Chapter 27 Trauma Overview: The Trauma Patient and the Trauma System Notes
Case Study: Hunting Accident in Remote Area
Incident Overview:
EMTs Nina Segall and Scotty Lindquist respond to a report of a person shot in a hunting accident.
Response Time: The EMTs had a response time to a remote area.
Scene Safety: State police confirmed the scene was safe and all weapons were secured.
Patient Profile: A -year-old male accidentally shot by another hunter with a high-velocity rifle.
Initial Assessment:
Scene Size-up: A police officer is holding direct pressure on the patient's thigh.
Patient Presentation: The patient is lying supine on the ground.
Mental Status: The patient appears combative and confused.
Skin Condition: Pale and sweating, despite cool environmental temperatures.
Vital Signs: Nina detect a weak, thready radial pulse estimated to be > 100\,beats/min.
Airway and Breathing: The airway is open; breathing is adequate. Oxygen is applied via a nonrebreather mask.
Secondary Assessment:
Rapid Secondary Assessment: Nina identifies an entry wound on the front of the thigh and an exit wound posteriorly.
Preparation: Scotty prepares a long backboard for transport.
Outcome and Disposition:
Destination Decision: There is a community trauma center away and a regional trauma center away.
Medical Direction: Advised transport to the community trauma center for initial stabilization, with a likely subsequent transfer to the regional trauma center for definitive treatment.
The Kinetics of Trauma
Definitions:
Mechanism of Injury (MOI): The process or method by which a person is injured.
Kinetics: This is the branch of mechanics dealing with the movements of bodies. It is the science used to analyze the mechanism of injury.
Key Factors in Kinetics:
Mass and Velocity: These are the primary determinants of kinetic energy.
Kinetic Energy Formula: Velocity is a more significant factor than mass. The energy involved is calculated as: where is mass and is velocity.
Assessment Tip: Estimating the speed of objects involved in motor vehicle collisions or penetrating trauma is vital for predicting injury severity.
Acceleration and Deceleration Laws:
Law of Inertia: A body at rest remains at rest, and a body in motion remains in motion unless acted upon by an outside force.
Rate of Change: A faster change of speed (acceleration or deceleration) results in more force exerted on the body.
Energy Transformation:
Energy travels in a straight line unless it meets interference.
Interference causes kinetic energy to change direction or form (e.g., from motion into heat or tissue deformation).
Impact Types in Vehicle Collisions
The Three Impacts: In a typical motor vehicle collision, energy is absorbed in three distinct stages:
Vehicle Collision: The vehicle strikes an object (e.g., an automobile hitting a tree).
Body Collision: The occupant continues moving forward due to inertia and strikes the interior of the automobile (e.g., hitting the steering wheel or dashboard).
Organ Collision: Internal organs continue moving forward and strike the inside of body cavities (e.g., the brain striking the skull, or the heart striking the sternum/ribs).
Mechanisms of Injury (MOI) in Vehicle Collisions
Indicators of High-Risk Injury: A high suspicion of injury should be maintained if any of the following are present:
Death of another vehicle occupant.
Altered mental status.
Intrusion of the vehicle over into the occupant site.
Ejection from the vehicle.
Vehicle telemetry data indicating a high risk of injury.
Frontal Impact Pathways:
Up-and-Over Pathway: The occupant moves upward over the steering wheel. Injuries occur to the head, neck, face, chest, and abdomen.
Down-and-Under Pathway: The occupant moves downward under the dashboard. Injuries occur to the knees, femurs, hips, acetabulum, and spine.
"Paper Bag" Syndrome: Compression of the chest against the steering column occurs while the patient has a closed glottis, causing the lungs to pop like a paper bag.
Rear-End Impact:
Initially, the head and neck are whipped back (hyperextension).
Properly adjusted headrests and seat belts reduce these injuries.
Subsequent motion can lead to up-and-over or down-and-under pathways.
Lateral (Side) Impact:
Injuries occur to the side of the body struck.
Impacts often involve the head, neck, shoulder, lateral chest, lateral abdomen, lateral pelvis, and femur.
Rotational and Rollover Crashes:
Injury patterns are less predictable.
Rollovers involve multiple impacts and changes in direction.
Ejection is common; ejected occupants are frequently crushed.
These crashes carry a high risk of multisystem trauma.
Specific Mechanisms: Pedestrians, Restraints, and Specialized Vehicles
Vehicle-Pedestrian Collisions: Severity depends on:
Vehicle speed.
Body part hit.
Distance the pedestrian was thrown.
Landing surface and initial impact point on the ground.
Differences exist between child and adult injury patterns (children are often run over, whereas adults are often thrown up onto the hood).
Restraint Systems:
Benefits outweigh the risks, but improper use can cause hidden injuries.
Lap belts and shoulder straps must be positioned correctly over the pelvis and shoulder.
Air bags are not designed for secondary collisions.
Infants and Children in Vehicles:
Head and neck are not secured; the head snaps forward straining the neck.
Spinal cord injury can occur without visible vertebrae damage.
Car seats should only be placed in the backseat.
Motorcycles and ATVs:
Motorcycles: Helmets significantly reduce morbidity/mortality. Injuries result from head-on impacts, angular impacts, or ejection. "Laying the bike down" causes severe abrasions and burns.
ATVs: Highly unstable and easily tipped. Impacts are similar to motorcycle collisions but with added crushing risks from the vehicle itself.
Falls
Severity Factors:
Distance of the fall.
Surface landed on.
Body part that impacted first.
Critical Fall Heights:
Adults: Severe if > 20\,ft.
Children: Severe if > 10\,ft or two to three times the child's height.
Fall Mechanics:
Feet-First Falls: Energy is transmitted up the skeletal system. Common injuries: lower extremities, spine, internal organs, and wrists/elbows (if arms were used to break the fall).
Head-First Falls: Upper extremity, head, neck, chest, spine, and pelvis injuries.
Penetrating Injuries
Velocity Categories:
Low-Velocity: Knives or similar objects. Damage is usually limited to the path of the object. Defensive slash wounds are possible.
Medium-Velocity: Shotguns and handguns.
High-Velocity: Rifles. These cause massive injury due to cavitation.
Energy Dissipation Factors:
Drag: Air resistance on the projectile.
Profile: The surface area of the projectile pointing forward.
Cavitation: The pressure wave creates a temporary cavity in the tissues much larger than the projectile diameter.
Fragmentation: The projectile breaks into smaller pieces, increasing damage.
Gunshot Statistics:
of fatal wounds involve the head, thorax, and abdomen.
Blast Injuries
Primary Phase (Pressure Wave): Air molecules slam into one another. The pressure wave causes injuries to hollow, air-filled organs (lungs, ears, GI tract).
Secondary Phase (Blast Wave): Pieces of the bomb casing or other projectiles strike the patient.
Tertiary Phase (Patient Displacement): The blast wind propels the patient to the ground or against objects.
Quaternary/Quinary Phase: Exposure to chemicals, toxins, or structural collapse.
Management of Multisystem Trauma
The Multisystem Trauma Patient: Patients with injuries to multiple body systems have higher morbidity/mortality rates. Care focuses on managing immediate life threats and rapid transport.
The Golden Principles:
Personal safety is the highest priority.
Maintain airway and adequate ventilation/oxygenation.
Control significant external bleeding.
Perform assessments in a systematic sequence.
Use a backboard to splint fractures in unstable patients.
Avoid "tunnel vision" on dramatic injuries.
The Golden Period and Platinum 10 Minutes:
Best survival occurs with rapid intervention.
EMS goal: Limit scene time to or less for severely injured patients.
Indications for Rapid Transport ( Scene Time):
Airway/Respiratory: Occlusion, Rate < 10 or > 29/min, inadequate tidal volume, hypoxia, respiratory failure.
Head/Neurological: Suspected skull/brain injury, GCS , altered mental status, seizures, paralysis, sensory/motor deficits.
Circulation/Bleeding: Shock signs, uncontrolled external hemorrhage, suspected internal hemorrhage.
Specific Anatomical Injuries:
Flail chest, suspected pneumothorax/tension pneumothorax.
Pelvic fracture.
Two or more proximal long-bone fractures.
Crushed or mangled extremity.
Amputation proximal to the finger.
Penetrating trauma to the head, neck, torso, or proximal extremities (above elbow/knee).
Special Populations: Multisystem trauma, trauma in pregnancy, patients over , or those with significant medical history (MI, COPD, CHF).
The Trauma System and Triage
Trauma Center Levels:
Level I: Regional Trauma Center.
Level II: Area Trauma Center.
Level III: Community Trauma Center.
Level IV: Trauma Facility.
Triage Guidelines (ACS-COT 2022):
Red Criteria: High risk for serious injury; requires transport to the highest level trauma center.
Yellow Criteria: Moderate risk for serious injury.
Questions & Discussion
What are the priorities in managing the case study patient?
Response: Airway management, ensuring adequate breathing, administering oxygen, and controlling the femoral hemorrhage while preparing for rapid transport due to signs of shock (tachycardia and altered mental status).
What information will help determine the extent of the patient's injuries?
Response: Understanding the MOI (high-velocity rifle), the location of entry and exit wounds, and the patient's clinical signs of shock.
What factors should EMTs consider in determining transport destination?
Response: The level of surgical capability required, distance to specialized trauma centers, and medical direction guidance.