Trauma Conditions - Standard of Care

Abdomen: Evisceration

Definition: Open wound to abdomen resulting in protrusion of abdominal organs/tissue.

Signs & Symptoms:

• Abdominal organ/tissue visible through open abdominal wound

• Shock: hypovolemia

• Hypothermia w/ prolonged exposure

Assessment:

• Evaluate MOI

• Espose

• VS

Treatment:

• Moint, non-fibrous, occlusive dressing over exposed organs taped x4 sides

• Do not touch or attempt to replace exposed organs/tissue

• O2 via NC/NRB

  • SpO2 >= 95%

• Treat for shcok: blanket

• Supine positive w/ knees flexed

• ALS intercept: IV fluid, medication

• Rapid Transport

Amputation

Definition: Open injury caused by ripping/tearing away of a limb or body part or organ

Forms: Complete or incomplete

Signs & Symptoms:

• Body part partially or completely severed

• Shock signs: hypovolemia

Assessment:

• Evaluate MOI

• Get history

• Perform focused exam of affected area

• VS

Treatment:

• Calm/reassure

• O2 w SpO2 target 95%

• Flush to remove gross contaminants

• Control bleeding: pressure dressing and/or tourniquet

• Cover wound: sterile dressing and bandage

• * Do not complete any partial amputations but dress/bandage in place

• Package/transport amputated part

  • Wrap (sterile dressing)

  • Label

  • Cooler

  • Transport

• Treat shock

• ALS Intercept: IV fluids, medication

• Rapid transport

Burn

Definition: Destruction of tissue secondary to contact w/ heat/fire

Forms:

• Depth:

  • Superficial

  • Partial-thickness

  • Full-thickness

• Severity

  • Major: full thickness > 5% BSA or respiratory injury or critical area (hand/foot/face/eye/ears/genitalia/fracture)

  • Moderate: full thickness 2-5% BSA or circumferential

  • Minor: full thickness <2% BSA

Signs & Symptoms:

• Superficial:

  • Red, dry, no blisters, pain/tender at site

• Partial-thickness:

  • White/red, moist, blisters, intense pain

• Full-thickness:

  • Dry/hard/tough/leathery (eschar), waxy to brown, no pain at site but at periphery

Assessment:

• Evaluate MOI

• Assess airway:

  • Voice: clear vs hoarse

  • Singed facial/nasal hair

  • Sooty deposits

• Obtain BSA (Rule of Nines/Palms)

• Classify severity

• If due ot CO poisoning, beware of inaccurate SpO2

Treatment:

• Calm/reassure

• Cool burn within 10 mins

• Brush away chemical & irrigate

• O2 via NRB or BVM

• Dress/bandage w. dry sterile dressing or burn sheet

• Keep patient warm

• No lotion or ointments

• ALS intercept: IV, advanced airway, medication

• Tranport to burn center

Chest Trauma: Commotio Cordis

Definition: Sudden cardiac arrest caused by blunt trauma to the chest wall during vulnerable period in the cardiac cycle

Signs & Symptoms:

• History of s/s of blunt chest trauma

• Unresponsive

• Apneic

• Pulseless

Assessment:

• Evaluate MOI

• Responsiveness (AVPU)

• Breathing: visible/palpable chest rise

• Pulse: carotid

• History: blunt trauma

Treatment:

• CPR

  • Attach + monitor EtCO2

• AED

• ALS: ECG, IV, Medications

• Return of spontanous circulation (ROSC)

  • Jump in EtCO2

  • O2: maintain SpO2 94%

  • Rapid Transport

• Consult/advice family

Chest Trauma: Flail Segment

Definition: 2+ adjacent ribs broken in 2+ places, creating an unattached section of ribs that moves independently from the rest of the chest wall

Forms:

• Early: no paradoxical movement, inhibited movement due to intercostal muscles

• Late: paradoxical movement, intercostal muscles fatigue

Signs & Symptoms:

• Blust chest trauam

• Paradoxical movement

• Respiratory distress/dyspnea

• Decreased air movement on injured side

• S/s of pulmonary contusion

  • Rale & crackles

• Decreased SpO2

Assessment:

• Evaluate MOI

• Visualize & palpate (tenderness, pain, instability, paradoxical movement) chest wall

• Auscultate BBS

Treatment:

• Calm/reassure

• O2 via BVM/CPAP

  • SpO2 95%+

• No external pressure to chest wall

• ALS: IV, medication

• Rapid Transport

Chest Trauma: Pericardial Tamponade

Definition: Blood/fluid in pericardial sac surrounding heart —> pressure on heart surface —> inhibits pumping ability

Forms:

• Blunt trauma

• Penetrating Trauma

• Non traumatic

Signs & Symptoms:

• Chest pain

• Tachycardia

• Dyspnea

• Pale/clammy skin

• Narrow pulse pressure

• Beck’s triad

  • JVD

  • Hypotension

  • Muffled heart tones

• Pulsus paradoxus (weaker pulse during inspiration)

• Kussmaul’s sing (increased JVD during inspiration)

• Clear BBS

Assessment:

• Evaluate MOI/NOI

• Visualize chest for trauma or deformity

• Auscultate BBS

• Palpate chest wall: reproducible pain, equal chest rise

• Monitor BP

Treatment:

• Calm/reassure

• Support ABCs

  • SpO2 95%+

• ALS: ECG

• Rapid transport

Chest Trauma: Pneumothorax

Definition: Rupture of pleura —> air sucked into pleural space —> pressure on lungs —> collapse

Forms:

• Spontaneous

  • Primary: overstretched visceral pleura

  • Secondary: smoking & lung disease

• Open (sucking chest wound)

• Tension

Signs & Symptoms:

• Sudden dyspnea, chest pain (sharp, stabbing, localized)

• Decreased BS one side

• Subcutaneous emphysema

• Tachypnea

• SpO2 <94%

• Cyanosis late

• Penetrating chest trauma

• Tension pneumothorax:

  • Declining BP/narrowing pulse pressure

  • Lightheadedness

  • Increased dyspnea/ventilatory resistance

  • JVD

  • Tracheal deviation (late sign)

Assessment:

• Evaluate MOI

• Visualize chest for trauma/deformity

• Auscultate BBS

• Palpate chest wall: reproducible pain, equal chest rise

Treatment:

• Calm/reassure

• Support ABCs

  • O2 via NRB

  • Beware of BVM

  • No CPAP (contraindicated)

• Cover penetrating chest wound:

  • Gloved hand

  • Occlusive dressing taped 3 sides

• ALS: needle thoracotomy

• Rapid Transport

Chest Trauam: Pulmonary Contusion

Definition: Bleeding within lung tissue

Forms: With or without flail segment

Signs & Symptoms:

• Blunt chest trauma

• Respiratory distress/dyspnea

• Paradoxical movement

• Decreased air movement on injured side

• Rale/crackles

• Decrease SpO2

Assessment:

• Evaluate MOI

• Visualize chest wall

• Palpate chest wall (tenderness, pain, instability, paradoxical movement)

• Ausculate BBS

Treatment:

• O2 via BVM/CPAP

  • SpO2 95%+

• ALS: IV, advanced airway

• Rapid transport

Eye Trauma: Chemical Burn

Definition: Chemical exposure/contact with eye

Forms:

• Acid

• Alkali

Signs & Symptoms:

• History of exposure

• Irritated/swollen eyelids

• Redness

• Blurriness

• Pain

• Burned skin around eye

Assessment:

• Visually inspect eye & orbit

• Assess for contact lenses

• Assess pupils

Treatment:

• Irrigate immediately w/ water flowing away from other eye and body

  • 20 mins

  • Continue in transport

  • Do not use chemical antidote

• Remove contact lenses

• Identify chemical

• Rapid transport

Eye Trauma: Extruded Eyeball

Definition: Globe of eye presents outside of orbit but still attached

Signs & Symptoms:

• History of blunt trauma to face

• Globe outside orbit

• Vision disturbance

• Injury to surrounding orbit

Assessment:

• Visually inspect globe/orbit

• Palpate surrounding orbit

Treatment:

• Calm/reassure

• Dress/bandage extrusion: moist, sterile dressing & cup

• Cover other eye

• Do not attempt to replace globe

• Do not touch/manipulate globe

• ALS: IV

• Rapid transport

Eye Trauma: Foreign Object

Definition: Foreign object, such as dust, cinders, sand, metal, etc., lodged in the eye

Forms:

• Lodged in conjunctiva

• Lodgegd in cornea/globe

Signs & Symptoms:

• Complaint of feeling object under eyelid

• Redness of eye/globe

• Blurriness

• Lacrimation: tearing/crying

Assessment:

• Evaluate MOI

• Life eyelid to inspect eye/globe

• Assess for contact lenses

• Assess pupils

Treatment:

• Calm/reassure

• Lodged in conjunctiva:

  • Removal using sterile gauze or eyelid

  • Flush w/ clean water

• Lodged in cornea/globe:

  • Do not attempt removal or irrigation

  • Cover both eyes w/ loose sterile dressing/bandage

• Transport

Eye Trauma: Globe/Orbit Injury

Definition: Any bruising, laceration, abrasion, inflammation, etc. to globe of eye

Forms:

• Traumatic

• Non traumatic

Signs & Symptoms:

• Trauma to eye/orbit

• Irregularly shaped globe

• Swelling/redness

• Vision disturbance

• Hyphema (blood in anterior chamber)

Assessment:

• Lift eyelid to inspect

• Assess for contact lenses

• Assess pupils

• Palpate surroundings

Treatment:

• Cover both eyes with loose, sterile dressing

• Supine position

• Do not apply cold pack

• Rapid transport

Genital Trauma

Definition: Wound involving reproductive organs

Forms: Male/female

Signs & Symptoms:

• Traumatic injury/wound

• Genital pain & bleeding

Assessment:

• Report of trauma

• Visually inspect external genitalia

• Palpate surrounding area

Treatment:

• Support ABCs

  • SpO2 95%+

• Treat for shock

• Male:

  • Direct pressuring dressing for bleeding

  • Cold pack for swelling/pain

  • Amputation: see amputation

• Female:

  • Direct pressure dressing for vaginal bleeding

  • Never place dressing inside vagina

• ALS: IV, pain medication

• Transport

Head Trauma

Definition: Blunt/penetrating injury to the head

Forms:

• Concussion: mild diffuse axonal injury associated with no permanent damage

• Contusion: bruising of brain tissue

• Subdural hematoma: venous bleed between dura mater and arachnoid space

• Epidural hematoma: arterial bleed between skull and dura mater

• Brain herniation: increased intracranial pressure within the skull causing the brain to push through the foramen magnum

Signs & Symptoms:

• HA/tenderness/swelling/wound

• Confusion/amnesia or Loss of consciousness

• Nausea/vomiting

• Unequal pupil size

• Seizures

• Battle/raccoon signs (supports basilar skull fracture)

• Paralysis to one side of body (supports contusion, hematoma)

• Lucid interval (supports epidural hematoma)

• Posturing (supports herniation)

• Cushing reflect (supports increased intracranial pressure)

  • High BP

  • Low HR

  • Irregular respirations

Assessment:

• Assess mentation

• Complete history over past month

• Palpate head/neck

• Assess pupils:

  • Consensual reflex

• Assess battle/raccoon signs

• Complete neuro assessment: motor/sensation each extremity

• Obtain VS: Cushing, EtCO2

Treatment:

• Manual C-spine & supine spinal motion restrictions

• Maintain ABCs:

  • SpO2 95%+

  • Herniation: titrate ventilations to EtCO2 goal 30-35 mmHg

• Control bleeding: non-pressure dressing for open/depressed skull injury

• Rapid transport

Hemorrhage

Definition: Bleeding

Forms:

• External vs internal

• Arterial vs venous vs capillary

Signs & Symptoms:

• Arterial: bright red, spuriting/pulsating blood

• Venous: dark red, flowing blood

• Capiillary: slowly oozing blood

• Anxiety/restlessness

• Pain/tenderness

• Swelling/discoloration

• Tachycardia/tachypnea

• Weak, thready pulse

• Pale/cool/clammy skin

• Narrowing pulse pressure

Assessment:

• History & traumatic event

• Visualize site of pain/tenderness/bleeding

• VS

Treatment:

• O2 via NRB or BVM

  • 95%+

• External:

  • Direct pressure using pressure dressing

  • Tourniquet to extremity

  • Pack hemostatic dressing to junctional wound

  • Treat for shock

  • Immobilize fracture

• Internal:

  • ABCs

  • Treat shock

• ALS: IV

• Rapid transport

Musculoskeletal Fracture: Extremity Fracture

Definition: Broken bone in arm/hand/leg/foot

Forms:

• Open or closed

Signs & Symptoms:

• Pain/tenderness

• Deformity/discoloration

• Paresthesia/anesthesia distal to site

• Paresis/paralysis of extremity

• Decreased distal pulse

• Skin cool distal to site

• Crepitus

• Exposed bone ends

Assessment:

• Assess circulation/sensation/motor distal to injury

• Assess joints/bones above & below site of injury

• Assess skin on extremity

• VS

• Possibility extremity fracture is distracting fracture

Treatment:

• Support ABCs

  • SpO2 95%+

• Supine SMR

• Split bone/joint

• Apply cold pack for swelling/pain

• Elevate extremity

• ALS: IV, pain medication

• Transport

Musculoskeletal Fracture: Femur Fracture

Definition: broken thigh bone

Forms:

• Open or closed

Signs & Symptoms:

• Pain/tenderness

• Deformity/discoloration

• Paresthesia/anesthesia distal to site

• Paresis/paralysis of extremity

• Decreased distal pulse

• Skin cool distal to site

• Crepitus

• Exposed bone ends

Assessment:

• Assess circulation/sensation/motor distal to injury

• Assess joints/bones above & below site of injury

• Assess skin on extremity

• VS

Treatment:

• SpO2 95%+

• HARE traction splint if:

  • Mid shaft: site at least 2 inches from knee/hip

  • Isolated: no other fracture on that extremity or hip/pelvis

  • Closed: no broken skin or protruding bones

  • Unilateral: no femur fracture on other leg

• KTD traction splint if:

  • Mid shaft: site at least 2 inches from knee/hip

  • Isolated: no other fractures

• Supine SMR

• Cold pack for swelling

• ALS: IV, pain med

• Rapid transport

Musculoskeletal Fracture: Pelvis Fracture

Definition: Broken pelvis

Signs & Symptoms:

• Pain/tenderness

• Deformity/discoloration

• Unstable on palpation

• Swollen/discorlored scrotum

Assessment:

• Visualize pelvis/genitalia

• Palpate pelvis/hips

• VS

• Assess for shock: hypovolemia

Treatment:

• SpO2 95%+

• Splint:

  • Commercial pelvis binder

  • Imrpovised pelvis sheet wrap

• Move using scoop stretcher

  • Do not log roll

• Supine SMR

• ALS: IV, pain medication

• Rapid transport

Neck Injury

Definition: Damage to tissues/structures in neck

Forms:

• Blunt trauma

• Penetrating trauma

Signs & Symptoms:

• Wound

• Pain/tenderness

• Deformity/discoloration

• Difficulty speaking

• Subcutaneous emphysema in neck

• Tracheal deviation

Assessment:

• Visualize & palpate neck:

  • Trauma/wound

  • Cervical spine

  • JVD

  • Trachea

• Assess airway/breathing

• Assess carotid pulse

Treatment:

• C-spine stablization

• Control/dress/bandage major bleeding:

  • Immediate direct pressure on bleed w/ gloved hand

  • Occlusive dressing taped x4 sides

    • Consider c-collar

• SpO2 95%+

• Supine SMR

• ALS: IV

• Transport

Spinal Trauma

Definition: Damage/insult to any vertebrae of spinal column or to spinal cord

Forms:

• Spinal column injury

• Spinal cord injury

  • Complete:

    • Quadriplegic

    • Paraplegic

  • Incomplete:

    • Anterior Cord syndrome

    • Central cord syndrome

    • Brown-Sequard syndrome

Signs & Symptoms:

• Spinal column:

  • Pain/tenderness

  • Deformity

• Spinal cord:

  • Loss of motor/sensory function

    • Paresis/paralysis (motor)

    • Paresthesia/anesthesia (sensory)

  • Neurogenic hypotension

  • Incontinence/priapism

Assessment:

• Palpate entire spinal column

• Assess for spinal shock

  • Evaluate/compare each extremity:

    • Motor vs light touch vs pain

  • Neurogenic hypotension

  • Incontinence

  • Priapism

Treatment:

• C-spine stablization

• SpO2 95%+

• Supine SMR

• ALS: IV, medication

• Rapid Transport