Presentation on theme: "Trauma Systems and Mechanism of Injury"— Presentation transcript:
1Trauma Systems and Mechanism of Injury Chapter 29Trauma Systems and Mechanism of Injury
2National EMS Education Standard Competencies TraumaIntegrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan.
3National EMS Education Standard Competencies Trauma OverviewPathophysiology, assessment, and management of the trauma patientTrauma scoringRapid transport and destination issuesTransport mode
4National EMS Education Standard Competencies Multisystem TraumaRecognition, pathophysiology, assessment, and management ofMultisystem traumaPathophysiology, assessment, and management ofBlast injuries
5IntroductionTrauma is the primary cause of death and disability between ages 1 to 44 years.Analyzing a trauma scene is a vital skill.
7Trauma Different forms of energy produce different kinds of trauma. Mechanical energyChemical energyElectrical energyBarometric energy
8TraumaBiomechanics: Study of physiology and mechanics of living organismsKinetics: Study of the relationship among speed, mass, direction of force, and physical injury caused by these factors
9Factors Affecting Types of Injury Ability of body to disperse energy deliveredForce and energySize of objectVelocityAcceleration or decelerationAffected body areaDuration and directionThe larger the area of force dissipation, the more pressure is reduced to a specific spot.Position of victim
10Factors Affecting Types of Injury The impact resistance of body parts has a bearing on types of tissue disruption.Organs that have gas inside are easily compressed.Liquid-containing organs are less compressible.
12Kinetics Velocity (V): Distance per unit of time Acceleration (a): Rate of change of velocityGravity (g): Downward acceleration imparted to any object moving toward earthKinetic energy = mass/2 × velocity2
14KineticsOther factors that will affect energy dissipation in a crash include:Vehicle’s angle of impactDifferences in sizes of the two vehiclesRestraint status and protective gear of occupants
15KineticsLaw of conservation of energy: Energy can neither be created nor destroyedEnergy dissipation: Process by which KE is transformed into mechanical energyProtective devices can manipulate the way in which energy is dissipated.
16KineticsNewton’s first law of motion: A body at rest will remain at rest unless acted on by an outside force.Newton’s second law of motion: The force an object can exert is the product of its mass times its acceleration.
17Kinetics Force = mass (weight) × acceleration (or deceleration) Deceleration and acceleration can be measured in numbers of g force
19Motor Vehicle Crashes Five phases of trauma: Phase 1: Deceleration of the vehiclePhase 2: Deceleration of occupantCourtesy of Captain David Jackson, Saginaw Township Fire Department
20Motor Vehicle Crashes Five phases of trauma (cont’d): Phase 3: Deceleration of internal organsPhase 4: Secondary collisionsPhase 5: Additional impacts received by the vehicle
21Impact Patterns Frontal or head-on impacts Front end of the car distorts.Passengers decelerate at same rate as vehicle.Abrupt deceleration injuries are produced by a sudden stop of a body’s forward motion.
22Impact Patterns Frontal or head-on impacts (cont’d) Unrestrained occupants usually follow one of two trajectories:Down-and-under pathwayUp-and-over pathway
31Motorcycle Crashes Four types of motorcycle impact: Head-on impact Angular impactEjectedLaying the bike down
32Motorcycle Crashes The helmet should be removed carefully if: Airway management techniques cannot be performed with the helmet in place.Helmet does not fit snuggly to the head.The helmet should be cut if it cannot be removed without further deformation.
33Pedestrian Injuries Three predominant MOIs: First impact: auto strikes body with its bumpers.Second impact: adult is thrown on hood and/or grille of vehicle.Third impact: body strikes the ground or some other object.
34Pedestrian InjuriesWaddell triad: Pattern of injuries in children and people of short statureBumper hits pelvis and femur.Chest and abdomen hit grille.Head strikes vehicle and ground.
35Falls from Heights Severity of injuries impacted by: Height Position Don Juan syndrome or lover’s leapSurfacePhysical condition
36Penetrating TraumaInvolves disruption of skin and tissues in a focused areaLow velocity: Caused by sharp edgesMedium and high velocity: Object might flatten out, tumble, or ricochet.
37Penetrating TraumaIn the United States, the most common sources of penetrating injuries are firearms.
38Stab Wounds Severity depends on: Anatomic area involved Depth of penetrationBlade lengthAngle of penetration
39Gunshot Wounds Severity depends on: Type of firearm Velocity of projectilePhysical design/size of projectileDistance of victim from muzzleType of tissue struck
40Gunshot Wounds Handgun Shotguns Rifles Revolver holds 6 to 10 rounds of ammunitionPistol holds up to 17 rounds of ammunitionAccuracy is limited.ShotgunsFire round pelletsRiflesFire single projectile at a very high velocityImpart a spin for accuracy
41Gunshot WoundsThe most important factor for seriousness of wound is type of tissue involved.Entry wound is characterized by the effects of the initial contact and implosion.
42Gunshot Wounds Deformation/ tissue destruction is based on: Density CompressibilityMissile velocityMissile fragmentation
43Gunshot Wounds Projectile creates a permanent cavity. May be straight line or irregular pathwayPathway expansion: Tissue displacement that results from low-displacement sonic pressureMissile fragmentation: Projectile sends off fragments that create paths through tissues.
45Gunshot Wounds Wounding potential depends on: Powder charge Size and number of pelletsDispersion of the pelletsRange at which the weapon was firedBarrel lengthType of choke at the end of the barrel
46Gunshot Wounds Try to obtain the following: Look for: Weapon usedRange firedBullet usedLook for:Powder residue around the woundEntrance and exit wounds
47Primary Blast Injuries Damage is caused by pressure wave generated by explosionClose proximity to the origin of the pressure wave carries a high risk of injury or death.
48Secondary Blast Injuries Result from being struck by flying debrisA blast wind occurs.Flying debris may cause blunt and penetrating injuries.
49Tertiary Blast Injuries Occur when a person is hurled against stationary, rigid objectsGround shock: Physical displacement when the body impacts the ground
50Quaternary (Miscellaneous) Blast Injuries Occur from the miscellaneous events that occur during an explosionMay include:BurnsRespiratory injuryCrush injuryEntrapment
51Quinary Blast Injuries Caused by biologic, chemical, or radioactive contaminants added to an explosiveAssociated with “dirty bombs”
52Physics of an Explosion When a substance is detonated, it is converted into large volumes of gas under pressure.Propellants: Explosives designed to release energy relatively slowly
53Physics of an Explosion Blast front: Leading edge of a blast wavePositive wave pulse: Pressure front is higher than atmospheric pressureShock wave: High-explosive blast wavesNegative wave pulse: Pressure is less than atmospheric
54Physics of an Explosion The speed, duration, and pressure of the shock wave are affected by:Size of the explosive chargeNature of surrounding mediumDistance from explosionPresence or absence of reflecting surfaces
55Physics of an Explosion An explosion is more damaging in closed spaces.Blast pressures cause destruction at:Interface between tissues of different densitiesInterface between tissues and trapped air
56Tissues at RiskAir-containing organs are more susceptible to pressure changes.Junctions between tissues of different densities and exposed tissues are prone.The ear is most sensitive.
57Tissues at RiskPrimary pulmonary blast injuries occur as contusions and hemorrhages.If there is any reason to suspect lung injury in a blast victim, administer oxygen.
58Tissues at Risk Assessment/management of blast injuries If scene safety cannot be ensured, evacuate until advised that it is safe.Assess for other hazards.Form a general impression as you approach.
59Tissues at Risk Assessment/management of blast injuries (cont’d) Assess breath sounds frequently.Examine for the presence of DCAP-BTLS.Establish a baseline pulse oximetry value.
60Multisystem Trauma Injuries that involve several body systems If you suspect multisystem trauma:Assess the entire body.Prioritize the treatment of the injuries.Transport without delay.
61Trauma Score Used to determine the likelihood of survival Takes into account:Glasgow Coma Scale (GCS) scoreRespiratory rateRespiratory expansionSystolic blood pressureCapillary refill
62Trauma ScoreGCS: Evaluation tool used to determine level of consciousnessScores are assigned for eye opening, verbal response, and motor response.Does not accurately predict survivability in patients with severe head injuries
63Revised Trauma ScoreUsed to assess injury severity in patients with head traumaData used to calculate the score include:GCS scoreSystolic blood pressureRespiratory rate
64Scene Size-Up Attention to PPE is required. Anticipate possible scene hazards.Assess your environment carefully.Consider whether you will need additional medical resources.
65Primary Assessment Form a general impression. Keep the MOI in mind as you approach.Consider whether spinal stabilization will be necessary.Evaluate the patient using the AVPU.
66Primary Assessment Airway and breathing If patient is unconscious, open the airway using the jaw-thrust maneuver.If necessary, remove foreign objects and suction out blood or vomitus.
67Primary Assessment Airway and breathing (cont’d) Once the airway is clear, assess breathing.Note the skin color.Observe chest wall movement.
68Primary Assessment Airway and breathing (cont’d) Assess the thorax and neck for:Deviated tracheaTension pneumothoraxNeck and chest crepitationBroken ribsFractured sternumOther problems that may inhibit breathing
69Primary Assessment Circulation Check radial and carotid pulses simultaneously.If there is no pulse, begin CPR.Skin condition can also be a good indicator.Scan for significant external bleeding.
70Primary Assessment Transport decision Immediate transport include those with:Altered mental statusAirway or breathing problemsMultisystem traumaSignificantly compromised circulation
71Primary Assessment Transport decision (cont’d) If a patient needs immediate transport, continue your assessment en route to the trauma center.On-scene time should be limited to 10 minutes.“Platinum 10 minutes”
72History Taking Obtain a SAMPLE history and OPQRST. Important information to obtain includes:AllergiesMedicationsPast medical historyPatient’s last oral intakeEvents leading up to the situation
73Secondary Assessment Vital signs Obtain a full set of initial or baseline vital signs.Should include an assessment of:PulseRespirationsAuscultatory blood pressure
74Secondary Assessment Physical examinations Most patients should have a thorough physical exam prior to or during transport.The head-to-toe exam should be done in a systematic manner.
75Secondary Assessment Head and neck Chest, abdomen, and pelvis Palpate and visualize for injuries.Look in the nose, mouth, and ears for bleeding.Check for jugular vein distension and tracheal deviation.Chest, abdomen, and pelvisExamine and palpate the chest wall.Listen to breath and heart sounds.Palpate the abdomen.Press the iliac crests down.
76Secondary Assessment Extremities Back Palpate the legs from top to bottom.Check both feet for:Distal pulseMotionSensationExamine the arms.BackWhile the patient is on his or her side, examine the back for injuries.
77Reassessment Repeat the primary assessment. Reevaluate vital signs. Review the status of the interventions.Notify the hospital staff.
78Management of Trauma During transport, begin interventions. Most trauma patients will need to be treated for shock.Give oxygen.Keep supine with extremities slightly elevated.Transport rapidly to a trauma center.
79Management of Trauma Consider fluid resuscitation. Consult with medical control.Begin fluid resuscitation at volumes that maintain a minimum blood pressure.Several techniques can be used.Use a team approach.Critical thinking is important.
80Criteria for Referral to a Trauma Center Physiologic criteriaGCS score of less than or equal to 13SBP of less than 90 mm HgRR of less than 10 or more than 29 breaths/min or need for ventilator support
81Criteria for Referral to a Trauma Center Anatomic criteriaPenetrating trauma to head, neck, torso, and extremitiesChest wall instability or deformityTwo or more proximal long bone fracturesCrushed, mangled, or pulseless extremityAmputation proximal to wrist or anklePelvic fracturesOpen or depressed skull fracturesParalysis
82Criteria for Referral to a Trauma Center MOI criteriaAdults: falls more than 20 ftChildren: falls more than 10 ftHigh-risk auto crashIntrusion into passenger compartmentEjection from automobileConsistent with high risk of injuryPedestrian/bicyclist thrown or run overMotorcycle crash at more than 20 mph
83Criteria for Referral to a Trauma Center Special considerationsPatient’s age is more than 55 yearsSystolic blood pressure of less than 110 mm Hg in persons older than 65 yearsChildren triaged to a pediatric-capable centerPatient uses anticoagulants or bleeding disorderPatient is pregnantLow-impact mechanism in older adultsBurns with other traumaEMS provider judgment
84Criteria for Referral to a Trauma Center The ACS-COT defines four separate levels of trauma centers (level I, II, III, and IV).Give the trauma center early notice of the patient’s arrival.
85Mode of Transport When deciding to transport by ground, consider: Can the facility be reached within reasonable time?Extent of injuries?Can the patient be transported to a more accessible landing zone?Courtesy of Mark Woolcock
86Mode of Transport Criteria for use of air medical services: There is an extended period required to access or extricate a remote or trapped patient.Distance to the trauma center is greater than 20 to 25 miles.Patient needs ALS, and no ALS-level ground ambulance service is available.
87Mode of Transport Criteria for use of air medical services (cont’d): Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center within the ideal time frame.There are multiple patients who will overwhelm resources at the trauma center(s).
88Mode of Transport Criteria for use of air medical services (cont’d): EMS systems require the patient be brought to the nearest hospital.There is a multiple-casualty incident.
89Mode of Transport When making the transport decision, consider: If the patient can be transported by ground within a reasonable amount of timeTime for aircraft to lift off, travel, and landTerrain
90SummaryTrauma is the primary cause of death and disability in people between ages 1 and 44 years.The amount of force and energy delivered are factors in the extent of trauma sustained. Duration and direction of the force of application are also important.
91SummaryUnderstanding the effects of forces and energy will help in developing a high index of suspicion.Kinetic energy (KE) of an object is the energy associated with that object in motion.The law of conservation of energy states that energy can be neither created nor destroyed.
92SummaryBlunt trauma refers to injuries in which the tissues are not penetrated by an external object.In a motor vehicle crash, the angle of impact, mechanical characteristics of the vehicle, and the occupant’s position at the time of impact will determine types of injury.
93SummaryTrauma in a crash is composed of five phases representing the effects of progressive deceleration: deceleration of the vehicle, deceleration of the occupant, deceleration of internal organs, secondary crashes, and additional impacts.There are five primary types of impacts: frontal or head on, lateral or side, rear, rotational, and rollover.
94SummaryThe front seat occupants of vehicles during a frontal or head on crash usually follow a down-and-under or up-and-over pathway.Protective devices are designed to manipulate the way in which energy is dissipated into injury.In a motorcycle crash, any structural protection afforded to the victims is derived from protective devices worn by the rider.
95SummaryThere are four types of motorcycle impacts: head-on collisions, angular collisions, ejected riders, or laying the bike down.Adult pedestrians involved in a crash experience three predominant mechanisms of injury: lower extremity injuries from the initial hit, second impact injuries from being thrown onto the hood or grille, and third impact injuries when the body strikes the ground or another object.
96SummaryThe severity of injuries from falls from heights depends on the height, position, and orientation of the body at the moment of impact; the area over which the impact is distributed; the surface onto which the person falls; and the physical condition of the patient.
97SummaryPenetrating trauma involves a disruption of the skin and underlying tissues in a small, focused area.The severity of a stab wound depends on the area involved, depth of penetration, blade length, and angle of penetration.Firearms are the primary mechanism resulting in penetrating trauma.
98SummaryBlast injuries include primary, secondary, tertiary, and quaternary (miscellaneous) injuries.A blast wave or shock wave is dependent on the size of the explosive charge, the nature of the surrounding medium, the distance from the explosion, and the presence or absence of reflecting surfaces.
99SummaryAir-containing organs are most susceptible to pressure changes and blast injuries.Multisystem trauma describes trauma that involves several body systems.Management of trauma patients requires a thorough and accurate assessment of the patient as well as a good working knowledge of the mechanisms of injury.
100SummaryThe criteria for transport to a trauma center vary from system to system. However, there are key variables for transport to a trauma center.There are four categories of trauma centers.The Association of Air Medical Services and MedEvac Foundation International identify criteria for the appropriate use of air medical services for trauma patients.