International Trauma Life Support, 6e Key Lecture Points Explain the relationship of time to patient survival and how this affects our actions at the scene. Explain the steps of the Scene Size-up and the importance of each step. Explain the importance of being aware of mechanisms of injury. Briefly review the concept of transfer of energy. Stress the concept of the “three collisions.” Briefly review the highlights of specific situations. Large vehicle accidents Frontal deceleration—effect on driver and passengers Lateral impact Rear impact Rollover Effect of restraints—lap belts, cross-chest lap belts, and air bags Tractor accidents Small vehicle accidents Motorcycles All-terrain vehicles Personal watercraft Snowmobiles Pedestrian injuries Falls Penetrating injuries Knives Gunshot wounds Blast injuries Chapter 1 Scene Size-up

Scene Size-up NOTE: Additional useful information can be found in: Appendix E: Role of the Medical Helicopter Appendix H: Injury Prevention and the Role of the EMS Provider    Appendix I: Multicasualty Incidents and Triage   Appendix J: Agricultural Rescue Course Overview    Appendix K: ITLS Access Overview Appendix L: Tactical EMS Trauma continues to be most expensive health problem in United States and most other countries. In United States, trauma is fourth leading cause of death for all ages and leading cause of death for children and adults under age 45. Cost of injury in United States is estimated to be twice that of cardiovascular disease and cancer combined. EMS personnel should learn more about how to treat effects of trauma and decrease its incidence. (See Appendix H, “Injury Prevention and the Role of the EMS Provider.”) Courtesy of Bonnie Meneely, EMT-P

Overview Relationship of time to patient survival Actions on scene Steps of Scene Size-up Two basic mechanisms of motion injury Mechanisms and settings Two most common forms of penetrating injury Mechanisms and extent Assessment criteria for falls Anticipated injuries NOTE: Overview of presentation – continued on next slide Scene Size-up -

Overview Blast injury factors related to assessment Collisions in motor-vehicle crash Potential injuries related to vehicle damage Common motor-vehicle crash forms Lateral-impact compared to head-on collision Potential head-on collision injuries Proper and improper use of safety devices Potential rear-end collision injuries Higher mortality rate for ejection NOTE: Overview of presentation Scene Size-up -

For severely injured patients, survival is time-dependent! Trauma For severely injured patients, survival is time-dependent! NOTE: This is transition slide from objectives into next topic. Scene Size-up -

Trauma Survival Golden Hour EMS “platinum 10 minutes” From moment of injury To definitive treatment EMS “platinum 10 minutes” Assessment and management Every action must have lifesaving purpose Organized, detail-oriented, selective, rapid “Golden Hour” Direct relationship between timing of definitive treatment (surgical) and survival of trauma patient. First described by Dr. R. Adams Cowley of Shock-Trauma Center in Baltimore, Maryland. When seriously injured patients were able to gain access to operating room within an hour of time of injury, highest survival rate was achieved (approximately 85%). Begins at moment patient is injured, not at time you arrive at scene. “Platinum 10 minutes” Must identify patients, make treatment decisions, and begin movement to appropriate facility. Time must be used efficiently. Scene Size-up -

Trauma Care Teamwork is important! You must know: What you can handle and what you can’t What you should handle and what you shouldn’t When to stay and when to leave Fastest route there and fastest route away What to do, what not to do, and when to wait Often patient’s life depends on how well you manage details, and not all of details are at scene. You or a member of your team must: Know how to maintain your ambulance or rescue vehicle so that it is serviced and ready to respond when needed. Know quickest way to scene of an injury. Know how to size up a scene in order to recognize dangers and identify mechanisms of injury. Know which scenes are safe and, if not safe, what to do about them. Know when you can handle a situation and when to call for help. Know when to approach patient and when to leave with patient. Know your equipment and maintain it in working order. Know most appropriate hospital and fastest way to get there. Know where to put your hands, which questions to ask, what interventions to perform, when to perform them, and how to perform critical procedures quickly and correctly. Scene Size-up -

Scene Size-up A critical part of trauma assessment Anticipate what you will find at scene Anticipate equipment and resource needs Form a plan of approach Be prepared to modify that plan Failure to size-up can jeopardize lives. Scene Size-up -

Scene Size-up First step in ITLS Primary Survey NOTE: This is presented as an overview for a frame of reference for Scene Size-up. Assessment will be taught in detail in another section. Emphasize that 1st step in assessment is always Scene Size-up. Performing a good Scene Size-up will facilitate a good assessment; a poor Scene Size-up will complicate ensuing assessment and management. Scene Size-up -

Scene Size-up Standard precautions Scene safety Initial triage (total number of patients) Need for more help or equipment Mechanism of injury Scene Size-up includes taking standard precautions to prevent exposure to blood and other potentially infective material, evaluating scene for dangers, determining total number of patients, determining essential equipment needed for this particular scene, and identifying mechanisms of injuries. Scene Size-up actually begins at dispatch, with anticipation of what will be found at scene. At that time, think about what equipment will be needed and whether other resources may be needed. Information from dispatch is useful in enabling you to begin to think about a plan, but this information is often exaggerated by caller or even completely wrong. Be prepared to change your plan depending on Scene Size-up. Scene Size-up -

Personal protective equipment is always needed at trauma scenes. Standard Precautions Personal protective equipment is always needed at trauma scenes. NOTE: Covered in more detail in Chapter 22. Trauma scenes are among most likely to subject rescuer to contamination by blood or other potentially infectious material (OPIM). Remember to protect your patient from body fluids by changing gloves between patients. Scene Size-up -

Scene Safety Ambulance positioning Windshield survey Safe place to park Facing away from scene Windshield survey Threats to you Threats to/from patient Threats to/from bystanders Position response vehicle away from hazards, but close enough to retrieve equipment efficiently and in a direction to leave scene easily. Consider using vehicle as barrier to hazards (like oncoming traffic). Windshield survey: Look out windshield for hazards before leaving your response vehicle. Look for hazards as you approach. Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

Initial Triage Total number of patients Call for backup Medical command Initiate MCI protocols Any more patients? IMAGE: Where are patients at this scene? Where should you look? Where else should you look? It is possible a patient could have been located off-screen to top-left of image. Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

Need for More Essential equipment Additional resources Carry to scene for time efficiency Change gloves between patients Additional resources Call early Relay what to expect, where to respond The following equipment is always needed for trauma patients: Personal protection equipment Long backboard with effective strapping and head motion-restriction device Appropriately sized rigid cervical extrication collar Oxygen and airway equipment (Suction equipment, BVM should be included.) Trauma box (bandage material, blood pressure cuff, stethoscope) Scene Size-up -

Mechanism of Injury Energy follows physics laws. Injuries present in predictable patterns High-energy at risk for severe injury. Consider injured until proven otherwise Factors to consider: Direction and speed of impact, patient kinetics and physical size, signs of energy release Missed or overlooked injuries may be catastrophic. 5–15% of patients involved in a high-energy event, despite normal vital signs and no apparent anatomic injury on initial assessment, will exhibit severe injuries on later exams. A strong correlation exists between injury severity and automobile velocity changes, as measured by amount of vehicle damage. Severity of vehicle damage has also been suggested as a nonphysiologic triage tool. Scene Size-up -

Basic Motion Mechanisms Blunt injuries Penetrating injuries Rapid forward deceleration Rapid vertical deceleration Blunt instrument energy transfer Projectiles Knives Falls upon objects Motion (mechanical) injuries are by and large responsible for majority of mortality from trauma in United States. Generally, blunt trauma is more common in rural setting, and penetrating trauma is more common in urban setting. Rapid forward deceleration is usually blunt, but may be penetrating. Most common example of rapid forward deceleration is motor-vehicle collision (MVC). Scene Size-up -

Motor-Vehicle Collisions Each collision is three collisions: Machine Collision 1 Body Collision 2 Organ Collision 3 ANIMATION: Numbers appear and arrows come in from left. Consider all MVCs to occur as three separate events (Figure 1-2). Machine collision Body collision Organ collision To explain forces involved, consider Sir Isaac Newton’s first law of motion: “A body in motion remains in motion in a straight line unless acted upon by an outside force.” Motion is created by force (energy exchange), and, therefore, force will stop motion. If this energy exchange occurs within body, damage of tissues is produced. Scene Size-up -

Other Collisions Secondary collisions Additional impacts Objects are missiles at original speed Additional impacts Vehicle collides with another object Other vehicles collide with original vehicle ANIMATION: ON CLICK package flies in from left of screen and hits patient’s head. Additional impacts may make it more difficult to predict injuries in these cases. Quickly but carefully look for clues inside vehicle. Scene Size-up -

Clues to Injury Deformity of vehicle Deformity of interior structures What forces were involved in collision? Deformity of interior structures What did patient hit? Deformity or injury patterns on patient What anatomic areas were hit? Scene Size-up -

Common Collisions Common types Head-on Lateral-impact (T-bone) Rear-impact Rollover Rotational NOTE: Overview of next slides. Scene Size-up -

Head-on Collision Windshield injuries Steering wheel injuries Brain, soft-tissue injury, cervical spine Steering wheel injuries Traumatic tattooing of skin Dashboard injuries Face, brain, cervical spine, pelvis, hip, knee In head-on collision, body is brought to a sudden halt, and energy transfer is capable of producing multiple injuries. Windshield injuries: of utmost concern is potential for serious airway and cervical-spine injury. Steering wheel deformity is a cause for alarm and must heighten your index of suspicion. You must also relay this information to receiving physician. Potential injury patterns: Deformed steering wheel • Cervical-spine fracture Dashboard knee imprints • Flail chest Spider deformity of windscreen • Myocardial contusion • Pneumothorax • Aortic disruption • Spleen or liver laceration • Posterior hip dislocation • Knee dislocation Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

Lateral-Impact Collision Similar to head-on with lateral energy Not easily predicted Consider organ damage Check impact side Head, neck, upper arm, shoulder, thorax, abdomen, pelvis, legs Potential injury patterns: Contralateral neck sprain Cervical-spine fracture Lateral flail chest Pneumothorax Aortic disruption Diaphragmatic rupture Laceration of spleen, liver, kidney Pelvic fracture Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

Rear-Impact Collision Posterior displacement Rapid forward deceleration also possible Headrest position Hyperextension injuries Damage back and front Deceleration injuries Sudden forward increase in acceleration from rear-impact produces posterior displacement of occupants and possible hyperextension of cervical spine if headrest is not properly adjusted. If seat back breaks and falls backward into rear seat, there is greater chance of lumbar-spine injury. Rapid forward deceleration may also occur if car suddenly strikes something in front or if driver applies brakes suddenly. Note deformity of auto anterior and posterior as well as interior deformity and headrest position. Potential injury patterns: Cervical-spine injury Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

Rollover Collision Multiple impacts Axial-loading injuries Ejection Multiple directions Multiple injuries Axial-loading injuries Spine injury Ejection Chance of death increases 25 times The chance for axial-loading injuries of spine is increased in this form of MVC. Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

International Trauma Life Support, 6e Rotational Collision Head-on, lateral-impact combination Converts forward motion to spinning motion Windshield, dashboard, steering wheel, side Same possible injuries of both mechanisms Rotational collision: One part of vehicle stops and rest of vehicle remains in motion, converting forward motion to a spinning motion. The results are combination of frontal-impact and lateral-impact mechanisms with same possibilities of injuries of both mechanisms. Scene Size-up -

Occupant Restraint Lap belt Three-point restraint Air bags Clasp-knife effect Abdomen Lumbar spine Three-point restraint Cervical spine Clavicular fracture Air bags First impact only Always “lift and look” Restrained occupants are more likely to survive a collision, because they are protected from much of impact inside auto and are unlikely to be ejected from auto. If belt is in place and victim is subjected to a frontal deceleration crash, his body tends to fold together like a clasp (or pocket) knife. Air bags: Do not prevent “down and under” movement, so may still impact with legs and suffer leg, pelvis, or abdominal injuries. Small drivers who bring seat up close to steering wheel may sustain serious injuries as bag inflates. Infants in car seats placed in front seat may be seriously injured by air bag. Supplemental restraint systems are only effective if occupant is NOT out of position (OOP). Scene Size-up -

Tractor Accidents One-third of farm fatalities Common injuries Side overturns 85% Likely to throw clear Rear overturns 15% Likely to entrap or crush Common injuries Crush injuries Thermal and chemical burns Two basic types of tractors are two-wheel drive and four-wheel drive. In both, center of gravity is high, and thus tractors are easily turned over. The majority of fatal accidents are due to tractor turning over and crushing driver. Primary mechanism is crush injury, and severity depends on part of anatomy involved. Additional mechanisms are chemical burns from gasoline, diesel fuel, hydraulic fluid, or even battery acid. Thermal burns from hot engine parts or ignited fuel are also common. Courtesy of Roy Alson, MD Scene Size-up -

Small-Vehicle Crashes Small vehicles Motorcycles All-terrain vehicles Personal watercraft Snowmobiles Factors Protective gear Additional impacts Operators of these machines are not encased within them and wear no restraining devices. They could be considered high-speed pedestrians. Only forms of protection: Evasive maneuvering Helmet usage Protective clothing (such as leather clothes, helmet, boots) Use of vehicle to absorb kinetic energy (such as bike slide) NOTE: If any of these small vehicles are common in your area, include additional information from chapter. Scene Size-up -

Pedestrian Injuries Mechanism Common injuries Primary collision Additional impacts Common injuries Severe internal injuries and fractures Adult: bilateral leg, knee Child: pelvis, torso IMAGE: “Exploded” leg from being struck by an auto. Pedestrian almost always suffers severe internal injuries as well as fractures. This is true even if vehicle is traveling at low speed. Adult usually has bilateral lower-leg or knee fractures plus whatever secondary injuries occur when body strikes hood of car and then ground. Children are shorter, so bumper is more likely to hit them in pelvis or torso. They usually land on their heads in secondary impact. Courtesy of Bonnie Meneely, EMT-P Scene Size-up -

Falls Vertical deceleration Distance of fall Anatomy impacted Surface struck IMAGE: How high up was patient when he fell? Primary groups involved in vertical falls are adults and children under age of 5 years. Children Most commonly involve boys and occur mostly in summer months in urban high-rise, multiple-occupant dwellings. Head injuries are common. Adults Generally occupational or due to influence of alcohol or drugs. “Lover’s leap” fall. Attempt to land on feet, impacts initially on feet and then falls backwards, landing on buttocks and outstretched hands. Fractures of feet or legs Hip and/or pelvic injuries Axial loading to lumbar and cervical spine Vertical deceleration forces to organs Colles fracture of wrists Greater height, greater potential for injury. Surface density and irregularity also influence severity. Scene Size-up -

Penetrating Injuries Knife-wound severity Stabilize impaled object Anatomic area penetrated Fourth intercostal space may be chest and abdomen Length of blade Angle of penetration Stabilize impaled object Minimize external movement IMAGE: Figure 1-16: Stab wounds at nipple level or below frequently penetrate abdomen (on page 20). Upper abdominal stab wound may cause intrathoracic organ injury, and stab wounds below fourth intercostal space may have penetrated abdomen. Usually stabilize any impaled object in place. Impaled objects in cheek of face and those blocking airway are exceptions to this rule. Scene Size-up -

Penetrating Injuries Firearms Type of weapon Caliber Distance traveled Low-velocity High-velocity Caliber Missile size Bullet construction Tumbling/yaw Distance traveled IMAGE: High-velocity leg wound. Notice entrance and exit wounds. Remember that you treat patient and wound, not description of weapon. Low-velocity: Less than 2,000 feet per second, include essentially all handguns and some rifles. Injuries are much less destructive than those sustained from high-velocity weapons. High-velocity: Wounds carry additional factor of hydrostatic pressure. Factors that contribute to tissue damage include: Missile size. The larger bullet, more resistance and larger permanent tract. Bullet construction Missile deformity. Hollow point and soft nose flatten out on impact, resulting in involvement of a larger surface. Semijacket. The jacket expands and adds to surface area. Tumbling. Tumbling of missile causes a wider path of destruction. Yaw. The missile can oscillate vertically and horizontally (wobble) about its axis, resulting in a larger surface area presenting to tissue. Courtesy of Roy Alson, MD Scene Size-up -

Penetrating Wounds Entry wound Exit wound Smaller May be darkened, burned Exit wound One, none, or many Larger May be ragged TOP IMAGE: A bloody hole in flesh where a projectile entered a body. BOTTOM IMAGE: A gaping X-shaped wound torn in flesh at site of exit of a projectile. Penetrating wounds consist of 3 parts: entry wound, exit wound, and internal wound. Scene Size-up -

Penetrating Wounds Internal wound Tissue contact damage High-velocity transfer of energy Shock waves Temporary cavity Pulsation of temporary cavity Damage proportional to tissue density Highly dense tissue sustains more damage IMAGE: Figure 1-18: High-velocity vs. low-velocity injury (on page 22). Penetrating wounds consist of 3 parts: entry wound, exit wound, and internal wound. Low-velocity projectiles inflict damage by tissue contact. High-velocity projectiles inflict damage by tissue contact and transfer of kinetic energy to surrounding tissues. Shock waves Temporary cavity, which is 30 to 40 times bullet’s diameter and creates immense tissue pressures Pulsation of temporary cavity, which creates pressure changes in adjacent tissue Shotgun wounds, injury determined by kinetic energy at impact, which is influenced by: Powder charge Size of pellets Choke of muzzle Distance to target Scene Size-up -

Blast Injuries Primary Secondary Tertiary Quaternary Initial air blast Material propelled Tertiary Impact on object Quaternary Dispersed hazardous IMAGE: Facial injuries shown here are tertiary from patient being thrown against a wall. Note that patient shown here has “raccoon eyes.” NOTE: Figure 1-19 on on page 23 depicts blast areas. Primary air-blast injuries are almost exclusive to air-containing organs. Secondary injuries may be penetrating or blunt. Tertiary injuries are much same as when a person is ejected from an automobile. Now that terrorists are using explosives to disperse chemical, biological, or radiological material, some classify injuries resulting from this as “quaternary injuries.” Courtesy of Roy Alson, MD Scene Size-up -

International Trauma Life Support, 6e Caution Do not approach until Scene Size-up is complete! Scene Size-up -

Summary Time is critical; teamwork is essential. Scene size-up can be lifesaving. Mechanism of injury: An aid to predict injury Part of overall management of trauma patient Record scene and mechanism findings. Stress need to do an accurate patient assessment. MOI is a tool but not an absolute. We do not know all forces body may have been exposed to. Scene Size-up -

Discussion Photo © Jeff Forster Scene Size-up -

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