Chapter 24 Trauma Overview

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.

Penetrating Trauma

Low-energy penetrating trauma may be caused accidentally by impalement or intentionally by a knife, ice pick, or other weapon. It may be difficult to determine entrance and exit wounds from projectiles in a prehospital setting. With low-energy penetrations, injuries are caused by the sharp edges of the object moving through the body. Try to determine the length of the penetrating object. In medium- and high-velocity penetrating trauma, the path of the projectile may not be as easy to predict. The path the projectile takes is referred to as a trajectory. Fragmentation, especially frangible bullets, will increase damage as multiple fragments increase the likelihood of multiple organ/vessel injury. The bullet's speed is another factor in the resulting injury pattern.

Rearrange the steps of the decision scheme for field triage of injured patients into the correct order.

Measure vital signs and LOC Correct. This is the correct order. Assess anatomy of injury Correct. This is the correct order. Assess MOI and evidence of high-energy impact Correct. This is the correct order. Transport Correct. This is the correct order.

Trauma centers are categorized as either adult trauma centers or pediatric trauma centers, but not necessarily both.

Pediatric trauma centers are not as common as adult trauma centers. Transport a pediatric patient to a pediatric trauma center if there is one in your area.

Three concepts of energy are typically associated with injury (not including thermal energy, which causes burns):

Potential energy Kinetic energy The energy of work

People who are injured in explosions may be injured by any of four different mechanisms:

Primary blast injuries Secondary blast injuries Tertiary blast injuries Quaternary blast injuries

Level III facilities serve communities that do not have access to Level I or II facilities.

Provide assessment, resuscitation, emergency care, and stabilization A 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.

Blunt or Penetrating Trauma

Signs and Symptoms Noisy and lobred breathing Increased respiratory rate Swelling of the face/neck Altered gag reflex Decreased GCS<9 Decreased Spo2 Rapid weak pulase Decreasing/low blood pressure Index of Suspicion Significant bleeding or foreign bodies in the upper/lower airway causing obstruction Be alert for airway compromise

Any significant blunt force trauma, falls from a siginficant height, or penetrating trauma

Signs and Symptoms Severe back or neck pain; history of difficulty moving extremities, loss of sensation or tingling in extremities Decreased GCS Rapid, weak pulse or slow pulse Index of Suspicion Injury to the bones of the spinal column or to the spinal cord

Significant chest wall blunt trauma from Motor vehicle crashes; car-versus-pedestrian, and other crashes; penetrating trauma to the chest wall

Signs and Symptoms Significant chest pain Shortness of breath increased respiratory rate assymetric chest wall movt subcutaneous emphysema Decreased GCS low Spo2 presence of jugular vein distention rapid, weak pulse decreasing blood pressure, loss of peripheral pulses during inspiration narrowing pulse presures Index if Suspicion Cardiac or pulmonary contusion pneumothorax or hemothorax broken ribs

The organs of the abdomen and retroperitoneum (the space immediately behind the true abdomen) can be classified into two simple categories, solid and

Solid Liver Spleen Pancreas Kidneys 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. Be alert to vital signs that begin to worsen; this can be a sign of serious, unseen bleeding inside the abdominal region of the body. Hollow Stomach Large and small intestines Urinary bladder Hollow organs may rupture and leak toxic chemicals used for digestion into the abdomen. Occasionally, large blood vessels rupture or tear and cause serious unseen bleeding. Maintain a high index of suspicion when the MOI suggests injury to the abdominal region. This is best accomplished by reassessing the abdominal region using DCAP-BTLS.

Air bags

Some passengers may pass out before impact, and you may find them lying against the deployed air bag. Look for abrasions and/or traction-type injuries on the face, lower part of the neck, and chest. Use extreme caution when extricating a patient in a vehicle with an air bag that has not deployed.

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.

Temporary cavitation injury results from a stretching of the tissues that occurs with the pressure changes. Permanent cavitation injury results closer to the bullet path where the pressure fluctuations are greatest and remains after the projectile has passed through the tissue.

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

tympanic membrane

The eardrum; a thin, semitransparent membrane in the middle ear that transmits sound vibrations to the internal ear by means of auditory ossicles.

Take the following factors into account:

The height of the fall The type of surface struck The part of the body tha

Medical emergencies

include illnesses or conditions not caused by an outside force.

Work

is defined as force acting over a distance.

Potential energy

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

Blunt trauma

is the result of force to the body that causes injury without anything penetrating the soft tissues or internal organs and cavities.

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.

The index of suspicion

is your awareness and concern for potentially serious underlying and unseen injuries.

You are assessing a 10-year-old boy who fell out of a tree. Evaluation of the MOI would concentrate on which of the following?

Calculating the speed at which the child hit the ground The height from which the child fell The surface onto which the child fell The part of the body that struck the ground first Submit Correct. These are all factors in determining MOI in a fall.

Other types of crashes include:

Car versus pedestrian Car versus bicycle Car versus motorcycle

Car versus pedestrian

Car-versus-pedestrian crashes often result in patients who have graphic and apparent injuries, such as broken bones. Maintain a high index of suspicion for unseen injuries as well. A thorough evaluation of the MOI is critical. Estimate the speed of the vehicle that struck the patient. Determine whether the patient was ejected, what surface the patient landed on, and at what distance, or whether the patient was struck and pulled under the vehicle. Evaluate the vehicle that struck the patient for structural damage that might indicate contact points with the patient and alert you to potential injuries. Multisystem injuries are common after this type of event. Summon advanced life support (ALS) backup for any patients who have or are thought to have sustained a significant MOI.

Multiple air bags and side curtains are designed to protect the occupants of the vehicle, but can also alter injury patterns.

Certain areas of a vehicle's body may have air bags that will deploy when impacted. Pushing on or using extrication tools in those areas may cause air bags to unexpectedly deploy. This can happen even after the car battery has been disengaged.

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. Objects are propelled by the force of the blast wave and strike the victim, causing injury. These objects can travel great distances and be propelled at tremendous speeds, up to nearly 3,000 mph for conventional military explosives.

Trauma emergencies

occur as a result of physical forces applied to the body.

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.

Important factors in caring for a trauma patient include the following:

Scene time Type of transport

Understanding the MOI after a crash involves evaluation of the supplemental restraint system, including:

Seat belts Air bags

Any significant blunt force trauma from MVC or penetrating injury

Signs and Symptoms Blunt or penetrating trauma to neck,chest, abdomen, or groin Blows to the head sustained during MVCs, falls, or other accidents producing loss of consciousness, altered mental status, inability ot recall events, combativeness, or changes in speech pattern Difficulty moving extremities, headache with nausea and vomiting Decreased GCS Decreasing spo2 Rapid, weak pulse Decreasing blood pressure with slow puls Index of Suspicion Injuries in these regions may tear and cause damage to the large blood vessels located in these body areas, resulting in significant internal/external bleeding Be alert to the possibility of bruising to the brain and bleeding and bleeding in and around brain tissue, which may cause the development of excess pressure inside the skull around the brain

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 Because of the extensive requirements, most Level I facilities are university-based teaching hospitals.

Falls

A fall from more than 20 feet (6 m) is considered significant. Suspect internal injuries in a patient who has fallen from a significant height. Always consider syncope or other underlying medical causes of the fall.

projectiles

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

coup-contrecoup brain injury

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 original impact; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds.

trauma score

A score calculated from 1 to 16, with 16 being the best possible score. It relates to the likelihood of patient survival with the exception of a severe head injury. It takes into account the Glasgow Coma Scale (GCS) score, respiratory rate, respiratory expansion, systolic blood pressure, and capillary refill.

Revised Trauma Score (RTS)

A scoring system used for patients with head trauma.

Air bags

Air bags provide the final capture point of the passengers and decrease the severity of deceleration injuries. Air bags decrease injury to the chest, face, and head very effectively, but you should still suspect that other serious injuries to the extremities, resulting from the second collision, and to internal organs, resulting from the third collision, have occurred.

arterial air embolism

Air bubbles in the arterial blood vessels.

Penetrating Trauma (continued)

Air resistance, often referred to as drag, slows the projectile, decreasing the depth of penetration and energy of the projectile and thus reducing damage to the tissues. If the mass of the bullet is doubled, the energy that is available to cause injury is doubled. If the velocity of the bullet is doubled, the energy that is available to cause injury is quadrupled. For this reason, it is important for you to try to determine the type of weapon that was used. Medium-velocity injuries may be caused by handguns and some rifles. High-velocity injuries may be caused by a military weapon. The majority of civilian gunshot wound injuries in the United States are the result of low-velocity weapons.

Glasgow Coma Scale (GCS) score

An evaluation tool used to determine level of consciousness, 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.

Kinetic and Potential Energy

Because KE = m × v2, the energy that is available to cause injury doubles when an object's weight doubles and quadruples when its speed doubles. The speed of a bullet has a greater impact on producing injury than the mass (size) of the bullet. 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 to an appropriate facility to have any hope of survival.

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. The following criteria will help you identify a critically injured patient: Dangerous MOI Decreased level of consciousness Any threats to airway, breathing, or circulation Patients who present with these criteria, are very young or old, or have chronic illnesses should be considered to be high risk.

Golden Principles of Prehospital Trauma Care

Begin by assessing and managing the airway, including ventilatory support and high-flow oxygen, while maintaining cervical spine immobilization. Ensure that basic shock therapy, such as controlling hemorrhages, stopping arterial bleeding, and keeping the patient warm, is completed. If bleeding cannot be controlled rapidly by direct pressure, use a tourniquet. Once threats to the ABCs are corrected, protect the patient's cervical spine and rapidly proceed with spinal immobilization if indicated. If the patient is entrapped, consider the use of rapid extrication techniques. In most patients with multisystem trauma, definitive care requires surgical intervention; therefore, on-scene time should be limited to 10 minutes or less. (This is referred to as the platinum 10 minutes.) During transport, obtain a SAMPLE history and complete a secondary assessment. For critically injured patients, consider ALS intercept and/or air medical transportation. Ensure that the patient is transported to an appropriate facility and that the facility is notified as soon as possible.

Chest

Blunt trauma to the chest can fracture ribs or the sternum. 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. Depending on the severity of the trauma, the large vessels of the heart may be torn inside the chest, causing massive unseen bleeding that can quickly kill the patient. In some chest injuries the lungs become bruised, thus interfering with normal oxygen exchange in the body. If air accumulates between the lung tissue and the chest wall, the lung tissue compresses and becomes a pneumothorax. If left untreated or unrecognized, the lung tissue squeezes under pressure until the heart is also squeezed and can no longer pump blood (tension pneumothorax). A hemothorax occurs when blood collects between the lung tissue and the chest wall and causes interference with breathing. An open chest wound is a penetration or perforation of the integrity of the chest. As air enters the chest cavity, the natural pressure balance is no longer equal. If left untreated, shock and/or death will result. Regardless of the particular injury, it is imperative that you reassess a trauma patient's chest region every 5 minutes. The assessment should include DCAP-BTLS, lung sounds, and chest rise and fall. Some patients will not have obvious signs or symptoms, such as absent breath sounds or respiratory difficulty, immediately.

Many older patients are seriously injured from falls.

Completely assess older patients for all possible injuries, even from low-impact falls.

Frontal crashes

Contact points are often obvious as you perform a simple quick evaluation of the interior of the vehicle. If there is no intrusion into the passenger compartment, you might see that an unrestrained front-seat passenger has come into contact with the dashboard or instrument panel at the knees, transferring loads from the knees through the femur to the pelvis and hip joint. 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. Signs of most of these injuries can be found by inspecting the interior of the vehicle during extrication of the patient.

The collision of the car against another car, a tree, or some other object

Damage to the car is perhaps the most dramatic part of the collision, but it does not directly affect patient care, except possibly to make extrication difficult. The greater the damage to the car, the greater the energy that was involved and, therefore, the greater the potential to cause injury to the patient. If there is significant damage to a vehicle, your index of suspicion for the presence of life-threatening injuries should automatically increase. Such damage suggests the presence of high-energy trauma.

Significant MOIs are suggested by the following findings:

Death of an occupant in the vehicle Severe deformity of the vehicle or intrusion into the vehicle Severe deformities of the frontal part of the vehicle, with or without intrusion into the passenger compartment Moderate intrusions from a lateral (T-bone) type of accident Severe damage from the rear Crashes in which rotation is involved (rollover and spins) Ejection from the vehicle

Level 1

Definition comprehensive regional resource that is a tertiary care facility; capable of providing total care for evry aspect of injury- from prevention to rehabilitiation Key Term 1. 24 hour in-house coverage by general surgeons Availiablity of care in specialties such as oprthopaedic surgery, neurosurgeries, medicine, radiology, internal medicine, critical care 3. Should also include cardiac, hand, pediatric, microvascular surgery and hemodialysis 4. Provides leadership in prevention, public education, and continuing education of trauma team members 5. Committed to continuing improvement through a comprehensive quality assessment program and organzied researcg to help direct new innovations in trauma care

Level 2

Definition able to intitate definitive care for all injured patients Key Term 1. 24 hour in-house coverage by general surgeons 2 availiability of orthopaedic surgery, neurosurgwery, anesthesiology, emergency medicine, radiology, and critical care 3. Tertiary care needs such as cardiac surgery, hemodialysis, and microvascular surgery may be reffered for a Level 1 Trauma centr 4 Commited to trauma prevention and contniuing education of trauma team mebmers 5 Provide continued improvement in trauma care through a comprehensive quality assessment program

Level 4

Definition able to provide ATLS before transfer of patients to a high level trauma center Key Term 1 includes vasic emergency department facilities to implement ATLS protocols and 24 hour laboratory coverage 2 Transfer to higher level trauma centers follows the guidelines outlined in former transfer agreements 3 Comitted to continuing improvement of theses formal transfer agreements 4 Involved in prevention, outreach, and education within its comunity

Level 3

Definition able to provide prompt assesment, resuscitation, and stabilization of injured patients and emergency operations Key Term 1 24 hour immediate coverage by emergency medicine physicians and prompt availiability of general surgeons and anesthesiologist 2 Program dedicated to continuing improvement in trauma care thorugh a comprehensive quality assessment program 3 Has developed transfer agreement for patients requiring more comprehensive care at a Level 1 or Level 2 trauma center Commited to continuing education of nursing and allied health perssonel or the trauma team 5 Must be involved with prevention and have an active outreach program for its referring communities

Seat belts

Determine whether the passenger was restrained by a full and properly applied three-point restraint. Seat belts may decrease the severity of the third collision of the passenger's organs with the chest or abdominal wall. Some older vehicle models have seat belts that require the passengers to buckle the lap portion. If the lap belt is unsecured during a crash, the occupant can travel down and under the shoulder strap as the body continues forward, resulting in the lower body striking the dashboard. Seat belts may cause unseen abdominal injuries, particularly in pediatric patients. Seat belts are designed to be worn over the iliac crests of the pelvis to distribute the force over the bony surface. Hip dislocations may result if seat belts are worn too low. Internal injuries can occur when the belt is worn too high, resulting in damage to abdominal organs. Lumbar spine fractures are also possible, particularly in children and older patients.

Car versus bicycle

Evaluate the MOI in much the same manner as car-versus-pedestrian crashes. Also evaluate damage to and the position of the bicycle. If the patient was wearing a helmet, inspect the helmet for damage and suspect potential injury to the head if the helmet is damaged. Presume that the patient has sustained an injury to the spinal column until proven otherwise at the hospital. Initiate and maintain spinal immobilization during the encounter. When practical, roll the patient onto his or her side to allow for an appropriate assessment of the posterior side of the body.

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.

Even small air bubbles can enter a coronary artery and cause myocardial injury. Air embolisms to the cerebrovascular system can produce disturbances in vision, changes in behavior, changes in state of consciousness, and a variety of other neurologic signs.

Glasgow Coma Scale (GCS) score The GCS is used to determine level of consciousness by evaluating and assigning point values (scores) for:

Eye opening Verbal response Motor response Scores are then totaled and help to effectively predict patient outcomes. The lower the score, the more severe the extent of brain injury.

Newton's Second Law Force (F) equals mass (M) times acceleration (A), that is:

F = M × A in which acceleration is the change in velocity (speed) that occurs over time. The change in velocity with respect to time generates the forces that cause injury.

Newton's Third Law

For every action, there is an equal and opposite reaction.

Other types of crashes include:

Frontal crashes Rear-end crashes Lateral crashes Rollover crashes Rotational crashes

The Revised Trauma Score (RTS) is most commonly used for patients with head trauma.

Glasgow Coma Scale (GCS) score Revised Trauma Score (RTS)

Assessment of injury is discussed for the following functional areas (or systems) of the human body:

Head Neck and throat Chest Abdomen

There are four types of motorcycle impacts:

Head-on crash Angular crash Ejection Controlled crash .

Car versus motorcycle

In a motorcycle crash, any structural protection afforded to the victim is not derived from a steel cage, but from protective devices worn by the rider—that is, helmet, leather or abrasion-resistant clothing, and boots. While helmets are designed to protect against impact forces to the head, they do not protect from cervical injury. Patients who have experienced a motorcycle crash should undergo cervical spine assessment and have cervical collars placed if indicated. Leather clothing will protect against road abrasion but offers no protection against blunt trauma from secondary impacts. When assessing the scene of a motorcycle crash, look for deformity of the motorcycle, the side of most damage, the distance of skid in the road, the deformity of stationary objects or other vehicles, and the extent and location of deformity in the helmet. These findings can be helpful in estimating the extent of trauma in a patient.

The collision of the passenger's internal organs against the solid structures of the body

Injuries that occur during this type of collision may not be as obvious as external injuries, but they are often the most life threatening. As the passenger's head hits the windshield, the brain continues to move forward until it comes to rest by striking the inside of the skull. This results in a compression injury to the anterior portion of the brain and stretching (or tearing) of the posterior portion of the brain, known as a coup-contrecoup brain injury. In the thoracic cage, the heart may slam into the sternum, which may rupture the aorta and cause fatal bleeding.

Examples of significant MOIs include:

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

The trauma score calculates a number from 1 to 16, with 16 being the best possible score.

It takes into account the Glasgow Coma Scale (GCS) score, respiratory rate, respiratory expansion, systolic blood pressure, and capillary refill.

The energy of a moving object is called kinetic energy.

Kinetic energy reflects the relationship between the mass (weight) of the object and the velocity (speed) at which it is traveling, expressed as: Kinetic energy = 1⁄2 mass × velocity2 or KE = 1⁄2 m × v2

Lateral crashes

Lateral or side impacts (commonly called T-bone crashes) are a very common cause of death. 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. The movement is to the side, and the passenger's shoulders and head whip toward the intruding vehicle. This may thrust the shoulder, thorax, upper extremities, and skull against the doorpost or the window. The cervical spine has little tolerance for lateral bending. If there is substantial intrusion into the passenger compartment, suspect your patient to have lateral chest and abdomen injuries on the side of the impact, as well as possible fractures of the lower extremities, pelvis, and ribs. The organs within the abdomen are at risk because of a possible third collision. 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.

Type of transport

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. The Association of Air Medical Services and MedEvac Foundation International identified the following criteria in the 2006 white paper Air Medicine: Accessing the Future of Healthcare, for consideration in deciding the appropriate use of emergency air medical services for trauma patients: 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. This may add delay to definitive surgical care and necessitate air transport to mitigate the impact of that delay. There is a mass-casualty incident.

Revised Trauma Score (RTS)

Most commonly used for patients with head trauma because it is weighted to compensate for major head injury without multisystem injury or major physiologic changes The RTS is a physiologic scoring system that is used to assess the severity of a trauma patient's injuries. Objective data used to calculate the RTS include: GCS score Systolic blood pressure (SBP) Respiratory rate (RR) In addition to assessing injury severity, the RTS has also demonstrated reliability in predicting survival in patients with severe injuries. The highest RTS a patient can receive is 12; the lowest is 0.

Keep Newton's Laws in mind to help you estimate the types of injuries you are likely to find.

Newton's First Law Newton's Second Law Newton's Third Law

Newton's First Law

Objects at rest tend to stay at rest and objects in motion tend to stay in motion unless acted on by some force.

pulmonary blast injuries

Pulmonary trauma resulting from short-range exposure to the detonation of high-energy explosives

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. On impact, the passenger's body and torso move forward. As the body is propelled forward, the head and neck are left behind because the head is relatively heavy, and they appear to be whipped back relative to the torso. As the vehicle comes to rest, the unrestrained passenger moves forward, striking the dashboard. The cervical spine and surrounding area may be injured because the cervical spine is less tolerant of damage when it is bent back. Headrests decrease extension of the head and neck during a crash and help reduce injury. Other parts of the spine and the pelvis may also be at risk for injury. The patient may sustain an acceleration injury to the brain (the third collision of the brain within the skull). Passengers in the backseat wearing only a lap belt might have a higher incidence of injuries to the thoracic and lumbar spine.

In all situations, you must:

Remain calm. Complete an organized assessment. Correct life-threatening injuries. Do no harm. Never hesitate to contact ALS backup or medical control for guidance.

drag

Resistance that slows a projectile, such as air.

The collision of the passenger against the interior of the car

The kinetic energy produced by the passenger's mass and velocity is converted into the work of stopping his or her body. Like the damage to the exterior of the car, the injuries that result are often dramatic and usually immediately apparent. Common passenger injuries include: Lower extremity fractures (knees into the dashboard) Rib fractures (rib cage into the steering wheel) Head trauma (head into the windshield) Such injuries occur more frequently if the passenger is not restrained.

Neck and throat

The neck and throat contain many structures that are susceptible to serious injuries from trauma. The trachea may become torn or swell after an injury to the neck or deviate after an injury to the lungs. 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) When a neck injury occurs, swelling may prevent blood flow to the brain and thus cause injury to the central nervous system, even though the brain may not have been directly affected by the initial force. 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. Use occlusive dressings to keep this from happening. A crushing injury to the upper part of the neck may cause the cartilages of the upper airway and larynx to fracture, leading to the leakage of air into the soft tissue. When air is trapped in subcutaneous tissue (subcutaneous emphysema), it produces a crackling sound or feeling when palpated, called subcutaneous crepitation. Either air in the circulation or an airway cartilage fracture may cause rapid death.

trajectory

The path a projectile takes once it is propelled.

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.

The patient may report ringing or pain in the 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. These findings can be used to assist in triaging patients, as they indicate risk of pressure injuries to the lungs.

deceleration

The slowing of an object.

Older patients often have osteoporosis and can sustain a fracture as a result of a fall from a standing position.

These cases do not constitute true high-energy trauma unless the patient fell from a significant height.

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. Hollow organs are the most susceptible to the pressure wave. In some cases, pressure wave injuries can amputate limbs.

Tertiary blast injuries

These injuries occur when the patient is hurled by the force of the explosion against a stationary object. A blast wind (sudden change in the surrounding atmosphere) creates a pressure wave. This can cause the patient's body to be hurled or thrown, resulting in further injury. This physical displacement of the body is also referred to as ground shock when the body impacts the ground.

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.

They may have very serious injuries to the lower extremities and pelvic and spinal injuries from energy that the legs did not absorb.

When passengers are riding in vehicles equipped with air bags but are not restrained by seat belts, they are often thrown forward in the act of emergency braking and come into contact with the air bag and/or the doors at the time of deployment.

This MOI is responsible for some severe injuries to children who are riding unrestrained in the front seats of vehicles, unrestrained passengers, and those sitting too close to the air bag.

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

Rollover crashes

Vehicles with a high center of gravity are more prone to rollovers. Injury patterns that are commonly associated with rollover crashes differ, depending on whether the passenger was restrained or unrestrained. The most common life-threatening event in a rollover is ejection or partial ejection of the passenger from the vehicle. Passengers who have been ejected may have struck the interior of the vehicle many times before ejection. Passengers may also have struck external objects (eg, trees, a guardrail, the vehicle's exterior) before landing. Passengers who have been partially ejected may have struck both the interior and exterior of the vehicle and may have been sandwiched between the exterior of the vehicle and the environment as the vehicle rolled. Ejection and partial ejection are significant mechanisms of injury; in these cases, prepare to care for life-threatening injuries. A passenger on the 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). Rollover crashes can cause injury when the roof of the vehicle hits the ground during the rollover; a passenger who is restrained can still move far enough toward the roof to make contact and sustain a spinal cord injury. Rollover crashes are dangerous for both restrained and, to a greater degree, unrestrained passengers because these crashes provide multiple opportunities for second and third collisions.

Head

When the head is injured from trauma, disability and unseen injury to the brain may occur. The brain itself may tear or become bruised, causing bleeding. The blood vessels around the brain may also tear and produce bleeding. Bleeding or swelling inside the skull from brain injury is often life threatening; therefore, your assessment must include conducting frequent neurologic examinations. Neurologic assessments, coupled with the patient's level of consciousness, will often provide details on subtle changes in the patient's condition. Some patients will not have obvious signs or symptoms of unseen brain injury, such as changes in pupillary size and reactivity, until minutes or hours after the injury has occurred.

Tissues at Risk from Blast Injuries (continued)

You may find anything from petechiae to large hematomas in patients with blast injuries. Perforation or rupture of the bowel and colon is a risk. Underwater explosions result in the most severe abdominal injuries. Subarachnoid and subdural 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 by cardiovascular problems. Bradycardia and hypotension are common after an intense pressure wave from an explosion. Patients with traumatic amputation by post-blast wind are likely to sustain fatal injuries secondary to the blast. Body armor may limit or prevent shrapnel from entering the body, but it "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.

Multisystem Trauma

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.

cavitation

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

Pneumothorax is a common injury

and may require emergency decompression in the field for your patient to survive. Pulmonary edema may ensue rapidly. If there is any reason to suspect lung injury in a blast victim, administer oxygen. Avoid giving oxygen under positive pressure (by demand valve) because that may simply increase the damage to the lung. Be cautious with intravenous fluids, which may be poorly tolerated and result in pulmonary edema.

Pulmonary blast injuries are

pulmonary trauma, consisting of contusions and hemorrhages, that result from short-range exposure to the detonation of explosives. When the explosion occurs in an open space, both lungs are usually injured. Primary blast injury is often characterized by a lack of external visible injuries and can go unrecognized. The patient may report tightness or pain in 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 the use of palpation, indicating air in the thorax.

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.