1. Chapter 30 Putting It All Together for the Trauma Patient

2. Putting It All Together
Balance need for prompt transport vs. treatment on scene.
Select critical interventions to implement at scene of multiple-trauma patient.
Choose an appropriate destination for a critical trauma patient. 2

3. Multiple Trauma More than one serious injury Mechanism of injury
Teamwork
Timing
Transport decision
The multiple-trauma patient has more than one serious injury. For example, a patient with crush injuries to the chest and a painful, swollen, deformed extremity is a multiple-trauma patient.
When the mechanism of injury suggests that your patient has more than one injury, decisions beyond what are called for on more typical EMS runs become necessary.
These decisions are made easier when your crew works well together, each member knowing what to expect from another. This is called teamwork.
Crew members also must be aware of the importance of moving a multiple trauma patient to definitive care as soon as possible, since it is rarely possible for EMS providers (even EMT-Paramedics) to truly stabilize a trauma patient in the field. This is called timing.
Finally, the appropriate destination must be chosen for the patient. This is a transport decision. 3

4. Multiple-Trauma Management
Motorcycle vs. car
Scene safe
25-year-old adult male
Unresponsive
No helmet 4

5. Assessment Findings Unresponsive to painful stimulus Gurgling Snoring
Suction
Snoring
OPA
Breathing 30 per minute
BVM with 100% oxygen
Angulated thigh with bleeding
Control bleeding
Pulse 5

6. High priority
Low priority
You assign this patient a high priority for rapid treatment and transport based on mechanism of injury, altered mental status, and presence of shock (hypoperfusion). You cannot request ALS back-up, because you work in a BLS system. 6

7. Rapid Assessment—Findings
Hematoma
Left side of head
Neck veins
Flat
C Spine
No deformity
Breath sounds
Decreased on left
Abdomen
Soft
Pelvis
Stable
Femur
Mid shaft fracture
Forearm
Minor lacerations
Pulses
Weak 7

8. Transport Oxygenation Ventilations Re-assessment Dressing
Continued
Re-assessment
Multiple injuries
Mental status
Unchanged
Airway
OPA
Gurgling
Suctioned
Oxygenation
Chest rises
Dressing
Intact
Pulse
Rapid
Weak
Priority
High 8

9. Second Initial Assessment
Report to trauma center
ETA 10 minutes
Vitals—pulse 108, BP 100/80, Resp. 12
Pupils slow to react
Mandible deformed
Abdomen firm
Mid-shaft femur left side
Repeat vitals—pulse 120, BP 90/p, Resp. 12 assisted
Skin pale and sweaty 9

10. Arrival—Emergency Department
Mental status improves.
Ventilation stopped
Patient conscious, confused, and disoriented
Vitals stabilized
Traction splint applied.
Further tests and surgery 10

11. In-Hospital Findings Cerebral contusion Bilateral fractured mandible
Left hemothorax
Fractured femur
Discharged after lengthy stay 11

12. Analysis Airway Partial obstruction Breathing High priority
Partially obstructed
Suctioned
Partial obstruction
Snoring
Artificial airway (OPA)
Breathing
Shallow
Labored
Inadequate
Ventilated with high-flow oxygen
High priority
No traction splint
No bandaging lacerations
The text scenario is an example of a patient who has critical injuries. Immediate threats to his life included shock (hypoperfusion) and bleeding into an airway that was partially obstructed by his tongue. Other serious injuries included an apparent head injury, inadequate ventilation, a presumed chest injury, a mandible injury, a compound angulated femur fracture, and a suspected spine injury (based on mechanism of injury). 12

13. Judgment The EMT showed good judgment by: 13 Postponed vitals
Alerted hospital 13

14. General Principles Preparation: Follow steps of assessment:
Determine roles.
Review roles enroute to call.
Follow steps of assessment:
ABCD
DCAP
BTLS
PMS
Follow the priorities you discover in your initial assessment (airway, breathing, and circulation). Then balance the need for scene interventions with the time needed to perform them. As you may recall, the concept of the “golden hour” refers to the need for critical trauma patients to get to surgery within one hour of injury (not one hour from when you get to the patient).
(cont.) 14

15. General Principles Priorities: Airway Breathing Circulation
Follow the priorities you discover in your initial assessment (airway, breathing, and circulation). Then balance the need for scene interventions with the time needed to perform them. As you may recall, the concept of the “golden hour” refers to the need for critical trauma patients to get to surgery within one hour of injury (not one hour from when you get to the patient). 15

16. Immobilization of c spine
Scene Treatment
Suctioning airway
Inserting OPA
Seal sucking chest
Ventilation
Oxygenation
Bleeding control
Immobilization of c spine 16

17. Additional Principles
Scene safety
Assure an open airway
Perform urgent or emergency moves as necessary
Adapt to the situation
Different kinds of trauma tend to have different kinds of dangers. Blunt trauma, more common in rural and suburban areas, can be associated with such dangers as bent power poles, leaking fuel, sharp glass and metal edges, and passing traffic. Penetrating trauma, such as stab wounds and gunshot wounds, tend to occur more commonly in urban settings. 17

18. Trauma Scoring Determines need for a trauma center
Allows less seriously injured to go to local hospitals
Assists in evaluating outcomes of trauma patients with similar severity of injuries
Follow local protocol for use.
In some EMS systems, hospitals ask EMTs and other providers not only to perform the usual assessment of trauma patients but also to evaluate trauma patients according to a numerical rating system. By evaluating certain patient characteristics and assigning a number to each of them, the provider can determine a score (a trauma score) that may do two things. 18

19. Revised Trauma Score 19

20. Review Questions
What considerations must the EMT weigh when considering whether to perform an intervention at the scene?
What are the interventions that should generally be performed for a critical trauma patient at the scene?
There are a variety of game show templates that instructors may use to enhance the learning process. These can be a fun way to evaluate student comprehension and, depending upon how you conduct the game, build teamwork among the students.
The following link is a collection of templates like Jeopardy, Who Wants to be a Millionaire, etc.
There are a variety of sites that contain predesigned templates that may be found during a web search.
(cont.) 20

21. Review Questions
When might it be appropriate for EMTs to bypass a closer hospital for a trauma center?
What are the three “Ts” of multiple-trauma patient management?
When might it be appropriate not to apply a traction splint in the field to an obviously fractured femur? 21

22. Street Scenes What is your initial impression of the crash?
What additional resources will be necessary on-scene?
(cont.) 22

23. Street Scenes Which patient should be transported first?
What is your critical decision regarding the female patient?
What critical interventions should you perform on-scene?
(cont.) 23

24. Street Scenes
What further information would you like to obtain about the female patient?
To what type of receiving facility should your patient be transported? 24

25. Sample Documentation 25