Trauma Overview: The Trauma Patient and the Trauma System Chapter 27

Objectives Discuss Kinetics of Trauma Discuss Mechanism of Injury Discuss the Multi-system Trauma Patient Discuss The Golden Period Discuss the Trauma System Discuss Special Considerations in Trauma Care

The Kinetics of Trauma – Mass and Velocity Mechanism of Injury (MOI)- How a person was injured Kinetics of Trauma – Science of analyzing mechanisms of injury Kinetic Energy – Energy contained in a moving body Directly proportional to mass Directly proportional to the square of velocity During scene size-up, get the best estimate of the speed of the vehicle or vehicles at the time of the collision Kinetic energy of two moving bodies that collide will be combined

Acceleration and Deceleration The motion of an object will not change unless force acts upon it Acceleration – An increase in speed Deceleration – A decrease in speed Faster acceleration or deceleration results in greater force on the human body

Kinetics of Trauma Energy Changes Form and Direction If energy is transmitted to a body in a straight line, injure may not occur If energy is interrupted, injury can occur May be interrupted by a curve of bone by an organ between a hard surface by tissue pulled against a fixed point

Kinetics of Trauma Impacts Types of Impacts Vehicle collision – Vehicle suddenly stops and gets bent out of shape Body collision – Patient comes to a quick stop on some part or parts of the inside Organ collision – Internal organs come to a quick stop Investigating kinetics Person in or on a moving vehicle gets thrown has a much greater chance of injury than one who is restrained or remains within the vehicle The faster a vehicle is travelling, the greater the kinetic energey, greater the force, and greater the potential for injury

Mechanism of Injury Vehicle Collisions Situations that should have a high index of suspicion: Death of another occupant Unresponsive patient or patient with an altered mental status Intrusion of greater than 12” for the occupant side or greater than 18” anywhere on the vehicle Ejection

Mechanism of Injury Vehicle Collisions Classification of collisions Frontal Impact Rear-end impact Lateral impact Rotational/rollover Vehicle-pedestrian Restraints Considerations for infants and children Motorcycle collisions

Frontal Impact Frontal impact Abdomen, Chest, Face, Head, and neck In a frontal collision, the occupant continues to move forward at the same speed the vehicle was moving. The up-and-over pathway causes impact to the head, neck, chest, and abdomen.

Frontal Impact The down-and-under pathway causes impact to the knees, femurs, hips, acetabulum, and spine. Examples of mechanisms of injury associated with frontal impact.

Frontal Impact A deformed steering wheel indicates possible chest or abdominal injury. (© Jeff Forster) The “paper bag” syndrome results from compression of the chest against the steering column. Impact marks or cracking to the windshield indicates a possible head injury

Rear-end impact Injuries to suspect: Head or Neck (a) In a rear impact with an unrestrained occupant, initial movement is backward, causing potential neck injury (b) The occupant then moves forward, causing impact to the head and chest

Lateral impact Injuries to suspect: Lateral impact causes impact to the head, shoulder, lateral chest, lateral abdomen, lateral pelvis, and femur.

Rotational or Rollover crash In a rollover of an unrestrained occupant, impact to the body is difficult to predict and commonly results in multiple system injury Ejection is common Crushing injuries

Vehicle-pedestrian collision A child about to be hit by a vehicle generally turns toward the vehicle. (© Mark C. Ide) Consider the speed of the vehicle What part of the body was hit How far the body was thrown The surface the body landed on Body part that first struck the ground

Restraints Airbags or Seatbelts Seat belt injuries to (a) the upper chest. (Photo: © Edward T. Dickinson, MD) Seat belt injuries to (b) the abdomen. (Photo: © Edward T. Dickinson, MD)

Considerations for infants and children Any parts of the body that are not restrained continue to move forward Children should always be restrained in the back seat to avoid injury from air bag deployment

Motorcycle collisions Head-on impact Angular impact Ejection “Laying down the bike” Motorcycle collisions can result in multisystem trauma from multiple impacts to the rider. (© CW McKean/ Syracuse Newspapers/The Image Works) Soft tissue injury to the forehead and face All-terrain vehicles (ATVs) can cause multiple injuries from the combination of speed and instability.

Mechanism of Injury Falls Severity factors Distance Surface Body part impacted first Objects that interrupt the fall

Mechanism of Injury Falls Feet-first falls Fractures of the heels and fractures/dislocations of the ankles are common Spine will absorb the force at every curve of the lumbar Falls more than 20 ‘ the internal organs are likely to be injured from deceleration forces A fracture of the wrist is common If the body is thrown backward, the most common injuries are head, back, and pelvis

Mechanism of Injury Falls Head-first falls Injury begins with the arms and extends up to the shoulders The head may be forcibly hyperextended, hyperflexed, or compressed Extensive damage to the cervical spine can occur Chest, lower spine, and pelvis injuries are common

Mechanism of Injury Penetrating injuries The severity of injury caused by penetrating trauma is related to the velocity of the penetrating object. Low-velocity injuries An object impaled exerts damage to the immediate area of the impact and its underlying structures The length of the object used provides valuable clues about the injury

Mechanism of Injury Penetrating injuries Medium-and-high velocity injuries Trajectory - the path or motion of a projectile during its travel Dissipation of energy is the way energy is transferred to the human body from the force acting upon it; Drag Profile Cavitation Fragmentation

Fatal wounds – 90% involves the head, thorax, and abdomen Wounds also occur to the neck and extremities Head; Projectile entering the skull causes brain tissue to be compressed Projectile entering the face threatens the airway Chest Pneumothorax is common Outer covering of the heart may be able to seal itself from low-velocity, high-velocity causes significant wounds Suspect both thorax and abdominal injuries if entrance wound between nipple and waist Abdomen Often secondarily injured when chest involved Majority are not rapidly fatal but needs surgery Extremities Bone injury becomes bony fragments turning into secondary missiles Muscle expands, resulting in capillary tears and swelling Vessels can be severed, ripped, buckled, and/or obstructed Gunshot wounds A wound resulting from close-range shotgun blast. Note the tattooing of the skin from the gunpowder.

Mechanism of Injuries Blast injuries Primary phase injuries are due to the pressure wave of the blast Secondary phase are due to flying debris propelled by the force of the blast Tertiary phase injuries occur when the patient is thrown away from the source of the blast

Blast injuries can cause injury with the initial blast, when the patient is struck by debris, or by the patient being thrown from the site of the blast. Blast injuries can cause injury with the initial blast, when the patient is struck by debris, or by the patient being thrown from the site of the blast

Blast injuries can cause injury with the initial blast, when the patient is struck by debris, or by the patient being thrown from the site of the blast. Blast injuries can cause injury with the initial blast, when the patient is struck by debris, or by the patient being thrown from the site of the blast

The Multisystem Trauma Patient Has multiple injuries or involvement of more than one body system Multiple organ injuries also are considered to by multisystem trauma Multisystem trauma carries a high incidence of morbidity and mortality

The Golden Period Relates to the time during which a patient needs intervention in order to survive Length of time indicated by the “golden period” depends on the patient injury EMT’s must assess, treat, and transport the injured patient as quickly as possible

The Golden Period The “platinum ten minutes” is the maximum time the EMS team should devote to on-scene activities with patient assessment, emergency care for life threats, and preparation for transport If a patient is not severely injured, more time can be devoted to completing normal on-scene assessment and emergency care before transport

The Trauma System Designed to provide immediate surgical intervention for patients with internal trauma Requires significant resources and is expensive to maintain Common designation of trauma centers; Level 1 – Regional Trauma Center Level II – Area Trauma Center Level III – Community Trauma Center Level IV – Trauma Facility Crucial that EMS personnel triage patients accurately for transport to the appropriate trauma center

Special Considerations in Trauma Care Principles of out-of-hospital trauma care; Ensure at all times the safety of EMS personnel, patients, and bystanders Quickly determine need for additional resources Determine the MOI and kinematics involved Provide a primary assessment Establish and maintain spinal stabilization Establish and maintain airway Establish and maintain adequate oxygenation Provide ventilation

Special Considerations in Trauma Care Principles of out-of-hospital trauma care; Control external hemorrhage with direct pressure Treat for shock Consider application of PASG (Whatcom Co Protocol Page 17) Maintain manual spinal stabilization until patient is immobilized on backboard Transport critically injured or multisystem trauma patients with 10 minutes Obtain a history from patient, relatives, bystanders Perform secondary assessment

Special Considerations in Trauma Care Your personal safety is of utmost importance Airway management, adequate ventilation, and oxygenation are key elements Stop significant bleeding Assessment of trauma patient is conducted in a sequence that promotes a rapid systemic approach Rapid transport is essential A backboard can secure suspected fractures in an unstable patient who requires rapid transport Do not develop tunnel vision and become focused on dramatic injuries or dramatic patients

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