Advance Preparation
Review local protocols on the management and transportation of multisystem trauma patients and trauma patients in special populations.
Bring all needed equipment for students to practice realistic multisystem and special patient population trauma scenarios.
Arrange for assistant instructors to help supervise students in lab scenarios. A ratio of one instructor for every four students is recommended.
Teaching Time
30 minutes
Discussion Questions
What is the relationship between multisystem trauma and shock?
Under what circumstances should you request ALS or air medical support when caring for a multisystem trauma patient?
What are the priorities when managing a multisystem trauma patient?
What are some reasons why performing a secondary assessment and obtaining a medical history from a trauma patient are important?
Points to Emphasize
Multisystem trauma is associated with high morbidity and mortality.
Understand the relationship between kinematics and injury, and do not develop tunnel vision.
Transport without delay to the closest appropriate hospital, and communicate your findings to the hospital as early as possible.
Class Activity
Have groups of students prepare multisystem trauma scenarios to demonstrate their understanding of the effects of multisystem trauma. Review the scenarios for accuracy during a break, and use them for lab practice.
Knowledge Application
Students should be able to apply the principles of managing multisystem trauma patients to a variety of lab scenarios.
Teaching Tips
Allow ample opportunity for students to apply the principles in lab scenarios.
If weather and resources allow, have students practice outdoors.
Talking Points
Keep these principles in mind when managing multisystem trauma patients:
•Ensure safety of the rescue personnel and the patient.
•Determine additional resources needed after arriving on the scene.
•Understand kinematics. Knowing the mechanism of injury can help the EMT anticipate what injuries the patient may have.
•Identify and manage life threats. Airway, ventilation, and oxygenation are key to the successful management of a multisystem trauma patient.
•Manage the airway while maintaining cervical spine stabilization.
•Support ventilation and oxygenation. Determine if your patient is breathing adequately based on the rate and tidal volume.
•Control external hemorrhage and treat for shock.
•Perform a secondary assessment and obtain a medical history.
•Splint musculoskeletal injuries and maintain spine immobilization on a long spine board.
•Make transport decisions. Rapid extrication and rapid transport of critically injured multisystem trauma patients is essential.
Teaching Time
60 minutes
Talking Points
Trauma occurs in approximately six to seven percent of all pregnancies and is the leading cause of death for pregnant women.
Pregnant patients can, of course, sustain all types of trauma and are especially susceptible to physical abuse and falls.
Motor vehicle crashes account for about half of all injuries sustained during pregnancy.
Point to Emphasize
Trauma is the leading cause of death in pregnant women.
Discussion Questions
What are common causes of injury in pregnant patients?
How does the anatomy and physiology of pregnancy affect the response to injuries?
Talking Points
You have two patients when you deal with a pregnant trauma patient: the mother and the fetus. Because assessing the fetus is difficult, treat the mother aggressively, especially if you note severe trauma. All pregnant women who have suffered trauma should be evaluated by a physician in the ED.
Anatomical and physiological changes during pregnancy include:
– Total blood volume increases by 50 percent in the pregnant patient, and the mother will have a 10–15 bpm increase in her heart rate in the third trimester.
– The uterus becomes more vascular, making the patient more susceptible to shock. The diaphragm elevates, making her susceptible to tension pneumothorax. She might have an altered perception of pain in the abdomen. Gastric motility decreases, which increases risk of vomiting and aspiration.
– The bladder is displaced upward, increasing the risk for traumatic injury. Renal blood flow is increased. Pelvic joints are loosened, and the center of gravity changes; both of these changes can make the patient prone to accidents and falls.
– Fetus size during the third trimester can affect venous blood return. If a pregnant patient lies flat on her back, she may develop supine hypotensive syndrome. Manage this by tilting the backboard to the left.
Talking Points
Trauma to a pregnant woman, whether severe or minor, can have significant effects on the health of the fetus. Approximately one to three percent of minor traumas involving pregnant women result in fetal loss.
The more severe the injury to the mother, the greater the chances of fetal injury. Fetal death rates are nine times higher than maternal death rates following trauma.
The most common problem caused by maternal trauma is uterine contractions that may progress into labor.
You must assess for crowning or bleeding in these trauma patients.
Points to Emphasize
In the third trimester, laying a pregnant patient supine can result in hypotension due to the weight of the fetus on the inferior vena cava. If the patient is immobilized, tilt the backboard to the left.
Fetal distress may occur due to hypoxia or hypovolemia in the mother.
Talking Points
Abruptio placentae, or the separation of the placenta from the uterine wall, can result from a traumatic injury, especially when the patient suffers blunt trauma. Abdominal pain and vaginal bleeding are often present with this condition and pose a high risk of fetal and maternal death.
Motor vehicle crashes account for a large number of maternal and traumatic injuries. Pregnant patients wearing their seat belts properly are more likely to have a favorable outcome when involved in a crash than those who don’t wear their seat belts.
Fetal distress can also be caused by hypoxia or hypovolemic shock, which can result from any traumatic injury. Shock and internal blood loss in a third trimester patient may be difficult to detect. Because of the cardiovascular changes in the pregnant patient, the signs of maternal hypotension resulting from traumatic bleeding may be delayed or masked. You must anticipate shock and not rely solely on vital sign changes to manage the patient aggressively. Shock is a frequent cause of death to both the fetus and the mother.
It is estimated that 41 percent of fetuses die when the mother suffers a life-threatening injury.
Talking Points
Most of the emergency care for a pregnant trauma patient is the same as for nonpregnant trauma patients and obstetric emergencies.
However, there are some special considerations for caring for the pregnant trauma patient.
Talking Points
Establish full spine immobilization for pregnant patients whom you suspect of having a spine injury; however, tilt the long spine board to the left if the patient is in her third trimester or obviously pregnant. This helps prevent supine hypotensive syndrome. The pregnant patient should remain on her left side throughout transport.
Airway, ventilation, and oxygenation are critical to the pregnant trauma patient. You should anticipate vomiting and have suction readily available. Assess if the patient is breathing adequately and if bilateral breath sounds are present.
Assess the patient’s circulation and check for major bleeding. If vaginal bleeding is present, absorb the blood flow with a pad and do not pack the vagina. Anticipate, prevent, and treat shock.
Perform a visual exam at the vaginal opening to assess for crowning or bleeding.
Consider ALS intercept or air medical transport for major traumas involving pregnant patients. Follow your local protocol.
Talking Points
Children are at risk of being abused by adults and older children.
Child abuse accounts for approximately 25 to 35 percent of pediatric trauma deaths.
Child abuse also can result in significant injuries and impairments.
Discussion Question
What are the differences in pediatric patients that account for the increased severity of their injuries as compared to adults exposed to similar forces?
Talking Points
Some findings that may prompt you to suspect abuse include:
– Bruises or burns in unusual shapes and locations
– An injury that doesn’t seem to correlate with the cause provided
– More injuries than usual for a child that same age
– Multiple injuries in various healing stages
Anatomical and physiological considerations for assessment include:
– Traumatic forces are more widely distributed in pediatric patients than in adults, making them more prone to suffering multisystem trauma.
– Children lose heat faster because their body surface area is greater.
– Children have big heads and weak neck muscles that increase their risk of head and cervical spine injuries. Their internal organ placement makes them more susceptible to injuries to the spleen and liver.
– Infants and children have greater chest wall flexibility than adults, which can allow for injuries with few external signs of trauma. The growth plates in children are not fully developed, and trauma to these plates may impact the bones’ normal growth. Children also have higher energy requirements and can fatigue faster than adults.
Talking Points
Children respond differently to injury than adults do.
A child’s physiologic response and vital signs are influenced by his age and the severity of his injury.
Point to Emphasize
Use the Pediatric Assessment Triangle to assess the pediatric trauma patient.
Talking Points
The Pediatric Assessment Triangle is a tool to help form a general impression. The triangle is composed of three sides:
– The appearance side refers to the child’s overall mental status, body position, and muscle tone.
– The work of breathing side relates to the visual effort of breathing and any audible sounds associated with the patient’s respiration.
– The circulation side is assessed through the patient’s skin color.
Subtle changes in heart rate, blood pressure, or perfusion status may indicate cardiorespiratory failure. A slow pulse rate in these patients may indicate hypoxia, which is not tolerated well by a child.
Assess the brachial pulse in an infant less than one year of age. Remember that normal blood pressures may be present in pediatric patients with compensated shock. Blood pressure readings are unreliable in children three years of age or less.
Because of the these characteristics of the pediatric patient, you should rely on other signs and symptoms such as skin color, temperature, and condition; mental status; and capillary refill to assess the patient’s perfusion status.
Point to Emphasize
Most of the management for a pediatric trauma patient is the same as for an adult. However, there are several important considerations for children, such as preventing heat loss because of their larger body surface area.
Talking Points
Establish spine immobilization for suspected spine injuries. During cervical spine immobilization of a child who is less than eight years of age, pad from the shoulders to the hips to prevent flexion of the neck.
Open the airway and assess for any possible obstructions from injury, teeth, blood, or vomitus. Gurgling or stridor may indicate upper airway obstruction.
Assess the breathing rate and tidal volume. Look at both the chest and the abdomen when doing so. Carefully provide ventilations if either the rate or the tidal volume is inadequate or if bradycardia is present. Pediatric trauma patients can fatigue very quickly.
Administer high-flow, high-concentration oxygen, and monitor the saturation via the SpO2 monitor. Keep the saturation as close to 100 percent as possible.
Assess the circulation and control any external bleeding by direct pressure.
Manage hypovolemia and shock as you would for an adult.
Prevent hypothermia; pediatric patients are very susceptible to heat loss.
Transport to an appropriate facility.
Continually reassess the pediatric trauma patient.
Talking Points
Vehicle crashes, burns, penetrating trauma, pedestrian versus vehicle collisions, vehicle crashes, and elder abuse can all cause traumatic injuries in elderly patients.
Geriatric patients are more susceptible to injury than other adults, even in cases of minor trauma. Many elderly patients have osteoporosis, placing them at increased risk for fractures and other injuries, even with minor traumatic force or no traumatic force at all.
Points to Emphasize
Falls are the most common cause of injury in the elderly. Motor vehicle and pedestrian injuries are significant causes of mortality in the elderly.
Anatomical and physiological changes as well as medication use in the elderly impact the rate and types of injury sustained. They also impact the patient’s ability to compensate following the injury.
Discussion Question
What are some factors that affect the elderly patient’s ability to compensate from hemorrhage?
Talking Points
Motor vehicle collisions are the second most common cause of trauma in the elderly. Older drivers are more likely to be killed or injured in these accidents than younger drivers. Most crashes involving the elderly occur during the day and close to their home. Auto versus pedestrian accidents are the third most common injury in this age group and carry the highest fatality rate.
Anatomical and physiological changes in the elderly include:
– Poor eyesight and hearing, decreased mobility, and longer reaction times make elderly patients more susceptible to motor vehicle collisions and pedestrian accidents than their younger counterparts.
– Circulation changes can lead to the inability to maintain vital signs during hemorrhage. An elderly trauma patient’s blood pressure drops sooner than a younger adult’s does.
– With aging, the brain shrinks, leading to a higher risk of cerebral bleeding following head trauma.
– Skeletal changes can cause curvature of the upper spine that may require padding during supine spine immobilization.
Teaching Tip
Arrange with an extended care facility for students to assess elderly patients under nursing supervision.
Talking Points
Preexisting medical conditions may affect the traumatic injuries a geriatric patient sustains and influence the patient’s outcomes. Multiple medications are more common in this age group and may also affect the patient’s assessment and the patient’s outcome. Medications can especially affect the patient’s vital signs and blood clotting capabilities.
As with other trauma patients, an altered mental status in the elderly trauma patient may indicate a severe injury. You should not attribute a patient’s altered mental status to age and should suspect a head injury.
Many elderly patients use dentures, which may cause an airway obstruction in the trauma patient. Elderly patients have a decrease in their cough reflex and may require suctioning. Chest wall injuries may quickly lead to respiratory failure in this population. You should monitor the elderly trauma patient’s oxygenation using pulse oximetry.
Elderly patients who are hypertensive prior to an injury may have normal blood pressures when they are in shock.
Pelvic and hip fractures are common in this population.
Talking Points
The management for an elderly trauma patient is very similar to that provided to other adults.
However, recognize and understand how anatomical and physiological changes in the elderly patient prior to the injury (such as hearing loss and weakened bones) may impact the patient’s presentation and outcome.
Talking Points
Establish spine immobilization for suspected spine injuries and maintain throughout care. Add padding around the spaces in the back if necessary.
Open and maintain a clear airway. Remember that suctioning is important in the elderly due to a decreased cough reflex.
Provide and support ventilation as needed. Administer high-flow, high-concentration oxygen, and use pulse oximetry to monitor the patient’s oxygen saturation.
Prevent hypothermia.
Splint factures: Remember that traction splints are not used to treat hip fractures.
Rapidly transport to the closest appropriate facility. The American College of Surgeons recommends that all trauma patients older than 55 years of age be taken to a trauma center.
Talking Points
Recognizing patients with cognitive impairment can be difficult when you begin your assessment. Some patients have no physical signs of their mental condition. They may be confused or unresponsive, making assessment of their condition difficult.
Never assume that the altered mental status of your trauma patient is due to a previous cognitive impairment or medical condition.
Always maintain a high index of suspicion that your patient may have suffered a traumatic head injury.
Talking Points
Cognitively impaired patients are more susceptible to trauma than patients who do not have cognitive impairment.
Types of impairment include vascular dementia, autistic disorders, brain injuries, strokes, Alzheimer’s disease, and Down syndrome. Many other causes of cognitive impairments exist that may affect your patient’s assessment and treatment.
Anatomical and physiological considerations depend on the underlying cause of each individual’s impairment. Many patients may have sensory loss related to aging and disease. This may increase their risk of injury and can alter their response to an injury. Some patients with dementia may experience cardiovascular changes that make them prone to injury. Other patients may have a loss in musculoskeletal strength due to aging or impairment that can lead to falls and other injuries. Memory loss from Alzheimer’s disease or other cognitive impairments will alter the patient assessment.
Point to Emphasize
Address the cognitively impaired trauma patient with respect but recognize that you may need to get the history from someone else.
Discussion Question
What are some guidelines to follow when dealing with the cognitively impaired trauma patient?
Talking Points
Considerations for your assessment of a cognitively impaired trauma patient include:
Patients with cognitive impairments are poor historians. They may not be good at recalling or relating their past medical history or events of the trauma. You should address them with respect and initially approach them in the same fashion as you would any other patient; however, you will often have to rely on others to provide information about the patient’s past history.
The psychological implications of trauma may be different in this population. Many of these patients may not know what is happening even before the trauma. They may be confused or upset. The traumatic event may make it even more difficult for them to communicate and cooperate with you.
Understand that their pain perception may be altered. This may alter some of the responses that would normally be associated with injury.
The trauma assessment will provide the most pertinent information about your patient. Because many of these patients may not be able to tell you what is wrong, you should constantly reevaluate them.
Always maintain a high level of suspicion that your patient’s presenting signs and symptoms have resulted from trauma.
Talking Points
Cognitively impaired trauma patients need special care. Some of the special management considerations for this population of patients include:
You will often need to involve the patient’s care givers in emergency treatment. Like children, these patients may be more cooperative if a trusted care giver is present. These care givers may also provide you with important information about the patient’s conditions.
Err on the side of caution and do what is in the best interest of the patient. Manage the patient as if he has a head injury.
Knowledge Application
Students should be able to apply the knowledge in this section to scenarios involving assessment and management of pregnant, pediatric, geriatric, and cognitively impaired patients.
Teaching Time
30 minutes
Teaching Tip
Arrange a tour of a pediatric emergency department, or if not available, consider a tour of the area of the ED in which pediatric patients are treated.
Talking Points
Because traumatic injuries occur from so many different mechanisms, ensure a scene that is safe for you and others.
Look for a possible mechanism of injury and maintain a high index of suspicion that more than one major body system may be affected in your patient.
Identify if your patient belongs to any special populations, and use your knowledge about that population throughout your assessment.
Unresponsiveness or altered mental status, especially in trauma patients, should always suggest the possibility of head injury.
Never assume that mental status changes in a trauma victim are due to drug or alcohol intoxication or previous medical conditions.
Points to Emphasize
The approach to any trauma patient is first to assess for and manage immediate life threats.
Because of the forces involved in multisystem trauma, establish and maintain in-line manual stabilization of the cervical spine until the patient is fully immobilized to a long backboard.
Patients in special populations may respond to their injuries, your questions, and assessment differently than expected.
Discussion Question
What are the priorities of care for multisystem trauma patients?
Talking Points
When performing the primary assessment on a trauma patient, suspect a cervical spine injury. Manual in-line stabilization of the spine should be your first step and should be maintained throughout your care.
Assess your patient’s mental status, using the AVPU mnemonic. Utilize tools like the Glasgow Coma Scale and the Pediatric Assessment Triangle to provide additional information about the patient’s mental status.
Establish an airway, using a jaw-thrust maneuver, while holding in-line spine stabilization. Ensure that the airway is free from obstructions like blood, vomit, or dentures. Suction the airway if necessary. Remember that elderly and pregnant patients may vomit easily. Maintain the patient’s airway, and assess the breathing rate and quality. Provide oxygen via a nonrebreather mask at 15 lpm if breathing is adequate in the multisystem trauma patient or in those presenting with signs of hypoxia, respiratory distress, or poor perfusion. If the patient’s breathing is inadequate, provide positive pressure ventilation via a bag-valve-mask with supplemental oxygen.
Assess the patient’s circulatory status, and check the pulse. Look for major bleeding, and control it with direct pressure.
Talking Points
Perform a rapid physical exam. Keep in mind that multiple systems may be affected by the trauma and that if your patient is pregnant, you have two patients to consider.
Check and record vital signs every five minutes, staying alert to any changes. Remember that in pregnant women and the elderly you may have what appear to be normal vital signs, even though your patient is in shock. Even the slightest changes in a pediatric trauma patient’s vital signs may indicate impending cardiorespiratory failure and must be managed aggressively.
The history can provide vital information about the mechanism of injury. Patients, especially children, those with cognitive impairments, or those with an altered mental status, may not be able to provide you with the information you need. You may have to obtain this information from others at the scene.
Signs and symptoms will vary based on the patient and the trauma. Remember that a special trauma patient may not respond to injury the same way that another trauma patient would. Make sure to document any signs and symptoms accurately.
Discussion Questions
How is the management of pediatric trauma patients different from the management of adult patients?
What are some special considerations in management of geriatric trauma patients?
Talking Points
Take Standard Precautions.
Establish and maintain manual in-line spine stabilization. Tilt the backboard to the left for pregnant patients; pad beneath the shoulders to the hips during cervical immobilization to prevent flexion of the neck for pediatric patients; add padding around the spaces in the back if necessary for elderly patients.
Maintain a patent airway, and adequate breathing and oxygenation. Remember bradycardia in the pediatric patient requires ventilation.
Control bleeding. If the pregnant patient is bleeding from the vagina, use a pad to collect the blood flow.
Treat for shock. Remember to cover any special population trauma patient with blankets to prevent hypothermia.
Identify any other injuries and treat them appropriately.
Transport immediately.
Critical Thinking Discussion
How do the psychosocial developmental stages of children of various ages affect their response to trauma and to treatment by health care providers?
Talking Points
Provide reassessment during transport, paying close attention to the mental status, airway, breathing, and circulation of all these patients.
Repeat the vitals every five minutes.
Knowledge Application
Given a series of scenarios, students should be able to assess and manage a variety of patients from special populations.
