Trauma Foundations pt 1

Scene History: SAMPLE & OPQRST

• Always attempt to obtain a full SAMPLE history (Signs/Symptoms, Allergies, Medications, Past history, Last oral intake, Events) and an OPQRST pain assessment (Onset, Provocation/Palliation, Quality, Radiation/Region, Severity, Time) while the patient is still awake.

  • Rationale: patients can rapidly deteriorate and lose the ability to communicate; the crew will then arrive at the ED with no information.

  • Example given: provider stopped asking questions on scene, patient became unresponsive in the truck, leaving crew with no name, age, meds, or history. This caused embarrassment and delayed care.

• Strategies for data-gathering when the patient cannot talk:

  • Send a crew member to search the patient’s vehicle, purse, or wallet for IDs and medication lists.

  • Interview family, friends, or bystanders immediately.

  • Photograph medication bottles (if allowed by policy) before leaving scene.

Focused vs. Rapid Physical Assessment

• Isolated, minor injury → Focused exam on affected system/part.

• Mandatory rapid head-to-toe when:

  • Altered mental status (unable to verify "it’s just my ankle").

  • Multi-system trauma (e.g.

  • Pedestrian hit by car → potential chest, lung, and orthopedic injuries).

Maintaining an Organized Exam Sequence

• Choose one sequence and repeat it exactly the same every time to prevent omissions.

  • Instructor’s preferred order: Head → Chest → Abdomen → Pelvis → Legs → back up to Arms.

  • Alternates acceptable (e.g. right leg → right arm → left leg) if consistent.

DCAP-BTLS Detailed Checklist

Definitions & Pitfalls:

• Incision = clean cut from a sharp object (knife, scalpel) – NOT technically a laceration.

• Many clinicians misuse the word “laceration”; know the difference for documentation, but use language appropriate to receiving facility expectations.

Exposure & Modesty

• “Expose what you need to see, but preserve dignity.”

  • Pre-plan with sheets/blankets.

  • Cutting clothing: split pant legs but keep waistband fastened to create impromptu shorts.

  • Avoid leaving patient fully naked on roadside, mall, or Walmart parking lot (“they’re probably exposed already” → humor, but still unethical).

Systematic Physical Exam Elements

1. Head / Skull / Face / Scalp / Ears / Nose / Mouth

   • DCAP-BTLS on all surfaces.

   • Eyes: assess pupils for PERRLA (Pupils Equal, Round, Reactive to Light, Accommodating).

2. Neck / Cervical Spine

   • DCAP-BTLS + look for:

     • $\text{JVD}$ (Jugular Venous Distension)

     • Tracheal deviation (late tension pneumothorax sign)

   • Manual in-line stabilization ➔ palpate spinous processes for stepoff or focal pain.

   • Decide on C-collar after palpation; placing blindly or skipping exam both criticized.

3. Clavicles

   • High incidence of fracture; sits over subclavian vessels.

   • Fracture + dropping blood pressure → suspect vascular injury, alert ED for possible emergent OR.

4. Chest / Thorax

   • Inspect, palpate, auscultate lungs.

   • Consider loading patient with multi-system chest trauma for rapid transport.

5. Abdomen / Pelvis

   • Palpate all four quadrants.

   • Assess pelvic stability; avoid repeated rocking.

6. Extremities

   • Palpate long bones; compare bilaterally; assess distal CSM (Circulation, Sensation, Movement).

   • Run DCAP-BTLS on arms and legs; order does not matter as long as it is consistent.

Cervical Spine Decision-Making

• Mechanisms warranting suspicion: MVCs, falls, blunt head trauma, etc.

• Signs: midline tenderness, stepoff deformity, neurological deficit.

• If lateral neck pain (muscle) only—no C-spine pain—C-collar may not be needed, but ED may overrule.

Ethical / Practical Implications

• Patient dignity: unnecessary exposure = loss of trust, potential legal issues.

• Thorough information improves ED hand-off, speeds diagnostics, and avoids provider embarrassment.

• Consistency in exam reduces error; variability increases missed injuries.

Memory Aids & Mnemonics Used

• SAMPLE, OPQRST, DCAP-BTLS, PERRLA/Perla, CSM.

• “If it isn’t the spine, don’t immobilize the spine.”

Key Takeaways

• Gather history early; you may not get a second chance.

• Any altered or multi-system trauma patient defaults to rapid head-to-toe.

• Use DCAP-BTLS on every body surface in a repeatable order.

• Understand wound terminology: laceration ≠ incision.

• Expose intelligently—see injuries while maintaining modesty.

• Cervical spine must be physically assessed before collaring or dismissing.

• Check clavicles; vascular structures lie beneath.

• Aim to arrive at hospital able to answer every foreseeable question about your patient.

Trauma Foundations pt 2 (Assessment)

Why Trauma Assessment Matters

• Trauma is the single leading cause of death from ages 1 – 46.
• Nationally, only ~$20\%$ of EMS responses are trauma—meaning you see it less often and must rely on memorized, practiced algorithms rather than routine exposure.
• Goal scene time for “emergent” trauma is $\le 10\text{ min}$ (“10-and-under club”). That clock moves fast; effective critical thinking must happen in real time.

Preparation & Mind-set

• Learn the assessment sheet until you can “word-vomit” it on command.
• Remember some steps are literal check-boxes (e.g., “Consider C-spine”)—but you must follow the words with actions (direct a partner to obtain manual stabilization).
• Resources you can call: fire, police, haz-mat, SWAT, helicopter, National Guard, specialized rescue teams, extra ALS units, etc. State them aloud so the evaluator hears you.

The Four-Quarter Framework

1st Quarter – Scene Size-Up & Initial Decisions

• BSI / Scene safety.
• Mechanism of injury (MOI); note energy transfer.
• “Consider C-spine” → then assign a rescuer: “Partner, hold manual C-spine.”
• Additional resources as above.
• Rapid extrication vs. “dirty grab.”
– Rapid extrication = maintain C-spine but move quickly because life threat cannot be treated in current position (e.g., apnea, tension pneumothorax, uncontrolled hemorrhage).
– Dirty grab = truly life-over-C-spine (car on fire, haz-mat).
– Target: ≤ $60\ \text{s}$ (sometimes up to 2 min in real cars, obese pt, 2-door Civic, steering-wheel entrapment).
– Do NOT wait on a backboard; ventilate on the ground if necessary.

2nd Quarter – Primary Survey / ABCs

• General Impression
– Look at patient and scene (“quick 360” around the vehicle: airbag deployment, intrusion, ejection points, other cars).
• Level of Consciousness (AVPU), introduce yourself, obtain name.
• Chief Complaint & Apparent Life Threats—address the following immediately:
– Uncontrolled external bleeding → direct pressure / tourniquet.
– Sucking chest wound → glove hand → occlusive dressing.
– Tension pneumothorax (absent L lung sounds after blunt chest) → needle decompression.
– Airway obstruction (snoring, gurgling) → jaw-thrust, suction, OPA/NPA.
– Environmental threats (still in water, smoldering clothes, ant mound) → remove from danger first.
• Airway
– Open with jaw-thrust (trauma standard).
– Insert airway adjunct if snoring or tongue obstruction persists.
• Breathing
– Look for equal chest rise.
– Auscultate quickly: right apex, left apex, right base, left base.
– Treat injuries compromising ventilation; administer O₂.
• Circulation
– Carotid & radial pulses, skin color/temp/moisture.
– Re-scan for bleeding.
– Shock management if needed:
* Supine positioning (no Trendelenburg/leg-raise in modern practice).
* Keep warm (blanket).
* High-flow O₂ + place ETCO₂ cannula.
• Shock Recognition
– Pale/ashen, diaphoresis, cool skin, weak pulses, ↓BP.

ETCO₂ (“Capnography”) Pearls

• Attach nasal ETCO₂ early—gives continuous perfusion feedback.
• Low ETCO₂ (< $35\ \text{mmHg}$) = one of the “3 P’s” (classic mnemonic):
1. Perfusion problem (hemorrhage, hypovolemia, PE, CHF pulmonary edema).
2. Pump problem (severe cardiogenic shock, tamponade).
3. Pulmonary problem (massive asthma, tension pneumo).
• High ETCO₂ (> $45\ \text{mmHg}$) = hypoventilation / respiratory depression (e.g., opioid OD, high cervical cord injury causing low RR).

Transport Decision (“Load & Go” vs “Stay & Play”)

• State it clearly for the team and evaluator: “This is a load-and-go patient—goal scene time < 10 min.”
• 90 % of exam scenarios = load & go.
• Stay & play only if isolated, stable injury with no ABC compromise and no shock signs.
• Saying the words ≠ leaving instantly; you still finish priority interventions while packaging.

Purpose of the Primary Survey

• Quickly identify and correct immediate threats to life.

Halftime Checklist (Before Secondary Survey)

Instructor’s memory aid—say it out loud so your crew and evaluator track your plan (write these on your practice note card):

1. Vitals? (BP, HR, RR, SpO₂, ETCO₂, temp if indicated).

2. Delegated interventions running? (O₂ flowing, bleeding controlled, dressing secured).

3. Backboard / stretcher ready?

4. ALS / Air Medical requested if needed?

5. Estimate scene time (keep ≤ 10 min).

3rd Quarter – Secondary Assessment

• Decide Rapid Head-to-Toe or Focused Exam.
– Rapid = multi-system trauma, altered LOC, significant MOI, or any abnormality found in primary.
– Focused = isolated, minor, stable injury (e.g., ankle fracture, skateboard femur, lac to forearm).
• Examination considerations (not detailed in transcript but implied):
– Head/face (DCAP-BTLS, pupils, raccoon eyes, Battle’s sign, airway burns).
– Neck (tracheal deviation, JVD, step-offs).
– Chest (paradoxical motion, crepitus, auscultation in 6 spots if time).
– Abdomen (rigidity, distention, seat-belt sign).
– Pelvis (gentle compression).
– Extremities (CMS, deformity, bilateral pulses).
– Posterior (log-roll if safe, inspect spine & back of head).
• Obtain complete set of vitals during or immediately after.

4th Quarter – Ongoing Assessment & Transport

• Re-check ABCs, vitals every 5 min (critical) or 15 min (stable).
• Prepare for hand-off: MIST/ATMIST report, mechanism details from your 360 survey, treatments given, patient response.

Immediate Life-Threat Examples & Quick Fixes

Shock Management Summary

• Position: supine (spinal precautions maintained).
• Heat: blankets, ambulance heater.
• O₂: prefer high-flow NRB or BVM; add ETCO₂.
• Fluids: per local protocol (two 18-gauge IVs, $\ge 20\,\text{mL·kg}^{-1}$ crystalloid titrated to radial pulse).
• Monitor: ECG, SpO₂, ETCO₂, glucose as needed.

Common Pitfalls on Practical Exams

• Saying “consider C-spine” but not assigning manual stabilization.
• Not physically treating a discovered life threat before continuing.
• Forgetting to auscultate breath sounds in primary survey.
• Omitting shock management when pt looks gray/diaphoretic.
• Ignoring ETCO₂; no capno = lost points and missed diagnosis.

Ethical & Operational Reflections

• Time vs. Thoroughness: Balancing rapid scene departure with adequate stabilization reflects the ethical duty to do the most good in the least time.
• Resource Utilization: Requesting fire or air med early prevents later delays—under-requesting can harm patients; over-requesting wastes public resources.
• Scope of Practice & Protocol Variability: Traumatic arrest protocols differ by region (blunt vs. penetrating, PEA < 40 etc.). Providers must know their local guidelines to honor legal/ethical obligations.

Real-World Connections

• MVC 360-survey habit links biomechanics (physics) to likely internal injuries.
• ETCO₂ waveform interpretation merges physiology with technology, immediately exposing perfusion deficits long before BP cuff shows hypotension.
• Rapid extrication drills today reflect actual limited manpower situations (e.g., rural volunteer EMS or multi-patient highway crashes).

Key Numbers & Formulas to Memorize

• Emergent trauma scene time goal: $\le 10\ \text{min}$
• Low ETCO₂ threshold: < 35\ \text{mmHg} • High ETCO₂ threshold: > 45\ \text{mmHg}
• Adult fluid challenge (many protocols): $20\,\text{mL·kg}^{-1}$ isotonic crystalloid to maintain radial pulse ≈ SBP > $90\ \text{mmHg}$.
• Needle decompression landmarks: $2^{nd}\,\text{ICS MCL}$ or $5^{th}\,\text{ICS AAL}$, 14-ga catheter.

Final Take-Home Checklist (Practice Daily)

1. PPE / Scene Safe.

2. MOI / Number of Patients / Additional Resources.

3. Consider & direct C-spine control.

4. Rapid extrication decision (life threat that can’t be fixed in situ).

5. Primary Survey (ABCs + fix life threats + shock management + breath sounds).

6. ETCO₂ & O₂ in place.

7. Transport decision stated (< 10 min).

8. Halftime verbal review (vitals, interventions, packaging, ALS/air requests).

9. Rapid or focused secondary.

10. Re-assess q 5 min, communicate hand-off report.

Soft Tissue Injuries (DCAP-BTLS)

ABCs, Scene Priorities & General Concerns

• Always return to the trauma ABCs, expanded in class as:

  • Airway / Breathing

  • Bleeding control

  • C-spine & other injuries survey

  • Infection risk

  • Distraction injuries (do not get tunnel–vision on the obvious wound)

  • Pain management

• Other universal issues

  • Nerve, muscle, ligament damage

  • Shock, hypovolemia, hypothermia

  • Psychological impact on patient & bystanders

Pain Management Overview

• Immobilize the affected extremity → limits motion & decreases pain

• Pharmacology (not detailed in the clip) must be tailored to patient

• Non-pharmacologic: splinting, cold packs, calm coaching, rapid transport

Soft-Tissue Classifications

• Two broad categories

  • Closed wounds – epidermis intact

  • Open wounds – disruption of skin

• Either can result from blunt or penetrating mechanisms

Closed Wounds

Classic findings

• Bruising (contusion) / hematoma formation

• Ecchymosis

  • Board/Registry questions often use it to describe “raccoon eyes” or mastoid bruising (Battle’s sign)

• Erythema = redness

• Swelling

Pathophysiology & Red-Flags

• Damaged vessels bleed into soft tissue

• May hide deep muscle, nerve or vascular injury → always check distal PMS + cap-refill (CRT)

Management

• RICES concept: Rest, Ice, Compression, Elevation, Splint

• Sterile dressing only if skin later breaks

• No scene-time delay → interventions can continue en-route

Open Wounds

1. Laceration / Incision

• Laceration = jagged tear, usually blunt-force

• Incision = clean linear cut (sharp object)

• Assessment factors

  • Depth, length, organ involvement, blood loss

  • Underlying nerves & vessels

• Treatment

  • Direct pressure → sterile dressing

  • Tourniquet if pressure fails (extremities only)

  • Check distal PMS/CRT before & after dressings

2. Abrasion ("road-rash")

• Partial thickness scrape of epidermis (still an open wound)

• Classic in cyclists / kids / motorcyclists

• Findings: minimal bleeding, intense pain, oozing sero-sanguinous fluid (pink serum + blood)

• Textbook guidance (J&B):

  • Do NOT scrub, brush, or wash in field → increases pain & bleeding

  • Cover lightly with sterile dressing

• Real-world nuance discussed:

  • Gently irrigate obvious large debris if easily removed & patient stable

  • Avoid aggressive cleaning in multi-system trauma or pediatrics (time & pain)

3. Puncture / Penetrating

• Objects: nail, fish-hook, knife, bullet; gunshot = high-energy puncture

• Kinetic energy reminder: $KE = \frac{1}{2} m v^2$ → velocity is the dominant injury variable

• Assessment

  • Depth & direction of tract

  • Entry and exit wounds

  • Type & speed of object

  • Internal bleeding signs (may bleed little externally)

• Management

  • Never remove impaled object unless it obstructs airway or CPR

  • Do NOT apply pressure directly on or immediately adjacent to the object

  • Stabilize object with bulky dressings; splint entire limb to limit motion

  • Consider hemostatic gauze if available & not contraindicated

4. Avulsion

• Flap of skin partially or completely torn

• Concerns: blood loss, fluid loss, infection, nerve/vessel injury

• Management Steps

  1. Irrigate gross contamination

  2. Gently realign the flap to anatomical position

  3. Cover with moist sterile dressing, apply light pressure dressing

  4. Ice packs around (not directly on) wound for pain/swelling

• Real-world example: 7-inch scalp avulsion filled with gravel → irrigate then fold flap

5. Amputation

• Complete vs partial (tissue bridge remains)

• Immediate priorities

  • Catastrophic hemorrhage → tourniquet ASAP (caution with direct hand pressure – bone shards)

  • Rapid transport

• Care of the stump

  • Moist sterile dressing over exposed tissue

  • Additional bulky compression only if it won’t delay transport

• Care of the amputated part (complete amputations)

  1. Rinse with cool sterile water

  2. Wrap loosely in saline-moistened sterile gauze

  3. Seal in bio-bag / plastic bag

  4. Place bag in cool container (ice near, not direct contact)

  5. Transport part with patient

• Scene-time rule of thumb: ≤ 10 min; limb search delegated to others, do not delay critical patient transport

• Partial amputation: treat like large avulsion → support dangling part, moist dressing, tourniquet if needed, immobilize together with limb

Hemorrhage Control Toolbox (Review)

• Direct pressure (sterile pad, gloved hand if necessary)

• Pressure dressings

• Tourniquet (high & tight; record time)

• Hemostatic gauze / agents

• Junctional tourniquet devices (not covered in transcript but relevant)

Distal Neurovascular Check (PMS + CRT)

• Pulse – distal radial/dorsalis pedis/posterior tibial

• Motor – wiggle fingers/toes

• Sensation – light touch

• Capillary refill < 2\,\text{s} ideal (adult norm)

• Re-assess after every intervention (splint, dressing, tourniquet)

Scene & Transport Pearls

• Critical multi-system trauma: life-saving airway & bleeding moves only → load & go

• Dressing/wound care that is nice-to-have can be finished en-route

• Always anticipate hidden injuries surrounding a dramatic wound (TBI with scalp avulsion, abdominal bleed with thigh laceration, etc.)

Ethical & Practical Implications

• Balance between text-book guidelines ("don’t clean abrasions") and provider judgment (large visible debris)

• Delegation: Fire or bystanders may retrieve amputated parts; EMS focuses on patient

• Documentation: describe wound, size, location, depth, contamination, PMS findings, tourniquet time

Mnemonic Quick-Reference

• C-LAP for laceration/incision:

  • Control bleeding

  • Length & depth assessment

  • Apply sterile dressing

  • Peripheral PMS/CRT check

• SAVE for avulsion:

  • Stop bleeding (direct pressure / tourniquet)

  • Align flap anatomically

  • Verify cleanliness (irrigate)

  • Enclose with moist sterile dressing

Trauma Foundations pt 2.5 (Bleeding & Shock)

Core Definitions

• Shock (Hypoperfusion)

  • A state in which cells receive inadequate $O_2$ and nutrients.

  • Metabolism switches from aerobic ➔ anaerobic, ↓ ATP, ↑ lactic acid.

  • Key global definition: hypoperfusion of the cells—nothing more, nothing less.

Major Etiologic Categories of Shock

• Cardiogenic

• Obstructive

  • Examples: Pulmonary embolism (PE), cardiac tamponade, tension pneumothorax.

• Hypovolemic

  • Classic form: hemorrhagic shock.

• Distributive

  • Anaphylactic, neurogenic, septic.

Hemorrhagic-Shock–Specific Pathophysiology

• Body cannot compensate for > $20\%$ (~1 L) blood loss; VS begin to change.

• Compensation sequence: vasoconstriction ➔ tachycardia ➔ thirst ➔ shunting from skin/extremities ➔ altered mentation once cerebral perfusion drops.

• Systemic Vascular Resistance (SVR)

  • Definition: resistance LV must overcome to eject blood.

  • During distributive shock SVR ↓ because core vessels dilate.

  • $\text{SVR}$ conceptually mirrors afterload.

Stages of Shock

1. Compensated (Early)

   • Agitation/anxiety, tachycardia, cool/clammy skin, thirst, normal BP.

2. De-compensated (Progressive)

   • BP ↓, altered mental status, laboured breathing, loss of radial/peripheral pulses, mottled/ashen/cyanotic skin.

3. Irreversible (Late)

   • Bradycardia or agonal respirations, severe hypotension, multi-organ failure.

(Detailed four-class hemorrhagic chart appears in book & homework—know fluid loss %, HR, BP, RR, mental status for Classes I–IV.)

Lethal Trauma Triad

• Hypothermia + Acidosis + Coagulopathy

  • >$30–60\%$ of trauma pts arrive hypothermic—even in summer.

  • Drives home: Stop bleeding, keep pt warm, prevent acidosis.

Assessment Highlights

• Early signs: restlessness, tachycardia, pallor.

• Late signs: hypotension, slow/irregular respirations (“circling the drain”).

• Pulse-ox may still read $100\%$—hemoglobin fully saturated but total Hb ↓; give high-flow $O_2$ anyway.

• In dark-skinned pts assess sclera & gums for pallor.

Hemorrhage Control Techniques

• Direct Pressure – first line for all external bleeding.

• Tourniquet

  • Placement: $\ge 2$ inches proximal to wound, never over joints.

  • Document: time, location, haemorrhage control achieved, distal pulse status.

  • If bleeding persists ➔ apply 2nd tourniquet proximal to first.

• Junctional Control

  • Groin/axilla/neck: digit pressure, knee/hand compression, commercial junctional devices, or improvised (e.g., racquetball under strap).

• Hemostatic Gauze/Agents

  • Gauze impregnated with clotting factors for deep wounds, large muscle bellies.

  • Causes stinging; new formulations safer (previous powders risked ocular injury).

• Pelvic Binder / KED

  • Suspected pelvic fracture = splint to ↓ pelvic volume & hemorrhage.

• Varicose Veins

  • Can spurt like arteries; usually controlled with compression wrap rather than tourniquet.

Fluid & Medication Management

• IV/IO Access

  • Obtain as early as possible after ABCs without delaying transport.

  • Large-bore $18\text{ G}$ preferred; $16\text{ G}$ if achievable, $\ge 20\text{ G}$ acceptable when needed.

• Permissive Hypotension (hemorrhagic)

  • Titrate fluids to $\text{MAP}\approx 60\text{–}65\,\text{mmHg}$.

  • Formula: $\text{MAP}=\tfrac13(\text{SBP}-\text{DBP})+\text{DBP}$.

• Fluids

  • Gold standard: whole blood ➔ other blood products ➔ crystalloids (NS/LR).

  • NS pH ≈ $5.5$; large volumes exacerbate acidosis.

  • Warm to $102^\circ\text{F}$ (≈$38.9^\circ\text{C}$). Room temp bags (68–75 °F) risk hypothermia.

  • Dashboard/heater warming is an improvised option.

• TXA (Tranexamic Acid)

  • Given within $\le 3$ h of injury to inhibit fibrinolysis; covered further in lab.

Time Benchmarks

• Golden Hour: Injury ➔ OR/definitive care within $\le 60$ min.

• Platinum 10: Aim to leave scene within 10 min.

Complications of Shock

• ARDS – Acute Respiratory Distress Syndrome

  • Post-trauma/sepsis/inhale injury; inflammatory leak fills alveoli with fluid.

  • CXR = “white-out”, requires high PEEP, may need ECMO & prone-rotation beds.

• Acute Renal Failure / Acute Kidney Injury (AKI)

  • Hypoperfusion + highly concentrated blood = “sludge” damaging nephrons.

  • May need temporary dialysis; can become chronic.

• MODS – Multi-Organ Dysfunction Syndrome

  • Domino failure of ≥2 organ systems; mortality ≈ $67\%$.

  • Occurs in ≈ $29\%$ of significant-trauma pts.

Practical Pearls & Exam Triggers

• Thirst = early compensation cue; persists into later phases but consciousness may fade.

• Slow respirations in shock = pre-arrest; start BVM support.

• Do NOT rely solely on BP—look for AMS & peripheral pulses.

• Amputations: Vessel retracts upward—consider “high & tight” tourniquet even if wound low.

• Document EVERYTHING: mechanism, vitals trend, interventions, response.

• Know the Hemorrhagic-Shock Classes table (homework): fluid loss, HR, BP, RR, mental status.

• MAP on NREMT: expect $\ge 65$ mmHg threshold question.

• SVR = Systemic Vascular Resistance (afterload analog).

Quick Reference Numbers

• Body cannot tolerate >$20\%$ blood volume loss.

• Target MAP: $60\text{–}65\,\text{mmHg}$.

• Fluids warmed to $102^\circ\text{F}$.

• Golden Hour: $\le 60$ min; Platinum 10: scene $\le 10$ min.

• Tourniquet: document time; reassess; maintain distal pulse check.

• Normal-saline pH ≈ $5.5$ (acidic).

Example Scenario Connections

1. MVA patient with pelvic pain & hypotension ➔ binder, large-bore IV, warm NS titrated to MAP 65, TXA en-route; keep heater on despite ambient 98 °F.

2. Farmer amputates hand ➔ high & tight tourniquet, note time, second tourniquet if oozing; assess for retraction.

3. Dark-skinned assault victim, BP borderline, confused ➔ look at sclera/gums, note mottled skin, transport emergent.

4. Construction worker lacerates varicose vein on shin: spurting but mechanism minor (this was NOT arterial bleeding - remember, they’re varicose VEINS) ➔ compression wrap not tourniquet.

Chest and Thoracic Trauma

Pericardial Tamponade

• Layers to recall – outside → inside: parietal pericardium → potential pericardial space → visceral pericardium (epicardium).
• Causes: infection (pericarditis, strep, viral), blunt or penetrating chest trauma, post-surgical injury, malignancy, iatrogenic (central line, pacer wires).
• Pathophysiology: fluid (blood, exudate) collects in pericardial space → intrapericardial pressure ↑ → diastolic filling ↓ → SV & CO ↓.
▪ As little as $50\;\text{mL}$ can impede venous return / CO.
▪ Up to $300\;\text{mL}$ may accumulate before pulseless electrical activity (PEA) declared.
• Classic clinical signs (Beck’s Triad – appears only $10!–!40\%$ of cases):
▪ Muffled or distant heart tones
▪ Jugular venous distention (JVD)
▪ Narrowing pulse pressure / hypotension.
• Additional indicators:
▪ Pulsus paradoxus = inspiratory fall in systolic BP $\ge 10\;\text{mmHg}$ – pulse disappears when pt inhales.
▪ Electrical alternans on 12-lead (beat-to-beat QRS height changes).
▪ Low QRS voltage, sinus tachycardia.
• Management (prehospital):
▪ Supportive – high-flow O₂, keep pt calm, rapid transport.
▪ Careful fluid bolus may transiently raise preload; avoid aggressive volumes (worsens tamponade / bleeding).
▪ Pericardiocentesis (rare in field): sub-xiphoid approach, 45° cephalad, continuous ECG lead on needle – ST elevation or PVCs = myocardium contact.
▪ Definitive = surgical pericardial window / drain.

Aortic Disruption / Transection

• Usually at aortic isthmus just distal to left subclavian; fixed by ligamentum arteriosum – deceleration tears vessel.
• MOI: high-speed MVC, fall from height, blast.
• Presentation: tearing chest/back pain, rapid hypotension, large left-side hemothorax, mediastinal widening on CXR.
• Mortality extremely high; many exsanguinate before EMS arrives.

Commotio Cordis (Cardiac Concussion)

• Sudden blunt blow to precordium during 15-30 msec vulnerable phase of ventricular repolarisation → immediate VF/VT.
• Seen in youth baseball, hockey, lacrosse, occasionally football.
• Management: instantaneous CPR & defibrillation – survival drops ≈$10\%$ per minute delay.

Other Thoracic Injuries

• Tracheo-bronchial disruption: airway trauma from decel or misplaced ETT → massive air leak, subcutaneous emphysema, possible tension pneumo; definitive = surgical repair.
• Traumatic asphyxia: sudden chest compression → retrograde venous congestion → cyanotic / petechial face & upper chest, subconjunctival hemorrhage. Treat like crush injury + airway/O₂.

Hemothorax / Hemopneumothorax Scenario (case in transcript)

• Findings: small posterior stab, frothy pink sputum, RR $32$, absent L-side breath sounds, weak rapid radials, cool/diaphoretic.
• Initial care sequence:
▪ Glove, direct pressure, occlusive dressing (three-sided if sucking chest).
▪ Rapid ABC → consider needle decompression if tension suspected (burp dressing first).
▪ Suction airway → OPA/NPA → BVM + PEEP 5–10 cmH₂O; if resistance ↑ reassess for pneumo.
▪ Large-bore IVs (≥18 G) or EJ/IO, warm fluid challenge.
▪ Monitor ETCO₂, SpO₂; keep on-scene time <$10\;\text{min}$.

Trauma Assessment Algorithms

• “Rapid” (unresponsive, multi-system): 60-90 sec head-to-toe, then vital signs, SAMPLE if caregivers present.
• “Focused” (isolated alert pt).
• Verbalise Plan between B & C: “Need rapid trauma, c-spine maintained, partner obtains vitals/O₂, prepare long board…”
• On trauma practical & registry exams examiners expect:
▪ Airway → Breathing → Circulation → Disability → Expose (ABCDE).
▪ Life-threatening interventions as they are found, not after survey.
▪ Package & depart ≤$10$ min (load-and-go).

Shock Review (Exam Hot-Spot)

• Compensated vs decompensated vs irreversible; recognise by mental status, pulse pressure, skin, etc.
• Hemorrhagic shock – triad of death: acidosis, coagulopathy, hypothermia; core temp ↓ increases mortality ≈$70\%$ → cover pt, turn heat on, warm fluids.
• Cardiogenic, distributive (neurogenic, septic, anaphylactic), obstructive, hypovolemic – know patho & treatment priorities.

Hemorrhage Classes (know volumes & vitals)

• Class I: <15\% blood loss ((≤750\;mL)). • Class II: $15!–!30\%$ ((750!–!1500\;mL)); tachycardia, narrow PP. • Class III: $30!–!40\%$ ((1500!–!2000\;mL)); hypotension, AMS. • Class IV: >$40\%$ (>(2000\;mL)); pre-terminal.
• Charts in instructor slide deck – will appear on quiz.

Blood Product Compatibility

• Whole blood / packed RBC universal donor = O- negative.
• Universal plasma donor = AB (antibodies absent).
• Universal recipient (RBC) = AB positive.

Mechanisms of Injury (MOI) Patterns

• MVC:
▪ Up-and-over (face/chest, aortic tear).
▪ Down-and-under (knees, femur, pelvis).
▪ Lateral (splenic/liver, aorta).
▪ Rear-end (whiplash/brain shear, airway).
• Motorcycle – lower extremity, degloving, head/neck.
• Pedestrian struck:
▪ Adult – bumper → legs, hood → torso, ground → head.
▪ Child (Waddell triad): femur #, chest/abd injury, head injury.

Blast Injuries

• Primary – barotrauma (TM rupture, lung blast).
• Secondary – shrapnel penetration.
• Tertiary – body displacement vs object.
• Quaternary – burns, asphyxia, tox gases.
• Quinary – biological/chemical contaminants causing hyper-inflammatory state.

Ballistics & Cavitation

• Low-velocity (<$300\;m/s$): knives, handguns – laceration/track.
• Medium (rifle), High (military) – temporary cavitation expands tissues → wider damage than bullet diameter.
• Exam buzzword: “cavitation visualised in ballistic gel”.

Pelvic Injuries

• Unstable pelvis can hide >!3\,000\;mL blood.
• Binder at greater trochanters ASAP; minimal log-rolling.
• Consider proximal tibial IO if IV access poor; Trendelenburg / external jugular tricks (stethoscope loop around neck lightly occludes jugular to distend vein).

Thoracic Needle Decompression Key Points

• Indications: penetrating trauma + hypotension + unilateral absent sounds + progressive dyspnea.
• Site: 2nd ICS mid-clavicular or 5th ICS anterior-axillary; 14 G / 3.25 in.
• “Burping” three-sided dressing first may release initial tension.

Spinal Injuries

Complete vs. Incomplete Spinal‐Cord Injury (SCI)

• Complete SCI
– Disruption of all ascending & descending tracts → permanent loss of all cord-mediated motor, sensory, and autonomic function below the lesion.
– Expect flaccid paralysis, no voluntary movement, absent reflexes, total anesthesia, loss of bladder/bowel/sexual function.
• Incomplete SCI
– At least one neural pathway remains intact → some motor/sensory function preserved.
– Exam questions typically present “patchy” findings; identify the syndrome by matching deficits to tract functions.

Spinal‐Cord Anatomy Refresher

• Central gray matter = neuronal cell bodies.
• Major white-matter tracts referenced in lecture:
– Corticospinal (blue dots) → voluntary motor.
– Spinothalamic (brown) → pain & temperature.
– Dorsal columns (green) → vibration, fine touch, proprioception (spatial/body awareness).
• Ipsilateral = same side; Contralateral = opposite side.

Incomplete SCI Syndromes

1. Anterior Cord Syndrome (ACS)

• Typical mechanism: fracture/displacement of anterior vertebral fragments → compress anterior 2⁄3 of cord.
• Findings below lesion:
– Loss of motor, pain, temperature (corticospinal + spinothalamic).
– Preservation of vibration & proprioception (dorsal columns spared).
• Prognosis generally poor (only ~10–20 % regain useful motor function).

2. Central Cord Syndrome (CCS)

• Classic scenario: older pt with cervical spondylosis sustains hyper-extension injury (diving, MVC, “hanging”).
• Pathology: hemorrhage & edema of central cervical segments; often ligamentum flavum buckles.
• Deficits:
– Motor & sensory loss in UPPER extremities > lower (“shawl distribution”).
– Variable bladder involvement.
• Prognosis fair—lower limbs often recover first.

3. Brown-Séquard Syndrome (Hemisection)

• Mechanism: penetrating trauma (knife, arrow, GSW) disrupting half the cord.
• Deficit pattern:
– Ipsilateral (same side) loss of motor, vibration, proprioception (corticospinal + dorsal columns).
– Contralateral loss of pain & temperature (spinothalamic decussates early).
• Relatively good prognosis; many walk again.

4. Cauda Equina Syndrome (CES)

• Latin “horse’s tail” = bundle of L2–S5 nerve roots in lumbar canal.
• Etiologies: axial load fall on buttocks, lumbar burst fracture, expanding hematoma, large central disc herniation, stab/GSW.
• Hallmark S/Sx:
– Severe low-back pain.
– Bilateral radicular pain/myalgia & weakness in legs.
– Saddle anesthesia (numb perineum & inner thighs in saddle distribution).
– Acute bladder, bowel & sexual dysfunction (retention or incontinence).
• Surgical emergency—decompression ideally < 48 h.

Spinal Shock (Transient Areflexia)

• Pathophysiology: edema & inflammation of cord within ≈ 30 min post-injury → temporary abolition of reflexes.
• Clinical picture:
– Flaccid paralysis, areflexia, flaccid sphincters, absent sensation, impaired thermoregulation below lesion.
• Duration: hours → weeks; resolves as swelling subsides.
• Treatment concepts: steroids (methylpred.), cold packs/ice to limit edema (historical anecdote).
• DIFFERENT from neurogenic shock—vital to distinguish.

Neurogenic Shock

• Definition: distributive shock caused by loss of sympathetic tone after high spinal or brainstem injury.
• Patho cascade:
– Sympathetic outflow interrupted → arteriolar & venous vasodilation.
– Container size ↑; blood volume unchanged → relative hypovolemia; $SVR \downarrow$.
– Parasympathetic (vagus) unopposed.
• Clinical triad:
– Hypotension (often profound).
– Bradycardia (or low-normal HR).
– Warm, dry, flushed skin below injury (contrasts with cold/clammy hemorrhagic shock).
• Oxygenation usually intact unless lesion involves phrenic nucleus (≈C5) → diaphragmatic compromise.
• Hemodynamic goal: maintain $MAP = 85\text{–}90\,\text{mmHg}$ (formula $MAP = \frac{SBP + 2 \times DBP}{3}$) to assure cord perfusion.
• Pharmacology:
– Atropine 0.5 mg IV q3-5 min (max 3 mg) for bradycardia.
– Epinephrine infusion: mix 1 mg (1 : 1000) in 250 mL → $\frac{1\,mg}{250\,mL} = 4\,\mu g/mL$.
• 60 gtt/min delivers ≈ $4\,\mu g/min$; titrate 2–10 µg/min to target HR & BP.
– Alt: norepinephrine, dopamine, or phenylephrine per protocols.

Practical / Exam Pearls

• Memorize tract-function chart to match deficits quickly.
• Mnemonic for ACS vs. Dorsal column: “Anterior = Absent pain/temperature/Absent motor” but proprioception preserved (PP).
• Central cord: think “Elderly Extenders” (old + hyper-extension).
• Brown-Séquard: "stabbed in the back, half the tracts whacked.”
• Cauda Equina: any patient with low-back trauma + urinary change = EMERGENT MRI.
• Distinguish Spinal vs. Neurogenic Shock → one transient reflex loss, the other systemic vasodilation.
• For neurogenic shock, fluids first (fill the larger container), then pressors if MAP < 85.
• Keep cervical collar until cord injury definitively ruled out.

Real-World Stories (Contextual Memory Aids)

• Instructor knocked unconscious at home plate → transient pseudo-paralysis (illustrates spinal shock sensation).
• “Jumped off roof & missed pool” → mechanism for CES.
• Diving accident → classic central cord.
• Penetrating arrow/knife → prototype Brown-Séquard.

Ethical & Practical Considerations

• Early recognition of CES prevents lifelong incontinence; failure = medicolegal risk.
• Aggressive MAP targeting improves neurological outcome—balances organ perfusion vs. pressor adverse effects.
• Warm, brady-hypotensive trauma patient ≠ hemorrhage — avoid “volume tunnel vision” & treat the right shock.

Abdominal Trauma

Abdominal Anatomy & Cavities

• Abdominal cavity extends from the xiphoid/diaphragm to the pelvis.

• Bony protection is minimal anteriorly ➜ energy from trauma is easily transmitted to organs.

• Three anatomic spaces to remember (testable):

  • Peritoneal cavity

  • Lined by the peritoneum (thin, slick, fibrous tissue – analogous to pleura of lungs).

  • Organs: stomach, ileum, jejunum, transverse colon, appendix, gallbladder, spleen, liver.

  • Retro-peritoneal space

  • Posterior to the peritoneum.

  • Organs: kidneys, ureters, part of pancreas, portions of colon, major vessels (abdominal aorta, IVC).

  • Pelvic cavity

  • Lies below brim of pelvis.

  • Contains bladder, distal colon/rectum, reproductive organs, urethra, terminal ureters.

• Mesentery

  • Double fold of peritoneum that suspends bowel from the anterior abdominal wall.

  • Appears as a white “net” (analogy → the web-like fascia around deer organs when field-dressing, or a net bag of tennis balls where the balls = organs, net = mesentery).

Overview of Abdominal Trauma

• Chapter is “full of details yet changes little in management” – most pre-hospital care is supportive.

• Most common mechanism overall: blunt trauma.

• Penetrating trauma (gunshot, stabbing, impalement) is less common but carries higher mortality when it occurs.

• Injury may be subtle; high index of suspicion is mandatory – correlate MOI with findings.

• Solid organs bleed, hollow organs contaminate.

Blunt Trauma: Three Mechanisms

1. Deceleration

   • Newton’s 1st law: organs continue moving at pre-impact velocity → collide with anterior abdominal wall or each other → shear, contusion, laceration.

2. Compression

   • Abdominal contents crushed between external force and rigid posterior structures (spine, pelvis).

   • Examples: lap belt “seat-belt sign,” pinned between car & wall, hoof to abdomen.

3. Shear

   • Differential movement tears attachments (mesentery, vessels).

   • Classic with lap-belt or sudden flexion; can produce aortic injury.

Key Blunt Findings & How to Detect Them

• Visual

  • Bruising/ecchymosis (e.g., seat-belt sign).

  • Distension.

• Palpation

  • Rigidity or involuntary guarding.

  • Rebound tenderness (pain on release) ➜ peritonitis/appendicitis.

• Auscultation (controversial pre-hospital but can add data)

  • Absent bowel sounds in distended rigid belly.

• Always think of concurrent spinal injury (abdominal organs share posterior wall with spine).

Unique Blunt Concern: Traumatic Aortic Injury

• 18\% of deaths in MVCs are related to aortic disruption.

• Common site: just distal to left subclavian (aortic isthmus).

• Clues: unequal UE/LE BPs, upper quadrant ecchymosis, rib/vertebral fractures.

• Pre-hospital care = rapid transport & permissive hypotension; nothing we can definitively fix.

Hollow vs. Solid Organ Injury

• Solid organs are vascular → massive bleeding.

• Hollow organs, if distended, “pop” like a balloon; leak bile, gastric acid, feces, urine.

Penetrating Trauma

• High-velocity (gunshot) ➜ cavitation, fragmentation, ≈10× mortality of low-velocity wounds.

• Low-velocity (knives, rebar, fence posts) ➜ damage generally confined to track.

• Always search for: entry & exit, multiple tracts, hidden shrapnel, spinal involvement.

• Commonly damaged organs (%): liver 40, small bowel, large bowel, spleen, kidneys, pancreas.

Special Conditions

Evisceration

• Definition: penetration with external protrusion of abdominal contents.

• Management (three-layer rule):

  1. Cover with sterile, soaked gauze (use sterile water/NS).

  2. Overlay with occlusive dressing to retain moisture & warmth.

  3. Cover patient with blanket to prevent hypothermia.

• DO NOT:

  • Attempt to replace organs.

  • Enlarge wound.

• Risks: strangulation of bowel, infection, underlying hemorrhage.

Impalement

• Object remains in situ (stakes, fence posts, angle grinders, chainsaws, hooks).

• Principles:

  • Stabilize in place (foam head-blocks, rolled towels, bulky dressings, etc.).

  • Manually support during any move; secure after packaging.

  • Do NOT shorten, cut, or remove unless absolutely necessary for transport & safe to do so.

  • Consider spinal involvement (perform motor/sensory checks).

Abdominal Compartment Syndrome (ACS)

• Elevated intra-abdominal pressure compromises perfusion/organ function.

• Rare pre-hospital needle decompression shown in slide – not current EMS practice.

• Signs: progressive distension, worsening ventilatory compliance, decreased urine output.

Fluid Resuscitation & Permissive Hypotension

• Goal: maintain MAP $\approx 60\text{–}65\,\text{mmHg}$ until surgical control.

• Titrate crystalloid/blood to effect; reassess q 3 min automatic NIBP.

• Whole blood preferred; if unavailable, LR/NS acceptable but avoid over-resuscitation.

• Concept reinforced after adjunct gave conflicting advice (“turn wide open” vs “no fluids”).

TXA & Other Adjuncts (brief mention)

• Tranexamic acid given early (<3 h) for bleeding control.

• Other EMT-P tools: pressure dressings, hemostatic gauze, tourniquets for junctional bleeds, pain meds (fentanyl, ketamine), O₂, temperature control.

Packaging & Spinal Considerations

• Scoop stretcher favored over backboard for impalements & blunt abdominal injuries to avoid rolling.

• Backboard considered if patient found motionless or neuro-deficit suspected.

• Always secure impaled object before moving.

Communication / Trauma Activation

• Include: age, sex, mechanism, specific injury (e.g., “angle grinder blade impaled mid-epigastrium”), vitals, GCS, interventions (IV $18\,\text{ga}$, ketamine, fluids), ETA.

• Clarify if unsure: “This might meet your Tier 2 criteria; please advise.”

• Example numbers raised in class:

  • Tier 2 at some hospitals: age $\ge 65$ plus fall >3 stairs.

  • Scenario: 75 y F fall down 7 stairs.

Scenario Walk-Through: Angle Grinder Impalement

• 46 y M, low-velocity impalement, 10 in disc protruding.

• Primary Survey

  • LOC: initially alert; monitor for decline.

  • Airway/Breathing: maintain, auscultate for diaphragmatic injury.

  • Circulation: control any external bleeding; consider internal.

• Scene Interventions (delegated)

  • One provider manually stabilizes saw & unplug power.

  • Obtain BP & ETCO₂ early.

  • Complete focused assessment (thorax, abdomen, motor/sensory in extremities).

  • Package on scoop; avoid log-roll torque.

• Truck Interventions

  • Dual IVs, pain control (ketamine for dissociation), fluids titrated to MAP.

  • Reassess ABCs, vitals, neuro.

• Hospital Report (sample):

  • “Trauma alert. 46 male, angle-grinder blade impaled mid-abdomen, object stabilized. Initial BP 92/60 (MAP ≈ $61$), HR 116, ETCO₂ 32, SpO₂ 99 \%. Ketamine 50 mg IV for pain, 18 ga bilat AC, titrating LR. GCS 13 (E4 V4 M5). ETA 15 min.”

Miscellaneous Class Points & Anecdotes

• Mesentery analogy for non-hunters: net bag of tennis balls.

• Seat-belt sign ➜ high suspicion for shear injury & bowel perforation.

• Rebound tenderness explained (pain on release → peritonitis).

• Catfish fin impalements and “floppy fish” – hurts like bee sting.

• Friend at KSU lost leg pinned by car ➜ highlights complications of infection & staged amputations.

• Catfish, Taco Bell gas, diaphragm rupture = whimsical student theories of free air.

• Humor: “backboards cause cancer,” “8,000,000,000 slides,” “field-dressing deer.”

Ethical / Practical Take-Aways

• Keep your composure on scene.

• Respect patient autonomy & comfort (pain control, avoid unnecessary movement).

• Communicate clearly with ED; confusion wastes resources & creates tension.

• Understand local trauma criteria; when uncertain, over-communicate.

Numerical / Statistical References

• Abdominal cavity injury distribution: liver 40 \%, small bowel, large bowel, spleen, kidneys, pancreas.

• Aortic rupture: 18 \% of MVC deaths.

• Gunshot mortality ≈ 10× low-velocity.

• Target MAP $60\text{–}65\,\text{mmHg}$.

• Auto-NIBP interval recommended: $3\,\text{min}$.

• Age $\ge 65$ + ≥3 stairs = Tier 2 at certain centers.

• Scenario ages/values: 46 y M impalement; 75 y F fall; 7 stairs.

Obstetric Bleeding Conditions

• Placenta Previa
  • Painless, bright-red vaginal bleeding ("bleeding and no pain")
  • Often occurs late in pregnancy; placenta partially/completely covers cervical os
  • High fetal–maternal morbidity; anticipate C-section, large-bore IVs, oxygen, rapid transport

• Abruptio Placentae
  • Painful vaginal bleeding ("abruption = painful")
  • Premature separation of placenta → sharp abdominal pain, uterine rigidity, fetal distress
  • May present with minimal external blood loss yet massive concealed hemorrhage

• Exam Tip: be able to distinguish “painless vs.​ painful” bleeding scenarios; resolve confusion quickly on test

Abdominal Quadrants & Organ Map (Know Cold for Exam)

• Right Upper Quadrant (RUQ)
  • Liver (primary), Right Kidney, Gallbladder, Portion of Small Intestine, Part of Pancreas (head), Descending Colon

• Left Upper Quadrant (LUQ)
  • Spleen, Stomach, Left Kidney, More of Pancreas (body/tail), Small Intestine, Colon

• Right Lower Quadrant (RLQ)
  • Appendix, Ascending Colon, Small Intestine, Right Ureter, Portions of Reproductive Organs, Bladder (variable)

• Left Lower Quadrant (LLQ)
  • Descending & Sigmoid Colon, Small Intestine, Left Ureter, Great Saphenous Vein region, Bladder (variable)

• Test Favorite:
  • Bruising/tenderness RUQ ⇒ suspect Liver or Right Kidney injury
  • Similar LUQ signs ⇒ think Spleen

Systematic Abdominal Assessment

• Always palpate in a consistent pattern when no pain (e.g., clockwise starting RUQ)

• If pain present: start farthest from the pain → move toward it

• Key findings
  • Tenderness on palpation
  • Rebound tenderness (quick release elicits pain) = potential peritoneal irritation → example of somatic pain
  • Differentiate from visceral pain (dull, diffuse, poorly localized)

Visible/Palpable Signs & What They Mean

• Distension
  • Abdomen can hide $\approx1.5\,\text{L}=1500\,\text{mL}$ blood before obvious swelling
  • Equals about ¼ total blood volume ⇒ classified as Stage 2 hemorrhage

• Hemorrhage‐Stage Quick Sheet
  • Stage 1: $0!–!750\,\text{mL}$
  • Stage 2: $750!–!1500\,\text{mL}$ (15–30 % loss) – pallor, diaphoresis, anxiety, ↑HR

• Rigidity
  • Board-like abdomen; indicates blood accumulation, peritoneal irritation, or muscle guarding

• Pulsating Masses
  • Possible Abdominal Aortic Aneurysm (AAA)
  • Do NOT continue pressing; minimize movement, transport gently ("no potholes")

Penetrating Trauma Essentials

• Always search for entry AND exit wounds

• Gunpowder “tattooing” = extremely close / point-blank firearm discharge

• Apply occlusive dressings to sucking chest wounds—front and back
  • Remember classroom demo where the back wound was missed

• High- vs.​ Low-Velocity Firearms (test tidbit)
  • High-velocity: Rifles → small projectile, very high speed
  • Low-velocity: Shotguns (large pellets, major tissue damage only at close range), handguns

• Velocity determines cavitation & internal damage more than visible size of wound

Evisceration & Hernias

• Evisceration = organs protrude through open abdominal wound
  • Driven by intra-abdominal pressure; cover with moist, sterile dressing & occlusive layer, flex knees, rapid transport

• Hernia = organ pushes through abdominal wall but remains under skin
  • Hiatal hernia: stomach through diaphragm into thorax
  • Inguinal, umbilical, etc.—conceptually an “internal evisceration”

Patient Management Checklist

• Scene safety & mechanism evaluation

• Rapid trauma survey; expose chest & abdomen, inspect/palpate systematically

• Monitor mental status, skin signs, vitals for evolving shock

• Large-bore IVs, fluid resuscitation per protocol, oxygen

• Choose facility with surgical capability (trauma center, OB-capable if pregnant)

• Smooth transport—especially if AAA suspected; avoid jarring patient

Firearm & Ballistic Takeaways

• Shotgun shells spread; low velocity, limited range

• Rifle cartridges spin via rifled barrel → greater stability, straighter trajectory, much higher velocity

• Higher velocity ⇒ bigger temporary cavity, more unseen internal injury

• "Big hole" ≠ high velocity; velocity is about speed of projectile

Head Trauma

Scalp & Superficial Head Injuries

• Scalp lacerations

  • Can bleed profusely and distract responders (“looks like a murder scene”).

  • Common in: elderly, falls, patients on anticoagulants.

  • Management

  • Direct firm pressure; wrap head but avoid excessive exploration.

  • Inspect for debris; reassess frequently.

  • Consider c-spine if MOI significant.

• Infection risk

  • Overlying laceration + skull fracture dramatically increases chance of infection entering cranial vault.

  • Keep wounds clean, cover with sterile dressings.

Skull Fracture Types & Key Facts

• Linear (≈80 % of skull #)

  • 50 % traverse the temporal-parietal region → high risk epidural bleed.

  • Often occult—may not be palpable/visible.

• Depressed

  • High-energy blunt object (bat, hammer, bottle).

  • Most common over parietal or frontal bones.

  • Frequently presents with focal neuro deficits or alteration.

• Basilar

  • Extension of linear # to skull base after diffuse impact.

  • Classic signs (may be delayed 24 h):

  • Raccoon eyes = periorbital ecchymosis.

  • Battle’s sign = mastoid ecchymosis.

  • CSF rhinorrhea/otorrhea → Halo sign on 4 × 4 (blood centre, yellow ring). CSF glucose ≈ $50–80\;\text{mg·dL}^{-1}$.

• Open/compound

  • Massive force; often multisystem trauma (falls from height, MVC, pedestrian struck).

  • Exposed brain tissue → cover with sterile saline-soaked gauze.

  • Do NOT occlude CSF drainage; apply loose dressing only.

  • Stabilise impaled objects; high infection & mortality risk.

Assessment & General Management of Skull

• Palpate with finger pads; note edema, deformity, depression, crepitus.

• Look/feel for basilar signs, CSF leakage.

• Inline c-spine stabilisation; backboard if indicated.

• Treat ABC life-threats first; rapid transport.

Monro–Kellie Doctrine & Autoregulation

• Cranial vault contents: brain tissue, blood, CSF (fixed volume).

• ↑ in one component ↓ the others; excess pushes brain through foramen magnum (herniation).

• Autoregulation loop

  1. ↓ Cerebral perfusion pressure (CPP) detected.

  2. Body ↑ mean arterial pressure (MAP) → cerebral vasodilation.

  3. ↑ Cerebral blood flow ↑ intracranial pressure (ICP).

  4. ↑ ICP further ↓ CPP (positive feedback).

ICP, MAP & CPP Numbers/Formulae

• Normal ICP: $0–15\;\text{mmHg}$.

• Field assumption for suspected raised ICP: $ICP = 20\;\text{mmHg}$.

• Cerebral perfusion pressure: $CPP = MAP - ICP$.

  • Brain death likely if CPP < 60\;\text{mmHg}; target $≈70\;\text{mmHg}$.

• Desired MAP for isolated TBI: $85–90\;\text{mmHg}$ (even higher than trauma permissive hypotension).

• Example
  $MAP = 85,\ ICP = 20 \Rightarrow CPP = 65\;\text{mmHg}$ → marginal.

• Hypotension in TBI (SBP < 90) increases mortality 50–75 %.

Cushing’s Triad (Late ↑ICP)

• Bradycardia.

• Irregular respirations (Biot’s, Cheyne–Stokes, etc.).

• Hypertension or widened pulse pressure.

Abnormal Breathing Patterns (test-able)

• Eupnea – normal.

• Tachypnea / Bradypnea.

• Apnea.

• Hypopnea.

• Hyperpnea = ↑ depth & rate (Kussmaul).

• Cheyne–Stokes – crescendo/decrescendo apnea cycles.

• Biot’s – irregular, gasping clusters with apnea.

• Apneustic – prolonged insp ± exp pause.

Cerebral Herniation & Posturing

• Decorticate (flexor) – arms flexed, legs extended; early herniation.

• Decerebrate (extensor) – arms/legs extend, back arch; deeper brainstem injury (worse prognosis).

• Posturing = sign to hyperventilate (controlled):

  • Maintain end-tidal CO₂ $30–35\;\text{mmHg}$ (normal 35–45).

  • Cerebral vasoconstriction buys space; last-ditch temporising step.

Airway & Ventilation Strategy

• Anticipate need for advanced airway in moderate–severe TBI.

• Medication-assisted intubation

  • Ideal: etomidate/ketamine + rocuronium (safer than succinylcholine in TBI; fewer side-effects, longer paralysis).

  • Georgia EMT-P workaround: fentanyl + midazolam for analgesia/sedation if RSI not in protocol.

  • Ketamine no longer contraindicated—does not raise ICP, may lower it.

• Avoid stimulation: intubation spikes ICP; pre-sedate adequately.

• Post-intubation sedation/analgesia mandatory (Versed, fentanyl, ketamine).

Fluid Resuscitation in Isolated TBI

• Goal: keep MAP ≈ $90\;\text{mmHg}$ (CPP ≥ 70).

• "Normal" BP (e.g.
  $113/68 \Rightarrow MAP≈83$) may still yield poor CPP ⇒ consider fluids.

• Use isotonic crystalloids; if available, hypertonic (3 % NaCl) may be superior.

• Hospital therapies: mannitol, hypertonic saline, surgical decompression.

Early vs Late Signs of ↑ICP

• Early

  • Headache, altered LOC, restlessness.

  • Pupils still reactive.

  • Irregular breathing (Cheyne–Stokes).

  • Projectile vomiting without preceding nausea.

  • Possible seizures.

• Late

  • Cushing’s triad.

  • Fixed or unequal pupils.

  • Posturing (de-corticate → de-cerebrate).

  • Herniation signs (loss of gag, apnea, flaccidity).

Miscellaneous Testable Nuggets

• Temporal bone fracture = high risk epidural hematoma → rapid deterioration, death.

• Halo sign, Battle’s sign, Raccoon eyes may appear up to 24 h post-injury.

• Do NOT pack/plug CSF leaks; allow egress.

• Halo test false-positive: high blood glucose NOT reliable (CSF glucose low-normal).

• Breathing support for metabolic acidosis: assist at patient’s own rapid rate (don’t slow them).

• Monro–Kellie: excess blood/CSF displaces brain downward through foramen magnum.

Quick Management Algorithm (Field)

1. Scene safety, MOI evaluation (falls, blunt weapons, MVC, elderly anticoagulated, etc.).

2. ABCs; control external bleeding with gentle pressure.

3. Inline c-spine; pad head for palpation; backboard if significant MOI.

4. Identify skull # signs (laceration, deformity, Battle, Raccoon, CSF leak → Halo).

5. Monitor vitals, GCS, pupils q 5 min.

6. Calculate MAP → ensure ≥ 85–90; give isotonic fluids early if trending down.

7. Prepare airway; sedate/analgesic; preferentially rock for paralysis.

8. After intubation: target ETCO₂ 35–45; if posturing/herniation, adjust to 30–35.

9. Cover exposed brain tissue, loosely dress CSF leaks, stabilise impaled objects.

10. Rapid transport to neurosurgical facility; pre-alert of potential increased ICP/TBI.

Rising Intracranial Pressure (ICP)

• Progressive sequence discussed in class

  • Widening pulse pressure or frank hypertension → bradycardia → irregular respirations (Biot’s / central neurogenic patterns)

  • Pupils: sluggish ➜ unequal ➜ fixed/non-reactive

  • Posturing appears (decorticate/decerebrate)

  • ECG may show dysrhythmias; eventually profound hypotension (considered the gravest prognostic sign)

• Cushing’s Triad (tie-in to previous lecture)

  • ↑ SBP / widened pulse pressure

  • ↓ HR

  • Abnormal respirations (Cheyne-Stokes, Biot’s)

Management Goals for ICP

• Maintain Mean Arterial Pressure (MAP)

  • Target ≈ $90\;\text{mmHg}$

  • Remember formula: $MAP = \dfrac{SBP + 2(DBP)}{3}$

  • Treat downward trend early with judicious crystalloid; avoid large, rapid bolus unless needed

• Airway & Ventilation

  • RSI with long-acting paralytics (vecuronium, rocuronium) so patient doesn’t buck the tube

  • Controlled hyperventilation: titrate ETCO₂ / PaCO₂ to $30–35\;\text{mmHg}$ (temporary bridge to definitive care)

• Pharmacology

  • Mannitol 20 %

  • ↓ blood viscosity → plasma expansion → ↑ cerebral O₂ delivery

  • Triggers autoregulatory cerebral vasoconstriction → ↓ cerebral blood volume

  • Contra/precaution: worsens outcome if patient hypovolemic or hypotensive

  • Benzodiazepines for seizure prophylaxis & additional sedation

• Positioning / Mechanical factors

  • Elevate head 20–30 ° (reverse Trendelenburg even on a backboard); harness gravity to aid venous drainage

  • Loosen or remove cervical collar once spine is chemically/physically stabilized; collar can impede jugular flow

Monroe-Kellie Doctrine (review)

• Cranial vault contains fixed volume of: brain tissue + blood + CSF

• Increase in any one component must be offset by decrease in the others or ICP rises

Diffuse Brain Injuries

Concussion

• Transient confusion → disorientation; may exhibit

  • Immediate or brief LOC or none at all

  • Retrograde amnesia (before impact)

  • Anterograde amnesia (after impact)

• Usually recover, but monitor for deterioration

• Example given: softball–related concussion

Diffuse Axonal Injury (DAI)

• Mechanism: shearing/tearing of axons during rapid acceleration–deceleration (MVC, falls, shaken-baby syndrome)

• Numerous micro-haemorrhages throughout cerebrum

• High mortality, poor prognosis; often comatose at scene

• NASCAR “halo” restraint cited as real-world mitigation example

Focal Brain Injuries

Epidural (Extradural) Hematoma

• Arterial bleed between skull & dura (often middle meningeal artery)

• Classic sequence

  1. Impact to temporal bone → linear fracture (≈70–80 % rupture artery)

  2. Immediate LOC

  3. Lucid interval (awakens, appears normal)

  4. Rapid decline; rising ICP → ipsilateral fixed, dilated pupil

• Treat as any ICP emergency; surgical evacuation definitive

Subdural Hematoma

• Venous bleed between dura & arachnoid (tearing of bridging veins)

• Slow onset; S/S can appear 24 h – 2 weeks post-injury

• Common in elderly falls, anticoagulated pts

• Presentation

  • Fluctuating LOC, personality change, hallucinations, hemiparesis → mimics stroke

  • May or may not have skull fracture

• Case study: lecturer’s father misdiagnosed with acute dementia due to delayed subdural bleed (only 2–3 mL blood)

Subarachnoid Hemorrhage (SAH)

• Blood within subarachnoid space (mixes with CSF)

• Etiology: trauma, ruptured aneurysm, AVM

• Hallmark: sudden, severe “thunderclap” / worst-ever headache → spreads from focal to diffuse

• Signs of meningeal irritation; bloody CSF if present

• High fatality; survivors often with permanent deficits

Intracerebral Hematoma / Hemorrhage

• Bleeding within brain parenchyma itself

• Penetrating trauma, high-speed deceleration, or extension of DAI

• Rapid neurological decline; often fatal

Practical & Ethical Considerations

• Preventing even a single episode of hypotension markedly improves neurologic outcome; once blood pressure collapses, cerebral perfusion may be unrecoverable → brain death

• Tight prehospital control of ventilation & perfusion buys surgeons time but does not cure pathology—rapid transport to neurosurgical care remains paramount

Key Numbers & Formulas

• Target MAP: $\ge 90\;\text{mmHg}$

• Hyperventilation target PaCO₂ / ETCO₂: $30–35\;\text{mmHg}$

• Head elevation: $20–30^{\circ}$

• Monroe-Kellie doctrine states that the sum of the volumes of the brain, blood, and cerebrospinal fluid (CSF) within the cranial cavity remains constant; any increase in one component must result in a decrease in one or both of the others.

Quick Field Checklist

• ABCs; C-spine only until definitively cleared → then loosen collar if ICP rising

• Secure airway, RSI with long-acting paralytic

• Ventilate to ETCO₂ 30–35 mmHg

• Monitor MAP continuously; titrate crystalloid, consider vasopressor if needed

• Administer Mannitol if not hypovolemic & protocol allows

• Elevate head 20–30 °, maintain neutral alignment

• Reassess neuro status q5 min (GCS, pupils, motor)

• Rapid transport to Level 1/2 trauma or neuro-capable center

Pediatrics and Obstetrics

Recognition of Pediatric Shock

• “Shock stuff” begins with EARLY RECOGNITION.

  • Look for subtle perfusion changes before blood pressure falls.

• Key early indicators

  • ↑ Heart rate (tachycardia)

  • ↑ Respiratory rate (tachypnea)

  • Delayed capillary-refill time (CRT)

  • Normal pediatric CRT ≈ $!!2\;\text{s}$.

  • Mental-status changes or increased agitation

• Hypotension is a late and dangerous sign

  • “Once they get hypotensive, we’re way behind the 8-ball.”

  • Goal: titrate fluids pre-emptively while pressure still “looks OK.”

Fluid Management

• Fluid-bolus therapy

  • Question repeatedly raised: “When do we give a fluid bolus?”

  • Start when multiple early indicators appear (↑HR, ↑RR, prolonged CRT) even if systolic BP is normal.

  • Typical pediatric isotonic bolus (per PALS/ATLS): $20\;\text{mL·kg}^{-1}$ — although the specific volume was not quoted in the transcript, the discussion implied standard practice.

  • Re-assess after each bolus; avoid over-resuscitation (esp. in head injury).

Traumatic Brain Injury (TBI) in Children

• “Most common cause of death” in pediatrics; mechanism usually MVCs, occasionally sports.

• Hypotension & TBI

  • If a TBI pt becomes hypotensive, mortality rises dramatically.

  • Quoted figures: mortality climbs to $75\%$–$80\%$ once systolic BP drops.

  • Likely worse in children than adults because of lower physiologic reserve.

• Management pearls

  • Prevent even single hypotensive episode.

  • Maintain cervical-spine protection (see immobilization) and normoxia; avoid hyperventilation unless signs of impending herniation.

Pediatric Spinal Immobilization

• Decision factors

  • Mechanism of injury (MOI) — high-energy MVC, falls, direct back trauma, etc.

  • Patient report: If verbal child localizes spinal pain → immobilize.

  • Non-verbal / preverbal children → safer to immobilize empirically.

• Devices discussed

  • “Little pediatric thing” on a backboard – generic foam-wedged pediatric board insert.

  • Commercial systems: PediaMate®, ACR (Ambulance Child Restraint), color-coded wrap systems.

  • Older colloquial names (“CPR device,” “Child CRP”) likely refer to same harness-wrap.

Transport & Restraint of Infants / Children in Ambulances

• Car-seat on stretcher

  • Very common in the field but NOT recommended; stretcher is not considered a fixed object.

  • If ambulance crashes and child is injured, liability falls on crew: “That’s our fault.”

• Preferred hierarchy for infants/children who are not requiring active resuscitation:

  1. Approved ACR/PediaMate fixed to stretcher (device is crash-tested for EMS stretchers).

  2. Rear-facing car seat secured in captain’s seat using base & vehicle restraint system.

  • If base is missing, run lap/shoulder belt through rear belt-path; ensure no lateral
    after-movement.

  1. Car seat on stretcher only if no other option AND seat is tightly anchored with multiple belts; realize it remains sub-optimal.

• Practical complications

  • Many infant carriers need a separate base; field crews often lack it.

  • Newborn scenario: placenta still attached to mother in unit #1; second unit dispatched solely to transport newborn.

  • Crew improvised: car seat w/o base strapped to captain’s chair vs. stretcher — debate weighed number of attachment points versus “fixed-object” principle.

• “Cannonball” effect: If provider releases stretcher rail or seat belts, the entire assembly can become a projectile in a collision.

• Provider compromises

  • If absolutely forced to move “lights & sirens,” some medics physically brace car seat by sitting adjacent, feet under rail, acting as a human barrier (NOT textbook approved, but reported in field reality).

Resuscitating the Neonate en route

• Active CPR/ALS conflicts with restraint devices.

  • Car seats are useless for CPR; ACR/PediaMate straps may obstruct pad placement or compressions on a very small infant.

• Options discussed

  • Work the arrest on scene until ROSC or termination whenever possible; then secure for transport.

  • For tiny neonates, consider padded towel roll “nest” on stretcher with manual stabilization if ACR too large.

• Recognition that guidelines leave a “gray area”; ongoing debate among educators, risk-managers, and street crews.

Ethical, Legal & Risk-Management Considerations

• Duty of care vs. product design

  • Using a device outside manufacturer’s intent (e.g., car seat on stretcher) exposes crew & agency to litigation.

• Balancing beneficence (do what helps the child now) with non-maleficence (don’t add crash-injury risk).

• Documentation

  • Clearly chart MOI, assessment findings, justification for (or against) immobilization, restraint method, and any deviations from best practice.

• Communication

  • “Talk to your kids.” Even 4-yr-olds can localize pain & aid decision-making.

  • For preverbal patients, error on side of caution.

Quick Reference Figures & Equations

• Delayed CRT: \text{CRT}>2\;\text{s}

• Standard isotonic bolus: $20\;\text{mL·kg}^{-1}$ (implied guideline)

• Hypotension-associated TBI mortality: $75\%!\text{–}!80\%$

Connections to Broader Principles

• Mirrors adult ATLS: “Hypotension + TBI = lethal combo,” but pediatric margin narrower.

• Reinforces PALS focus on early, aggressive shock treatment before blood pressure drop.

• EMS safety culture: follows same hierarchy of crash-tested restraint > improvised straps > no restraint.

Obstetric Patient Information Gathering

• Carry or memorize an obstetric quick-reference card (“patient-contact finder”) for every call that might involve pregnancy (trauma OR medical).

• Core questions to ask EVERY pregnant patient:
  • Gestational age – “How far along are you?”
  • Last menstrual period (LMP) – establishes possible due date.
  • Gravida / Para – total pregnancies vs. live births; higher para generally = faster deliveries, different pain expectations, possible uterine tone issues.
  • Known complications – gestational diabetes, hypertension, placenta previa, multiples, breech, etc.
  • Prenatal care & treating OB / delivery hospital – try to honor patient preference when not emergent.
  • Vaginal bleeding or fluid loss – quantity, color, clots.
  • Pain / contractions – onset, frequency, intensity.
  • Rupture of membranes (“water broke”) – time, color (clear vs. meconium), odor.
  • Fetal movement (“kick counts”) – decreased or absent movement since the event is ominous.
  • Seat-belt position at impact – lap belt should be under the belly across iliac crests.
  • Mechanism details – speed, direction, restraint type, air-bag deployment, interior intrusion.

Parity, Gravida, and Labor Considerations

• Gravida = total number of pregnancies.

• Para = number of deliveries ≥20 wks (live or stillborn).

• Higher para often → faster cervical dilation and easier expulsive stage (“It’s easier after the first one”).

Seat Belt & MVC Assessment

Correct placement: lap belt below uterus(belly), shoulder belt across chest as normal.

Key Documentation for Obstetric Calls

• Carry a quick-reference card or digital checklist for any call involving pregnancy (MVC, fall, medical complaint, etc.).

• Gather the “OB Hx” every time:

  • Last menstrual period (LMP) ➜ estimates gestational age.

  • Estimated due date (EDD) / “How many weeks pregnant?”

  • Gravida (total pregnancies) & Para (live births) – influences difficulty, risks, speed of labour.

  • Complications in this or previous pregnancies: pre-eclampsia, gestational diabetes, placenta previa, C-sections, multiples, etc.

  • Current symptoms: vaginal bleeding, abdominal/pelvic pain, contractions, rupture of membranes (“water broken?”), decreased fetal movement.

  • Prenatal care: OB provider & preferred hospital.

  • Trauma specifics: seat-belt position, air-bag deployment, speed, direction of impact.

• Even if the information does not change EMS care, hospital OB staff rate these complete reports as “best EMS handoffs.”

Assessing Pregnant Patients in Trauma

• Two patients every time: mother AND fetus.

• Primary survey = ABCs for mother first; fetal viability depends on maternal perfusion.

• Rapid trauma assessment additions:

  • Inspect abdomen for seat-belt sign, ecchymosis, uterine tenderness, fundal height.

  • Palpate: a term uterus should feel firm; unexpected softness may signal rupture or concealed bleed.

  • Ask mother about fetal movement (“kick counts”).

  • Auscultate / Doppler fetal heart tones (FHTs); normal range $120–160\,\text{bpm}$.

• Speed of crash matters: even $20\;\text{mph}\rightarrow0$ resembles a two-storey fall (≈ gravitational distance from $9.8\,\text{m/s}^2$).

Maternal Physiological Changes and Significance

• Blood volume ↑ ≈ $50\%$ by 24 weeks (≈ $5\,L \rightarrow 7.5\,L$).

  • Normal BP actually drops slightly; hypertension in pregnancy = possible pre-eclampsia.

• Heart rate ↑; benign systolic murmurs common.

• Weight gain: typical $20–30\,lb$ (can reach $60–70\,lb$).

• Slower gastric emptying ➜ high aspiration risk.

• Marked pelvic vascularity ➜ pelvic fractures bleed more.

• Supine hypotensive syndrome: gravid uterus compresses inferior vena cava, ↓ pre-load, ↓ BP, syncope.

Supine Hypotension & Positioning

• Goal: tilt uterus off vena cava.

• Techniques:

  • Left-lateral tilt $15–20^{\circ}$ (entire stretcher or backboard).

  • Pad $4–6\,in$ under right side of board if full immobilisation required.

  • Flex right hip/knee if straps allow.

Seat-Belt & MVC Considerations

• Lap belt LOW under abdomen, across iliac crests; shoulder belt between breasts.

• Belt across belly or visible “seat-belt sign” on uterus = red flag for placental injury.

• Transport ALL pregnant MVC patients for evaluation—even low speed.

Obstetric Trauma Complications

• Placental abruption: complete separation ➜ massive, rapid hemorrhage; may be concealed (no vaginal bleed).

• Placenta previa: partial separation/low-lying placenta; can bleed intermittently.

• Ruptured membranes pre-labour (> 24 h) ➜ infection/sepsis risk; expect antibiotics in ED.

• Uterine rupture: uterus wall tears; fetal parts or blood may extrude; fatal hemorrhage.

• Penetrating trauma can wound fetus directly (knife, bullet, shrapnel).

Field Management Strategies

• Treat visible hemorrhage, oxygenate, establish IVs early (large-bore, anticipate fluids/Tx).

• Continuous maternal SpO₂, ECG, BP; consider fetal monitoring if Doppler available.

• Rapid transport; preference to mother’s OB hospital when stable, otherwise nearest trauma/OB centre.

• Spinal precautions per usual; if back-boarded, remember the tilt/padding.

• Air medical: some services reluctant but consider for long ground times or critical bleeding.

• Traumatic arrest & peri-mortem C-section:

  • If mother pulseless & gestation ≥ $24–26\,wk$ (viable), some systems continue CPR en route for emergent C-section in OR.

  • Rare case reports of on-scene C-section by physician/medic under direct medical control; carries legal scope risks.

Fetal Assessment Quick Sheet

• FHT $120–160\,bpm$ via Doppler/stethoscope.

• Normal maternal kick counts: ≥ 10 movements in 2 h.

• Absence or ↓ movement after trauma = high suspicion of distress.

Pediatric Trauma Overview

• Trauma = #1 cause of paediatric mortality.

  • $90\%$ blunt; MVCs most common.

• Children ≠ “small adults,” but treatment principles are analogous once size & psychology addressed.

Paediatric Anatomical & Physiological Differences

• Minimal fat; flexible bones/ligaments; internal organs less protected.

• Head proportionally large ➜ head-first falls; airway prone to flexion when supine.

• Airway: anterior, narrow; large floppy epiglottis.

• Liver & spleen proportionally larger—more injury surface.

• Ramping: pad shoulders to align ear-to-sternum for BVM/intubation.

Paediatric Vital Sign Norms

Formula reminder: $\text{Systolic}_{\text{min}} = 70 + 2(\text{age in yrs})$ up to 10 y; after that use $90\,\text{mmHg}$.

Weight Estimation Tools

• “HandTevy” / “1-3-5 Rule” (kg): index fingers = $10$, $15$, $20$ kg for ages $1$, $3$, $5$ → add $5$ kg every two years.

• Broselow tape: colour-coded length-based tape gives ET-tube size, IO needle, drug dosages.

Age Classifications (EMS Documentation)

• Newborn: day of delivery.

• Neonate: $1\,\text{day}–1\,\text{month}$.

• Infant: $1–12\,\text{months}$.

• Toddler: $1–3\,\text{years}$.

• Preschool: $3–5\,\text{years}$.

• School-age: $6–12\,\text{years}$.

• Adolescent: $13–18\,\text{years}$.

Psychosocial Considerations in Paediatrics

• Stranger anxiety peaks 1–3 y; use caregiver’s lap, familiar toys.

• Poor reasoning skills—explain but do not lie (“This will pinch” not “won’t hurt”).

• Older children may cooperate if given choices & control ("mask or blow-by oxygen?").

Formulas & Numerical References (Quick Recall)

• Blood pressure (paeds): $70 + 2\times\text{age}$ up to 10 y; $90$ thereafter.

• Fetal heart tones: $120–160\,\text{bpm}$.

• Tilt angle for pregnant patient: $15–20^{\circ}$.

• Padding under board: $4–6\,\text{in}$.

• Maternal blood volume ↑ $\approx 50\%$.

• Gravitation acceleration $g = 9.8\,\text{m/s}^2$.

Practical & Ethical Implications Discussed

• Complete OB data collection gains hospital trust and improves inter-professional relationships.

• Seat-belt education for expectant mothers prevents avoidable fetal loss.

• Decision to attempt peri-mortem C-section in field balances fetal benefit vs. provider scope/legal risk—requires real-time medical control and training.

• Honest communication with paediatric patients fosters long-term trust in healthcare providers.

Burns

Skin Anatomy & Fundamental Physiology

• Skin = largest organ; 3 principal layers

  • Epidermis

  • Thin, avascular, external barrier

  • Keeps pathogens out / water in

  • Dermis

  • Vascular / innervated layer (nerves, capillaries, sweat & sebaceous glands, hair follicles)

  • Most pain fibers located here

  • Sub-cutaneous (superficial fascia)

  • Adipose (“yellow fat”) + larger vessels/ nerves

• Skin regulates temperature; once destroyed → rapid heat loss, fluid loss, ↑ infection risk

Burn Pathophysiology & Principal Causes of Mortality

• Immediate lethality: airway compromise from thermal/chemical injury

• Early complications (first 24–48 h)

  • Airway edema/obstruction

  • Massive fluid shift ("third spacing") → hypovolemic shock

• Later complications (days)

  • Infection → sepsis (major killer once acute phase survived)

• Other contributors

  • Hypothermia (loss of barrier)

  • Dehydration / electrolyte derangements

Mechanisms of Heat Transfer

• Conduction – direct contact with hot surface (e.g.
  branding iron, curling iron)

• Convection – moving hot gases/air or steam (flash‐over, airway injury)

• Radiation – radiant heat from sun, fire-front, etc.

• Evaporation – minor for external burns, but key in evaporative cooling of skin

Classification by Depth

Note: Beneath full-thickness lies possibility of 4th-degree (into muscle / bone).

Clinical Features & Care by Depth

• Superficial

• Cool running water (NOT ice) 5–10 min

• Moist dressings, aloe, topical lidocaine

• Analgesia prn
  • Partial-thickness

• Don’t pop blisters (natural biologic dressing)

• Light, moist, non-adherent dressing; topical antimicrobials

• Aggressive pain control
  • Full-thickness / extensive burns

• Stop burning process, remove non-adherent clothing/jewelry

• Cover with dry, sterile sheet (limit evaporative & convective heat loss)

• Keep patient warm—warm IV fluids, blankets, heated cab

• High-dose analgesia/sedation; many protocols allow “procedural/sedative” ketamine dose (≈1–2 mg·kg⁻¹ IV) when airway stable

• Fluid resuscitation (see formulas)

• Early airway management (edema develops rapidly)

Fluid Resuscitation Formulas

• Traditional Parkland: $4\,\text{mL} \times \text{kg} \times \%TBSA$

  • Give 1⁄2 in first 8 h from time of injury, remainder over next 16 h

• Updated “Consensus” formula (less aggressive): $2\,\text{mL} \times \text{kg} \times \%TBSA$

• Use LR; titrate to urine output (adult target ≈0.5 mL·kg⁻¹·h⁻¹)

• Do NOT start formal resuscitation for burns <10 % TBSA; risk of edema > benefit

Airway & Inhalation Injury

• Clues: facial burns, singed nasal hair, soot in mouth/sputum, carbonaceous sputum, hoarseness, stridor, confined-space fire

• Edema progresses; secure airway early • In many GA systems RSI prohibited for field medics → must decide:

  • Transport directly to burn center while patent, OR

  • Go to closest ED for airway control, OR

  • Activate air-medic (RSI capable)

• Worst-case: surgical/needle cricothyrotomy (14 ga = “last-ditch straw”)—poor long-term ventilation, emphysema risk

Destination Criteria (GA examples)

• Major / complicated burns: Grady, WellStar Cobb, JMS Augusta

• Consider balance: 40 min ground to burn center vs 15 min to local for airway stabilization

Pain Management Options (protocol dependent)

• Fentanyl 1–2 µg·kg⁻¹ IV/IN q5 min

• Ketamine (analgesic 0.2–0.3 mg·kg⁻¹; sedative 1–2 mg·kg⁻¹)

• Diazepam/midazolam as adjunct

Smoke Inhalation Toxicology

Modern Fire Load

• Synthetic furniture = petro-plastics ⇒ hotter, faster, dirtier fires

• Combustion products: CO, HCN (hydrogen cyanide), hydrogen chloride, phosgene, sulfur species

Carbon Monoxide (CO)

• Binds Hb with ≈$250$× affinity of O₂ → forms carboxyhemoglobin (HbCO)

• Shifts oxy-Hb curve left → tissue hypoxia

• S/S: headache, dizziness, N/V, cherry‐red skin (late), altered mentation, multiple pts same scene

• Diagnosis

  • Pulse-ox unreliable (reads false 100 %) unless device has SpCO channel

  • Scene 4-gas / dedicated CO meter (>35 ppm triggers alarm)

• Treatment

  • 100 % high-flow O₂ (NRB/BVM) or ventilator with FiO₂ 1.0 → accelerates HbCO half-life

  • Hyperbaric O₂ considered if neuro deficits, pregnancy, HbCO > 25–30 %

  • Remove from source, ventilate structure

Hydrogen Cyanide (HCN)

• Disrupts cytochrome oxidase ⇒ cells cannot utilize O₂ (“metabolic asphyxiant”)

• Often co-exists with CO in plastic fires

• Antidote of choice: Hydroxocobalamin (Cyanokit®)

  • Adult dose: $5\,g$ IV over 15 min; may repeat once (max 10 g)

  • Converts cyanide → cyanocobalamin (vitamin B₁₂) excreted renally

  • Side effects: transient hypertension, chromaturia (red urine/skin), interferes with colorimetric labs & BGL meters → obtain baseline glucose before admin

  • Cost ≈ $1 500/vial → often stocked only in battalion chief / med-ops vehicles or flight crews

CO & HCN Source Scenarios

• House/apt fires, vehicle fires, garage suicide (car running), generators or grills indoors, faulty gas/kerosene heaters, RV & camper propane heaters, battery charging (false‐positive CO alarms)

Environmental / Operational Considerations

• Multiple pts w/ similar neuro/GI symptoms → think toxic exposure

• EMS crews: carry personal CO monitor on first-in bag; alarm >35 ppm → back out, ventilate, don SCBA or call FD

• Four-gas meters on engines/ladders: O₂, CO, H₂S, LEL readings

Field Treatment Algorithms (Integrated)

1. Scene safety, remove from hazard, alert FD for metering

2. Stop burn: extinguish flames, remove smoldering clothing unless melted into skin

3. Airway evaluation every few minutes; consider early supraglottic device if RSI unavailable

4. Oxygen therapy: NRB/BVM 15 L·min⁻¹ or higher; prepare to assist ventilations

5. Estimate %TBSA (Rule of Nines, palmar method)

6. If >10 % TBSA → start LR per consensus formula; 2 large-bore IVs through unburned skin

7. Cover with dry sterile sheet; keep warm (ambient heat, Warm IV, blankets)

8. Analgesia/sedation per protocol; titrate to patient comfort/consciousness

9. Consider Cyanokit when: enclosed-space fire + soot + ALOC + hypotension/seizure/lactic acidosis

10. Decide destination:

    • Unstable airway → closest capable ED or rendezvous with RSI-capable flight crew

    • Stable airway + major burn → verified burn center

11. Continuous reassessment: temp, airway patency, pain, vitals, urine output if foley in ED

Ethical / Practical Issues Highlighted

• Balance "ideal" burn-center care vs emergent airway needs

• Limited drug budgets: $1 500 cyanide kits may not be on every truck→ know who carries it

• GA scope limits (no RSI except critical-care or flight): necessitates advance planning & collaboration with FD/flight

• Hypothermia prevention vs wound cooling: small superficial = cool water; extensive = DRY sheet & active warming to avoid core hypothermia

Quick Reference Numbers & Formulas

• Parkland: $4 \times \text{kg} \times \%TBSA$ (1⁄2 first 8 h)

• Consensus: $2 \times \text{kg} \times \%TBSA$

• SpO₂ ≈100 % can still equal severe CO poisoning ⇒ trust clinical picture, not pulse-ox

• Needle cric catheter ≈14 ga: internal diameter ≈1.6 mm → poor ventilation (use only as bridge)

Illustrative Examples Shared

• Child with circumferential leg scald → suspect immersion injury (possible abuse)

• Firefighters wearing wet gear hit by steam → convection/steam burns despite PPE

• Backyard gasoline on bonfire resulted in flash facial burn & inhalation injury (airway at risk)

• CO incident: family with headache/weakness, grill burning indoors → meter confirmed high CO

Practical Tips & “Pearls”

• Keep blister roofs intact; they’re sterile dressings

• Superficial burns often hurt MORE than central full-thickness (nerve destruction)

• Never apply ice directly: causes vasoconstriction & further tissue damage

• Burn sheets: sterile but may adhere; clean cotton sheet is acceptable alternative

• Document %TBSA, depth, location, mechanism, time of injury, fluids given, urine output, airway assessments, meds

• Always rehearse "what if the airway closes en-route?" before leaving scene

Burn Classification, Appearance, Healing

• Superficial/Partial Thickness: red, painful, moist, blanches.

• Full-thickness (3rd-degree): white/brown/charred, dry, no sensation, cannot heal without surgical grafting.

  • Adult lecture mnemonic: “Adults: the burned area is white, brown, dry, charred, has no sensation, needs surgery.”

Determining Total Body Surface Area (TBSA)

Rule of Nines (ADULT)

• Head & neck: $9\%$ (front $4.5\%$ / back $4.5\%$)

• Each arm: $9\%$ (front $4.5\%$ / back $4.5\%$)

• Anterior trunk (chest + abdomen): $18\%$
  • Several instructors teach “upper abdomen 9, lower abdomen 9” to help remember.

• Posterior trunk: $18\%$

• Each leg: $18\%$ (front $9\%$ / back $9\%$)

• Genitals: $1\%$

Rule of Palms

• Patient’s own palm (including fingers) = $1\%$ TBSA.

• Use for irregular, patchy, or very small burns, especially in children.

• Practical tip: in the field grab their hand, not yours (“my palm is a medium glove, Tyler’s is XL → use his”).

Clinical Use

• Dispatch/receiving hospitals will ask “What % burn?”; give a rapid, honest estimate—per instructor, minor variation is acceptable in the field.

• Cheat-sheet cards taped to the truck/inside badge strongly encouraged.

Pathophysiology & Burn Shock

1. Capillary leak → hypovolemic phase
   • Water, electrolytes, proteins exit vessels → widespread edema.

2. Burn shock phase
   • ↓ Intravascular volume → ↑ blood viscosity & SVR → compensatory tachycardia.
   • Tissue hypoxia → organ failure.

Treatment goals: restore volume (IV fluids/electrolytes/colloid), prevent infection (wound care), control pain (analgesia).

Airway / Inhalation Injury

• Red flags: hoarseness, stridor, facial burns, singed nasal hair, carbonaceous sputum, exposure in enclosed space.

• Immediate actions
  • High-flow humidified O₂.
  • Nebulised cool normal saline ± albuterol (soothes inflamed airway).
  • Ice pack externally to neck if no neb kit.

• Prepare for early advanced airway; have surgical/needle cric kit available.

Circumferential Burns & Compartment Syndrome

• Entire circumference of limb/torso = risk of skin “tourniquet” as edema develops.

• Monitor 5 P’s: Pain, Pallor, Paresthesia, Pulselessness, Paralysis.

• Re-check distal pulses frequently; rapid transport to burn centre for possible escharotomy/fasciotomy.

Fluid Resuscitation Formulas

Consensus / Parkland

$\text{Volume (mL)} = 2{-}4\,\text{mL} \times \text{Body mass (kg)} \times \%\text{TBSA}$

• Give ½ in first 8 h (clock starts at burn time) and ½ over next 16 h.

• Example from class (2 mL guideline): 81 kg patient, 27 % TBSA ⇒ $2\times81\times27 = 8748\,\text{mL}$
  • 1st 8 h ≈ $4374\,\text{mL}$ (≈ 550 mL hr⁻¹).

Agency-Specific Shortcuts Discussed

• %TBSA × 10 mL h⁻¹ (initial) • Some services: min 250 mL h⁻¹, max 500 mL h⁻¹.

• Others: single bolus $20\,\text{mL kg}^{-1}$ up to 2 L, then consult.

Field pearl: Start an IV, begin gentle infusion (≈ 500 mL h⁻¹ LR if available); upscale if hypotensive. Don’t delay care doing math.

Crystalloids

• Preferred: Lactated Ringer’s (pH & electrolyte profile closer to plasma).

• Acceptable: 0.9 % NaCl if LR unavailable.

Trauma + Burns

• If concomitant hemorrhage, follow permissive-hypotension trauma strategy first; uncontrolled bleeding kills faster than burns.

Analgesia

• Fentanyl: $1\,\mu\text{g kg}^{-1}$ IV/IN; comes 100 µg/2 mL.
  • Easy dilution trick: draw 100 µg into a 10 mL flush → 10 µg mL⁻¹, then give desired dose in mL (e.g., 8 mL = 80 µg).

• Ketamine:
  • Analgesic: 0.1–0.3 mg kg⁻¹ IV (≈30 mg typical).
  • Dissociative: 1–2 mg kg⁻¹ IV or 3–5 mg kg⁻¹ IM (used if no IV or extreme pain).

• Toradol 30 mg IV/IM optional (check renal status & no GI bleed).

Chemical Burns

• Identify agent: acids vs alkalis (bases). Alkaline injuries often worse – liquefaction necrosis.

• Dry powder → brush off completely before irrigation.

• Copious water irrigation (“solution to pollution is dilution”).

• PPE + Fire/HazMat decon; avoid self-contamination.

• Special agents
  • Hydrofluoric acid: apply calcium-gluconate gel / inject $10\%$ Ca-gluconate.
  • Soap (Dawn) acts as surfactant to strip oils/chemicals.

• Eyes: continuous irrigation; Morgan lens or improvised drip-set + trimmed nasal cannula over eyes.

Electrical & Lightning Injury

• Look for entry & exit wounds; skin damage may underestimate internal injury.

• Dysrhythmias (VF/VT/asystole) common → attach monitor, treat like medical arrest (defib/ACLS, high survivability if early).

• Deep tissue necrosis → high myoglobin → aggressive fluids to prevent ATN.

• Fractures from tetanic muscle contraction or blast‐type throw; full trauma survey.

Radiation

• Types
  • Alpha: stopped by skin/paper.
  • Beta: penetrates farther, stopped by clothing.
  • Gamma: deeply penetrating (DNA damage) – major threat.

• Illness depends on dose/time/type: prodrome (nausea/vomiting), hematologic collapse, CNS/GI failure, cutaneous burns.

• Scene management = HazMat, time–distance–shielding, decon, supportive care.

Special Populations – Elderly

• >1,300 U.S. fire‐related deaths/yr in ≥65 yo.

• Slower reaction/mobility, ↓ smell, ↑ baseline pulmonary & cardiac compromise → higher mortality, more airway injury.

Transport Decisions & Disposition

• Burn centre indications (American Burn Association + lecture):
  • ≥10 % TBSA partial-thickness.
  • Full-thickness, circumferential, face, hands, feet, perineum, major joints.
  • Electrical/chemical/inhalation injury.
  • Concomitant trauma → go to trauma centre; if stable & available, select combined burn/trauma facility (e.g., Grady/Kennestone, GA).

Field Mnemonics & Practical Tips

• "Ditch doctor" philosophy: carry laminated rule-of-nines card; plan for when memory fails.

• Five P’s – monitor circumferential limbs for compartment: Pain, Pallor, Paresthesia, Pulselessness, Paralysis.

• ABCs first, burns second – airway/bleeding/shock trump %TBSA paperwork.

• PPE: never become the 2nd patient; don’t run into gas clouds.

• Humidified O₂ + cool nebulised saline = “inside-the-throat burn dressing.”

Key Equations & Numbers Quick-Reference

• Rule of Nines adult chart (see above).

• Rule of Palms: $1\%\text{ = patient palm}$.

• Parkland / Consensus: $2{-}4\,\text{mL} \times \text{kg} \times \%\text{TBSA}$ (½ in 8 h).

• Service shortcut: $\%\text{TBSA} \times 10\,\text{mL h}^{-1}$ initial drip.

• Analgesia:
  • Fentanyl 1mcg/kg (repeat PRN).
  • Ketamine pain 0.1–0.3 mg/kg; dissociation 1–2 mg/kg IV.

Ethical / Practical Reminders

• Field estimates are guides; definitive numbers calculated later – don’t delay care.

• “Cheat sheets are not cheating; they’re planning.” Have resources pre-staged.

• Maintain compassion: keep burn patients warm, protect exposed tissue with clean sheets, manage severe pain early.

• Safety hierarchy: Scene safety → Decon → ABCs → %TBSA → Fluid → Analgesia → Destination choice.

Enviornmental Emergencies and Snakes

Venomous Snakes of Georgia

• Total venomous species in Georgia: 6

  • 5 pit vipers (family Viperidae-subfamily Crotalinae)

  • Rattlesnakes (3)

    • Eastern Diamondback

    • Timber (a.k.a. Canebrake)

    • Pygmy

  • Copperhead

  • Cottonmouth (Water-moccasin)

  • 1 elapid

  • Eastern Coral Snake

• Mnemonic for banded red/yellow/black snakes

  • “Red on black, friend of Jack” ➔ non-venomous Scarlet King Snake

  • “Red on yellow, kill a fellow” ➔ venomous Coral Snake

  • Must see all three colours; partial patterns can mislead

• Identification cues (pit vipers)

  • Triangular head, facial “pit” between eye & nostril (infra-orbital heat sensor)

  • Vertical slit pupil

  • Thick body, short tail, single row of sub-caudal scales beyond vent

  • Swimming: entire body often floats on surface

  • Strike distance ≈ $\frac13$–$\frac12$ of body length (e.g. 6-ft snake → 2–3 ft reach)

• Non-venomous identifiers

  • Smooth, rounded head, round pupils

  • When swimming, only head above water

  • Examples: Rat Snake, King Snake, Corn Snake, Black Racer, Rainbow Snake, Worm Snake, Mud Snake

  • Scarlet King Snake mimics Coral colours (see mnemonic)

• Legal/ethical note

  • Illegal to kill any non-venomous snake in Georgia (state wildlife statute)

Snake-bite Epidemiology & Numbers

• U.S. annual average

  • $\approx 55\,000$ snake bites

  • $\approx 45$ fatalities (≈ $0.1\%$ case-fatality)

• Georgia

  • $\approx 6$ deaths per year (parallels 6 venomous species)

• Comparative fatality figures (U.S.)

  • Bees/wasps $\approx 51$ deaths/yr

  • Dogs $\approx 30$ deaths/yr

  • Spiders $\approx 67$ deaths/yr

  • MVC (motor-vehicle collision) deaths $\approx 32\,000$ (2011 data)

  • Heart disease $\approx 600\,000$ deaths/yr

Snake-bite Pathophysiology & Presentation

• 25 % of pit-viper bites are “dry” (no venom injected)

• Venom effects: local swelling, pain, bruising, coagulopathy, potential anaphylaxis (major actual cause of most deaths)

• Systemic signs: tachycardia, hypotension, paresthesia, metallic taste, nausea/vomiting

• Track swelling by marking margins and time with Sharpie every 15–30 min

Pre-hospital Management of Snake Bites

• Scene safety; prevent second bite

• Do NOT: apply tourniquet, cut/suction wound, apply ice, bring snake to hospital (dead heads still bite)

• Initial care

  • Remove rings/jewellery ⇒ anticipate massive swelling

  • Immobilise bitten limb in neutral position (splint); keep at/above heart level depending on protocols

  • Minimise patient movement; keep patient supine & calm (reduces venom spread)

  • Support ABCs, O₂ as needed

  • Pain control: fentanyl/morphine

  • Mark swelling progression as above

• Anaphylaxis

  • If airway compromise / distributive shock: standard $0.3\,\text{mg}$ IM epinephrine $1:1000$ despite theoretical venom dispersion risk (confirmed by Georgia Poison Ctr.)

• Transport

  • Fast transport to trauma/antivenom center; call ahead

  • Polyvalent Crotalid Fab antivenin covers all pit vipers; Coral antivenom is different (usually not in GA because coral bites rare)

• Hospital availability

  • Trauma centers (e.g., Cartersville, Kennestone) stock antivenom; small EDs may not—confirm via base station

  • Typical adult course ≈ 4–12 vials; cost \$\$ > $10,000–20,000

Prevention Pearls

• Wear boots, avoid tall grass, use lights at night, never handle “dead” snakes

• Education: campers, gardeners, church “snake-handling” groups (historic fatal cluster in Bartow Co.)

Heat-Transfer & Thermoregulation Basics

• Controlled by hypothalamus

• Mechanisms of heat movement

  • Radiation – infrared transfer (camp-fire)

  • Conduction – direct contact (metal poker in flame)

  • Convection – fluid/gas movement (boiling water, circulating blood)

  • Evaporation – phase change of sweat → major physiologic cooling

• Vascular response

  • Heat ⇒ vasodilation ⇒ skin flushing & BP drop

  • Cold ⇒ vasoconstriction ⇒ pale skin & shivering

Heat Illness Spectrum

Heat Cramps

• Early, salt-depletion muscle spasms (abdomen/back/arms)

• Normal or slightly elevated core Tº

• Tx:

  • Oral rehydration with electrolytes (sports drinks, ORS, lightly salted water)

  • IV fluids only if N/V prevents PO intake

Heat Syncope

• Dilated vessels + orthostatic drop (e.g., concert standing, gardening squat → sudden stand)

• Brief LOC, rapid recovery

• Tx: supine position, oral fluids with salt, cooling environment

Heat Exhaustion

• Prolonged fluid & Na⁺ loss

• S/S: heavy sweating, weakness, headache, dizziness, nausea, tachycardia, tachypnea

• Core Tº < $104^{\circ}\text{F}$ (≈ $40^{\circ}\text{C}$)

• Risk of carpopedal spasm (hyperventilation ↓Ca²⁺)

• Tx: move to shade/AC, cool mist/fans, oral or IV isotonic fluids + Na⁺, no plain water chugging (hyponatremia)

Heat Stroke (true emergency)

• Core Tº ≥ $104^{\circ}\text{F}$ plus altered mental status (irritability, confusion, seizures, coma)

• May sweat or be anhidrotic; pupils often pinpoint; possible rhabdomyolysis

• Complications: pulmonary edema, DIC, renal failure

• Pre-hospital priorities

  • Remove from environment; strip clothing

  • Active cooling: ice packs axilla/groin/neck, cold-water immersion, ice-soaked sheet

  • Goal: stop active cooling at approx. $102^{\circ}\text{F}$ core (rectal) to avoid overshoot hypothermia (field rectals rare—balance clinical judgment/time)

  • Cool IV fluids judiciously; continuous lung-sound & EtCO₂ monitoring (pulmonary edema risk)

  • Consider sedation (midazolam) & airway control if combative/LOC/seizures; benzodiazepines also blunt shivering

Cold-Related Injuries

Frostbite

• Superficial: white, waxy, firm skin over soft tissue ("like frozen halibut")

• Deep: mottled blue-black, hard tissue, hemorrhagic blisters

• Pain, numbness, tingling; massive edema during thaw

• Field care

  • Remove from cold/wind; do not rub/massage

  • Protect & elevate limb

  • Cover with dry, sterile, preferably warmed dressing

  • Re-warm only if no chance of refreezing (water bath $100–104^{\circ}\text{F}$ for 15–30 min in hospital ideal)

  • Analgesia (fentanyl, ketorolac) for re-warming pain

Trench Foot (Immersion Foot)

• >24 h exposure to cold, wet (above freezing) conditions in boots

• Path: vasoconstriction → ischemia → edema → necrosis

• S/S: pale, numb, then hyperemic painful swelling; may mimic frostbite but without ice crystal formation

• Tx: preventive foot hygiene, dry socks; field care identical to frostbite minus water bath

Chilblains (Pernio)

• Repeated exposure to damp & cool (1–15 °C /33–59 °F) temps

• Itchy, burning, reddish-purple papules on fingers, toes, ears, nose

• Usually self-limited; treat with gentle warming, topical steroids if ordered

Hypothermia Basics (preview)

• Defined as core Tº < $95^{\circ}\text{F}$ (≈ $35^{\circ}\text{C}$)

• Cold pathophysiology mirror-opposite of heat illnesses (vasoconstriction, shivering, slowed metabolism)

• Management principles teased for next lecture

Practical / Ethical / Real-World Connections

• Outdoor workers, athletes, military, hikers = high-risk cohorts: educators should emphasize prevention

• Legal ramifications of killing protected wildlife & dangerous implication of transporting snake body parts

• Community myths (tourniquets, “suck & cut,” bringing dead snake) contrast with evidence-based care

• Cost barrier of antivenom ⇒ insurance/EMS resource planning

• Ethical dilemma: balancing epi for anaphylaxis vs. theoretical venom spread—current consensus favors treat the anaphylaxis

• Climate change → longer heat seasons & altered snake habitats = increasing call volumes for both problems

Quick-Reference Values

• Core temp thresholds

  • Heat stroke ≥ $104^{\circ}\text{F}$

  • Active cooling stop ≈ $102^{\circ}\text{F}$

  • Hypothermia ≤ $95^{\circ}\text{F}$

Hypothermia Fundamentals

• Core temp < $95\,^{\circ}\mathrm F$ (≈ $35\,^{\circ}\mathrm C$).

• Risk factors (environmental + intrinsic):

  • Prolonged exposure to cold / wet / wind.

  • Alcohol intoxication: impairs thermoregulation and judgment ("I’m fine at 12 °F").

  • Geriatrics:

  • ↓ muscle mass → ↓ shivering heat production.

  • On vasodilating/antihypertensive meds → poor vasoconstriction.

  • Burns (loss of skin barrier), sepsis, severe trauma, dehydration.

  • Endocrine & metabolic: hypothyroidism, adrenal insufficiency.

  • Neurologic / autonomic: Parkinson’s, MS, dementia, diabetic neuropathy (don’t feel cold).

  • Eating disorders, malnutrition.

  • Neonates < 6-12 mo cannot shiver; rely on brown-fat metabolism.

  • “Over-zealous” cooling in burn pts.

  • Outdoor adults: poor planning (single pair of socks, soaked by rain, temp drops to 33 °F).

Physiologic Responses to Cold

• Peripheral vasoconstriction (conserves core heat).

• Shivering thermogenesis

  • Burns calories from glycogen & adipose.

  • Cold-plunge / chronic cold exposure ↑ brown fat, ↓ white fat, ↑ dopamine (anecdotal 11 min ∙ wk⁻¹ study).

• Metabolic shift: ↑ catecholamines, glucose use.

Classification of Hypothermia (Celsius)

(Quick conversion) $T<em>F = T</em>C \times\frac{9}{5}+32$

Rewarming Strategies

Passive External (Mild)

• Remove from cold, strip wet clothes, dry pt.

• Warm ambulance; heater on.

• Insulate with blankets; place hands in axillae/groin.

Active External (Mild–Moderate)

• Chemical/gel heat packs to neck, axillae, groin.

• Warm blankets; forced-air system (“Bear Hugger”: inflatable plastic blanket attached to hot-air hose ‑ likened to a pool float).

• DIY EMS hack: connect flexible tubing from heater vent to improvised blanket sleeve or body-bag zipper system.

Active Core/Internal (Moderate–Severe)

• Warmed IV fluids at 102 degrees. Many trucks heat bags on defroster; textbook target = 102 degrees.

• Warm humidified O₂.

• Body-cavity lavage (warm saline gastric, peritoneal or rectal—"Judah’s warm-fluid enema"—uncommon pre-hospital).

• Continue until core ≥ 95 degrees, then slow rate.

Field Pearls / “Not Dead … ”

• Cold-water submersion: profound hypothermia may protect brain ➜ “You’re not dead until warm and dead.”

• Continue resuscitation until core ≈ $32\,^{\circ}\mathrm C$ unless obvious lethal injuries.

Lightning Strike Mass-Casualty Incidents

• Scene safety: risk of second strike.

• Reverse triage: treat apparent dead first—often in $V!F$ that converts with a single shock.

• Support ABCs, monitor, defib early.

• Look for entrance/exit burns, fractures, tympanic rupture; cover wounds with dry sterile dressings.

Spider Envenomation

Black Widow (Latrodectus mactans)

• Bite = pin-prick; 30–60 min later sudden severe local pain.

• Triad: localized pain, muscle spasms, localized diaphoresis.

• Progression: large-muscle spasms (thighs, shoulder girdle, abdomen) → diaphragmatic involvement → resp distress.

• Tx: ABCs, analgesia, benzodiazepines for spasms, antivenin available (rarely used).

Brown Recluse (Loxosceles reclusa)

• Often painless; majority asymptomatic.

• Small % develop systemic illness or loxoscelism → severe inflammation & gangrenous skin sloughing (“necrotic crater”).

• Supportive care, wound management, monitor for hemolysis/kidney injury.

Tick-Borne Concerns

• Remove tick promptly (fine tweezers, steady pull).

Lyme Disease (Borrelia burgdorferi)

• Vector: deer tick (Ixodes). Classic bull’s-eye rash (erythema migrans) in only ~70 %.

• Early S/S: fever, fatigue, headache.

• Late: migratory joint pain, neuropathy, cognitive “brain fog”.

• Tx: doxycycline; early treatment prevents chronic sequelae.

Alpha-Gal Syndrome

• Lone Star tick bite → sensitization to galactose-α-1,3-galactose.

• Delayed anaphylaxis 3–6 h after eating mammalian meat (beef, pork, venison). Poultry usually safe.

• Manage like any IgE anaphylaxis (epi, airway, antihistamines).

Key Numbers to Memorize

• Mild hypothermia: 33-35 degrees C or 91-95 degrees F

• Moderate: 28-32 degrees C or 82 degrees F

• Severe: 27.7 degrees C or 78 degrees F

• Warm IV fluids: 102 degrees F

Ethical / Practical Notes

• Geriatric & pediatric populations deserve aggressive prevention (can’t shiver / can’t self-advocate).

• Substance use counseling: alcohol dramatically ↑ hypothermia risk by blunting both physiology and judgment.

• Field improvisation (heater-vent blanket, dashboard IV warmer) illustrates need for EMS ingenuity balanced with evidence (target temps, infection control).

• Documentation: note environment, clothing wetness, time to heat source, temp readings, shiver presence, core temp device/location.

Mr. King’s Hurricane Michael Recap (MCI Caveats from experiences)

Hurricane Context & Pre-Storm Warnings

• Hurricane Michael (Category 5 at landfall on FL Panhandle) was initially warned to be a Category 3, then advanced to Category 5 in the last 12 hours prior to hitting land. Very little time to decide to evacuate in those last 12 hours.

• Repeated public advisories:

  • Officials broadcast: “If you stay, EMS will not be able to reach you.”

  • Fire/EMS drove neighborhoods with loud-hailers reiterating non-response after a cut-off time.

  • Keep in mind, typically these announcements occur up to a week prior to storm landfall. Locals at the time of Hurricane Michael had 12 hours.

• Community reactions:

  • Many residents—especially elderly or long-time locals—chose to “ride it out,” citing past storms survived. Keep initial Category 3 denomination in mind.

  • Shelters with generators (schools, gyms) were opened, but some people declined to use them.

  • Parents of medically fragile kids (e.g., diabetics with insulin needing refrigeration) were reminded to prep or evacuate.

Immediate Post-Landfall Environment

• Physical damage

  • Radio towers “bent in half.”

  • Cell towers & underground cable ripped out by uprooted trees ➔ near-zero comms (≈ $80\%$ of county workers used Verizon/Comcast lines that failed).

  • Main hospitals:

    • Bay Medical (Level II Trauma) flooded; glass façade shattered, ICU patients hand-bagged by family members with BVMs.

    • Second hospital (cardiac specialty) shifted $2.5$ inches off its foundation.

  • Roads blocked; took 4 days for King’s home street to become passable despite not being on or near the beach.

  • On Hwy 231, trees all felled northward on one side, southward on the other—clear path of the eye.

• Atmospheric conditions afterward (24-48 hrs post storm ending)

  • Beautiful weather: blue skies, temps in high 40 °F, intense pine scent from thousands of snapped trees.

EMS/Fire Operational Orders & Friction

• Initial standing order: “Stay in place until contacted.”

  • Rationale: • Safety • No hospitals accepting patients • Tracking scarce resources • Preventing false hope.

• Crews sat idle ≈ 24 h with nonstop 911 traffic in their ears; morale deteriorated.

• Discovery of zero comms (bent towers) explained silence from command.

• Crews eventually self-deployed to cut through debris, check victims, and clear power lines.

Field Medical Encounters & Triage Dilemmas

• Golf-cart accident: middle-aged female with crushed trachea (stridor, rapid cyanosis).

  • Prepared surgical cricothyrotomy kit.

  • Command said: “Stabilize, return patient home.”

  • Lieutenant argued for Coast Guard LZ in golf course; command: “If you have their number, call them.”

  • SO arrived in an officer’s personal Hummer-type vehicle, after being informed by King and other FD that hospitals were not taking patients and that they’d be advised to stabilize and return pt home, SO officers insisted on taking pt and that they’d “get her in.”

  • King heard a rumor this pt died, unknown outcome. SO did indeed get her in when they pulled up, though.

• Triage protocol after hospitals partially reopened:

  • Only “Reds” (critical) accepted.

  • “Yellows” (e.g., bedridden elder w/ dementia but stable vitals) had to remain in place with note & water.

    • King told a story about him and FD coming upon this bedridden woman with dementia, there was a note near her bed stating she’d been checked on and was alright. King said they made sure she had water and that her vitals were alright before having to move on to more critical calls nearby.

• Typical post-storm traumas:

  • Falls from roofs while tarping.

  • Chainsaw/tree-felling injuries; leaning, damaged trees behave unpredictably.

  • GSWs from looting confrontations (streets painted: “Loot = We Shoot ||||”).

• Surge, yet scarcity:

  • Lifelight helicopter chain evacuating entire inpatient population.

  • Rapid depletion of hospital supplies anticipated.

Communication, Logistics & Resource Constraints

• Bent radio towers ➔ no dispatch; crews discovered situation only once they drove into signal range days later.

• Majority staff phones dead (Verizon/Comcast); landlines/cable destroyed by root-torn trees.

• Shelter assignments:

  • Some EMS shifts posted 24 h on / 24 h off at shelters, not stations.

  • King did continuous ≈2 weeks on shift before first day off.

• Pay structure (federal emergency rate):

  • $24$-h pay × double-time ≈ $4500$/wk as EMT-Basic; > $10{,}000$ earned in ~2 mo.

Further Impact

• Dispatcher calls replayed over radio during storm:

  • “I found my neighbor dead in the pool, I’ve started CPR. What do I do?” “Keep doing CPR; we can’t get there.”

  • “My house is on fire.”

    “Get out of danger, we have you on the list.”

  • “My baby needs a breathing treatment.”

    “Keep her comfortable, we can’t get crews out at this time.”

  • “My sister is dead—what do I do?”

    “Cover her and move to another part of your house, we cannot send crews out at this time.”

• Personal stress:

  • King had no word on wife for ~48 h; continuously tried to get through on the phone, a single call was picked up for a moment but dropped, King said it gave slight relief.

  • First reunion lasted 5 min before another fatality call.

  • Subsequent deaths of co-workers (e.g., medic killed by falling tree while clearing his yard).

Security & Public Safety

• National Guard & Coast Guard patrolled; closed areas (Fort Myers Beach example) to stop boat-borne looters.

• EMS USAR teams feared being mistaken for looters; limited door-to-door work to daylight (< 21:30).

• Armed homeowners on alert; concern of being shot while knocking.

Long-Term Aftermath & Lessons Learned

• Expect cluster & confusion during genuine MCIs; textbook ICS rarely matches field chaos.

• First on scene = You’re in charge for the time being.

  • When in doubt, START triage. “If you can hear my voice, walk to (this area)” designates your green, and you need to work from there.

  • Remember ICS command roles, vaguely, to promote scene success. This moreso means, put someone in charge of simple roles quickly so your bases are covered. While it’s near impossible to have every single role filled in textbook order, quick roles to delegate can include:

    • Having someone to watch the scene to make sure responders are safe - safety officer. This can be someone making sure removal of debris is not about to fall on crew + pt, or someone in PD advising crew if any threats are nearing the scene.

    • Having someone oversee the triage area and decide where pts are going to go if transport becomes available - transport supervisor

    • Having someone lead triage and treatment in the yellow/red area - triage leader/supervisor

• Redundancy in comms essential; loss of radio + cellular = paralysis.

• Follow stay-in-place until an all-clear comes across from command. This is difficult, but prevents false-hope among patients and allows hospitals time to actually be able to take those patients.

• Pre-storm patient education: evac guidelines for insulin refrigeration, oxygen dependence, emphasize importance of evacuation/preparation and prepare to be on the clock for a while after the emergency passes.

• Post-event hazards kill responders: chainsaw operations, unstable debris.

• Psychological resilience: idle time during disaster deployment can be as stressful as overwork. Do your best to think critically.