trauma block

Scene safety (trauma)

The first priority on every trauma call, assessed before approaching the patient; includes traffic, hazardous materials, hostile environment, unsecured crime scene, and sudden changes in patient behavior

PENMAN

Mnemonic for scene size-up hazards to check for at a trauma scene: Personal protective equipment, Environment, Number of patients, Additional resources, Need for a backboard/C-spine

Golden Hour / Golden Period

The time frame from injury to definitive surgical care during which severely injured patients have the best chance of survival if care is provided as quickly as possible; the actual time available varies by injury, so it is not a fixed 60 minutes

Platinum 10 Minutes

The recommended maximum on-scene time for a severely injured or multisystem trauma patient; assessment, life-threat management, and preparation for transport should be completed within 10 minutes of arrival

Mechanism of injury (MOI)

How a patient was injured (e.g., motor vehicle collision, fall, gunshot); it raises suspicion of injury but assessment findings are what actually determine emergency care

Kinetics of trauma

The science of analyzing mechanisms of injury to predict the kind and extent of injuries a patient may have sustained

Kinetic energy formula

Kinetic energy = mass x velocity squared, divided by 2; doubling mass doubles kinetic energy, but doubling velocity quadruples it because velocity is squared

Why velocity matters more than mass

Because velocity is squared in the kinetic energy formula, a small increase in speed causes a much greater increase in energy and potential injury than the same increase in mass

Law of inertia

One of Newton's laws of motion: a body at rest stays at rest and a body in motion stays in motion unless acted on by an outside force

Acceleration

The rate at which a body in motion increases its speed

Deceleration

The rate at which a body in motion decreases its speed; a faster rate of deceleration or acceleration produces greater force and injury

Three impacts of a vehicle collision

Vehicle collision (vehicle strikes an object), body collision (occupant strikes the interior of the vehicle), and organ collision (internal organs strike internal body surfaces)

Blunt trauma

Force applied to the body with no penetration of an object through the skin (e.g., a baseball bat to the chest)

Penetrating trauma

Trauma that produces a break in the continuity of the skin from an object such as a knife or bullet

Frontal impact injury pattern

Up-and-over path causes injury to head, neck, chest, and abdomen with possible ejection; down-and-under path causes injury to knees, femurs, hips, and spine

Paper bag syndrome

Chest compression injury where air trapped in the lungs by a closed epiglottis is compressed between the ribs and spine, causing lung bruising or rupture, seen in frontal impacts

Rear-end impact injury pattern

Head and neck are whipped backward first (potential whiplash/neck injury), then the body jolts forward causing frontal-type injuries once the vehicle stops

Lateral impact injury pattern

Vehicle is crushed inward causing injury to the head, neck, chest, abdomen, pelvis, and extremities on the side that bore the brunt of the impact; vertebral fractures and rib fractures with liver/spleen injury are common

Rotational/rollover crash injury pattern

Difficult to predict a specific pattern; common findings are multisystem injury, ejection if unrestrained, crush injuries to ejected occupants, and axial loading spinal injuries

High-risk MOI indications (vehicle)

Death of another occupant in the same compartment, unresponsive patient or altered mental status, intrusion greater than 12 inches at the occupant site or 18 inches anywhere, ejection from the vehicle, and vehicle telemetry data showing high risk

Ejection from a vehicle

Increases chance of death by 25 times and is associated with a much higher incidence of cervical spine fracture

Air bag injury risk

Air bags deployed within about 10 inches of the head, neck, or chest can cause significant injury; older adults, short adults under 5 ft 2 in, and children under 12 are most prone to air bag-related injury

Restraint hidden injuries

Lap belts worn alone can cause lumbar spine compression fractures; worn too low can dislocate hips; worn too high can cause abdominal compression and spinal fracture; a shoulder strap without a lap belt can cause severe neck injury

Motorcycle collision impact types

Head-on impact (rider pivots into handlebars), angular impact (rider strikes an object at an angle), and ejection (rider clears the handlebars)

Laying the bike down

An evasive motorcycle maneuver where the rider turns the bike sideways to slide out from under it and avoid a direct collision, commonly causing abrasions and burns to the inside leg

Helmet effect on motorcycle injury

Not wearing a helmet increases the incidence of severe head injury and death by 300 percent, the same increase seen with unrestrained vehicle ejections

SCIWORA

Spinal cord injury without radiologic abnormality; occurs in children when the spinal cord is stretched and injured but the pliable pediatric vertebrae show no fracture on imaging

Falls as MOI

The most common mechanism of injury overall but not the most lethal; a 20-foot fall (two stories) onto an unyielding surface is severe for an adult, and a fall greater than 10 feet or 2-3 times a child's height is severe for a child

Feet-first fall pattern

Energy travels up the skeletal system causing heel and ankle fractures/dislocations; if knees are locked, energy transmits through femurs to hips/pelvis and up the spine causing compression fractures

Head-first fall pattern

Injury pattern begins at the arms and shoulders and extends to the head, which can be hyperextended, hyperflexed, or compressed, causing extensive cervical spine damage

Colles fracture

A fracture of the wrist bones (silver fork fracture) commonly caused by extending the arms to break a fall

Low-velocity penetrating injury

Caused by objects like knives; damage limited mainly to the immediate area of impact and underlying structures because kinetic energy is low

Medium- and high-velocity penetrating injury

Caused by bullets and pellets; damage depends on trajectory and dissipation of energy (drag, profile, cavitation, fragmentation), producing tissue damage far beyond the entry point

Cavitation

Pathway expansion; a cavity formed in body tissue by the pressure wave from a bullet's kinetic energy, extending tissue damage well beyond the bullet's actual path; occurs with medium- and high-velocity but not low-velocity projectiles

Trajectory (ballistics)

The path or motion of a projectile during travel; faster bullets follow a flatter, straighter trajectory

Fragmentation

When a bullet breaks into pieces or releases fragments on impact, increasing the frontal impact area and spreading tissue damage over a larger area

Gunshot wound statistics

About 90 percent of fatal firearm wounds involve the head, thorax, and abdomen

Blast injury phases

Primary (pressure wave affecting gas-filled organs like lungs, GI tract, ears), secondary (flying debris causing lacerations, impaled objects, fractures), tertiary (patient thrown by the blast, ejection-type injuries), and quaternary/quinary (structural collapse, chemical/toxin/radiation exposure)

Primary blast injury danger

Often produces no external signs of injury yet can cause severe damage and death to gas-containing organs (lungs, GI tract, ears); frequently under-suspected compared to secondary/tertiary injuries

Multisystem trauma patient

A patient with injuries or involvement of more than one body system; about 90 percent of trauma patients have only a single-system injury

Level I trauma center

A regional trauma center that can manage the full range of traumatic injuries 24/7

Level II trauma center

An area trauma center with surgical capability 24/7 that can manage most trauma and stabilize/transfer specialized patients to a Level I center

Level III trauma center

A community trauma center with some surgical capability that stabilizes seriously injured patients and transfers them to a higher-level center

Level IV trauma facility

Typically a small, remote community hospital capable of stabilizing seriously injured patients before transfer to a higher-level trauma center

Trauma triage criteria examples (CDC/ACS field triage)

Airway compromise, GCS 13 or less, flail chest, two or more proximal long-bone fractures, crushed/mangled extremity, amputation proximal to the wrist or ankle, pelvic fracture, penetrating trauma to head/neck/torso, and multisystem trauma

Golden principles of prehospital trauma care

Ensure scene safety, determine MOI, primary assessment for life threats, spine motion restriction as indicated, maintain airway/breathing/oxygenation, control hemorrhage, maintain body temperature, splint fractures, and transport within 10 minutes on-scene time for critical patients

Trauma load-and-go criteria

Patients with airway compromise, inadequate breathing, uncontrolled bleeding, signs of shock, altered mental status, GCS 13 or less, or significant penetrating trauma who require rapid transport with minimal scene time

Arterial bleeding

Bright red, spurting blood that coincides with the pulse, from a severed or damaged artery; the most difficult type of bleeding to control because of high pressure

Venous bleeding

Dark red blood in a steady flow from a severed or damaged vein; usually easier to control than arterial bleeding

Capillary bleeding

Slow oozing of dark to intermediate red blood from damaged capillaries; usually clots spontaneously and is easy to control

Adult blood volume estimate

About 70 mL/kg; an average 154-lb (70-kg) adult has approximately 4,900 mL (4.9 L) of blood volume

Significant blood loss threshold

A loss of 15 percent or more of blood volume is considered significant and can lead to shock

Infant/child blood volume estimate

About 80 mL/kg; a 10-kg infant has approximately 800 mL of blood volume, so even small losses represent a large percentage

Classes of hemorrhage

Class I less than 15 percent blood loss (normal vitals), Class II 15-30 percent (increased HR/RR, narrowing pulse pressure), Class III 30-40 percent (decreased BP, marked tachycardia/tachypnea), Class IV greater than 40 percent (severe hypotension, may bradycardia, life threatening)

Signs of major life-threatening bleeding

Spurting blood, steady flow, blood pooling on the ground, blood-soaked clothes/dressings that keep soaking through, or a traumatic amputation/near-amputation

Methods to control major external hemorrhage (in order)

Direct pressure, compression/pressure dressing, tourniquet (if extremity), wound packing with hemostatic gauze plus direct pressure (if tourniquet not possible), and junctional tourniquet for junctional areas

Direct pressure technique

Apply fingertip or hand pressure directly to the bleeding point using a sterile dressing; large wounds may require packing with gauze plus direct hand pressure

Tourniquet application

Applied proximal to the wound (not over a joint), tightened until bleeding stops and the distal pulse is eliminated, with application time written on tape and left visible; a second tourniquet is applied proximal to the first if bleeding continues

Tourniquet mistakes to avoid

Not using one when clearly indicated, applying over the wound, removing without medical direction, not tightening enough to stop the pulse, failing to add a second tourniquet if needed, and loosening to relieve pain

Improvised tourniquet

A bandage at least 4 inches wide, four to six layers thick, used with a windlass/spindle device; a blood pressure cuff inflated to 20 mmHg above systolic pressure is another alternative

Wound packing indications

Used for junctional injuries (groin, axilla) or wounds where a tourniquet cannot be applied and direct pressure fails to control bleeding

Wound packing procedure

Apply direct pressure, pack the wound tightly (preferably with hemostatic gauze) making contact with the bleeding vessel, hold direct pressure for 3 minutes, then apply a compression/pressure dressing

Hemostatic agents

Dressings or gauze impregnated with substances (e.g., kaolin in QuikClot, chitosan in Celox) that accelerate clotting; used for bleeding in areas where a tourniquet cannot be applied; less effective for arterial bleeding; granule/powder forms are no longer recommended prehospital

Junctional bleeding control

Occurs where extremities meet the torso (groin, axilla, shoulder, neck); tourniquets cannot be used here, so direct pressure and hemostatic dressings (or approved junctional tourniquet devices) are used

Splinting as bleeding control

Splints reduce movement at a fracture site, decreasing further vessel damage; a traction splint reduces the diameter of the thigh, decreasing space for a femur fracture to bleed into

Blood loss around fractures

Up to 1,500 mL can be lost around a fractured femur, and 500-750 mL around the tibia/fibula

Stop the Bleed campaign

A 2015 White House-launched national initiative to teach bystanders to recognize and control severe bleeding before EMS arrives

Epistaxis

Nosebleed; bleeding from the nose that can result from injury, disease, or environment; usually more annoyance than life threat but can cause hemorrhagic shock with extreme blood loss

Nosebleed emergency care

Sit patient up with head tipped slightly forward (not back), pinch the soft part of the nose for a full 10 minutes without releasing, apply an ice pack to the nose/cheeks, and avoid nose blowing for 12 hours

Bleeding from ears/nose after trauma

Suspect a possible skull fracture; do not attempt to stop the flow, place a loose dressing to collect drainage without applying pressure

Common causes of nose/ear/mouth bleeding

Skull injury, facial trauma, digital trauma (nose picking), sinusitis/URI, hypertension, clotting disorders, and esophageal disease

Internal bleeding causes

Blunt trauma, abnormal clotting, rupture of a blood vessel, and certain fractures, especially of the femur or pelvis

Hematoma blood loss estimate

A hematoma the size of a patient's fist equals approximately 10 percent of blood volume

Blood loss capacity by cavity/site

Femur fracture up to 1,500 mL, tibia/fibula/humerus fracture 500-750 mL, and the thoracic cavity can hold approximately 3,000 mL of blood

Signs and symptoms of internal bleeding

Pain, tenderness, swelling or discoloration at the injury site, bleeding from an orifice, vomiting blood (bright red or coffee-ground), dark tarry stools, and a tender, rigid, or distended abdomen

Signs of hemorrhagic shock

Anxiety, restlessness, altered mental status, weakness/dizziness, thirst, rapid shallow breathing, rapid thready pulse over 90/min, pale cool clammy skin, delayed cap refill, narrow pulse pressure, dropping BP, sluggish dilated pupils, nausea/vomiting

Why abdomen may not appear distended with internal bleeding

1-2 liters of blood can be lost into the abdomen while distending it only about 1 inch

Factors that increase bleeding

Movement, low body temperature, anticoagulant/NSAID/aspirin medications, IV fluid administration, and removal of dressings/bandages

Hemorrhagic shock physiology

Blood loss reduces circulating volume, cardiac output falls, the sympathetic nervous system triggers vasoconstriction and tachycardia, and if uncorrected the brain becomes ischemic leading to medullary failure and death

Emergency care for hemorrhagic shock

Standard precautions, control external bleeding, maintain airway/breathing with high-concentration oxygen, supine position, keep warm (cover the patient, warm the compartment to about 85 degrees), immediate transport, splint fractures if time allows

Contusion

A closed soft tissue injury (bruise) to tissue and blood vessels within the dermis, causing localized swelling, pain, and ecchymosis (black-and-blue discoloration)

Hematoma (soft tissue)

Similar to a contusion but involves a larger blood vessel and larger tissue area, causing a large bluish lump; can equal 10 percent blood loss if fist-sized

Crush injury

Caused by severe blunt or crushing force; can be open or closed and cause serious internal bleeding, hemorrhagic or hypovolemic shock; bleeding may be tamponaded while the object is on the body and become profuse once it is removed

Abrasion

Scraping or shearing away of the epidermis; painful due to exposed nerve endings but usually only capillary bleeding

Laceration

A break in the skin of varying depth; can be linear (regular, from sharp objects, heals better) or stellate (irregular, from blunt objects, jagged edges)

Avulsion

A flap of skin and tissue torn loose (partial) or pulled completely off (complete); commonly involves fingers, toes, ears, and nose; bleeding can be severe

Amputation

Disruption in continuity of an extremity or body part from ripping/tearing forces; bleeding can be massive but is often limited by vessel elasticity; incomplete amputations often bleed more than complete ones

Penetration/puncture injury

Caused by a sharp, pointed object; the entry wound may look small but can conceal deep, severe internal damage

Gunshot entrance vs exit wound

Entrance wounds are generally smaller (with powder burns if close range) and exit wounds larger and more profuse, but EMS should not focus on labeling wounds as entrance/exit, only on locating and treating all wounds

Bite wound complications

Cellulitis, septicemia, rabies, and tetanus; human bites carry a high infection risk (more bacteria than animal mouths) and can cause hepatitis; most frequent human bite sites are ears, nose, and fingers

Clamping injury

A body part caught or strangled by machinery or an object; if the patient is stable, lubricate and attempt to gently free the part; if unstable, transport with the clamping object in place

High-pressure injection injury

Caused by injectors of water, grease, paint, sand (industrial) or home pressure washers (over 2,000 psi); may look minor initially but has amputation rates as high as 48 percent; requires immediate facility evaluation

Distracting injury

A painful injury (often a fracture) severe enough to distract the patient from complaining about other, potentially more serious injuries or wounds elsewhere on the body

Sucking chest wound emergency care

Cover with a gloved hand first, then apply a nonporous occlusive dressing taped on three sides to allow trapped air to escape during exhalation while preventing more air from entering

Abdominal evisceration care

Never touch or replace protruding organs; cover with a sterile dressing moistened with sterile water/saline, then an occlusive covering; flex the patient's hips and knees if no spinal injury is suspected

Impaled object general rule

Never remove an impaled object in the field except if it obstructs the airway through the cheek or neck, or prevents CPR/airway management; stabilize in place with bulky dressings

Amputated part care

Rinse with sterile water/saline to remove gross contamination, wrap in dry sterile gauze, seal in a watertight plastic bag, place the bag on ice (never direct contact with ice), and transport with the patient if possible

Large open neck wound care

Place a gloved hand over the wound, apply an occlusive dressing extending beyond the wound edges taped on four sides, cover with a regular dressing, apply only enough pressure to control bleeding, and never bandage circumferentially around the neck

Air embolism risk (neck injury)

A lacerated neck vein can allow air to be sucked into the venous system during inspiration and travel to the heart, which can be lethal; prevented with a properly applied occlusive dressing

Dressing

A sterile covering placed directly over a wound to control bleeding and prevent contamination