Alexander ch34 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 34
Mechanisms of Injury,
Trauma Assessment,
and Trauma Triage
Criteria

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely injured patient.
• Pathophysiology, assessment, and management
of the trauma patient, including trauma scoring,
rapid transport and destination issues, and
transport mode.
Advanced EMT
Education Standards

1. Define key terms introduced in this chapter.
2. Describe the purpose and goals of trauma patient
assessment.
3. Describe the components of the trauma patient
assessment process.
4. Discuss the decisions that must be made during
the trauma patient assessment process.
5. Explain the importance of various decision-making and
problem-solving approaches in the trauma patient
assessment and patient care processes.
Objectives

Figure 34-1
Because injury can occur to anyone at any time, you must be prepared to respond and
properly manage trauma patients. (© Edward T. Dickinson, MD)

• Trauma is injury to the body resulting from
external forces.
• Traumatic injury affects people of all age groups
and can occur in any environment at any time.
• Be prepared to respond to and properly assess
and manage trauma patients.
Introduction

Think About It
• What can the information provided so far tell
Mac and Courtney about the potential severity
of the patient’s injuries?
• What should Mac and Courtney include in their
initial plans for approaching the scene and
assessing the patient?

Figure 34-3
The law of inertia: A body in motion remains in motion and a body at rest remains at rest
unless acted upon by an outside force.

Kinematics of Trauma (1 of 6)
• Kinetics
– Branch of physics
▪ How objects in motion are affected by outside forces; how
energy distributed when objects collide
– Newton’s law of inertia
▪ A body in motion will remain in motion; body at rest will remain
at rest unless acted upon by outside force.

• Kinetics (continued)
– Law of conservation of energy
▪ Energy can neither be created nor destroyed; can change from
one form to another.
– Kinetic energy
▪ Function of mass (weight) and velocity (speed)
– Newton’s second law of motion
▪ Force = mass × acceleration or deceleration

• Classifying trauma
– Blunt trauma
▪ Direct injury
▪ Indirect energy
– Penetrating trauma
▪ Stab or bullet wound
▪ As an object passes through tissues, energy is dispersed to
surrounding tissues, creating temporary cavity and additional
internal injury.

Figure 34-4
As an object passes through the tissues [(A) and (C)], a permanent cavity is created. As the
object continues, energy is dispersed to the surrounding tissues (B), creating a temporary
cavity (cavitation) and additional internal injury.

Figure 34-5
The cone of injury provides an idea of how much internal damage may have occurred
through movement of the object within the tissues. For this reason, you must identify the
object that has caused the patient’s injury.

• Classifying trauma (continued)
– Low-velocity penetrating injuries
▪ Created by hand-driven objects such as stick, ice pick, or knife
▪ Energy involved not as significant
▪ Important to know the length and width of object to determine
the potential for injuries

– Medium-velocity weapons
▪ Handguns and smaller-caliber rifles
▪ Produce enough energy to cause injury beyond immediate
pathway of projectile
– High-velocity injuries
▪ Caused by high-velocity rifles
▪ Massive direct and indirect injuries

– Attempt to determine caliber of weapon that created
injury.
▪ Distance between weapon when fired and patient
– Identify both entrance and exit wounds.
▪ Idea of what underlying body structures injured

Figure 34-6
You must not approach a scene unless it is safe to do so. If a scene is not safe upon
arrival, you must call for appropriate additional resources to mitigate the hazards prior to
approaching the scene. (© Mark C. Ide / Science Source)

Assessment of the Trauma Patient
• Scene size-up
– Standard Precautions
– Ensure that the scene is safe.
– Identify number and location of injured.
– Assess mechanism of injury (MOI).
– Consider the need for additional resources.
– If there are hazards at the scene, do not approach.

(2 of 39)
• Mechanism of injury (MOI)
– Forces and energy that cause injury
– Important to identify forces sustained
– Each MOI has a predictable pattern of potential injuries
associated with it.
– Allows you to formulate list of potential injuries based
solely on MOI

Figure 34-7 (1 of 3)
(A)
Three collisions occur with a rapid-deceleration MOI: (A) The vehicle collides with
an object.

(B)
Three collisions occur with a rapid-deceleration MOI: (B) The driver collides with the
steering wheel.

(C)
Three collisions occur with a rapid-deceleration MOI: (C) The organs collide with the inside
of the body.

(3 of 39)
• Motor vehicle crashes (MVCs)
– Vehicle collides with object or another vehicle
– Patient inside vehicle forced to decelerate by restraint
systems or collides with interior of vehicle
– Internal organs collide with one another and the inside
of the body

(4 of 39)
• Motor vehicle crashes (MVCs) (continued)
– Collisions of internal organs
▪ Bruising, lacerations, tearing
▪ Can lead to massive internal bleeding not visible on external
examination
▪ Rely on assessment and MOI and indications of bleeding:
– Pale, diaphoretic skin
– Abnormal vital signs

Figure 34-8
(A) (B)
(A) In a frontal impact collision, the vehicle collides with another object, causing damage to
the front of the vehicle. (B) In a frontal impact collision, the occupant continues traveling at
the same speed after the initial impact. (© Mark C. Ide / Science Source)

(5 of 39)
• Motor vehicle crashes (MVCs) (continued)
– Five categories of impact
▪ Frontal
▪ Rear
▪ Lateral
▪ Rotational
▪ Rollover

(6 of 39)
• Frontal impact
– Head-on collision
– Two possible paths
▪ Up and over
▪ Down and under

(7 of 39)
• Frontal impact—up and over
– Patient collides with steering wheel.
– Head moves upward toward windshield.
– Chest, head, neck, abdominal trauma, partial ejection
through windshield

Figure 34-9
It is important to consider the predictable injuries of the head, neck, chest, and abdomen
associated with a patient’s up-and-over pathway.

(8 of 39)
• Frontal impact—down and under
– Patient collides with bottom of steering wheel and, in
some cases, legs collide with dashboard.
– Chest, abdominal, lower extremity injuries
– Often lower legs, ankles, and feet are forced into the
floorboard and pedals, creating injury.

Figure 34-10
It is important to consider the predictable injuries of the abdomen, hips, spine, and lower
extremities associated with a patient’s down-and-under pathway.

Figure 34-11
You should look for damage to the vehicle to predict potential injury to the patient. Starring
of the windshield indicates possible head injury to the patient.

(9 of 39)
• Frontal impact MVCs—predicting potential
significant injury
– More than 18 inches of damage to car
– Starring and shattering of windshield
– Bending of steering wheel
– Damage to dashboard

(10 of 39)
• Frontal impact MVCs
– Chest
▪ Internal bleeding
▪ Compression, shearing, or injury of heart and lungs
▪ Air pressure causing rupture of lung tissue
– Abdomen
▪ Compression and shearing injury
▪ Liver and spleen can be injured, leading to massive internal
bleeding and death

(11 of 39)
• Frontal impact MVCs (continued)
– Head
▪ Range from mild lacerations to massive skull fractures
▪ Massive fractures
▪ Direct injury to brain
▪ Indirect injury to neck

Figure 34-12 (1 of 2)
(A)
(A) Rear impact. A rear impact MOI results in rapid-acceleration injuries such as whiplash,
or hyperextension injuries. (© Mark C. Ide / Science Source)

Figure 34-12 (2 of 2)
(B) Following the acceleration, the occupant decelerates, moving forward and causing
injury to the head and chest.
(B)

(12 of 39)
• Rear impact MVCs
– Vehicle is struck from behind, driving vehicle forward.
– Acceleration of vehicle causes acceleration injuries.
– Whiplash:
▪ Hyperextension can lead to serious injury of soft tissues, spine,
spinal cord.

Figure 34-13 (1 of 2)
(A)
(A) Lateral impact. (© Mark C. Ide / Science Source)

Figure 34-13 (2 of 2)
(B)
(B) In a lateral impact MOI, you must consider the potential for injury to the side of the
patient that sustained the energy from impact.

(13 of 39)
• Lateral impact MVCs
– Vehicle is struck on side (“T-bone” collision).
– Determine if intrusion into passenger compartment of
vehicle occurred and what location.
– Injuries:
▪ Fractured extremities on side of impact
▪ Lateral chest trauma
▪ Hip fractures
▪ Head and neck

Figure 34-14
A rotational impact occurs when a lateral impact causes the patient’s vehicle to rotate or
spin. This rotation results in twisting forces to the patient. (© Ed Effron)

(14 of 39)
• Rotational impact MVC
– Causes vehicle to rotate or spin; occurs at either front
or rear fender locations.
– Patient subjected to twisting forces.
▪ Can lead to significant injury (neck and internal organs).

Figure 34-15 (1 of 2)
(A)
(A) Rollover impact. (© Daniel Limmer)

Figure 34-15 (2 of 2)
(B)
(B) A rollover MVC subjects the patient to forces of every kind and can lead to Significant
patient injury.

(15 of 39)
• Rollover MVCs
– Subject patient to forces of every kind; can lead to
significant injury.
– Unrestrained individuals inside vehicle may be ejected
from vehicle.
– Patients who have been ejected usually sustain serious
injury or death.

Figure 34-16
Adults tend to turn away from an approaching vehicle, whereas children tend to turn and
face directly toward it. (© Mark C. Ide / Science Source)

(16 of 39)
• Pedestrian–vehicle collisions
– Speed of vehicle
– Parts of patient’s body struck
– Distance patient thrown following impact
– Parts of the body that struck ground
– Type of surface patient landed on

(17 of 39)
• Pedestrian–vehicle collisions (continued)
– When person is about to be struck:
▪ Tends to turn his back to coming impact, absorbing it either on
lateral or posterior side of body
– As vehicle impacts, the person is:
▪ Lifted off his feet, and forward movement of vehicle causes him
to impact windshield of vehicle

(18 of 39)
• Pedestrian–vehicle collisions (continued)
– If speed of vehicle substantial:
▪ Person will travel completely over vehicle.
– If driver decelerates by applying brakes:
▪ Person will roll off hood of car and strike ground, causing
additional injury.

Figure 34-17
Motorcycle collisions can result in multiple impacts that injure the rider.
(© CW McKean/Syracuse Newspapers/The Image Works)

(19 of 39)
• Motorcycle crashes
– Driver of motorcycle is exposed.
▪ More risk for injury than driver of automobile
– Not wearing helmet
▪ Greater risk of sustaining head injury, increasing morbidity and
mortality
– Head-on motorcycle collision
▪ Rider is thrown into and over handlebars; continues until he
comes to rest after striking ground.

(20 of 39)
• Motorcycle crashes (continued)
– Lateral impact motorcycle collision
▪ Rider is struck by vehicle, sustaining injury to leg on side of
impact.
▪ After impact, rider loses control and crashes.
– Ejection of motorcyclist
▪ Rider is separated from motorcycle.
– When helmet isn’t worn, likelihood of significant head
trauma is much higher.

Figure 34-18
Direct injury occurs with contact with the ground, and indirect injury occurs as energy is
transferred to other parts of the body.

(21 of 39)
• Falls
– Height of fall
– Body part that hit landing surface first
– Surface fallen onto
– Direct injury
▪ Patient’s body contacts ground
– Indirect injury
▪ Energy continues to be absorbed by body; additional injury

(22 of 39)
• Blast injuries
– Result of explosions from natural gas, fireworks,
improvised explosive devices (IEDs)
– Ensure scene is safe prior to entering.
– Five phases of injury:
▪ Blast injury
▪ Secondary blast injury
▪ Tertiary blast injury
▪ Quarternary blast injury
▪ Quinary blast injury

(23 of 39)
• Blast injuries (continued)
– Primary blast injury
▪ Pressure wave from explosion; directly related to force of
explosion
– Secondary blast injury
▪ Debris thrown from explosion as result of pressure wave

(24 of 39)
• Blast injuries (continued)
– Tertiary blast injury
▪ Pressure wave and debris hit patient; thrown away from
explosion
– Quaternary blast injury
▪ Environmental conditions following explosion
– Quinary blast injury
▪ Hyperinflammatory state caused by exposure to contaminants
from the blast

(25 of 39)
• Significant mechanism of injury (MOI)
– Consider MOI of patient to determine if life-threatening
injury exists.
▪ Ejection
▪ Death in the same vehicle
▪ Vehicle telemetry consistent with high risk
▪ Pedestrian struck when vehicle was going faster than 20 mph
▪ Fall >20 feet
▪ Motorcycle crash >20 mph
▪ Penetrating trauma to head, neck, torso, or proximal extremity
▪ Amputation proximal to wrist or ankle

(26 of 39)
• Significant mechanism of injury (MOI) (continued)
– Maintain a high index of suspicion if significant MOI is
present.
– Transport to facility with surgical services.

Table 34-1
Mechanisms Indicating High Potential for Significant
Injury
Maintain a high index of suspicion for each of the following significant
mechanisms of injury:
• Ejection from a vehicle
• Death of someone in the same vehicle
• Rollover MVC
• High-speed collisions (>40 mph)
• Pedestrian struck by a vehicle
• Falls of >20 feet (>10 feet for children)
• Motorcycle and rider separation
• Penetrating trauma to the head, neck, torso, or proximal extremity
• Significant blunt trauma to the head, neck, or torso

(27 of 39)
• Nonsignificant mechanism of injury (MOI)
– Less-severe injuries also require EMS care.
– Your role:
▪ Assess patient.
▪ Treat and package.
▪ Provide transport to appropriate facility.

Think About It
• What pattern of injuries should Mac and Courtney
anticipate?
• How should they begin their assessment and
management?

(28 of 39)
• Primary assessment
– Identify immediate life threats and treat.
– Use systematic approach.
– Perform head-to-toe exam.
– Trauma patients have gruesome injuries that can be
distracting.
▪ Do not allow injuries to distract you from performing systematic
primary assessment.

Figure 34-19
When a trauma patient has the potential for spine injury, manually stabilize his head and
neck to restrict motion as soon as you make contact with him.

(29 of 39)
• Primary assessment (continued)
– Manual stabilization of head and neck when:
▪ Forces have been applied to head, neck, or back
▪ Neurologic deficits of extremities are present
▪ Patient has altered mental status
– Place hands on both sides of head and hold in neutral
inline position.

(30 of 39)
• Primary assessment—airway
– Assess airway; if blood, vomit, fluids in airway, clear by
suctioning.
– Determine if airway patent; look, listen, feel for
breathing.
– Abnormal respiratory sounds such as gurgling, snoring,
or stridor are indicative of a partially obstructed airway.

(31 of 39)
• Primary assessment—airway (continued)
– Unconscious or decreased level of responsiveness
▪ Look, listen, and feel for breathing.
▪ Use modified jaw-thrust .
– Use head-tilt/chin-lift maneuver if unsuccessful.
▪ Open airway and insert a nasal or oral adjunct to maintain
airway.

(32 of 39)
• Primary assessment—breathing
– If breathing adequate:
▪ Apply oxygen to maintain SpO2 of 95% or higher.
– If breathing not adequate:
▪ Ventilate using bag-valve mask with high-flow oxygen.
– If lung sounds diminished or absent on one side of
chest, pneumothorax or hemothorax may be present.

(33 of 39)
• Primary assessment—circulation
– Pulse check, skin condition, blood sweep
– Assess pulse for rate, rhythm, quality.
– Skin cool, clammy, diaphoretic: signs of shock
– Perform blood sweep:
▪ Control life-threatening bleeding immediately.

(34 of 39)
• Primary assessment—disability
– Patient’s level of responsiveness
– Use AVPU mnemonic.
– Determine Glasgow Coma Scale (GCS) score.

Table 34-2
Glasgow Coma Scale
EYE OPENING VERBAL RESPONSE
MOTOR
RESPONSE
Points Points Points
Spontaneous 4 Oriented 5 Obeys commands 6
To voice 3 Confused 4 Localizes pain 5
To pain 2 Inappropriate words 3 Withdraws 4
None 1 None 1 Abnormal flexion 3
Abnormal extension 2
None 1

(35 of 39)
• Primary assessment—expose
– Expose critical trauma patients to prepare for rapid
trauma exam.
– Protect patient’s modesty; keep patient warm.
– You cannot treat what you cannot see.

(36 of 39)
• Secondary assessment
– Rapid trauma exam for critical patients and those with
significant MOI
– Baseline vital signs
– Medical history
– Either focused or head-to-toe exam, depending on
patient’s MOI, complaints, overall condition
– Rapid trauma exam: quick visualization and palpation
of vital areas of body to identify life-threatening injuries
 What does the DCAP-BTLS mnemonic stand for?

(37 of 39)
• Secondary assessment (continued)
– Rapid trauma assessment
▪ Head
▪ Neck
▪ Chest
▪ Abdomen
▪ Pelvis
▪ Posterior
▪ Extremities

(38 of 39)
– Baseline vital signs: respiratory rate, pulse rate, blood
pressure
– Subsequent vital signs compared to baseline vital signs
allows you to identify trends.
– Obtain patient’s history.
 What does the SAMPLE mnemonic stand for?

(39 of 39)
• Critical trauma patients
– Glasgow Coma Scale less than 14
– Systolic blood pressure less than 90 mmHg
– Respiratory rate less than 12 or greater than 29 (less
than 20 in infant under 1 year of age)
– Goal: treat and package; begin transport

(1 of 3)
– Focused trauma exam
▪ Isolated injury without significant MOIs
– Head-to-toe exam
▪ Identify all injuries; use DCAP-BTLS mnemonic.

Scan 34-1 (1 of 13)
Head-to-Toe Assessment
1. Run your gloved hands over the scalp and through the hair. Note any blood on
your gloves.

Scan 34-1 (2 of 13)
2. Palpate the face, forehead, and jaw.

Scan 34-1 (3 of 13)
3. Observe the pupils using an appropriate light source.

Scan 34-1 (4 of 13)
4. Observe for drainage of blood or cerebrospinal fluid, flaring of nostrils, and damage to
teeth. Look behind the ears for bruising (Battle’s sign).

Scan 34-1 (5 of 13)
5. Observe for JVD and run your thumb and forefinger along both sides of the trachea to
confirm proper alignment. Note any retractions above the clavicles.

Scan 34-1 (6 of 13)
6. Palpate the chest with both hands, feeling for crepitus or subcutaneous emphysema,
then listen for equal breath sounds and observe for paradoxical movement of the chest.

Scan 34-1 (7 of 13)
7. Palpate each quadrant of the abdomen with both hands. Observe the patient’s face for
signs of grimacing, and note body language for evidence of guarding.

Scan 34-1 (8 of 13)
8. Palpate both sides of the pelvis gently with both hands. Press downward and outward
gently. Observe for signs of wetness that may be blood or urine.

Scan 34-1 (9 of 13)
9. Palpate each leg with both hands and assess distal pulses and sensation. Have the
patient push and pull against the resistance of your hands to test for motor function.

Scan 34-1 (10 of 13)
10. Palpate each arm with both hands, and assess distal pulses and sensation. Have the
patient squeeze both hands with his simultaneously to test for motor function.

Scan 34-1 (11 of 13)
11. Palpate as much of the back as you can with both hands, feeling for soft spots
(paradoxical movement) and crepitus (subcutaneous emphysema or rib fractures).

Scan 34-1 (12 of 13)
12. Use both hands to perform the grip test.

Scan 34-1 (13 of 13)
13. Perform the foot-flex test against both feet.

(2 of 3)
• For critical patients
– Reassess vital signs and interventions every
5 minutes.
• For noncritical patients
– Reassess every 15 minutes.
• Transport patient to most appropriate facility.
• Mode of transport
– Method used to transport; ground or air

Figure 34-22
You must determine the most appropriate mode of transport for the patient.

(3 of 3)
• Air transport
– Patient’s condition
– Estimated time of arrival (ETA) of aircraft
– Weather conditions
– Ground transport time
– Location of potential landing zones
• Specialty care hospitals provide specific services.

Chapter Summary
• Scene of critical trauma patient is hectic.
• Remain focused and organized; systematic
assessment, treatment, packaging; make
decisions about transport.
• Failure to manage emergency in efficient manner
can lead to increase in morbidity and death.
• Goal: minimize scene times; begin transporting
patient to nearest appropriate medical facility.

Alexander ch34 lecture

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