Trauma

Brentwood Legion Ambulance Probationary Class

AVPU Scale (Level of Consciousness)

Alert: The patient is awake, responsive, and oriented. The listed “silly questions”

1.     Where are you?

2.     What month and year is it?

3.     How many Quarters are in a dollar? Or any other questions

These are standard questions used to check is a patient is oriented to person, place, time, and event.

Verbal: The patient is not fully alert but responds when you speak to them

Painful: The patient only responds to painful stimuli (like a sternal rub or pinching)

Unresponsive: The patient does not move or respond to any verbal or painful stimuli.

ABC’s (Primary Assessment)

Airway: Checking is the patients airway is open and clear

Breathing: Assessing if the patients is breathing adequality

Circulation: Checking for a pulse and controlling severe bleeding

PMS before and after

-       Stands for pulse, motor, sensory function

-       It is critical neurological assessment checked in a patient’s extremities

-       The note highlights doing this before and after splinting a fracture or moving a patient to ensure that blood flow and nerve function have not been compromised by the injury or medical intervention.

Scene Assessment

-              Components:

o   Safety

• Fire, contamination, combat, etc

o   Pre-Arrival information

o   Arrival on scene

o   Available resources

o   Mechanism of injury

o   Patients

-              Taught individually; performed simultaneously

-              Personal and personnel safety is paramount

Arrival on Scene

-              Global assessment

o   As you arrive at the scene

o   Before you get out of the vehicle

-              “What do I see, feel, hear, smell,.?”

o   Are there any hazards?

o   What happened?

o   Who, what, and how many are involved?

o   Are there any access issues?

o   What additional resources may be needed?

Mechanism of Injury

-              Energy

o   Cannot be destroyed

o   Can only be transferred or transformed

-              Energy transfer to human tissue results in:

o   Compression

o   Tearing

o   Shearing

-              Blunt trauma

o   Common injury patterns

• Motor vehicle crashes (MVCs)

• Pedestrian

• Falls

• Sports

• Blast injuries

-              Penetrating injuries

o   What was the velocity of the object?

• Low or high energy

o   How far away was the patient from the energy source?

• Apparent trajectory (pathway)

Patients

-              How many patients are involved?

o   Principles of triage

o   Who needs attention first?

o   Adequate resources available?

-              Can you gain access?

-              Can you get the patient out?

-              Initial Impression

o   Prior to formal primary assessment

o   Is the patient:

• “Sick” -- critical

• “Not yet sick” – potential for critical or serious injuries

•   “Not sick” – minor or no injuries

Principles

-              Machinery of life

o   Depends on the interactions of airway, breathing, and circulation

o   Adequate energy production is requires to maintain life functions

Primary Assessment

-              Is performed to immediately identify life-threatening conditions

o   Life-threating conditions should be managed as they are identified

-              Some life-threatening situations are not visually apparent

o   Internal hemorrhage

o   Traumatic brain injury (TBI)

-              Do not be distracted by visually dramatic, non-life-threatening injuries

-              Primary assessment and management take precedence over the secondary assessment

-              Decision-making considerations

o   Situation

o   Assessment

• MOI (kinematics)

• Patients

·      A-B-C-D-E

• A – Airway: Check if the airway is open and clear of objects, blood, or swelling. Fix blockages right away.

• B – Breathing: Look, listen, and feel for normal breathing. Check the rate, depth, and lung sounds, and give oxygen if needed.

• C – Circulation: Check the pulse, skin color, and blood pressure. Look for severe bleeding or signs of shock.

• D – Disability: Check basic brain function. Test responsiveness (using AVPU or GCS scales) and check pupil reactions.

• E – Exposure / Environment: Remove clothes to check for hidden injuries, then keep the patient warm to stop heat loss

o   Patient Severity

• Sick

• Not yet Sick

• Not sick

Transport Decision

-              Does the patient’s condition warrant immediate transport?

o   If yes, consider:

•   Method and mode of transportation

·      Ground versus air

·      Emergent versus non-emergent

• Patient packaging

·      Spinal immobilization as indicated

·      Consider use of long backboard as a full body splint

-              Does the patient’s condition warrant immediate transport?

o   If no:

•   Continue with the secondary assessment if indicated

Transport Considerations

-              Receiving facility selection

o   Choice of destination

•   Level of care needed

• Trauma center versus the closet hospital

o   Early Communication and notification

• Allows the facility to prepare

Circulatory System

-              A functioning circulatory system requires:

o   A heart that pumps adequately

o   Intact blood vessels to contain the fluids (blood) being pumped

o   Adequate amount of blood (fluid) to fill the vascular container

Shock in Trauma

-              Classifications

o   Hypovolemic

o   Distributive

o   Cardiogenic

Hypovolemic Shock

-              The most common cause of shock in the trauma patient

o   Due to hemorrhage

• Loss of RBCs impairs oxygen transportation

o   In any trauma patient with shock, assume hemorrhage is the cause until proven otherwise

Cardiogenic Shock

Intrinsic

-              Blunt Cardiac trauma leading to muscle damage and/or dysrhythmia

-              Valvular disruption

Extrinsic

-              Pericardial tamponade

-              Tension pneumothorax

Shock Without Obvious Cause

-              Assume the patient is bleeding somewhere, even if you can’t see it

o   Internal hemorrhage

o   Fracture

-              Internal hemorrhage

o   The chest and abdomen can hold large volumes of blood

o   The chest is usually associated with visible external signs trauma; the abdomen often is not

o   Abdominal Trauma is a cause of significant hidden hemorrhage

o   Assume abdominal trauma if hypovolemic chock is not otherwise explainable

-              Fractures

o   Multiple fractures

o   Blood loss into the surrounding soft tissues from a long-bone fracture, such as the femur, can be significant

o   Blood loss into the pelvic and abdominal spaces from a pelvis fracture can be massive

Mechanism of Injury and Shock

-              Penetrating injuries

o   Object traverses the chest, abdomen, or extremity

o   May injure organs, tissues, and blood vessels along its pathway

-              Blunt Injuries

o   Path of injury is less visible

o   Force (energy) is applied to the trunk and extremities

o   Energy is transmitted to the thoracic and abdominal organs and bones causing damage

o   Compression, cavitation, and deceleration can tear and shear organs and blood vessels and fracture bones

o   Damaged organs, tissues, and blood vessels bleed into surrounding cavities and tissue

o   As the amount of blood lost increases, sign of shock develop

Traumatic Aortic Rupture (Tear)

-              Usually occurs at the junction of the mobile and fixed portions of the aorta just beyond the left subclavian artery

-              80% to 85% die prehospital from intrathoracic hemorrhage

o   Of those who survive, 50% die within 48 hours is not treated

Hemothorax

-              Bleeding into pleural cavity

-              Blunt or penetrating mechanism

-              Each hemithorax can hold up to 30% to 40% of a patient’s total blood volume

Abdominal Organ Injury

-              Results from a blunt or penetrating mechanism

-              Injury to:

o   Solid organs (liver, spleen, kidney, pancreas)

• Results in hemorrhage that varies from mild to life-threatening

• May also be associated with leak of enzymes, bile, or urine into abdomen

o   Hollow organs (small and large bowel)

• Usually not a cause of major blood loss

• Leak contents and cause peritonitis

Fractures

-              Major or multiple fractures can lead to significant blood loss

-              Femur or pelvic fractures are the most common cause

-              DO NOT underestimate blood loss due to multiple fractures

External Hemorrhage Control:

-              Direct Hand Pressure  Pressure Bandage/Dressing  Bleeding controlled?  Yes? Hospital

-              Direct Hand Pressure  Pressure Bandage/Dressing  Bleeding controlled?  NO? Where is the Bleeding Site?  Extremity  Tourniquet  Hospital

-              Direct Hand Pressure  Pressure Bandage/Dressing  Bleeding controlled?  NO? Where is the Bleeding Site?  Trunk  Topical Hemostatic Agent  Hospital

Penetrating Head Injury:

• Gunshot wound

-              Stab wound

-              Other

-              Usually a major injury from direct damage to brain tissue

Traumatic Head and Brain Injury: Secondary Brain Injury

-              Secondary Brain injuries include:

o   Hypotension

o   Hypoxia

o   Cerebral edema

o   Increased ICP

o   Intracranial Infection

o   Seizure

-              Can further exacerbate the primary brain injury

Spinal Immobilization Algorithm: Blunt Trauma

-              Blunt trauma  Altered level of consciousness (GCS, 15)  Yes  Immobilize  Rapid Transport

-              Blunt trauma  Altered level of consciousness (GCS, 15)  No  Spinal pain or tenderness? Or Neurologic deficit or complaint? Or anatomic deformity of spine?  Yes  Immobilize  Rapid Transport

-              Blunt trauma  Altered level of consciousness (GCS, 15)  No  Spinal pain or tenderness? Or Neurologic deficit or complaint? Or anatomic deformity of spine?  No  Concerning mechanism of injury

Concerning mechanism of injury:

-              Violent impact to the head, neck, torso, or pelvis

-              Sudden acceleration, deceleration, or lateral bending forces to neck or torso

-              Falls

-              Ejection or fall from any motorized or human-powered transport device

-              Shallow-water diving incident

Spinal Immobilization Algorithm: Blunt Trauma

-              Blunt trauma  Altered level of consciousness (GCS, 15)  No  Spinal pain or tenderness? Or Neurologic deficit or complaint? Or anatomic deformity of spine?  No  Concerning mechanism of injury  Yes  Presence of: Evidence of alcohol/drugs or Distracting Injury or Inability to communicate?  Yes  Immobilize  Transport

-              Blunt trauma  Altered level of consciousness (GCS, 15)  No  Spinal pain or tenderness? Or Neurologic deficit or complaint? Or anatomic deformity of spine?  No  Concerning mechanism of injury  Yes  Presence of: Evidence of alcohol/drugs or Distracting Injury or Inability to communicate?  No  Immobilization not indicated  Transport

-              Blunt trauma  Altered level of consciousness (GCS, 15)  No  Spinal pain or tenderness? Or Neurologic deficit or complaint? Or anatomic deformity of spine?  No  Concerning mechanism of injury  No  Immobilization not indicated  Transport

Distracting Injuries:

-              Any injury that may impair the patient’s ability to appreciate other injuries, including:

o   Long-bone fracture

o   Suspected visceral injury

o   Large laceration, degloving, or crush injury

o   Large burns

o   Any other injury that produces acute functional impairment

Spinal Immobilization Algorithm: Penetrating Trauma

-              Penetrating trauma to head, neck, or torso  neurological deficit/complaint?  Yes  Immobilize  Rapid Transport

-              Penetrating trauma to head, neck, or torso  neurological deficit/complaint?  No  Immobilization not indicated  Rapid Transport

-              *****USE CLINICAL JUDGEMENT IF IN DOUBT, IMMOBLIZE*****

Trauma Resuscitation Issues

-              It may be allowable to withhold or terminate resuscitation efforts in:

o   Injuries not compatible with life

o   Pulseless and nonbreathing blunt trauma victims

o   Trauma patients with witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and CPR.

Equipment and Supplies:

-              Gauze Sponges

-              Combine ABD Pad

-              Combat -Application Tourniquet

-              Multi-Trauma Dressing

-              Chest Seals

-              Rolled Gauze

-              Israeli Emergency Bandage

-              Quick Clot