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Trauma Basics and Multiple Injuries

Level 1

EMSNeeds.com Trauma Basic Refresher CE

Overview | Assessment | Treatment | Roles

Objectives

Trauma Basics Refresher Course

In this Trauma Basics course you will earn 2 CE hours. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • List the signs and symptoms of trauma.
  • Describe the types and differentiations of shock.
  • List emergency medical technician roles and responsibilities.
  • Define key words related to trauma.
  • Provide care to a patient with shock (hypoperfusion).
  • State methods of emergency medical care of external bleeding.
  • List signs and symptoms of shock.
  • State the steps in the emergency medical care of the patient with signs and symptoms of shock (hypoperfusion).
  • Provide care to a patient with suspected spinal injury
  • State the signs and symptoms of a potential spine injury.
  • Describe how to stabilize the spine.
  • Provide care to a patient with a suspected head injury
  • Relate mechanism of injury to potential injuries of the head and spine.
  • Provide care to a patient with a soft tissue injury
  • Describe the emergency medical care of the patient with a closed soft tissue injury.
  • Describe the emergency medical care of the patient with an open soft tissue injury.
  • Prepare to perform a rapid extrication of a trauma patient.
  • Describe the indications for the use of rapid extrication.
  • List steps in performing rapid extrication.
  • Explain the sense of urgency to transport patients that are bleeding and show signs of hypoperfusion.
  • Explain the rationale for splinting at the scene versus load and go.
  • Explain the rationale for using rapid extrication approaches only when they will make the difference between life and death.

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

EMS Course Levels

Overview

Trauma is the leading cause of death in the United States for persons between the ages of 1 and 44. Understanding the mechanism of injury, relevant signs and symptoms and appropriate intervention techniques is of paramount importance when dealing with the traumatized patient.

Types of Shock

Keys to identifying the type of trauma are knowing and relating the types of shock that may occur in these areas:

  • Cardiogenic shock - low blood pressure
  • Hypovolemic shock - loss of blood
  • Neurogenic shock - bladder malfunction
  • Anaphylactic shock - respiratory allergies
  • Septic shock - infection
 

Definitions

  • Anaphylactic shock -Allergies and inflammatory responses may trigger a runny nose with mild irritation to life-threatening inability to breathe. Symptoms vary from mild irritation to sudden death from anaphylactic shock. Treatment usually involves epinephrine, antihistamines, and corticosteroids.

  • BSI - Body substance isolation

  • Cardiogenic shock - When the heart does not pump enough blood, the blood pressure decreases. This may result in circulatory collapse, backing up blood in the lungs, causing pulmonary edema. Myocardial ischemia further creates problems for the heart to pump enough blood.

  • Hypoperfusion - Shock resulting in inadequate perfusion of cells with oxygen and nutrients and inadequate removal of metabolic waste products.

    Hypovolemic or Hemorrhagic Shock - Trauma patients develop shock (hypoperfusion) from the loss of blood from both internal and external sites.

  • Neurogenic shock - hypofusion related to bladder malfunction

  • Perfusion - capillary refill; process of nutritive delivery of arterial blood to a capillary bed in the biological tissue.

  • Septic shock - Infection that is systemic triggers immune responses that are more extreme and lead to hypotension and perfusion dysfunction.
  • Supine -laying flat on the back with face up as opposed to prone (laying on the stomach)
Emergency Stop
Assessment

Identify the severity of the injury.

Shock (hypoperfusion) results in inadequate perfusion of cells with oxygen and nutrients and inadequate removal of metabolic waste products. Cell and organ malfunction and death can result from hypoperfusion; therefore, prompt recognition and treatment is vital to patient survival. Peripheral perfusion is drastically reduced due to the reduction in circulating blood volume. As a result, trauma patients develop shock from the loss of blood from both internal and external sites. This type of shock is referred to as hypovolemic or hemorrhagic shock.

  1. Responsive Patients

  • Attempt to identify the mechanism of injury.
  • Ask them questions, but ensure that they do not move while answering.

(1) Does your neck or back hurt?
(2) What happened?
(3) Where does it hurt?
(4) Can you move your hands and feet?
(5) Can you feel me touching your fingers?
(6) Can you feel me touching your toes?

  • Inspect for contusions, deformities, lacerations, punctures, penetrations, swelling.
  • Palpate for areas of tenderness or deformity.
  • Assess equality of strength of extremities.

(1) Hand grip.
(2) Gently push feet against hands.

  1. Unresponsive Patients

  • Attempt to identify the mechanism of injury.
  • Verify initial assessment.
  • Inspect for:

1) Contusions
(2) Deformities
(3) Lacerations
(4) Punctures/penetrations
(5) Swelling

  • Palpate for areas of tenderness or deformity.
  • Obtain information from others at the scene to determine information relevant to mechanism of injury or patient mental status.

Signs and Symptoms of Shock (Hypoperfusion)

1. Mental states

  • Restlessness
  • Anxiety
  • Altered mental status

2. Peripheral perfusion

  • Delayed capillary refill greater than 2 seconds in normal ambient air temperature
    infant and child patients only
  • Weak, thready or absent peripheral pulses
  • Pale, cool, clammy skin

3. Vital signs

  • Decreased blood pressure (late sign)
  • Increased pulse rate (early sign) - weak and thready
  • Increased breathing rate

(1) Shallow
(2) Labored
(3) Irregular

4. Other signs and symptoms

  • Dilated pupils
  • Thirst
  • Nausea and vomiting
  • Pallor with cyanosis to the lips

NOTE: Infants and children can maintain their blood pressure until their blood volume is more than half gone, so by the time their blood pressure drops they are close to death. The infant or child in shock has less reserve.

Signs and Symptoms of Injuries to Bones and Joints

1. Deformity or angulated
2. Pain and tenderness
3. Grating
4. Swelling
5. Bruising (discoloration)
6. Exposed bone ends
7. Joint locked into position

Signs and symptoms of Head and Spine Injuries

1. Tenderness in the area of injury

2. Pain associated with moving

a) Do not ask the patient to move to try to elicit a pain response.
b) Do not move the patient to test for a pain response.

3. Pain independent of movement or palpation

a) Along spinal column
b) Lower legs
c) May be intermittent

4. Obvious deformity of the spine upon palpation

5. Soft tissue injuries associated with trauma

a) Head and neck to cervical spine
b) Shoulders, back or abdomen - thoracic, lumbar
c) Lower extremities - lumbar, sacral

6. Numbness, weakness or tingling in the extremities

7. Loss of sensation or paralysis below the suspected level of injury

8. Loss of sensation or paralysis in the upper or lower extremities

9. Incontinence

Skull Injury Signs and Symptoms

1. Mechanism of trauma
2. Contusions, lacerations, hematomas to the scalp
3. Deformity to the skull
4. Blood or fluid (cerebrospinal fluid) leakage from the ears or nose
5. Bruising (discoloration) around the eyes
6. Bruising (discoloration) behind the ears (mastoid process)

Closed Head Injury Signs and Symptoms

(1) Altered or decreasing mental status is the best indicator of a brain injury.

(a) Confusion, disorientation, or repetitive questioning
(b) Conscious - deteriorating mental status
(c) Unresponsive

(2) Irregular breathing pattern

(3) Consideration of mechanism of injury

(a) Deformity of windshield
(b) Deformity of helmet

(4) Contusions, lacerations, hematomas to the scalp
(5) Deformity to the skull
(6) Blood or fluid (cerebrospinal fluid) leakage from the ears and nose
(7) Bruising (discoloration) around the eyes
(8) Bruising (discoloration) behind the ears (mastoid process)
(9) Neurologic disability
(10) Nausea and/or vomiting
(11) Unequal pupil size with altered mental status
(12) Seizure activity may be seen.

Open Head Injury Signs and Symptoms

(1) Consideration of mechanism of injury

(a) Deformity of windshield
(b) Deformity of helmet

(2) Contusions, lacerations, hematomas to the scalp
(3) Deformity to the skull
(4) Penetrating injury: do not remove impaled objects in the skull
(5) Soft area or depression upon palpation
(6) Exposed brain tissue
(7) Bleeding from the open bone injury
(8) Blood or fluid (cerebrospinal fluid) leakage from the ears and nose
(9) Bruising (discoloration) around the eyes
(10) Bruising (discoloration) behind the ears (mastoid process)
(11) Nausea and/or vomiting
(12) Possible signs and symptoms of a closed head injury may exist if brain injury has occurred.

Assess the Patient's Circulation

A. Assess the patient's pulse.

1. The circulation is assessed by feeling the carotid. If alert check the radial pulse.

a. In a patient one year old or less, palpate a brachial pulse.
b. If pulseless, palpate carotid pulse.

(1) If pulseless, medical patient >12 years old, start CPR and apply automated external defibrillator (AED).
(2) Medical patient < 12 years old, start CPR.
(3) Trauma patient, start CPR.

B. Assess if major bleeding is present. If bleeding is present, control
bleeding.

C. Assess the patient's perfusion by evaluating skin color and temperature.

1. The patient's perfusion may be assessed by looking at the nail
beds, lips and the skin inside the eyelids.

a. Normal - pink
b. Abnormal conditions

(1) Pale
(2) Cyanotic or blue-gray
(3) Flushed or red
(4) Jaundice or yellow

2. Assess the patient's skin temperature by feeling the skin.

a. Normal - warm
b. Abnormal skin temperatures

(1) Hot
(2) Cool
(3) Cold
(4) Clammy - cool & moist

3. Assess the patient's skin condition. This is an assessment of the amount of moisture on the skin.

a. Normal - dry
b. Abnormal - moist or wet

4. Assess capillary refill in infant and child patients.

a. Normal capillary refill is less than two seconds.
b. Abnormal capillary refill is greater than two seconds.

Emergency Stop
Treatment

Basics

Focus on these 3 areas:

  • Immobilization
  • Oxygenation
  • Transportation

Follow these guidelines and procedures:

1. Practice body substance isolation.
2. Maintain airway/artificial ventilation. Administer oxygen if indicated.
3. Control any external bleeding.

  • Apply finger tip pressure directly on the point of bleeding.
  • Elevate a bleeding extremity in conjunction with direct pressure.
  • Pack large gaping wounds with sterile gauze and direct hand pressure if direct finger tip pressure fails to control bleeding.
  • Apply additional pressure if bleeding does not stop or soaks through the dressing.
  • Find pressure points in upper and lower extremities.

4. If signs of shock (hypoperfusion) are present and the lower abdomen is tender and pelvic injury is suspected, with no evidence of chest injury, apply and inflate the pneumatic anti-shock garment if approved by medical direction.

5. Elevate the lower extremities approximately 8 to 12 inches. If the patient has serious injuries to the pelvis, lower extremities, head, chest, abdomen, neck, or spine, keep the patient supine.

6. Splint any suspected bone or joint injuries.

7. Prevent loss of body heat by covering the patient with a blanket whenappropriate.

8. Immediately transport.

Emergency medical care of an open chest wound

  1. Occlusive dressing to open wound
  2. Administer oxygen if not already done
  3. Position of comfort if no spinal injury suspected

Emergency medical care for an open abdominal injury

  1. Do not touch or try to replace the exposed organ.
  2. Cover exposed organs and wound with a sterile dressing, moistened with sterilewater or saline, and secure in place.
  3. Flex the patient’s hips and knees, if uninjured.

Emergency medical care of amputations

  1. Wrap the amputated part in a sterile dressing.
  2. Wrap or bag the amputated part in plastic and keep cool.
  3. Transport the amputated part with the patient.
  4. Do not complete partial amputations, immobilize to prevent further injury.

Emergency Medical Care of Burns

  1. Stop the burning process, initially with water or saline.
  2. Remove smoldering clothing and jewelry.
  3. Use body substance isolation.
  4. Continually monitor the airway for evidence of closure.
  5. Prevent further contamination.
  6. Cover the burned area with a dry sterile dressing.
  7. Do not use any type of ointment, lotion or antiseptic.
  8. Do not break blisters.
  9. Transport.
  10. Know local protocols for transport to appropriate local facility.

Treatment of Injuries to Bones and Joints

  1. Body substance isolation
  2. Administer oxygen if indicated.
  3. After life threats have been controlled, splint injuries in preparation for transport.
  4. Application of cold pack to area of painful, swollen, deformed extremity to reduce swelling.
  5. Elevate the extremity.

General Rules of Splinting

  1. Assess pulse, movement, and sensation distal to the injury prior to and following splint application and record.
  2. Immobilize the joint above and below the injury.
  3. Remove or cut away clothing.
  4. Cover open wounds with a sterile dressing.
  5. Align with gentle traction before splinting if there is a severe deformity or the distal extremity is cyanotic or lacks pulses.
  6. Do not intentionally replace the protruding bones.
  7. Pad each splint to prevent pressure and discomfort to the patient.
  8. Splint the patient before moving.
  9. When in doubt, splint the injury.
  10. If patient has signs of shock (hypoperfusion), align in normal anatomical position and transport.
Emergency Stop
Roles and Responsibilities

Place the interests of the patient with airway problems as the foremost consideration when making any and all patient care decisions.

Equipment needed: Sterile dressings, bandages, splints, pneumatic anti-shock garment, triangular bandage, stick or rod, air splints, gloves, eye protection, blanket, universal dressing, occlusive dressing, roller bandages, 4 x 4 gauze pads, burn sheets, sterile water or saline. Pay attention to these:

  • Isolating of body substances.
  • Maintaining airway/artificial ventilation/oxygenation.
  • Assessing initial spinal immobilization.
  • Immobilizing the spine with any head injury.
  • Monitoring the airway, breathing, pulse, and mental status for deterioration.
  • Controlling bleeding.

    (1) Do not apply pressure to an open or depressed skull injury.
    (2) Dress and bandage any open wounds as indicated in the treatment of soft tissue injuries.

  • Place the patient preferably on the left side if a medical injury or non-traumatic injury exist.
  • Check for changes in patient condition.
  • Prepare to transport the patient immediately.

Review Rapid Extrication

Rapid extrication is based on time and the patient, and not preference of EMS personnel.

Indicators

  • Unsafe scene
  • Unstable patient condition
  • Access to another, more seriously injured patient blocked by one less seriously injured

Procedures

  1. One EMT gets behind patient and brings cervical spine into neutral inline position and provides manual immobilization.
  2. A second EMT applies cervical immobilization device as the third EMT first places long backboard near the door and then moves to the passenger seat.
  3. The second EMT supports the thorax as the third EMT frees the patient’s legs from the pedals.
  4. Two EMTs rotate the patient in several short, coordinated moves until the patient’s back is in the open doorway and their feet are on the passenger seat.
  5. The first EMT who is supporting the patient’s head in the vehicle is replaced by another to go to support the head outside of the vehicle.
  6. The end of the long backboard is placed on the seat next to the patient’s buttocks. Assistants support the other end of the board as you lower the patient onto it.
  7. The second EMT and the third EMT slide the patient into the proper position on the board in short, coordinated moves.
  8. Several variations of the technique are possible, including assistance from bystanders. but all is done without compromising the spine.

Reminders for Practical Application of Skills Learned

  1. Review methods to control external bleeding.
  2. Review methods used to treat the patient in shock (hypoperfusion).
  3. List the steps in the care of open and closed soft tissue injuries. (chest injuries, abdominal injuries, burns and amputations).
  4. Identify the steps in the care of a patient with a head or spine injury.
  5. Demonstrate the procedure for rapid extrication.

You will respond to various traumatic emergencies during your career in EMS. Your ability to quickly control bleeding and recognize and treat shock are critical to the life of the patient. Failure to proper immobilize a bone or joint injury can result in damage to soft tissue, organs, nerves and blood vessels. Failure to recognize the possibility of a head or spine injury will lead to an increased patient morbidity and mortality. Therefore, for further study:

  • Hear simulated situations to identify signs and symptoms of external bleeding, internal bleeding and shock (hypoperfusion).
  • Hear simulations of various situations involving musculoskeletal injuries and the proper assessment and intervention.
  • See audio-visual aids or materials of the proper methods to control external bleeding and treat for shock (hypoperfusion).
  • View demonstrations for the proper method of managing an open chest wound.
  • Watch demonstrations for the proper method of managing an open abdominal injury.
  • Check out audio-visual aids or materials which illustrate superficial, partial thickness and full thickness burns.
  • Demonstrate the proper management of burns.
  • Learn more about the proper immobilization of a painful, swollen, deformed extremity.
  • View simulations of proper assessment and management of patients who have experienced head and spine injuries.
  • Study illustrations of situations that would require the use of rapid extrication.

Finally, review:

  • Managing patients with external bleeding, internal bleeding and shock.
  • Caring for patients with open and closed soft tissue injuries (chest injuries, abdominal injuries, burns and amputations).
  • Treating those who have an injured extremity.
Emergency Stop

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