Week 6/7 Trauma ABCS III

Our bodies change over time

As infants develop, their vital sign ranges change, their anatomy changes, and their response to injury changes. Older patients will begin to show signs of changing and failing body systems and their musculoskeletal anatomy may change shape and become less flexible. Medications that older patients may be on can change their response to injury.
Body systems continue to develop and mature in the young.

• Aging body systems show signs of dysfunction.

• There are anatomical differences.

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Respiratory issues in Children

• Hypoventilation and hypoxia are more likely than hypovolemia and hypotension.

• Injured children can rapidly deteriorate from labored breathing to tachypnea and on to exhaustion and apnea.

Shock

• Most pediatric injuries do not cause immediate exsanguination.

• Blood pressure is a poor indicator of blood loss and peripheral perfusion.

• Children remain in compensated shock longer than adults, but decline very rapidly.

physiologic Impact

Burns

• All burns are serious, regardless of size.

• Burns are not just a skin injury.

  • Large burns involve multiple organ systems.

• Smoke inhalation can be life-threatening.

  • It is often more dangerous than the burn itself.

    • Carbon monoxide

    • Cyanide

• Children account for 20% of all burn victims

  • Consider the possibility of intentional injury (abuse).

Burn Assessment

• Depth of injury

  • Superficial (1^st degree)

  • Partial thickness (2^nd degree)

    • Superficial

    • Deep

  • Full thickness (3^rd and 4^th degree)

  • Burn depth may evolve over time.

Burn Management

• Conduct primary survey–ABCDE. Airway breathing circulation disability, exposure

  • Airway occlusion may occur as swelling progresses.

  • Breathing may become compromised from chest wall eschar or toxic pulmonary injury.

  • Monitor respiratory rate, SaO₂

  • Circulatory status may be compromised as fluid leaks into damaged tissue, which causes swelling and hypotension.

• ALS/transport

• Specific burn therapy

  • Stop any ongoing burning.

  • Cover with dry, sterile non adherent dressing (sheet).

    • Do not use any ointments or other topical antibiotic.

Multiple Patient Situations

• A multiple patient scenario occurs each time there is more than one patient.

• Are there sufficient resources available on-scene to manage all patients?

  • Triage is used primarily when the number of patients exceeds the immediate treatment and/or transport capacity.

  • If number of patient exceeds resources- MASS CASUALTY INCIDENT

• Transport only one critical patient per ambulance.

• Patients who require spinal motion restriction require stretcher for transport

• When possible, distribute patients to all available hospitals.

Green - person can walk, regardless of broken arm.

black - deceased

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Trauma Resuscitation Issues

• In certain situations, it may be allowable to withhold or terminate resuscitation efforts in:

  • Injuries not compatible with life

  • Pulseless and non breathing blunt trauma victims

  • Trauma patients with EMS- witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and CPR--recommendations may be revised--

• Special consideration in trauma resuscitation must be given to patients who may have  greater likelihood of survival:

  • hypothermia

  • immersion incidents

  • lightning strike

• Follow protocols, system guideline, Online medical control  consult

Multisystem Trauma

• Multiple-trauma patient

  • More than one serious injury

• Multisystem-trauma patient

  • One or more injuries serious enough to affect more than one body system

• Teamwork, timing, and transport decision are key to proper management.

Determining Patient Severity

• Most critical decisions

  • Patient priority/severity

  • Whether to limit scene time or not

  • Which hospital or transport method is best for your patient

Determining Severity:
Physiologic Criteria

• Altered mental status (GCS < 14)

  • Head injury

• Hypotension (systolic < 90 mm Hg)

  • Shock, internal bleeding

• Abnormally slow respiratory rate

  • Head injury, later stages of shock

Determining Severity:
Anatomic Criteria

• Penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee

• Chest wall instability or deformity - crepidis everywhere. Flailed chest

• Two or more proximal long-bone fractures

Determining burn area adult vs pediatric.Rule of 9

Neck Zone Injuries

Determining Severity:
Anatomic Criteria

• Crushed, degloved, mangled, or pulseless extremity

• Amputation proximal to wrist or ankle

• Pelvic fractures - blood loss. Bind it.

• Open or depressed skull fracture

• Paralysis

Determining Severity:
Mechanism of Injury

• In absence of anatomic or physiologic signs, MOI is considered if severe.

• Falls

• Intrusion

• Ejection from automobile

• Death in same passenger compartment

• Vehicle telemetry data consistent with high risk of injury

Determining Severity: Special Patients and Considerations

• Older adults do not efficiently compensate for shock.

• Children may benefit by transport to a pediatric specialty facility.

• Patients with certain conditions

  • Taking anticoagulants

  • Pregnant

Managing the Multisystem-Trauma Patient

A Typical Call

• Practice with crew.

  • Determine roles.

• En route to call, review roles each member of the crew will have.

• Ensure scene safety.

  • Auto crash will have passing traffic.

  • Penetrating trauma - we want police. Stabs, gunshot wounds.

    • Assailant may still be on the scene.

• Perform the primary assessment.

• Ensure an open airway.

• Perform urgent or emergency moves.

• Transport.

• Give a report to the trauma team at the emergency department during handover.

Analysis of the Call

• In a scenario with critical injuries

  • Follow priorities determined by assessments.

  • Do not delay transport by performing treatments that would waste time.

  • Show good judgment.

    • Postpone taking vital signs until en route when appropriate.

    • Give the hospital staff time to prepare.

General Principles of Multisystem-Trauma Management

• Follow priorities determined by primary assessment.

• Attend to immediate threats to life.

• Reassess what to treat on scene and what needs definitive care.

• Call hospital so they can prepare.

General Principles of Multisystem-Trauma Management

• Depending on your primary assessment, you may postpone taking vital signs until you are en route to the hospital.

• As you reassess your patient in the vehicle, call the hospital as necessary to update the vital signs.

General Principles of Trauma Management

• Limit scene treatment

  • Stabilize cervical spine.

  • Suction airway.

  • Insert oral or nasal airway.

  • Restore patent airway.

  • Ventilate with bag-valve mask.

  • Administer high-concentration oxygen.

  • Control bleeding.

  • Immobilize patient on cot

General Principles of Multisystem-Trauma Management

• Scene safety is paramount.

• Ensure an open airway.

• Perform urgent or emergency moves as necessary.

• Adapt to the situation.

Remember

• Your primary assessment should determine whether your patient is seriously injured or potentially seriously injured.

• Limit scene treatment to life-threatening conditions.

• Your patient will tell you how severe their injuries are! (physiologic criteria, anatomic criteria, MOI)