a nonsignificant MOI should receive an assessment focused on the chief complaint

For what patients should a rapid full-body or rapid head-to-toe examination be performed?

Newton's second law -acceleration = change in velocity over time (a=v/t) -it is not that "speed kills" but rather the change in velocity with respect to time generates the forces that cause injury (e.g. if your car is traveling at 30 mph and you stop the breaks smoothly, you slow from 30 to 0 mph in 3 seconds. However, if your car going 30 mph hits a tree, you still slow from 30 to 0 mph (same change in velocity) but instead you slow to 0 mph in 0.01 seconds (shorter time). This generates a much larger force acting on your body *airbags have dual action --> they distribute the force of impact over a greater area and they also increase the duration of impact (increase deceleration time), leading to less severe injuries

Force = Mass x Acceleration (F=ma)

Work (W = Fxd) -forces that bend, pull, or compress tissues beyond their inherent limits result in the work that causes injury

Force acting over a distance (the product of forces x distance)

1. Head-on collision 2. Angular collision --> rider often sustains crushing injuries to lower extremity between object and motorcycle. This usually results in severe open and comminuted (multiple bone fragments/splinters) lower extremity injuries with severe neurovascular compromise, often requiring surgical amputation 3. Ejection --> severe abrasion injuries (road rash) down to bone can occur with drag. An unpredictable combination of blunt injuries can occur from secondary collisions 4. Controlled crash --> rider uses a technique called "laying the bike down" to separate the rider from the body of the motorcycle and object to be hit, thereby achieving a controlled crash. As a collision approaches, the motorcycle is turned flat and tipped sideways at 90 degrees to the direction of travel so that one leg is dropped to the grass or asphalt. If properly protected with leather or synthetic abrasion-resistant gear, injuries should be limited to those sustained by rolling over the pavement and any secondary collision that may occur

Four types of motorcycle impacts

1. Ensure your safety, your partner's, and your patient's 2. Determine need for additional personnel/equipment, evaluate kinematics of the MOI, and identify and appropriately manage life threats 3. Assess and manage airway, including ventilatory support and high-flow oxygen while maintaining cervical spine stabilization 4. Ensure that basic shock therapy is completed (such as controlling hemorrhages and stopping arterial bleeding) -apply tourniquet if direct pressure doesn't control bleeding 5. Once threats to ABCs are corrected, place patient on a long backboard and transport immediately -use rapid extrication technique if patient is entrapped **on scene time should be limited to 10 minutes ("platinum 10 minutes") 6. During transport, obtain SAMPLE history and complete a secondary assessment -for critically injured patients, consider ALS intercept and/or air medical transportation

Golden principles of prehospital trauma care (esp. for multisystem trauma)

Classified into Levels I through IV with Level I having the most resources, followed by Levels II, III, and IV, respectively -categorized as either adult trauma centers or pediatric trauma centers, but not necessarily both --> do not make the mistake of transporting a pediatric patient to an adult trauma center when a pediatric trauma center is available

How are trauma centers classified?

1. Assess eye opening spontaneous = 4 to voice = 3 to pain = 2 None = 1 2. Assess verbal response oriented = 5 confused = 4 inappropriate words = 3 incomprehensible words = 2 None = 1 3. Assess motor response obeys command = 6 localizes pain = 5 withdraws (pain) = 4 flexion (pain) = 3 extension (pain) = 2 None = 1 4. Calculate GCS score by totaling each assigned numerical value for eye opening, verbal response, and motor response (out of 15 possible points) Highest score possible = 15, lowest = 3

How do you calculate GCS score?

1. Calculate GCS score score of 13-15 =4 score of 9-12 = 3 score of 6-8 = 2 score of 4-5 = 1 score of 3 = 0 2. Calculate systolic BP > 89 mmHg = 4 76-89 mmHg = 3 50-75 mmHg = 2 1-49 mmHg = 1 0 mmHg = 0 3. Calculate RR 10-29 breaths/min = 4 >29 breaths/min = 3 6-9 breaths/min = 2 1-5 breaths/min = 1 0 breaths/min = 0 4. Calculate RTS by adding up each assigned numerical value for GCS, systolic BP, and RR (out of 12 possible points) Highest score possible = 12 and lowest = 0

How do you calculate RTS?

paint a picture of the scene (describe scene) -if possible, maybe take polaroid or digital pictures of the crash scene to provide information to physicians at trauma center

In written and verbal communication during history portion, make sure to ______.

multisystem trauma

Injury to more than one body system (trauma that affects more than one body system)

-blunt trauma to chest can fracture ribs or sternum, which can interfere with body's ability to obtain sufficient amounts of oxygen for the cells -bruising to heart can cause an irregular heartbeat -large vessels of heart may be torn inside chest, causing massive unseen fatal bleeding -lung bruising interfere with normal oxygen exchange in the body -chest injury can cause air to collect between lung tissue and chest wall (pneumothorax) --> if left untreated and unrecognized, lung tissue becomes squeezed under pressure until heart is also squeezed and can no longer pump blood (this = tension pneumothorax) -some patients develop bleeding between lung tissue and chest wall (hemothorax), interferes with breathing -penetration or perforation to chest can cause an open chest wound, allowing air to enter chest cavity and leading to shock and/or death *assessment should be performed every 5 minutes and you should look for DCAP-BTLS, lung sounds, and chest rise and fall -it should be noted that some patients will not immediately have obvious signs and symptoms such as absent breath sounds or respiratory difficulty

Patient assessment for injuries to the chest in trauma patients

-Brain itself may tear or become bruised, causing bleeding -Blood vessels around the brain may also tear and produce bleeding -Bleeding or swelling inside the skull from a brain injury is often life-threatening -Your assessment must include conducting frequent neurologic examinations -keep in mind that some patients will not have obvious signs/symptoms (such as change in pupillary size and reactivity) until minutes-hours after injury has occurred

Patient assessment for injuries to the head in trauma patients

-trachea may become torn or swell after injury to neck or deviate after an injury to the lungs --> these may cause an airway problem, therefore your assessment should include frequent physical exam looking for DCAP-BTLS in the neck region (also assessing for jugular vein distention and tracheal deviation) -swelling of neck may prevent blood flow to the brain and cause injury to CNS (even though brain itself was not directly affected by the initial force that caused neck injury) -if penetrating injury to neck results in an open wound, patient may have significant bleeding or air may be drawn into circulatory system resulting in an air embolism that may lead to cardiac arrest if the air enters the heart -a crushing injury to upper part of neck may cause cartilages of upper airway and larynx to fracture, leading to leaking of air into soft tissue of neck (when air is trapped in subcutaneous tissue, it produces a crackling sound called subcutaneous crepitation) **air in circulation or an airway cartilage fracture can cause rapid death

Patient assessment for injuries to the neck and throat in trauma patients

Petechiae

Pinpoint hemorrhages that show up on the skin

Pro = improved body armor has increased the number of survivors of blast injuries from shrapnel wounds to the torso (although the number of severe orthopaedic and extremity injuries have increased) Con = body armor "catches" more energy from the blast wave, possibly resulting in the victim being thrown backward, thus increasing the potential for spine and spinal cord injury *civilian blast injuries in industrial and mining settings are typically characterized by blast injuries and burns, whereas terrorist bombs often contain shrapnel

Pros and cons to body armor for blast injuries

Pulmonary blast injuries -patient may complain of tightness or pain the chest and may cough up blood and have tachypnea or other signs of respiratory distress -subcutaneous emphysema (crackling under the skin) can be detected over the chest through palpation, which indicates air in the thorax -Pneumothorax is a common injury and may require emergency decompression -Pulmonary edema may ensue rapidly *one of the most concerning pulmonary blast injuries = arterial air embolism (air bubbles in the arterial blood vessels) Treatment for blast victim with suspected lung injury = administer oxygen (even just the presence of a ruptured eardrum), although avoid giving oxygen under positive pressure. Also be cautious with IV fluids, which may result in pulmonary edema

Pulmonary trauma (consisting of contusions and hemorrhages) that results from short-range exposure to the detonation of explosives Possible signs/injuries? Treatment?

drag -slows the projectile, decreasing the depth of penetration and thus reducing damage to the tissues

Resistance that slows a projectile, such as air

Solid organs = liver, spleen, pancreas, and kidneys Hollow organs = stomach, large and small intestines, urinary bladder

Solid organs vs. hollow organs

1. First, estimate the speed of the vehicle that struck the patient 2. Determine whether the patient was thrown through the air and at what distance or whether patient was struck and pulled under the vehicle -Evaluate the vehicle that struck the patient for structural damage that may indicate contact points with the patient and alert you to potential injuries 3. Call for ALS backup for any patients who have or are thought to have sustained a significant MOI

Steps to understanding a car vs. pedestrian accident

1. GCS score of less than 14 when assoc. with trauma 2. Respiratory rate of less than 10 or more than 29 breaths/min (less than 20 breaths/min in infant younger than 1 year) when assoc. with trauma 3. Penetrating wounds (other than GSW) to head, neck, torso, and extremities proximal to elbow and knee 4. Flail chest 5. Combination of trauma with burns 6. Two or more proximal long bone fractures 7. Pelvic fractures 8. Limb paralysis and/or spinal cord injury 9. Amputation proximal to the wrist and/or ankle MOI indicators: 1. High-speed vehicle crash -initial speed of greater than 40 mph -major vehicle deformity -intrusions into the passenger compartment 2. Ejection from vehicle 3. Death in same passenger compartment 4. Extrication time of greater than 20 minutes 5. Falls of greater than 20' or significant falls in children or elderly 6. Vehicle rollover 7. Car vs. pedestrian or car vs. bicycle impact of greater than 5 mph 8. ATV or motorcycle crash of greater than 20 mph or separation of rider from ATV or motorcycle Pediatric indicators: 1. Falls of greater than 10' without loss of consciousness 2. Falls of less than 10' with loss of consciousness 3. Medium- to high-speed vehicle collision (>25mph) Consider Level II classification with the following preexisting conditions: 1. Age younger than 5 or older than 55 years 2. Cardiac disease, respiratory disease 3. Type I diabetes mellitus, cirrhosis of liver, morbid obesity 4. Pregnancy 5. Immunosuppressed patients 6. Patients with a bleeding disorder or on anticoagulants

What are some of the American College of Surgeons Recommendations for a Level II Patient?

1. The collision of the car against another car, a tree, or some other object 2. The collision of the passenger against the interior of the car 3. The collision of the passenger's internal organs against the solid structures of the body --> these injuries may not be as obvious as external injuries but they are often the most life-threatening e.g. as passenger's head hits windshield, brain continues to move forward until it strikes inside of skull, resulting in a compression injury (or bruising/contusions) to the anterior portion of the brain and stretching (or tearing) of the posterior portion of the brain = example of a coup-contrecoup brain injury

What are the 3 collisions in a typical motor vehicle crash?

1. Blunt trauma 2. Penetrating trauma -with low-energy penetrating trauma, such as a stab wound, injuries are caused by the sharp edges of the object moving through the body and are therefore close to the object's path -first determine the number of penetrating injuries and then combine that information with the important things you already know about the potential pathway of penetrating projectiles to form an index of suspicion about unseen life-threatening injuries -in medium- and high-velocity penetrating trauma, the path of the projectile (usually a bullet) may not be as easy to predict because bullet may flatten out, tumble, or even ricochet. Fragmentation, esp. frangible bullets that are designed to disintegrate on impact, will increase likelihood of injury to multiple organs/vessels -full metal jacket bullets cause LESS damage than fragmented rounds because of their tendency to pass through the body's tissues *it is important for you to try and determine the type of weapon that was used and this information should be relayed to medical control (type of gun such as shotgun or pistol, caliber, etc.) -medium-velocity injuries may be caused by handguns and some rifles -high-energy injuries may be caused by a military weapon

What are the first and second leading causes of trauma death in the U.S., respectively?

Neurologic injuries and head trauma -subarachnoid (beneath arachnoid layer covering brain) and subdural (beneath outermost covering of brain) hematomas are often seen -permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism -instant but transient unconsciousness (with or without retrograde amnesia) may be initiated by head trauma or cardiovascular problems *bradycardia and hypotension are common after an intense pressure wave from an explosion -this is a vagal-nerve mediated form of cardiogenic shock without compensatory vasoconstriction (e.g. vasovagal syncope -- fainting due to overreaction to trigger) -extremity injuries, including traumatic amputations, are common -other injuries are often associated with tertiary blasts --> patients with traumatic amputation by postblast wind are likely to sustain fatal injuries secondary to the blast

What are the most common causes of death from blast injuries? What are other common injuries due to blast injuries/explosions?

1. Potential energy 2. Kinetic energy 3. Work *remember that energy can be neither created nor destroyed, but can only be converted or transformed

What are the three concepts of energy typically associated with injury (not including thermal energy, which causes burns)?

1. dangerous MOI 2. decreased level of consciousness 3. any threats to airway, breathing, or circulation -patients who are very young or old or have chronic illnesses should also be considered high risk ^^for these patients, you should limit on-scene time to the minimum amount necessary to correct life-threatening injuries and package patient

What criteria indicates a critically injured patient for which scene time should be limited to less than 10 minutes?

-restrain passengers in a vehicle -prevent a second collision inside the motor vehicle -may decrease the severity of the third collision (passenger's organs against chest wall) -provide the final capture point of the passengers -decrease the severity of deceleration injuries by allowing seatbelts to be more compliant and by gently cushioning the occupant and providing even more "ride down" as the body slows or decelerates -effectively decrease injury to chest, face, and head

What do seatbelts do? What do airbags do?

traumatic injuries/traumatic emergencies -occur as a result of physical forces applied to the body whereas medical emergencies occur when the patient has an illness or condition that is not caused by an outside force -traumatic injury occurs when the body's tissues are exposed to energy levels beyond their tolerance (e.g. ruptured spleen)

What is the leading cause of death in the U.S. among people younger than age 40?

All children who are shorter than 4'9" should ride in the rear seat, or in the case of a pickup truck or other single-seated vehicle, the air bag should be turned off

What is the rule for children riding in the front seat of vehicles? (in regard to air bag)

organs that contain air, such as the middle ear, lung, GI tract *ear = organ system that is most sensitive to blast injuries -the junction between tissues of different densities and exposed areas such as head and neck tissues are prone to injury as well -solid organs are relatively protected from shock wave injury but may be injured by secondary missiles or a hurled body -whereas hollow organs may be injured by the same mechanisms that damage lung tissue --> dominant form of pathology = petechiae to large hematomas; perforation or rupture of the bowel and colon is a risk

What organs are most susceptible to pressure changes?

After the first 60 minutes, the body has increasing difficulty in compensating for shock and traumatic injuries -this = "Golden Period"

Why is it so important to spend as little time as possible on scene for trauma patients? (Limit on-scene time to 10 minutes or less, the "platinum 10 minutes")

index of suspicion

Your awareness and concern for potentially serious underlying and unseen injuries

Falls -injury potential is related to the height from which the patient fell (also account for the type of surface struck, and the part of the body that hit first followed by the path of energy displacement) **A fall from more than 15' or 3x the patient's height is considered significant (in a child, greater than 10' without loss of consciousness or less than 10' with loss of consciousness are considered significant)--> you should suspect internal injuries in patients who have fallen from a significant height -unless the fall is from a significant height, they are not considered a true high-energy trauma (e.g. elderly patient with osteoporosis sustains a fracture while in standing position and falls as a result is NOT a true trauma) -always consider syncope (fainting) or other underlying medical causes of the fall -patients who fall and land on their feet may have less severe internal injuries because their legs may have absorbed much of the energy of the fall. However, the energy is often also transmitted to the spine, producing a spinal injury in addition to injuries to the legs and pelvis

____ are common MOIs for blunt trauma and some texts consider them to be the most common form of trauma. What is considered significant?