1. 30
Multisystem Trauma

2. Multimedia Directory
Slide 23 Emergency: Gunshot Wound Video Slide 24 Multiple System Injuries in Front-end Collisions Video Slide 25 Mechanism of Injuries in Vehicle Collisions Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

3. Topics Multisystem Trauma Managing the Multisystem-Trauma Patient
Planning Your Time: Plan 60 minutes for this chapter.
Multisystem Trauma (30 minutes)
Managing the Multisystem-Trauma Patient (30 minutes)
Note: The total teaching time recommended is only a guideline.
Core Concepts
How to balance the critical trauma patient's need for prompt transport against the time needed to treat all of the patient's injuries at the scene
How to determine the severity of the trauma patient's condition, priority for transport, and appropriate transport destination
How to select the critical interventions to implement at the scene for a multiple-trauma patient
How to calculate a trauma score

4. Multisystem Trauma Teaching Time: 30 minutes
Teaching Tips: Use examples and scenarios to describe the trauma decision-making process. Discuss the Center for Disease Control Trauma Triage Guidelines. Discuss the guidelines of your local trauma center. Integrate this type of decision making into scenarios throughout class. Make it more than a one-time lesson.

5. Multisystem Trauma Multiple-trauma patient Multisystem-trauma patient
More than one serious injury
Multisystem-trauma patient
One or more injuries serious enough to affect more than one body system
Teamwork, timing, and transport decision are key to proper management.
Covers Objective: 30.1
Points to Emphasize: The multisystem-trauma patient has one or more injuries that are serious enough to affect more than one body system. Care for multisystem trauma is different from that for isolated trauma. Teamwork, timing (moving patient to definitive care as soon as possible), and transport (decision about appropriate destination) are essential.
Discussion Topics: Define multisystem trauma. Discuss how the treatment and transportation of a multisystem-trauma patient is different from that of an isolated trauma patient.
Knowledge Application: Have students work in small groups. Ask each group to discuss the different roles that would be necessary to treat and transport a multisystem-trauma patient. What would be the components of teamwork?
Critical Thinking: Is there isolated trauma that requires similar decision making and teamwork when compared to multisystem trauma? Give examples.

6. Determining Patient Severity
Most critical decisions
Patient priority/severity
Whether to limit scene time or not
Which hospital or transport method is best for your patient
Covers Objective: 30.3
Points to Emphasize: EMTs must look at actual physiologic injuries, anatomic locations, and mechanism of injury to adequately judge patient severity and transport priority. Special considerations, such as age and underlying medical condition, may alter the initial severity decisions.
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7. Determining Severity: Physiologic Criteria
Altered mental status (GCS < 14)
Head injury
Hypotension (systolic < 90 mm Hg)
Shock, internal bleeding
Abnormally slow respiratory rate
Head injury, later stages of shock
Covers Objective: 30.3
Knowledge Application: Using local geography, describe a trauma scene. Ask students to make severity decisions and to plan appropriate transportation.
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8. Determining Severity: Anatomic Criteria
Penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee
Chest wall instability or deformity
Two or more proximal long-bone fractures
Covers Objective: 30.3
Discussion Topic: What special considerations might alter the decision-making process when dealing with a trauma patient?
Class Activities: Hand out four written scenarios as a take-home assignment. Ask students to read each scenario and then to write out an initial treatment and transport plan.
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9. Determining Severity: Anatomic Criteria
Crushed, degloved, mangled, or pulseless extremity
Amputation proximal to wrist or ankle
Pelvic fractures
Open or depressed skull fracture
Paralysis
Covers Objective: 30.3
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10. Determining Severity: Mechanism of Injury
In absence of anatomic or physiologic signs, MOI is considered if severe.
Falls
Intrusion
Ejection from automobile
Death in same passenger compartment
Vehicle telemetry data consistent with high risk of injury
Covers Objective: 30.3
Discussion Topic: Describe the information needed to judge the severity of a multisystem trauma patient.
Class Activity: Discuss local trauma resources. Where are the local trauma centers? What transport options are present?
Knowledge Application: Use a programmed patient and simulate trauma scenarios. Have groups of students practice assessment, decision making, and teamwork.

11. Determining Severity: Special Patients and Considerations
Older adults do not efficiently compensate for shock.
Children may benefit by transport to a pediatric specialty facility.
Patients with certain conditions
Taking anticoagulants
Pregnant
Covers Objective: 30.3
Discussion Topic: Describe the information needed to judge the severity of a multisystem trauma patient.
Class Activity: Discuss local trauma resources. Where are the local trauma centers? What transport options are present?
Knowledge Application: Use a programmed patient and simulate trauma scenarios. Have groups of students practice assessment, decision making, and teamwork.

12. Managing the Multisystem-Trauma Patient
Teaching Time: 30 minutes
Teaching Tips: Use multimedia graphics to demonstrate multisystem trauma scenes. The scenario in the chapter is a helpful example of a trauma scene. Use it as a basis for discussion or as a framework for other scenarios. Relate this lesson to previous lessons. Discuss the context of airway management, bleeding control, and spinal immobilization in multisystem trauma patients. Describe how the primary assessment will guide these steps. Add context to scenarios. By now, students will be familiar with standardized skill sheets. Begin to teach flexibility and adaptation by using atypical situations.

13. A Typical Call Practice with crew.
Determine roles.
En route to call, review roles each member of the crew will have.
Ensure scene safety.
Auto crash will have passing traffic.
Penetrating trauma
Assailant may still be on the scene.
Covers Objective: 30.2
Point to Emphasize: The best way to prepare for multisystem trauma is to practice and develop teamwork before the call.
Discussion Topic: Describe the process of preparing for a multisystem trauma situation. What steps can you take before the call?
Knowledge Applications: Have students work in small groups. Ask each group to preplan multisystem trauma. Discuss roles and teamwork and compare notes among groups. Using the same groups and a programmed patient, create a multisystem trauma patient scenario. Discuss whether preplanning helped and how students might preplan differently.
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14. A Typical Call Perform the primary assessment. Ensure an open airway.
Perform urgent or emergency moves.
Transport.
Give a report to the trauma team at the emergency department during handover.
Covers Objective: 30.5
Point to Emphasize: Scene safety considerations are an essential component of multisystem trauma management. The EMT must adapt to unusual circumstances in multisystem trauma management. Expect the unexpected.
Discussion Topic: What safety hazards might be present at a multisystem trauma scene?
Use examples to discuss why it is important to be flexible and to adapt at a multisystem trauma scene.
Class Activity: Use multimedia graphics to illustrate unusual trauma scenes. Discuss examples that show how traditional response and treatment might not be appropriate. Demonstrate flexibility.

15. Analysis of the Call In a scenario with critical injuries
Follow priorities determined by assessments.
Do not delay transport by performing treatments that would waste time.
Show good judgment.
Postpone taking vital signs until en route when appropriate.
Give the hospital staff time to prepare.
Covers Objective: 30.5

16. General Principles of Multisystem-Trauma Management
Follow priorities determined by primary assessment.
Attend to immediate threats to life.
Reassess what to treat on scene and what needs definitive care.
Call hospital so they can prepare.
Covers Objective: 30.5
Points to Emphasize: The best way to prepare for multisystem trauma is to practice and develop teamwork before the call.

17. General Principles of Multisystem-Trauma Management
Depending on your primary assessment, you may postpone taking vital signs until you are en route to the hospital.
As you reassess your patient in the vehicle, call the hospital as necessary to update the vital signs.
Covers Objective: 30.5
Talking Points: Depending on your primary assessment, you may postpone taking vital signs until you are en route to the hospital. Alert hospital that you are on your way, and give them the information you have so that they can prepare the trauma team. As you reassess your patient in the vehicle, call the hospital as necessary to update the vital signs.

18. General Principles of Multisystem-Trauma Management
Limit scene treatment
Stabilize cervical spine.
Suction airway.
Insert oral or nasal airway.
Restore patent airway.
Ventilate with bag-valve mask.
Administer high-concentration oxygen.
Control bleeding.
Immobilize patient.
Covers Objective: 30.5
Point to Emphasize: Limit scene treatment to airway management, breathing control, administering high-concentration oxygen, controlling bleeding. and spinal immobilization.
Discussion Topic: What interventions are reasonable to conduct on scene with a multisystem trauma patient?
Knowledge Application: Use programmed patients to practice multisystem trauma scenarios. Time "on-scene interventions" and discuss decision making.
Critical Thinking: How might transport time affect the interventions completed at a scene? Might there be more on-scene interventions in the event of a long transport time? Might there be fewer?
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19. General Principles of Multisystem-Trauma Management
Scene safety is paramount.
Ensure an open airway.
Perform urgent or emergency moves as necessary.
Adapt to the situation.
Covers Objective: 30.5
Point to Emphasize: Limit scene treatment to airway management, breathing control, administering high-concentration oxygen, controlling bleeding. and spinal immobilization.
Discussion Topic: What interventions are reasonable to conduct on scene with a multisystem trauma patient?
Knowledge Application: Use programmed patients to practice multisystem trauma scenarios. Time "on-scene interventions" and discuss decision making.
Critical Thinking: How might transport time affect the interventions completed at a scene? Might there be more on-scene interventions in the event of a long transport time? Might there be fewer?

20. Trauma Scoring Numerical rating system for trauma
Assigns number to certain patient characteristics to create a score
Objectively describes severity
Helps determine transport to a trauma center or local hospital
Helps trauma centers evaluate the care of similar patients
Covers Objective: 30.6
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21. Trauma Scoring Revised Trauma Score (RTS) Components
Glasgow Coma Scale (GCS)
Systolic blood pressure
Respiratory rate
Follow local protocol for use of the trauma scoring system.
Do not let it interfere with patient care.
Covers Objective: 30.6

22. Sample RTS Form
Covers Objective: 30.6
Revised Trauma Score. Source: Champion, H. R., Sacco, W. J., Copes, W.S., et al. “A Revision of the Trauma Score,” J Trauma 29(5): 623–9, 1998.

23. Emergency: Gunshot Wound Animation
Covers Objective: 30.3
Video Clip
Emergency: Gunshot Wound
Discuss the importance of a complete assessment to identify any wounds.
Why can't an EMT accurately determine a bullet's path in a patient's body?
What might an EMT mistake for an exit wound?
Discuss the different sizes of entrance wounds made by different types of guns.
Click on the screenshot to view an animation on the subject of treating gunshot wounds.
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24. Multiple System Injuries in Front-end Collisions Animation
Covers Objective: 30.3
Video Clip
Multiple System Injuries in Front-end Collisions
What injuries frequently occur when a patient goes down and under during a front-end collision?
Discuss the use of restraints in preventing multisystem injuries.
What additional challenges does an EMT face when patients sustain multi-system injuries?
Click on the screenshot to view an animation on trauma due to front-end collisions.
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25. Mechanism of Injuries in Vehicle Collisions Animation
Covers Objective: 30.3
Video Clip
Mechanism of Injuries in Vehicle Collisions
What types of injuries should you anticipate in a patient who has been involved in a head-on collision?
Why are neck injuries common in rear-end collisions?
Discuss the types of injuries that you would expect if a patient has been ejected from a vehicle involved in a rollover.
Why should you consider the mechanism of injury when doing a scene size-up?
Click on the screenshot to view a view an animation on the types of injuries in motor vehicle collisions.
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26. Chapter Review

27. Chapter Review
Multisystem trauma is a serious condition in which two or more major body systems are injured or affected.
Recognizing multisystem trauma, triaging properly, transporting promptly, and choosing the correct destination are vital for the survival of your patient.
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28. Chapter Review
The CDC has issued guidelines for trauma triage and transport. These are a guide and should be used in conjunction with your protocols.
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29. Chapter Review
The Revised Trauma Score (RTS) is one method of classifying trauma patients by severity and includes the Glasgow Coma Score (GCS), systolic blood pressure, and respiratory rate.

30. Remember
Your primary assessment should determine whether your patient is seriously injured or potentially seriously injured.
Limit scene treatment to life-threatening conditions.
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31. Remember
Use patient severity (physiologic criteria, anatomic criteria, MOI) to decide whether to transport to a trauma center or local hospital.

32. Questions to Consider
Is my patient seriously injured or potentially seriously injured?
Should I expedite my scene time?
What is the most appropriate transport destination for my patient?
Talking Points: There are many different types of trauma situations, and decision-making in each will be determined by the conditions.

33. Critical Thinking
A patient was involved in a car crash with significant intrusion into the area where the patient was sitting. The patient is alert and complains of pain in the ribs. Pulse: 96 and regular; respirations: 30 and adequate; blood pressure: 100/62; pupils: equal and reactive; skin: cool and dry.
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34. Critical Thinking
Your partner says the patient is stable and could be easily transported to the community hospital nearby. You think the patient should be transported to the trauma center. How would you justify your decision to your partner?
Talking Points: Since the patient complains of pain in the rib area and the potential for considerable blunt injury trauma due to the crash, you should be alert for unseen internal injuries and the possibility that the patient may need critical care that is better supplied at a specialized trauma center than at a community hospital.