Ch. 24: Trauma Overview
13. List the Association of Air Medical Services criteria for the appropriate use of emergency air medical services. (p 867)
Consider air transport in these circumstances: -There is an extended period required to access or extricate a remote or trapped patient, which depletes the time window to get the patient to the trauma center by ground. -Distance to the trauma center is greater than 20 to 25 miles. -The patient needs medical care and stabilization at the ALS level, and there is no ALS-level ground ambulance service available within a reasonable time frame. -Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center within the ideal time frame for best clinical outcome. -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 for initial evaluation and stabilization, rather than bypassing those facilities and going directly to a trauma center.
6. Discuss the effects of high-, medium-, and low-velocity penetrating trauma on the body and how an understanding of each type helps EMTs form an index of suspicion about unseen life-threatening injuries. (pp 859-861)
Low-energy penetrating trauma may be caused accidentally by impalement or intentionally by a knife, ice pick, or other weapon. In medium- and high-velocity penetrating trauma, the path of the projectile may not be as easy to predict. The bullet's speed is another factor in the resulting injury pattern. Cavitation, which results from the rapid changes in tissue and fluid pressure that occur with the passage of the projectile, can result in serious injury to internal organs distant to the actual path of the bullet.
12. Explain trauma patient management in relation to scene time and transport selection. (p 867)
Scene time Because survival of critically injured trauma patients is time dependent, limit on-scene time to the minimum amount necessary to correct life-threatening injuries and package the patient. Optimally, on-scene time for critically injured patients should be less than 10 minutes—the platinum 10. Modes of transport ultimately come in one of two categories: ground or air. Ground transportation EMS units are generally staffed by EMTs and paramedics. Air transportation EMS units or critical care transport units are often staffed by critical care transport professionals such as critical care nurses and paramedics.
15. Explain the American College of Surgeon's Committee on Trauma and the Centers for Disease Control and Prevention field triage decision scheme as it relates to making an appropriate destination selection for a trauma patient. (pp 869-870)
The Scheme is intended for individual patients and not mass casualty incidents. Rearrange the steps of the decision scheme for field triage of injured patients into the correct order: 1. measure vital signs and LOC 2. Assess anatomy of injury 3. Assess MOI and evidence of high-energy impact 4. Transport According to the American College of Surgeons Committee on Trauma (ACS-COT), an adult trauma patient should be transported to the highest level of trauma center if he or she: has a GCS score of less than or equal to 13 with a mechanism attributed to trauma.
1. Define the terms mechanism of injury (MOI), blunt trauma, and penetrating trauma. (pp 847, 850)
The mechanism of injury (MOI) is the way in which traumatic injuries occur; it describes the forces (or energy transmission) acting on the body that cause injury.
8. Describe multisystem trauma and the special considerations that are required for patients who fit this category. (p 864)
The tympanic membrane evolved to detect minor changes in pressure and will rupture at pressures of 5 to 7 pounds per square inch above atmospheric pressure. Pulmonary blast injuries are pulmonary trauma, consisting of contusions and hemorrhages, that result from short-range exposure to the detonation of explosives. One of the most concerning pulmonary blast injuries is arterial air embolism, which occurs on alveolar disruption with subsequent air embolization into the pulmonary vasculature. __________________________ You must recognize patients who fit into the classification of multisystem trauma and provide rapid treatment and transportation. Alert medical control as to the nature of the patient's injuries so that the trauma center is prepared prior to your arrival. Multisystem-trauma patients have a high level of morbidity and mortality.
9. Explain the major components of trauma patient assessment; include considerations related to whether the method of injury was significant or nonsignificant. (p 865)
When you are caring for a patient with a significant MOI and the pt is considered to be in serious or critical condition, you should rapidly perform a physical exam. With a pt who has experienced a nonsignificant MOI, focus on the chief complaint while assessing the pt as a whole.
basic triage order
1. measure vital signs and LOC 2. assess anatomy of injury 3. assess MOI and evidence of high-energy impact 4. transport
5. Discuss the three specific factors to consider during assessment of a patient who has been injured in a fall, plus additional considerations for pediatric and geriatric patients. (pp 858-859)
1. the height of the fall 2. the type of surface struck 3. the part of the body that hit first, followed by the path of energy displacement. -When your patient is a child, the following constitutes a significant MOI: 1. falls of greater than 10 feet (or 2-3 times the kid's height) 2. medium-to-high-speed vehicle crash -many older patients are seriously injured from falls. Completely assess older patients for all possible injuries, even from low-impact falls
Following blunt force trauma to the anterior chest, a man presents with difficulty breathing, distended jugular veins, absent breath sounds over the left side of the chest, and hypotension. Which of the following BEST describes the pathophysiology of this patient's injury? A) Increased pressure in the pleural space is compressing the great vessels B) Blood is filling the pleural space and is collapsing the lung on the left side C) Blood is filling the pericardial sac and is restricting cardiac relaxation D) The aorta has been injured and blood is rapidly filling the thoracic cavity
A) Increased pressure in the pleural space is compressing the great vessels The patient is experiencing a tension pneumothorax. This type of injury occurs when air fills the pleural space and progressively collapses the lung. In the process, the vena cavae are compressed and blood return to the heart is reduced; clinically, this manifests as jugular vein distention because blood is backing up into the systemic venous system. If blood return to the heart is reduced, the amount of blood that leaves the heart will also be reduced; as a result, cardiac output falls and the patient becomes hypotensive. Breath sounds are markedly decreased or absent on the affected side of the chest because the lung is being collapsed. In a hemothorax, blood fills the pleural space instead of air. Breath sounds are decreased or absent on the affected side; however, because the patient is losing blood volume into the chest, the jugular veins would be collapsed, not distended as they are with a tension pneumothorax. Pericardial tamponade also causes jugular vein distention; however, the patient's breath sounds are equal bilaterally (unless a pneumothorax is also present). Aortic injury would be expected to cause collapsed jugular veins; like the hemothorax, the patient is losing blood volume into the chest cavity. By itself, aortic injury does not cause unequal breath sounds.
A hiker fell 25 feet from a ledge. There is obvious deformity to his thoracic spine and he has a large laceration on his forehead. His BP is 60/40 mm Hg, pulse is 50 beats/min, and respirations are 26 breaths/min. His face and chest are pale and cool, but his abdomen and lower extremities are pink and warm. Which of the following BEST describes the pathophysiology of these findings? A) Loss of nervous system control over the systemic vasculature B) Severe bleeding into the thoracic cavity from a ruptured aorta C) Systemic vasoconstriction due to nervous system hyperactivity D) Increased intracranial pressure due to bleeding within the brain
A) Loss of nervous system control over the systemic vasculature On the basis of the mechanism of injury and assessment findings, the EMT should suspect that the patient is experiencing neurogenic shock. Neurogenic shock occurs when an injury or condition (in this case, a spinal injury) interrupts the nervous system's control over the diameter of the blood vessels. As a result, the blood vessels dilate and the patient's blood pressure falls. The nervous system releases epinephrine and norepinephrine when a patient is in shock, which results in tachycardia and vasoconstriction. However, if the nervous sytem is impaired, as with neurogenic shock, these catecholamines do not get released. Therefore, the patient with neurogenic shock is bradycardic, not tachycardic as you would expect with other types of shock that do not involve nervous system impairment (ie, hypovolemic, septic, anaphylactic). The blood vessels above the level of the injury are still able to constrict, so the skin is pale and cool; however, the blood vessels below the level of the injury are dilated, so the skin is pink and warm. If this patient had a head injury with increased intracranial pressure, you would expect him to be hypertensive, not hypotensive
While assessing a patient who was ejected from his truck, the EMT notices that his chest collapses and his abdomen rises during inhalation. What should the EMT suspect? A) Spinal cord injury B) Fractured sternum C) Ruptured diaphragm D) Intra-abdominal bleeding
A) Spinal cord injury The patient is exhibiting diaphragmatic breathing, which explains why his abdomen moves but his chest does not. This indicates a spinal cord injury below the C5 level. The phrenic nerves, which innervate the diaphragm, arise from C3-C5. However, the intercostal nerves, which arise from below the C5 level, have been interrupted; this would explain the absence of chest wall movement. A fractured sternum, depending on the severity of the fracture, would be expected to cause the chest to collapse during inhalation and bulge during exhalation, similar to a flail chest. A ruptured diaphragm would be expected to present with a scaphoid (concave) abdomen and decreased abdominal movement; in some cases of diaphragmatic rupture, bowel sounds may be auscultated over the lung fields (usually the left side). Intra-abdominal bleeding would present with a rigid, distended abdomen; it would not explain this patient's abnormal chest and abdominal movement.
What type of injury occurs when a joint is twisted or stretched beyond its normal range of motion, resulting in swelling but no deformity? A) Sprain B) Strain C) Fracture D) Dislocation
A) Sprain A sprain occurs when a joint is twisted or stretched beyond its normal range of motion. As a result, the supporting capsule and ligaments are stretched or torn, resulting in injury to the ligaments, articular cartilage, synovial membrane, and tendons crossing the joint. Signs of a sprain include pain, swelling, ecchymosis, and increased motion of the joint. While a sprain is considered to be a partial dislocation, it is not associated with deformity. A dislocation is a disruption of a joint in which the bond ends are no longer in contact. The supporting ligaments are often torn, usually completely, allowing the bone ends to separate from each other; this results in deformity of the joint. A strain (pulled muscle) is a stretching or tearing of the muscle and/or tendon, causing pain, swelling, and bruising of the soft tissues in the area; deformity does not occur with a strain. A fracture is a break in the continuity of the bone. Non-displaced fractures may not be associated with deformity, whereas displaced fractures typically are. It takes radiographic evaluation to definitely determine the type of musculoskeletal injury a patient has; therefore, the EMT should treat any musculoskeletal injury as though an underlying fracture is present.
Assessment of a patient with multisystem trauma reveals decerebrate posturing, rapid irregular breathing, and bradycardia. These clinical signs indicate injury to the: A) brainstem. B) myocardium. C) temporal lobe. D) thoracic spine.
A) brainstem. Posturing, either decorticate (flexor) or decerebrate (extensor), is an ominous sign in a patient with a head injury because it indicates significant intracranial pressure. Posturing in conjunction with an abnormal breathing pattern (ie, central neurogenic hyperventilation, Cheyne-Stokes breathing, ataxic breathing) indicates injury to the brainstem. Cushing's triad (hypertension, bradycardia, abnormal breathing) is also representative of significant intracranial pressure. Temporal lobe injuries often manifest with loss of fine motor control. In order to posture, the spinal cord must be able to receive signals from the brain; therefore, a thoracic spine injury is unlikely. Myocardial injury would be more likely to present with signs of shock and possibly cardiac dysrhythmias
A man was stabbed in the right side of the chest, lateral to the nipple. He is tachypneic, tachycardic, and diaphoretic. His jugular veins are collapsed and breath sounds are difficult to hear on the right side. You should suspect a: A) hemothorax. B) ruptured spleen. C) liver laceration. D) pneumothorax.
A) hemothorax. Based on the injury location and the patient's clinical presentation, you should suspect a hemothorax. In addition to the lung, there is a TON of vasculature in the thoracic cavity that can easily be injured by a penetrating injury. Because the patient is losing blood, one would expect flattened or collapsed jugular veins and profound shock. In addition, because blood is filling the right hemithorax, breath sounds may be weak or absent on the affected side. Although a liver injury cannot be completely ruled out, the injury is above where the liver is located anatomically. If a pneumothorax is present, it is likely in conjunction with the hemothorax (hemopneumothorax). The spleen is located in the upper left quadrant; this patient's injury is on the right side.
A trauma patient has a BP of 172/94 mm Hg, a pulse rate of 45 beats/min, and a respiratory rate of 6 breaths/min. Which of the following conditions would MOST likely produce this vital sign pattern? A) Severe internal hemorrhage B) Increased intracranial pressure C) Increased intrathoracic pressure D) Bleeding into the pericardial sac
B) Increased intracranial pressure The classic vital sign pattern of Cushing's Triad (hypertension, bradycardia, abnormal breathing) is present. This vital sign pattern is seen in patients with increased intracranial pressure (ICP) secondary to a head injury; it can also be observed in patients who have experienced a severe hemorrhagic stroke. With a head injury, the blood pressure increases in an effort to push more blood to the brain; bradycardia occurs as a reflex response to the increased in blood pressure. Excessive ICP can produce a variety of abnormal breathing patterns, from slow and irregular to rapid with no identifiable pattern. Severe internal hemorrhage would be expected to present with signs of shock (ie, hypotension, tachycardia, tachypnea), not hypertension, bradycardia, and bradypnea. Likewise, an increase in intrathoracic pressure can also produce symptoms similar to shock; as intrathoracic pressure increases, venous return to the right side of the heart decreases. This can cause decreased cardiac output and hypotension. Bleeding into the pericardial sac (ie, pericardial tamponade) causes hypotension with a narrowing pulse pressure and tachycardia
A patient is unresponsive with snoring respirations. His arm is amputated just above the elbow and is bleeding heavily. The EMT should: A) open the patient's airway. B) apply a proximal tourniquet. C) administer high-flow oxygen. D) ventilate with a bag-valve mask device.
B) apply a proximal tourniquet. Major hemorrhage kills patients faster than a compromised airway, so in this case, bleeding control has the highest priority. The EMT should apply a proximal tourniquet and stop the bleeding immediately. Attention can then turn to the patient's airway and breathing status. As with any patient, treatment priorities must focus on injuries or conditions that will be the MOST immediately fatal.
A 70-year-old female fell and struck her head two days ago, but did not seek medical attention. Today, she is confused, is vomiting, and has slurred speech. The EMT should suspect a/an: A) epidural hematoma. B) subdural hematoma. C) intracerebral hematoma. D) acute ischemic stroke.
B) subdural hematoma. This case is classic for a subdural hematoma. A subdural hematoma occurs when bleeding occurs between the dura mater (the outer meningeal layer) and the surface of the brain; it is typically caused by venous bleeding. As such, subdural hematomas often do not present with symptoms until several hours, or even days, have past since a head injury. By contrast, epidural hematoma, bleeding between the skull and dura mater, is usually caused by arterial bleeding; patients with this type of injury usually present with symptoms immediately following the injury. Intracerebral hemorrhage, bleeding within the brain itself, would also be expected to produce immediate symptoms. While acute ischemic stroke could also explain this patient's symptoms, the fact that she recently experienced a head injury makes the diagnosis of a subdural hematoma more likely.
An unrestrained driver was crushed in between the steering wheel and his seat when his truck collided with a tree. Assessment reveals cyanosis to his neck and face, jugular venous distention, and bleeding into the sclera of his eyes. The EMT should suspect: A) aortic dissection. B) traumatic asphyxia. C) massive hemothorax. D) pericardial tamponade.
B) traumatic asphyxia. Rather classic signs of traumatic asphyxia are present in this patient. Traumatic asphyxia occurs when a sudden compressive force is applied to the chest, which results in a sudden massive amount of blood being shunted to the neck, face, and head. Signs include jugular venous distention (JVD); cyanosis to the neck, face, and head; bulging eyes; and scleral hemorrhage (blood in the whites of the eyes). Traumatic asphyxia has a high mortality rate, mainly because of the massive injuries that occur within the thoracic cavity. Aortic dissection and massive hemothorax do not present with JVD because both of these injuries are associated with massive blood loss; one would expect collapsed jugular veins. Pericardial tamponade can cause JVD; however, cyanosis to the upper body and scleral hemorrhage are not observed.
3. Provide examples of the MOI that would cause blunt and penetrating trauma to occur. (pp 850-861)
Examples: Injury to more than one body system (multisystem trauma) Falls from heights Motor vehicle and motorcycle crashes Car versus pedestrian (or bicycle or motorcycle) Gunshot wounds Stabbings Blunt trauma is the result of force to the body that causes injury without anything penetrating the soft tissues or internal organs and cavities. Penetrating trauma results in injury by objects that pierce and penetrate the surface of the body and injure the underlying soft tissues, internal organs, and body cavities. Motor vehicle crashes typically consist of a series of three collisions: The collision of the car against another car, a tree, or some other object The collision of the passenger against the interior of the car The collision of the passenger's internal organs against the solid structures of the body
4. Describe the five types of motor vehicle crashes, the injury patterns associated with each one, and how each relates to the index of suspicion of life-threatening injuries. (pp 853-856)
Frontal crashes The passenger's face often hits the steering wheel. The chest and/or abdomen may also hit the steering wheel. The passenger may launch forward and up, hitting the windshield and/or the roof header in the area of the visors. Rear-end crashes Rear-end impacts are known to cause whiplash injuries, particularly when the passenger's head and/or neck is not restrained by an appropriately placed headrest. The patient may sustain an acceleration injury to the brain (the third collision of the brain within the skull). Lateral crashes When a vehicle is struck from the side, it is typically struck above its center of gravity and begins to rock away from the side of the impact. This results in the passenger sustaining a lateral whiplash injury. According to the Journal of Safety Research, lateral crashes cause approximately 25% of all severe injuries to the aorta and approximately 30% of all fatalities that occur in motor vehicle crashes. Rollover crashes Vehicles with a high center of gravity are more prone to rollovers. The most common life-threatening event in a rollover is ejection or partial ejection of the passenger from the vehicle. Rotational crashes Rotational crashes (spins) are conceptually similar to rollovers. The rotation of the vehicle as it spins provides opportunities for the vehicle to strike objects such as utility poles.
10. Discuss the special assessment considerations related to a trauma patient who has injuries in each of the following areas: head, neck and throat, chest, and abdomen. (pp 865-866)
Head Bleeding or swelling inside the skull from brain injury is often life threatening; therefore, your assessment must include conducting frequent neurologic examinations. Neck and throat These types of injuries may result in an airway problem that could quickly become a serious life threat because it interferes with the patient's ability to breathe; therefore, your assessment must include: Frequent physical examination looking for DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, Swelling) in the neck region Looking for jugular venous (vein) distention and tracheal deviation (late sign of injury) If the patient has a penetrating injury to the neck, there may be significant bleeding, or air may be drawn into the circulatory system. Air entering the veins may result in air embolism, which may lead to cardiac arrest if the air enters the heart. Chest Broken ribs can interfere with the ability of the chest wall to expand normally during breathing. Bruising may occur to the heart and cause an irregular heartbeat. If air accumulates between the lung tissue and the chest wall, the lung tissue compresses and becomes a pneumothorax. Abdomen Solid organs may tear, lacerate, or fracture, causing serious bleeding into the abdomen that can quickly cause death. Be alert for a trauma patient who reports abdominal pain—it may be a symptom of abdominal bleeding. Hollow organs may rupture and leak toxic chemicals used for digestion into the abdomen. Maintain a high index of suspicion when the MOI suggests injury to the abdominal region.
7. Discuss primary, secondary, tertiary, and miscellaneous blast injuries and the anticipated damage each one will cause to the body. (pp 862-864)
Primary blast injuries These injuries are due entirely to the blast itself—that is, damage to the body is caused by the pressure wave generated by the explosion. When the victim is close to the blast, the blast wave may cause disruption of major blood vessels and rupture of eardrums and major organs, including the lungs. Secondary blast injuries Damage to the body results from being struck by flying debris, such as shrapnel from the device or from glass or splinters set in motion by the explosion. Tertiary blast injuries These injuries occur when the patient is hurled by the force of the explosion against a stationary object. This physical displacement of the body is also referred to as ground shock when the body impacts the ground. Quaternary blast injuries This category of miscellaneous injuries includes: Burns from hot gases or fires started by the blast Respiratory injury from inhaling toxic gases Suffocation Poisoning Medical emergencies incurred as a result of the explosion Crush injuries from the collapse of buildings Contamination of wounds from environmental, chemical, or toxic substances Mental health emergencies
2. Explain the relationship of the MOI to potential energy, kinetic energy, and work. (pp 847-849)
Three concepts of energy are typically associated with injury (not including thermal energy, which causes burns): Potential energy Kinetic energy The energy of work The kinetic energy of a speeding vehicle is converted into the work of stopping the vehicle, usually by crushing the car's exterior
14. List the American College of Surgeons' Committee on Trauma classification of trauma centers. (pp 867-868)
Trauma centers are classified into Levels I through IV, with Level I having the most resources. A Level I facility is a regional resource center. Generally serves large cities or heavily populated areas Must be capable of providing every aspect of trauma care from prevention through rehabilitation A Level II facility is typically located in less-populated areas. Level II centers are expected to provide initial definitive care, regardless of injury severity. These facilities can be academic institutions or a public/private community facility. A Level II trauma center may not be able to provide the same comprehensive care as a Level I trauma center. Level III facilities serve communities that do not have access to Level I or II facilities. Provide assessment, resuscitation, emergency care, and stabilization Level IV facilities are typically found in remote outlying areas where no higher level of care is available. These facilities provide advanced trauma life support prior to transfer to a higher-level trauma center.
