EMT: Chapter 24 [trauma overview]
Which of the following interventions is the MOST critical to the outcome of a patient with multisystem trauma?
rapid transport to a trauma center
In which type of vehicle crash are you most likely to find a patient with whiplash injuries?
rear-end
When a motor vehicle strikes a tree while traveling at 40 mph, the unrestrained occupant:
remains in motion until acted upon by an external force
When caring for an occupant inside a motor vehicle equipped with an air bag that did not deploy upon impact, it is MOST important to:
remember that it could still deploy and seriously injure you
blunt trauma
result of force to the body that causes injury without penetrating the soft tissues or internal organs
penetrating trauma
results in injury by objects that pierce and penetrate surface of the body; injure soft tissues, internal organs more significant
which of the following is NOT considered a type of impact associated with a motorcycle crash?
rotational
What types of motor vehicle collisions present the greatest potential for multiple impacts?
rotational and rollover
tympanic membrane rupture
ruptures at pressure of 5-7 pounds/sq inch above atmospheric pressure - ringing in ears - hearing loss - blood - dislocation of ossicles
"for every action, there is an equal and opposite reaction" is:
Newton's third law
When treating a patient who experienced a pulmonary blast injury, you should:
avoid giving oxygen under positive pressure
what type of blast injury occurs when objects are propelled by force of the blast wave and strike the victim, causing injury?
secondary
airbags decrease injury to all of the following EXCEPT:
heart
Evaluation of the interior of a crashed motor vehicle during extrication will allow the EMT to:
identify contact points and predict potential injuries
most important determining factor in kinetic energy?
speed
A 15-year-old female was struck by a small car while riding her bicycle. She was wearing a helmet and was thrown to the ground, striking her head. In addition to managing problems associated with airway, breathing, and circulation, it is MOST important for you to:
stabilize her entire spine
At what step in the ACS-COT/CDC updated field triage decision scheme would you assess mechanism of injury and evidence of high-energy impact?
step 3
If a person is standing near a building that explodes, which of the following injuries would he or she MOST likely experience as a result of the pressure wave?
stomach rupture
If one or more occupants in the same vehicle are killed in a crash, the EMT should:
suspect that all living occupants experienced the same serious trauma
prehospital trauma care
- ABCs - spinal immobilization - basic shock therapy (control hemorrhages, arterial bleeding, keep patient warm) > tourniquet application - rapid extrication - time on scene < 10 minutes - SAMPLE en route to hospital - consider ALS
field triage: step one
- Glasgow Coma Scale - systolic BP - respiratory rate if issues, transport immediately to highest level of care
critically inured patients have:
- dangerous MOI - decreased LOC - ABC threats - are young/old - have chronic illnesses
significant MOIs: vehicular collisions
- death of a vehicle occupant - severe deformity of vehicle (front, T-bone, rear) - rollover, spins - ejection from the vehicle
air bags
- decrease severity of deceleration injuries - still possibility of second, third collision injuries - worse injuries from air bag if sitting too close or unrestrained by a seat belt - look for abrasions and/or traction-type injuries on face, lower neck, and chest
car vs. bicycle
- evaluate MOI - estimate position of bicycle - evaluate whether helmet is damaged - spinal immobilization
car vs. motorcycle
- evaluate deformities of motorcycle, side of damage, distance of skid - evaluate helmet deformities 1. head-on crash 2. angular crash (crushing injuries to extremity between object and motorcycle) 3. ejection (abrasion, blunt injuries) 4. controlled crash (rider tips at 90 degree angle to separate from motor cycle; limited injuries)
when to use air medical service:
- extended period of time required to extricate a trapped patient - distance to trauma center is greater than 20-25 miles - patient needs ALS support (and no ALS ambulance services exist) - heavy traffic - multiple patients - MCI
field triage: step three
- falls (> 20 feet for adults, > 10 feet for children) - high-risk auto crash (intrusion, ejection, death of another passenger) - auto vs. pedestrian - motorcycle crash if any, transport to trauma center which need not be highest level of care
lateral (T-bone) crashes
- lateral whiplash - cervical spine injuries common - lateral chest/abdomen injuries on side of impact cause of 30% of fatalities in motor vehicle crashes
solid organs
- liver - spleen - pancreas - kidneys these may tear, lacerate or fracture -> serious bleeding signs: worsening vital signs/abdominal pain
significant MOIs: general
- multisystem trauma - falls from heights - motor vehicle and motorcycle crashes - car vs. pedestrian - gunshot wounds - stabbings maintain high index of suspicion for series unseen injuries
field triage: step four
- older adults (> 55 y.a., signs of shock, low impact mechanisms) - children - anticoagulants and bleeding disorders - burns - pregnancy - EMS provider judgment if any, transport to trauma center for initial evaluation of potentially serious injuries
field triage: step two
- penetrating injuries - chest wall instability - long-bone fractures - crushed/pulseless extremities - amputation - pelvic fractures - skull fractures - paralysis if any, transport immediately to highest level of care
patient assessment: chest
- rib/sternum fractures - heart bruising - vessel tearing (massive internal bleeding) - lung bruising - pneumothorax -> tension pneumothorax - hemothorax - open chest wound (-> shock -> death) DCAP + lung sounds + chest rise/fall
common blast injuries & symptoms
- rupture of bowel, colon - subarachnoid, subdural hematomas - amputation, facial injuries - bradycardia, hypotension - neurologic deficits (LOC changes, amnesia)
seat belts
- seat belts may decrease severity of collision of patient's organs with their chest/abdominal wall - may cause unseen abdominal injuries - worn too low -> hip dislocation - worn too high -> abdominal organ damage
falls
- significant when > 20 feet - internal injuries - consider NOI cause of fall - assess height of fall, type of surface struck, part of body that hit first - remember older patients have osteoporosis and do not sustain falls well 1. feet first (lower extremities, pelvic/spinal injuries) 2. head first (head/spinal injuries)
hollow organs
- stomach - intestines - urinary bladder may leak toxic chemicals into the abdomen
frontal vehicular crashes
- unrestrained front-seat passenger can come into contact with dashboard or instrumental panel - face often hits steering wheel - face may launch forward/up and hit windshield and roof header observe interior of vehicle during extriction
rear-end crashes
- whiplash common (body moves forward while heavy head left behind), especially without headrests - cervical spine injuries common in frontseat - brain injuries - thoracic/lumbar spine injuries common in backseat
trauma score
1-16 scale GCS + respiratory rate + respiratory expansion + systolic BP + capillary refill
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
You are assessing a patient who was in a front-end car crash. His GCS is 12, systolic blood pressure is 81 mm Hg, and respiratory rate is 22 breaths/min. What is this patient's Revised Trauma Score?
10
You are assessing a patient who opens her eyes when you speak to her, who can respond to you but seems confused as to time and place, and localizes pain. What is her Glasgow Coma Scale score?
12
a fall from more than ____________ times the patient's height is considered to be significant.
2-3x
how many collisions are there in a typical vehicle impact?
3
how many collisions took place when a young boy hit a parked car when riding his bicycle?
3
GCS
3-15 scale - eye opening (4 points) - verbal response (5 points) - motor response (6 points)
During your assessment of a patient with a head injury, you note that he opens his eyes when you pinch his trapezius muscle, is mumbling, and has his arms curled in toward his chest. You should assign him a GCS score of:
7 eyes open in response to pain - 2 incomprehensible sounds - 2 abnormal flexion - 3
Your patient has a Glasgow Coma Scale (GCS) score of 13, a systolic blood pressure of 80 mm Hg, and a respiratory rate of 8 breaths/min, his Revised Trauma Score (RTS) is:
9
DCAP-BTLS
Deformities Contusions Abrasions Punctures/Penetrations - Burns Tenderness Lacerations Swelling
newton's second law
F = M x A (acceleration is the change in velocity that occurs over time)
trauma center levels
I: regional resource center - large cities, heavily populated areas - university-based teaching hospitals - provide every aspect of trauma care II: less-populated areas - initial definitive care regardless of severity - academic OR public/private facilities III: no I or II center - assessment, resuscitation, emergency care, stabilization - must have transfer agreements with I or II centers IV: remote outlying areas - ex. clinic urgent care facility with/without physician can be adult/pediatric or both
collision of passenger against car interior
KE produced by passenger -> work of stopping their body immediately apparent injuries common injuries: - lower extremity fracture (knees into dashboard) - rib fracture (rib cage into steering wheel) - head trauma (head into windshield)
Which of the following patients has experienced the MOST significant fall?
a 4"6 patient who fell 13 feet
A 40-year-old female, unrestrained, impacted the steering wheel of her vehicle with her chest when her vehicle hit a tree while traveling at 45 mph. She is conscious and alert, but is experiencing significant chest pain and shortness of breath. Given the mechanism of injury and her present condition, it is LEAST likely that she experienced:
a head injury
drag
air resistance which slows the projectile and decreases depth of penetration
Which of the following injuries would MOST likely occur as a direct result of the third collision in a motor vehicle crash?
aortic rupture
When evaluating the mechanism of injury of a car-versus-pedestrian collision, you should first:
approximate the speed of the vehicle that struck the pedestrian
A young male sustained a gunshot wound to the abdomen during an altercation with a rival gang member. As your partner is assessing and managing his airway, you should control the obvious bleeding and then:
assess for an exit wound
index of suspicion
awareness and concern for potentially serious underlying and unseen injuries
While assessing a young male who was struck in the chest with a steel pipe, you note that his pulse is irregular. You should be MOST suspicious for:
bruising of the heart muscle
While assessing a young male who was struck in the chest with a steel pipe, you note that his pulse is rapid and irregular. You should be MOST suspicious for:
bruising of the heart rupture
The phenomenon that results from the rapid changes in tissue and fluid pressure that occur with the passage of a projectile, resulting in serious injury to internal organs distant to the actual path of the bullet, is known as what?
cavitation
in a motor vehicle collision, as the passenger's head hits the windshield, the brain continues to move forward until it strikes the inside of the skull, resulting in a _________________ injury.
compression
A small compact car was involved in a rollover crash. As you are approaching the vehicle, you note that the roof is significantly collapsed. The patient, a 29-year-old male, is complaining of severe pain in his neck and to the top of his head as well as numbness and tingling in his extremities. Witnesses who removed the patient from the vehicle state that he was wearing his seatbelt. What injury mechanism is MOST likely responsible for this patient's condition?
compression of the head against the roof
pulmonary blast injuries
contusions and hemorrhages that result from short-range exposure to detonation of explosives; both lungs injured in open spaces possibility of pneumothorax, pulmonary edema - tightness in chest - coughing up blood - respiratory distress - subcutaneous emphysema administer O2 (avoid positive pressure)
Signs of a pulmonary blast injury include:
coughing up blood
tertiary blast injuries
damage to body caused by hurling force of explosion (blast wind), knocking patient into a stationary object "ground shock"
primary blast injuries
damage to body caused by pressure wave generated by explosion; lack of external visible injuries - disruption of major blood vessels, rupture of eardrums and major organs - hollow organs most susceptible
secondary blast injuries
damage to body caused by primary debris (shrapnel, glass) set in motion by the explosion
Air bags are designed to:
decrease the severity of deceleration injuries
Which of the following would MOST likely occur as the direct result of the second collision in a motor vehicle crash?
deformed steering wheel
Which of the following findings would be LEAST suggestive of the presence of high-energy trauma?
deployment of the air bag
When a driver is in a car equipped with an air bag, but is not wearing a seatbelt, he or she will MOST likely strike the __________ when the air bag deploys upon impact.
door
During your assessment of a patient who experienced a blast injury, you note that he has a depressed area to the front of his skull. This injury MOST likely occurred:
during the tertiary phase
the most common life-threatening event in a rollover is ___________________ or partial ejection of the passenger from the vehicle.
ejection
A 12-year-old male jumped approximately 12' from a tree and landed on his feet. He complains of pain to his lower back. What injury mechanism is MOST likely responsible for his back pain?
energy transmission to the spine
collision of car against car/tree/object
extrication difficult greater damage to car = high-energy trauma, life-threatening injuries immediately apparent injuries
Two of the MOST common mechanisms of injury for blunt trauma are:
falls and motor vehicle collisions
newton's third law
for every action, there is an equal and opposite reaction
work
force acting over a distance
coup-contrecoup brain injury
force applied to head causes injury on opposite side of original impact as brain rebounds result of passenger's head hitting windshield in a vehicular collision
medium-velocity penetrating injuries may be caused by a:
handgun
According to the American College of Surgeons, an adult trauma patient meets Level I criteria if he or she:
has a GCS score of less than or equal to 8 with a mechanism attributed to trauma (NOT has systolic BP less than/greater than 110 beats/min, was involved in a MVC in which another patient in the same vehicle was killed, has a bleeding disorder/takes anticoagulants and has a blunt or penetrating injury)
In contrast to a Level III trauma center, a Level I trauma center must:
have general surgeons who are in-house 24 hours a day
You would use the Revised Trauma Score scoring system for a patient if there is potential for what type of trauma?
head
which of the following is the most common cause of death from a blast injury?
head trauma
The cervical spine is MOST protected from whiplash-type injuries when the:
headrest is appropriately positioned
medical emergencies
include illnesses or conditions not caused by an outside force
car vs. pedestrian
injuries often apparent - broken bones - multisystem injuries - evaluate MOI - estimate speed of vehicle - evaluate striking vehicle for structural damage - determine whether patient was ejected and if they were pulled under the vehicle
multisystem trauma
injury to more than one body system HIGH level of mortality
Following a blunt injury to the head, a 22-year-old female is confused and complains of a severe headache and nausea. On the basis of these signs and symptoms, you should be MOST concerned with the possibility of:
intracranial bleeding
A driver involved in a rollover motor vehicle crash will MOST likely experience serious injuries or death if he or she:
is ejected or partially ejected
Which of the following statements regarding the first collision that occurs during a motor vehicle crash is correct?
it is the most dramatic part of the collision and may make extrication difficult
The energy of a moving object is called:
kinetic energy
Approximately 25% of severe injuries to the aorta occur during:
lateral collisions (30% of all deaths)
What level of trauma center provides prompt assessment, resuscitation, and stabilization of injured patients and emergency operations, but not definitive care for all patients?
level III
When assessing the interior of a crashed motor vehicle for damage, you are gathering information regarding the:
mechanism of injury
what raises index of suspicion in a collision?
mechanism of inury
projectile
medium and high-velocity penetrating trauma caused by an object propelled by force can fragment and increase damage speed important in determining injury factor (and thus type of weapon)
quaternary blast injuries
misc. injuries, ex: - hot gas burns - respiratory injury from toxic gas - suffocation - poisoning - medical emergencies - crush injuries - infection - mental health emergencies
rollover/rotational crashes
more common in vehicles with a high center of gravity - high risk of ejection or partial ejection - passengers may have struck external objects or interior/exterior of vehicle - restrained patient can still move far enough toward the roof to make contact and sustain spinal injuries
While en route to a major motor vehicle crash, an on-scene police officer advises you that a 6-year-old male who was riding in the front seat is involved. He further states that the child was only wearing a lap belt and that the air bag deployed. On the basis of this information, you should be MOST suspicious that the child has experienced:
neck and facial injuries
collision of passenger's internal organs against body
not immediately apparent injuries common injuries: - coup-contrecoup brain injury - aortic rupture
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
trauma emergencies
occur as a result of physical forces applied to the body
When assessing an elderly patient who fell, it is important to remember that:
osteoporosis can cause a fracture that may have resulted in the fall
A 30-year-old male sustained a stab wound to the neck when he was attacked outside a nightclub. During your assessment, you should be MOST alert for:
potential airway compromise
By what mechanism is a person injured when he or she falls from a significant height?
potential energy is converted to kinetic energy; the kinetic energy is then converted into the work of bringing the body to a stop
energy associated with injury
potential, kinetic, work energy KE = m x v^2 (energy available to do work doubles with weight and quadruples with speed) amount of work converted to work = severity of the injury
damage to the body that resulted from a pressure wave generated by an expansion is found in what type of blast injury?
primary
When assessing a patient who experienced a blast injury, it is important to remember that:
primary blast injuries (internal) are the most easily overlooked
potential energy
product of mass, force of gravity, and height; associated with energy of falling objects
a patient complaining of chest tightness, coughing up blood, and subcutaneous emphysema following an explosion may be suffering from a:
pulmonary blast injury
arterial air embolism
pulmonary blast injury where air bubbles develop in arterial blood vessels - myocardial injury - LOC changes, other neurologic signs
When the speed of a motor vehicle doubles, the amount of kinetic energy:
quadruples
patients suffering from an open wound to the neck may experience all of the following EXCEPT:
tension pneumothorax (EXPERIENCE significant bleeding, air embolism, subcutaneous crepitation)
Which of the following statements regarding low-energy penetrating injuries is correct?
the area of injury is usually close to the path the object took through the body
Internal injuries caused by gunshot wounds are difficult to predict because:
the bullet may tumble or ricochet within the body
which of the following is NOT considered an appropriate use of air medical services?
the closest trauma center is 10 minutes away by ground transport
trajectory
the path that a projectile takes; may or may not involve an exit wound
Which of the following statements regarding gunshot wounds is correct?
the speed of a bullet has the greatest impact on producing injury
Factors that should be considered when assessing a patient who has fallen include all of the following, EXCEPT:
the speed of the fall
Passengers who are seated in the rear of a vehicle and are wearing only lap belts have a higher incidence of injuries to the _____________ spine during a rear-end crash.
thoracic and lumbar
patient assessment: neck and throat
trachea may tear or swell - jugular vein distention - tracheal deviation - assess via DCAP-BTLS of the neck region bleeding, air drawn into circulatory system -> embolism - use occlusive dressings crushing injury may cause upper airway to fracture = subcutaneous emphysema airway cartilage fracture -> rapid death
According to the Association of Air Medical Services (AAMS), you should consider air medical transport of a trauma patient if:
traffic conditions hamper the ability to get the patient to a trauma center by ground within the ideal time frame for the best clinical outcome
The driver of a sport utility vehicle lost control and struck a utility pole head-on. The driver was killed instantly. The passenger, a young female, is conscious and alert and has several small abrasions and lacerations to her left forearm. Treatment for the passenger should include:
transport to a trauma center
patient assessment: head
unseen injury to the brain may occur - tearing/bruising of brain - tearing/bleeding of vasculature frequent neurologic examinations + LOC changes = patient's condition symptoms may not appear immediately
revised trauma score (RTS)
used for patients with head trauma 0-12 scale - GCS - systolic BP - respiratory rate (RR) 0 = 3 GCS, 0 BP, 0 RR
mechanism of injury (MOI)
way in which traumatic injuries occur; describes forces acting on the body that cause injury
cavitation
when speed causes a bullet to generate pressure waves, which causes damage distant from the bullet's path - temporary: stretching of tissues - permanent: tissue damage closer to bullet path
Force acting over a distance defines the concept of:
work