Ch.25 Traumaoverview Flashcards
Occur as a result of physical forces applied to the body
Trauma emergencies
___ emergencies include illnesses or conditions; these are not caused by an outside force
Medical emergencies
Similarly,_____ may result from recent or remote traumatic injuries (pneumonia develops in a patient a few days after a fall that fractured the patient’s ribs).
medical illnesses
Next, different types of vehicle crashes and their effect
on the body are explained. By assessing a vehicle that has crashed, you can often determine what happened to the passengers at the time of impact. This may allow you to predict what injuries the passengers sustained at the time of impact.
Evaluation of the mechanism of injury for the trauma patient will provide you with an_____ for different types of serious and/or life-threatening underlying injuries.
index of suspicion
Certain injury patterns occur with certain types of injury events. The ______is your awareness and concern for potentially serious underlying and unseen injuries.
index of suspicion
Traumatic injury occurs when the body’s tissues are exposed to energy levels beyond their__
tolerance
The____ is the way in which traumatic injuries occur; it describes the forces (or energy transmission) acting on the body that cause injury.
mechanism of injury. (MOI)
The forces, or energy transmission, applied to the body that cause injury
Mechanism of injury
Three concepts of energy are typically associated with injury (not including thermal energy, which causes burns):___
potential energy, kinetic energy, and the energy of work.
When considering the effects of energy on the human body, it is important to remember that energy can be___
neither created nor destroyed: it can only be converted or transformed.
It is not the objective of this section to help you reconstruct the scene of a motor vehicle crash. Rather, you should have a sense of the effects of the event on the human body and understand, in a broad sense, how that event is related to potential and__.
kinetic energy
The product of mass, gravity, and height, which is converted into kinetic energy and results in injury, such as from a fall
Potential energy
The energy of a moving object
Kinetic energy
The measure of force over distance
Work
___is defined as force acting over a distance. For example, the force needed to bend metal multiplied by the distance over which the metal is bent is the work that crushes the front end of a vehicle that is involved in a frontal impact. Similarly, forces that bend, pull, or compress tissues beyond their inherent limits result in the work that causes injury.
Work
The energy of a moving object is called_____._____ reflects the relationship between the mass (weight)
of the object and the velocity (speed) at which it is traveling.
kinetic energy
Remember, energy cannot be created or destroyed, only converted. In the case of a motor vehicle crash, the____ of the speeding vehicle is converted into the work of stopping the vehicle, usually by crushing the vehicle’s exterior
kinetic energy
Similarly, the passengers of the vehicle have kinetic energy because they were traveling at the same speed as the vehicle. Their kinetic energy is converted to the work of bringing them to a stop. It is this work on the passengers that results in injury. Notice that, according to the equation for kinetic energy, the energy that is available to cause injury doubles when an object’s weight doubles but____ when its speed doubles. When a car’s speed increases from 50 to 70 mph, the energy that is available to cause injury nearly doubles.
quadruples
This point is even clearer when considering gunshot wounds. The speed of the bullet (high-velocity compared with low-velocity) has a greater impact on producing injury than the mass (size) of the bullet. Therefore, it is important to report to the hospital the type of firearm that was used in a shooting. The amount of ____that is converted to do work on the body dictates the severity of the injury. High-energy injuries often produce such severe damage that patients require immediate transport to an appropriate facility to have any hope of survival.
kinetic energy
_____is the product of mass (weight), force of gravity, and height and is mostly associated with the energy of falling objects. A worker on a scaffold has_____ because he or she is some height above the ground. If the worker falls,_______ is converted into kinetic energy. As the worker hits the ground, the kinetic energy is converted into work —that is, the work of bringing the body to a stop and thereby fracturing bones and damaging tissues.
Potential energy
____________states that objects at rest tend to stay at rest and objects in motion tend to stay in motion unless acted on by some force. The first part of the law is fairly clear. An object such as an empty soda can will not move spontaneously unless some force, such as a gust of wind, acts on it. An example will help to illustrate the second part. In a car traveling at 30 mph, the passengers and the car are moving at 30 mph. The passengers do not feel as though they are moving because they are not moving relative to the car.
However, when the car strikes a concrete barrier and comes to a sudden stop, the passengers continue to travel at 30 mph. They stay in motion until they are acted on by an external force most likely the windshield, steering wheel, or dashboard. To appreciate the severity of the impact, think of the driver as sitting motionless while a steering wheel rams into his or her chest at 30 mph. Now consider that the same thing happens to the driver’s internal organs. They also are in motion, traveling at 30 mph relative to the ground, until they are acted on by an external force, in this case the sternum, rib cage, or other body structure. This scenario illustrates the three collisions that are associated with blunt trauma.
Newton’s first law of motion
Traumatic injuries can be considered in two categories:___
blunt trauma and penetrating trauma.
___is the result of force (or energy transmission) to the body that causes injury without anything penetrating the soft tissues or internal organs and cavities.
Blunt trauma
_____results in injury by objects that pierce and penetrate the surface of the body and injure the underlying soft tissues, internal organs, and body cavities. Either type of trauma may occur from a variety of MOls. It is important to consider unseen as well as visible, obvious injuries with either type of trauma. Damage to the underlying deeper tissues is often more significant.
Penetrating trauma
____may not leave an external open wound, but it is important to remember the blunt forces involved in the traumatic event will transfer energy into internal organs, resulting in significant injury with no external signs.
Blunt force trauma
____results from an object making contact with the body. Any object, such as a baseball bat, can cause blunt trauma if it is moving fast enough. Motor vehicle crashes and falls are two of the most common MOls for blunt trauma. When providing care for your patient, be alert to signs of skin discoloration or reports of pain because these may be the only signs of blunt trauma. During assessment, maintain a high index of suspicion for hidden (internal) injuries in patients with blunt trauma.
Blunt trauma
Motor vehicle crashes are traditionally classified as____ The principal difference among these crash types is the direction of the force of impact; also, with spins and rollovers, there is the possibility of multiple impacts.
frontal (head-on), rear-end, lateral (T-bone), rollover, and rotational (spins).
Motor vehicle crashes typically consist of a series of three collisions.
Understanding the events that occur during each one of these three collisions will help you be alert for certain types of injury patterns.
The three collisions in a typical impact are as follows:
- The collision of the car against another car, a tree, or some other object. Damage to the car is perhaps the most dramatic part of the collision, but it does not directly affect patient care, except possibly to make extrication difficult (FIGURE 25-3).
However, it does provide information about the severity of the collision, and therefore has an indirect effect on patient care. The greater the damage to the car, the greater the energy that was involved and, therefore, the greater the potential to cause injury to the patient. - The collision of the passenger against the interior of the car. Just as the kinetic energy produced by the vehicle’s mass and velocity is converted into the work of bringing the vehicle to a stop, the kinetic energy produced by the passenger’s mass and velocity is converted into the work of stopping his or her body
- The collision of the passenger’s internal organs against the solid structures of the body. The injuries that occur during the third collision may not be as obvious as external injuries, but they are often the most life threatening. For example, as the passenger’s head hits the windshield, the brain continues to move forward until it comes to rest by striking the inside of the skull. This results in a compression injury (or bruising) to the anterior portion of the brain and a tension injury (stretching) of the posterior portion of the brain. This is an example of a coup-contrecoup brain injury
A brain injury that occurs when force us applied to the head and energy transmission through brain tissue causes injury in the opposite side of original impact
Coup-contrecoup brain injury
For example, as the passenger’s head hits the windshield, the brain continues to move forward until it comes to rest by striking the inside of the skull. This results in a compression injury (or bruising) to the anterior portion of the brain and a tension injury (stretching) of the posterior portion of the brain (FIGURE 25-5). This is an example of a coup-contrecoup brain injury.
(FIGURE 25-6). Similarly, traumatic aortic transection or rupture is associated with a sudden and rapid____ of the heart and the aorta within the thoracic cavity, which may rupture the aorta and cause fatal bleeding.
deceleration
Significant MOls are suggested by the following findings:
• Death of an occupant in the vehicle
• Severe deformity of the vehicle or intrusion into the vehicle
• Severe deformities of the frontal part of the vehicle, with or without intrusion into the passenger compartment
• Moderate intrusions from a lateral (T-bone) type of accident
• Severe damage from the rear
• Crashes in which rotation is involved (rollovers and spins)
• Ejection from the vehicle
Clearly, if one or more of the passengers are dead, you should suspect that the other passengers have sustained serious injuries, even if the injuries are not obvious. Therefore, focus on treating life-threatening injuries and providing rapid transport to a trauma center, because these passengers have likely___. Digital photos of the crash scene may provide valuable information to the staff and treating physicians at the trauma center; however, photos should be shown or transmitted only to appropriate personnel and should never be shared over social media. Photos containing patient images or other identifiable patient information may become part of the medical record or may need to be deleted after review by the receiving health care providers, depending on protected health information policies developed by the department privacy officer.
experienced the same amount of force that caused the death of the others
When properly applied, seat belts are successful in restraining the passengers in a vehicle and preventing a ____inside the motor vehicle. Seat belts may also decrease the severity of the third collision, that of the passenger’s organs with the chest or abdominal wall.
second collision
The protective abilities of seat belts are further enhanced by deployment of the__.___ provide the final capture point of the passengers and decrease the severity of deceleration injuries by allowing seat belts to be more compliant and by gently cushioning the occupant as the body slows, or decelerates.
Remember that___ decrease injury to the chest, face, and head very effectively. However, you should still suspect that other serious injuries to the extremities (resulting from the second collision) and to internal organs (resulting from the third collision) have occurred.
airbags
___have been standard equipment in most motor vehicles since 1999. These safety devices enhance the safety and survival of forward-facing occupants inside the vehicle during a crash. In an emergency braking event, or crash, the___ inflates very quickly. Because a rear-facing car seat is in proximity to the dashboard, rapid inflation of the___ could cause serious injury or death to an infant. All children who are shorter than 4 feet 9 inches (145 cm) should ride in the rear seat or, in the case of a pickup truck or other single-seated vehicle, the airbag should be turned off.
Airbags
The slowing of an object
Deceleration
When providing care to an occupant inside a motor vehicle, it is important to remember that if the airbag did not inflate during the accident, it may deploy during__. If this occurs, you may be seriously injured. Extreme caution must be used when extricating a patient in a vehicle with an airbag that has not deployed.
extrication
_____states that for every action, there is an equal and opposite reaction. Therefore, if you push on a door, the door pushes back (reacts) with an equal force but in the opposite direction. In the case of a dented A-pillar, the force of the driver’s head was sufficient to dent the strong metal. But in terms of patient assessment, the more important point is the reaction force of the pillar on the head. Newton’s third law states that the two forces are equal but occur in opposite directions. In other words, the head was essentially hit by an A-pillar traveling at 30 mph. Similarly, it takes a substantial force to collapse a steering wheel. When you notice a collapsed steering wheel during scene size-up, suspect serious chest injuries even if the driver initially has no visible signs of chest injury. Often, reading the scene and understanding the basic principles of energy transfer will give you as clear a picture of the patient s potential injuries and injury severity as the actual physical patient assessment.
Newton’s third law of motion
Different types of MOls will produce many types of injuries. Examples of nonsignificant injuries include injury to an isolated body part or a fall without the loss of consciousness. Examples of ____include injury to more than one body system (multisystem trauma), falls from heights, motor vehicle and motorcycle crashes, car versus pedestrian (or bicycle or motorcycle), gunshot wounds, and stabbings. Whether one or more body systems are involved, maintain a high index of suspicion for serious unseen injuries.
significant MOls
Trauma that affects more than one body system
Multisystem trauma
Seat belts may also cause unseen abdominal injuries, particularly in pediatric patients. Seat belts are designed to be worn over the ___of the pelvis to distribute the force over the bony surface. Hip dislocations may result if seat belts are worn too low.
Internal injuries can occur when the belt is worn too high, resulting in damage to abdominal organs (FIGURE 25-7). Lumbar spine fractures are also possible, particularly in children and older patients.
iliac crests
Longitudinal force applied to a structure
Traction
____decrease extension of the head and neck during a crash and, therefore, help reduce injury.
Other parts of the spine and the pelvis may also be at risk for injury.
Headrests
In addition, the patient may sustain an acceleration injury to the brain —that is, the____ collision of the brain within the skull.
third collision
Passengers in the backseat wearing only a lap belt might have a higher incidence of injuries to the thoracic and____.
lumbar spine
______impacts are known to cause whiplash injuries, particularly when the passenger’s head and/or neck is not restrained by an appropriately placed headrest (FIGURE 25-10). On impact, the passenger’s body and torso move forward. As the body is propelled forward, the head and neck are left behind because the head is relatively heavy, and they appear to be whipped back relative to the torso. As the vehicle comes to rest, the unrestrained passenger moves forward, striking the dashboard.
In this type of crash, the cervical spine and surrounding area may be injured. The cervical spine is less tolerant of damage when it is bent back.
Rear-end impacts
______(commonly called T-bone crashes) are a common cause of death associated with motor vehicle crashes. When a vehicle is struck from the side, it is typically struck above its center of gravity and begins to rock away from the side of the impact. This results in the passenger sustaining a lateral whiplash injury (FIGURE 25-11). The movement is to the side, and the passenger’s shoulders and head whip toward the intruding vehicle. This action may thrust the shoulder, thorax, and upper extremities, and, more important, the skull against the doorpost or the window. The cervical spine has little tolerance for lateral bending
Lateral or side impacts
If there is substantial intrusion into the passenger compartment, suspect your patient to have lateral chest and abdomen injuries on the side of the impact, as well as possible fractures of the lower extremities, pelvis, and ribs. In addition, the organs within the abdomen are at risk because of a possible third collision. According to the Journal of Safety Research,____ crashes cause approximately 25% of all severe injuries to the aorta and approximately 30% of all fatalities that occur in motor vehicle crashes.
lateral
Certain vehicles, such as large trucks and some sport utility vehicles, are more susceptible to rollover crashes because of their high center of gravity. Injury patterns that are commonly associated with rollover crashes differ, depending on whether the passenger was restrained or unrestrained. The most unpredictable types of injuries are caused by rollover crashes in which an unrestrained passenger may have sustained multiple strikes within the interior of the vehicle as it rolled one or more times. The most common life-threatening event in a rollover is ejection or partial ejection of the passenger|from the vehicle (FIGURE 25-12). Passengers who have been ejected may have struck the interior of the vehicle many times before ejection.
The passenger may also have struck several objects, such as trees, a guardrail, or the vehicle’s exterior, before landing.
Passengers who have been partially ejected may have struck both the interior and exterior of the vehicle and may have been sandwiched between the exterior of the vehicle and the environment as the vehicle rolled. Ejection and partial ejection are significant MOls; in these cases, prepare to care for life-threatening injuries
Rollover crashes
The most unpredictable types of injuries are caused by___ crashes in which an unrestrained passenger may have sustained multiple strikes within the interior of the vehicle as it rolled one or more times.
rollover
Even when restrained, passengers can sustain severe injuries during a____ crash, although the patterns of injury tend to be more predictable, and when the restraint system is properly used, ejection from the vehicle is less likely. A passenger on the outboard side of a vehicle that rolls over is at high risk for injury because of the centrifugal force (the patient is pinned against the door of the vehicle).____ crashes can also cause injury when the roof of the vehicle hits the ground during the rollover; a passenger who is restrained can still move far enough toward the roof to make contact and sustain a spinal cord injury. Therefore, rollover crashes are dangerous for both restrained and, to a greater degree, unrestrained passengers because these crashes provide multiple opportunities for second and third collisions.
rollover
Ambulances are vulnerable to rollover because of their
High center of gravity
____(spins) are conceptually similar to rollovers. The rotation of the vehicle as it spins provides opportunities for the vehicle to strike objects such as utility poles. For example, as a vehicle spins and strikes a pole, the passengers experience not only the rotational motion, but also a lateral impact.
Rotational crashes
___crashes often result in patients who have graphic and apparent injuries, such as broken bones; however, this type of crash can cause serious unseen injuries to underlying body systems. Therefore, you must maintain a high index of suspicion for unseen injuries. A thorough evaluation of the MOl is critical. First, estimate the speed of the vehicle that struck the patient; next, determine whether the patient was thrown, what surface the patient landed on, and at what distance or whether the patient was struck and pulled under the vehicle. Evaluate the vehicle that struck the patient for structural damage that might indicate contact points with the patient and alert you to potential injuries. Multisystem injuries are common after this type of event. If available, consider summoning advanced life support (ALS) backup for any patients who have or are thought to have sustained a significant MOl.
Car-versus-pedestrian
In a____ crash, evaluate the MOl in much the same manner as car-versus-pedestrian crashes. However, additional evaluation of damage to and the position of the bicycle is warranted. If the patient was wearing a helmet, inspect the helmet for damage and suspect potential injury to the head (FIGURE 25-13). Presume that the patient has sustained an injury to the spinal column, or spinal cord, until proven otherwise at the hospital. Initiate and maintain appropriate spinal motion restriction during the encounter. When practical, roll the patient on to his or her side to allow for an appropriate assessment of the posterior side of the body.
car-versus-bicycle
In a motorcycle crash, any structural protection afforded to the victim is not derived from a steel cage, as is the case in an automobile, but from protective devices worn by the rider-that is, helmet, leather or abrasion-resistant clothing, and boots.
Although helmets are designed to protect against impact forces to the head, they do not protect from cervical spinal injury.
Patients who have experienced a motorcycle crash should undergo cervical spine assessment and have a cervical collar placed if indicated. Leather and synthetic gear worn over the body was initially designed to protect professional riders in competition, where falls tend to be controlled and result in long sliding mechanisms on hard surfaces rather than multiple collisions against road objects and other vehicles. Leather clothing will mostly protect against road abrasion but offers no protection against blunt trauma from secondary impacts. In a street crash, collisions usually occur against other larger vehicles or stationary objects.
When assessing the scene of a motorcycle crash, look for deformity of the motorcycle, the side of most damage, the distance of skid in the road, the deformity of stationary objects or other vehicles, and the extent and location of deformity in the helmet. These findings can be helpful in estimating the extent of trauma sustained by a patient.
Car versus motorcycle
If possible, bring the helmet to the hospital for the trauma staff to see. The helmet will provide them with critical information about the type and extent of potential head injury.
Words of wisdom :)
There are four types of motorcycle impacts
Head-on crash
Angular crash
Ejection
Controlled crash
Type of motorcycle crash. The motorcycle strikes another object and stops its forward motion while the rider and parts of the motorcycle that are broken off continue their forward motion until stopped by an outside force, such as drag from the road or another opposing force from a secondary collision.
Head-on
Type of motorcycle crash. The motorcycle strikes an object or another vehicle at an angle so that the rider sustains direct crushing injuries to the lower extremity between the object and the motorcycle. This usually results in severe open and comminuted lower extremity injuries with severe neurovascular compromise, often resulting in traumatic amputation or otherwise requiring surgical amputation.
Angular crash
Type of motorcycle crash. The rider will travel at high speed until stopped by a stationary object, another vehicle, or road drag. Severe abrasion injuries (road rash) down to bone can occur with drag. An unpredictable combination of blunt injuries can occur from secondary collisions
Ejection
Type of motorcycle crash. A technique used to separate the rider from the body of the motorcycle and the object to be hit is referred to as laying the bike down. It was developed by motorcycle racers and adapted by street bikers as a means of achieving a controlled crash. As a crash approaches, the motorcycle is turned flat and tipped sideways at 90° to the direction of travel so that one leg is dropped to the grass or asphalt. This slows the occupant faster than the motorcycle, allowing the rider to become separated from the motorcycle. If properly protected with leather or synthetic abrasion-resistant gear, injuries should be limited to those sustained by rolling over the pavement and any secondary collision that may occur. When executed properly, this maneuver prevents the rider from being trapped between the bike and the object. However, a rider unable to clear the bike will continue into the vehicle, often with devastating results.
Controlled crash
The injury potential of a___ is related to the height from which the patient fell.___ are common MOls for blunt trauma. The greater the height of the fall, the greater the potential for injury.
falls
A fall from more than ____is considered significant.
The patient lands on the surface just as an unrestrained passenger smashes into the interior of a vehicle. The internal organs travel at the speed of the patient’s body before it hits the ground and stop by smashing into the interior of the body. Again, as in a motor vehicle crash, it is these internal injuries that are the least obvious during assessment but pose the gravest threat to life. Therefore, suspect internal injuries in a patient who has fallen from a significant height, just as you would in a patient who has been in a high-speed motor vehicle crash. Always consider syncope or other underlying medical causes of the fall.
20 feet (6 m)
Patients who fall and land on their feet may have less severe internal injuries because their legs may have absorbed much of the energy of the fall (FIGURE 25-14). However, as a result, they may have serious injuries to the lower extremities and pelvic and spinal injuries from energy that was transmitted through the legs. Patients who impact head first, as in diving accidents, will likely have serious head and/or spinal injuries. In either case, a fall from a significant height is a serious event with great injury potential, and the patient should be evaluated thoroughly. Take the following factors into account:
• The height of the fall
• The type of surface struck
• The part of the body that hit first, followed by the path of energy displacement
Many falls, especially those sustained by older patients, are not the result of high-energy trauma, even though broken bones may result. Older patients often have__, a condition in which the bones can fail under relatively low stress because they are structurally weakened. Because of this condition, an older patient can sustain a fracture as a result of a fall from a standing position. These cases do not constitute true high-energy trauma unless the patient fell from a significant height.
osteoporosis
A generalized bone disease, commonly associated with postmenopausal women, but that can occur in either sex, in which there is a reduction in the amount of bone mass, leading to fractures after minimal trauma
Osteoporosis
When your patient is a child, the following constitute a significant MOl:
___
Also note that young children are top-heavy, so they tend to land on their heads even from short falls. Triage children to a pediatric trauma center if possible.
- Falls of greater than 10 feet (3 m; or two to three times the height of the child)
- Medium- to high-speed vehicle crash (>25 mph)
____is the second leading cause of trauma death in the United States after blunt trauma. In 2017, the CDC reported over 38,000 deaths from firearms, which is just under the number of deaths related to motor vehicles. Low-energy penetrating trauma may be caused accidentally by impalement or intentionally by a knife, ice pick, or other weapon (FIGURE 25-15). Often, it is difficult to determine the entrance and exit wounds from a projectile in a prehospital setting. First, determine the number of penetrating injuries and then combine that information with the important things you already know about the potential pathway of penetrating projectiles to form an index of suspicion about unseen life-threatening injuries.
With low-energy penetrations, injuries are caused by the sharp edges of the object moving through the body and are, therefore, close to the object’s path. However, weapons such as knives may have been deliberately moved around internally, causing more damage than the external wound might suggest. Try to determine the length of the penetrating objact.
Penetrating trauma
Any object propelled by force, such as a bullet by a weapon
Projectile
Injuries from__, such as a stab wound, are caused by the sharp edges of the object moving through the body.
low-energy penetrations
In medium- and high-velocity (speed) penetrating trauma, the path of the projectile (usually a bullet) may not be as easy to predict. This is because the bullet may flatten out, tumble, or even ricochet within the body before exiting. The path the projectile takes is referred to as a____.
trajectory
Fragmentation, especially frangible bullets that are designed to disintegrate into tiny particles on impact, will____ damage as multiple fragments increase the likelihood of multiple organs/vessels sustaining injury. Full metal jacket bullets cause less damage than fragmented rounds because of their tendency to pass through the body’s tissues.
increase
The bullet’s speed is another factor in the resulting injury pattern; there is often additional damage caused by the object moving inside the body, but not along the suspected pathway. This phenomenon, called____, results from the rapid changes in tissue and fluid pressure that occur with the passage of the projectile, and it can result in serious injury to internal organs distant to the actual path of the bullet (FIGURE 25-16). Consequences of__ can be temporary or permanent. Temporary____ injury results from a stretching of the tissues that occurs with the pressure changes. Permanent____ injury results along the path where the projectile, such as a bullet, has passed through the tissue. Remain alert during assessment because patients will exhibit various signs and symptoms depending on the organ or organs affected
cavitation
A phenomenon in which speed causes a bullet to generate pressure waves, which cause damage distant from the bullets path
Cavitation
_____injury results from a stretching of the tissues that occurs with the pressure changes.
Temporary cavitation
___injury results along the path where the projectile, such as a bullet, has passed through the tissue.
Permanent cavitation
The relationship between distance and the severity of injury varies depending on the type of weapon involved, such as a rifle, pistol, or shotgun.____, often referred to as drag, slows the projectile, decreasing the depth of penetration and energy of the projectile and thus reducing damage to the tissues. Much like a boat moving through water, the bullet disrupts not only the tissues that are directly in its path but also those in its wake. Therefore, the area that is damaged by medium-and high-velocity projectiles is typically many times larger than the diameter of the projectile itself (FIGURE 25-17). This is one reason that exit wounds are often many times larger than entrance wounds.
Air resistance
As with motor vehicle crashes, the energy available for a bullet to cause damage is more a function of its speed than its mass (weight). If the mass of the bullet is doubled, the energy that is available to cause injury is doubled. If the velocity of the bullet is doubled, the energy that is available to cause injury is__. For this reason, it is important for you to try to determine the type of weapon that was used. Although it is not necessary (or always possible) for you to distinguish between medium- and high-velocity injuries, any information regarding the type of weapon that was used should be relayed to medical control.
quadrupled
Medium-velocity injuries may be caused by handguns and some rifles, whereas high-velocity injuries may be caused by a military weapon. Police at the scene may be a useful source of information regarding the caliber of weapon. Most civilian gunshot wound injuries in the United States are the result of low-velocity weapons.
An important factor for the seriousness of a gunshot wound is the type of tissue through which the projectile passes.
Tissue of high elasticity, such as muscle, is better able to tolerate stretch than tissue of__, such as the liver. In a gunshot wound, shotgun wadding, bits of clothing, skin, and hair driven into the wound can cause massive contamination, leading to increased potential for infection should the patient survive the initial trauma.
low elasticity
___. These injuries are due entirely to the blast itself; that is, damage to the body is caused by the pressure wave generated by the explosion. When the victim is close to the blast, the blast wave may cause disruption of major blood vessels and rupture of eardrums and major organs, including the lungs. Hollow organs are the most susceptible to the pressure wave. In some cases, pressure wave injuries can amputate limbs.
Primary blast injuries
___. Damage to the body results from being struck by flying debris, such as shrapnel from the device or from glass or splinters, which have been set in motion by the explosion. Objects are propelled by the force of the blast wave and strike the victim, causing injury. These objects can travel great distances and be propelled at tremendous speeds, up to almost 3,000 mph for conventional military explosives.
Secondary blast injuries
___. These injuries occur when the patient is hurled by the force of the explosion against a stationary object. A blast wind (sudden change in the surrounding atmosphere) creates a pressure wave. This can cause the patient’s body to be hurled or thrown, resulting in further injury. This physical displacement of the body is also referred to as ground shock when the body impacts the ground.
Tertiary blast injuries
____. This category of miscellaneous injuries includes burns from hot gases or fires started by the blast; respiratory injury from inhaling toxic gases; suffocation; poisoning; medical emergencies incurred as a result of the explosion; crush injuries from the collapse of buildings; contamination of wounds from environmental, chemical, or toxic substances; radiation injury from dirty bombs; and mental health emergencies. Essentially, all injuries due to the blast event that are not attributable directly to a primary, secondary, or tertiary mechanism are categorized as quaternary blast injuries.
Quaternary blast injuries
___(those that contain air), such as the middle ear, lung, and gastrointestinal tract, are most susceptible to pressure changes. The junction between tissues of different densities and exposed areas such as head and neck tissues are also susceptible to injury.
Hollow organs
The ear is the organ system that is most sensitive to blast injuries. The_____ evolved to detect minor changes in pressure and will rupture at pressures of 5 to 7 pounds per square inch above atmospheric pressure. Thus, the _____are a sensitive indicator that you can use to help determine the possible presence of other blast injuries. The patient may report ringing in the ears, pain in the ears, or some loss of hearing, and blood may be visible in the ear canal. Dislocation of structural components of the ear, such as the ossicles conforming the inner ear, may occur. Permanent hearing loss is possible. These findings can be used to assist in triaging patients as they indicate risk of pressure injuries to the lungs.
tympanic membrane
The eardrum; a thin, semitransparent membrane in the middle ear that transmits sound vibrations to the internal ear by means of auditory ossicles
Tympanic membrane
____are defined as pulmonary trauma (consisting of contusions and hemorrhages) that results from short-range exposure to the detonation of explosives. When the explosion occurs in an open space, both lungs are usually injured. Primary blast injury is often characterized by a lack of external visible injuries and thus can go unrecognized. The patient may report tightness or pain in the chest and may cough up blood and have tachypnea or other signs of respiratory distress. Subcutaneous emphysema (crackling under the skin) can be palpated over the chest, indicating air in the thorax.
Pneumothorax is a common injury and may require emergency decompression (which is covered in Chapter 30, Chest Injuries) in the field for your patient to survive. Pulmonary edema may ensue rapidly. If there is any reason to suspect lung injury in a blast victim (even just the presence of a ruptured eardrum), administer oxygen to maintain Saoz of 94% to 99%.
Avoid giving oxygen under positive pressure, however, because that may simply increase the damage to the lung or increase the size of a pneumothorax
Pulmonary blast injuries
One of the most concerning pulmonary blast injuries is___, which occurs on alveolar disruption with subsequent air embolization into the pulmonary vasculature. Even small air bubbles can enter a coronary artery and cause myocardial injury. Air embolisms to the cerebrovascular system can produce disturbances in vision, changes in behavior, changes in state of consciousness, and a variety of other neurologic signs.
arterial air embolism
Air bubbles in the arterial blood vessels
Arterial air embolism
Solid organs are relatively protected from shock wave injury but may be injured by secondary missiles or a hurled body.
___, however, may be injured by the same mechanisms that damage lung tissue. Skin injuries, ranging from petechiae, or pinpoint red-purple hemorrhages that show up on the skin, to large hematomas may be found. Perforation or rupture of the bowel and colon is a risk. Underwater explosions can result in severe abdominal injuries.
Hollow organs
The inability to remember events leading up to a head injury
Retrograde amnesia
_____injuries and head trauma are the most common causes of death from blast injuries related to terrorist incidents. Subarachnoid (beneath the arachnoid layer covering the brain) and subdural (beneath the outermost covering of the brain) hematomas are often seen. Permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism. Instant but transient unconsciousness, with or without retrograde amnesia, may be initiated not only by head trauma, but also by cardiovascular problems. Bradycardia and hypotension are common after an intense pressure wave from an explosion.
Neurologic
___injuries, including traumatic amputations, are common. Patients with traumatic amputation by postblast wind are likely to sustain fatal injuries secondary to the blast. In present-day combat, improved body armor has increased the number of survivors of blast injuries from shrapnel wounds to the torso. The number of severe orthopaedic and extremity injuries, however, has increased. In addition, whereas body armor may limit or prevent shrapnel from entering the body, it also catches more energy from the blast wave, possibly resulting in the victim being thrown backward, thus increasing the potential for spine and spinal cord injury.
Extremity
As with any EMS call, your main priority in managing____ is to ensure your safety and the safety of your crew and patient. Next, you must determine the need for additional personnel or equipment, evaluate the MOl, and identify and appropriately manage life threats. Once these steps have been completed, you can focus on patient care. Hemorrhage control has the highest priority. Severe bleeding from partial or complete amputations or other large wounds must be stopped. A tourniquet should be applied when bleeding from an extremity cannot be controlled using direct pressure (as discussed in Chapter 26, Bleeding). Assessing and managing the airway and breathing, including ventilatory support and high-flow oxygen, while maintaining appropriate spinal motion restriction is the second priority. Ensure that other shock therapy, such as keeping the patient warm, is completed. Initiate spinal motion restriction precautions as indicated.
multisystem trauma
_____is a term that describes a person who has been subjected to multiple traumatic injuries involving more than one body system, such as head and spinal trauma, chest and abdominal trauma, or chest and multiple extremity trauma. You must recognize patients who fit into this classification and provide rapid treatment and transportation, and alert medical control as to the nature of the patient’s injuries so that the trauma center is prepared prior to your arrival.
____patients have a high level of morbidity and mortality; therefore, they require teams of physicians to treat their injuries.
Multisystem trauma
If the patient is entrapped, consider the use of rapid extrication techniques. In most patients with_____, definitive care requires surgical intervention; therefore, on-scene time should be limited to 10 minutes or less, referred to as the platinum 10. During transport, obtain a SAMPLE history and complete a secondary assessment. Most care can be provided during transport. However, keep in mind that your patient has sustained___, and the order in which you usually provide treatment and care may need to be adjusted depending on the needs of the patient. For critically injured patients, consider ALS intercept and/or air medical transportation. Regardless of the mode of transport, ensure that the patient is transported to an appropriate facility and that the facility is notified as soon as possible. Specific standards of care regarding_____ are addressed in detail in the respective chapters.
multisystem trauma
Rapid transport decisions are needed for patients who have sustained significant trauma. If definitive care is not provided after the first____ from the time of injury, referred to as the Golden Hour, the body has increasing difficulty in compensating for shock and traumatic injuries. Because many injured patients require definitive care in less than 1 hour, this concept is also referred to as the golden period
60 minutes
When you are caring for a patient who has experienced a significant MOl and the patient is considered to be in serious or critical condition, you should___. With a patient who has experienced a nonsignificant MOl, focus on the chief complaint while assessing the patient as a whole. The human body is divided into areas (or systems) based on body function, and its internal organs are subject to unseen injuries when force is applied to the body. For example, the brain may have bruising, the heart and lungs may have bruising or unseen bleeding, and the organs of the abdomen may have life-threatening bleeding.
rapidly perform a physical examination
The brain lies well protected within the skull. However, when the head is injured from trauma, disability and unseen injury to the brain may occur. The brain itself may tear or become bruised, causing bleeding. The blood vessels around the brain may also tear and produce bleeding. Bleeding or swelling inside the skull from brain injury is often life threatening; therefore, your assessment must include conducting frequent neurologic examinations. Neurologic assessments, coupled with the patient’s_____, will often provide details on subtle changes in the patient’s condition. Some patients will not have obvious signs or symptoms, such as changes in pupillary size and reactivity, of unseen brain injury until minutes or hours after the injury has occurred
level of consciousness
The presence of air in the veins, which can lead to cardiac arrest if it enters the heart
Air embolism
The neck and throat contain many structures that are susceptible to injuries from trauma that could be serious or deadly to your patients. In this region of the human body, the trachea (or windpipe) may become torn or swell after an injury to the neck or deviate after an injury to the lungs. These types of injuries may result in an airway problem that could quickly become a serious life threat because they interfere with the patient’s ability to breathe; therefore, your assessment must include frequent physical examination looking for____ in the neck region. In addition, you should assess for jugular venous (vein) distention and tracheal deviation (late sign of injury).
DCAP-BTLS
DCAP-BTLS stands for
Deformities
Contusions
Abrasions
Punctures/penetrations
Burns
Tenderness
Lacerations
Swelling
The neck also contains large blood vessels that supply the brain with oxygen-rich blood. When a neck injury occurs, swelling may prevent blood flow to the brain and cause injury to the___, even though the brain may not have been directly affected by the initial force that caused the injury to the neck.
central nervous system
If a penetrating injury to the neck results in an open wound, the patient may have significant bleeding or air may be drawn into the circulatory system. If air enters the veins, this may result in___, which may lead to cardiac arrest if the air enters the heart. Occlusive dressings must be used to keep this from happening.
air embolism
A crushing injury to the upper part of the neck may cause the cartilages of the upper airway and larynx to fracture. This can lead to air leaking into the soft tissue of the neck. When air is trapped in subcutaneous tissue (________), it produces a crackling sound or feeling when palpated, called subcutaneous crepitation. Either air in the circulation or an airway cartilage fracture may cause rapid death.
subcutaneous emphysema
Some chest injuries result in air collecting between the lung tissue and the chest wall. As air accumulates in this space, the lung tissue becomes compressed, again interfering with the body’s ability to effectively exchange oxygen. This injury is called a___. If left untreated or unrecognized, the lung tissue becomes squeezed under pressure until the heart is also squeezed and can no longer pump blood. This condition is called a tension____ and is a life-threatening emergency. In some patients, bleeding develops in this portion of the chest. Instead of air collecting in this space, blood collects and causes interference with breathing. This condition is called a hemothorax, and it also poses a threat to the patient’s life.
pneumothorax
A penetration or perforation of the integrity of the chest is called an open chest wound. As air enters the chest cavity, the
natural pressure balance within the chest cavity is no longer equal. If left untreated, shock and/or death will result.
Regardless of the particular injury, it is imperative that you reassess a trauma patient’s chest region every 5 minutes. The assessment should include___, lung sounds, and chest rise and fall. Some patients will not have obvious signs or symptoms such as absent breath sounds or respiratory difficulty immediately.
DCAP-BTLS
The solid organs include the__
liver, spleen, pancreas, and kidneys.
The hollow organs include the__
stomach, large and small intestines, and urinary bladder.
When injuries from trauma occur in this region of the body, serious and life-threatening problems may occur. The___ organs may tear, lacerate, or fracture. This causes serious bleeding into the abdomen that can quickly cause death. Be alert for a trauma patient who reports abdominal pain—it may be a symptom of abdominal bleeding. Also be alert to vital signs that begin to worsen; this can be a sign of serious, unseen bleeding inside the abdominal region of the body.
solid
When the__ organs of the body have been injured, they may rupture and leak toxic chemicals used for digestion into
the abdomen. This not only causes pain, but a life-threatening infection also may eventually develop.
hollow
The abdomen also contains large blood vessels that supply the organs of this region and the lower extremities with oxygen-rich blood. Occasionally these vessels rupture or tear and cause serious unseen bleeding that may cause death.
Some patients, particularly healthy young adults, are able to compensate longer than others from blood loss; therefore, you should always maintain a high___ when the MOl suggests injury to the abdominal region. This is best accomplished by reassessing the abdominal region.
index of suspicion
Combine your assessment skills with critical thinking in order to provide the patient with excellent care. For example, remember that a multisystem trauma patient with associated traumatic brain injury (TBI) has twice the risk of death when compared with a trauma patient without associated TBI. Maintain a___ for all multisystem trauma patients, especially those with associated TBI.
high index of suspicion
Because survival of critically injured trauma patients is time dependent, limit on-scene time to the minimum amount necessary to correct life-threatening injuries and package the patient. Optimally, on-scene time for critically injured patients should be less than 10 minutes-the platinum 10. The following criteria will help you identify a critically injured patient:
• Dangerous MO!
• Decreased level of consciousness
• Any threats to airway, breathing, or circulation
Patients who present with these criteria or who are very young or old or have chronic illnesses should also be considered
to be high risk, thus requiring rapid treatment and transport.
Level ___ trauma center
A comprehensive regional resource that is a tertiary care facility; capable of providing total care for every aspect of injury-from prevention through rehabilitation
- 24-hour in-house coverage by general surgeons
- Availability of care in specialties such as orthopaedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, and critical care
- Should also include cardiac, hand, pediatric, and microvascular surgery and hemodialysis
- Provides leadership in prevention, public education, and continuing education of trauma team members
- Committed to continued improvement through a comprehensive quality assessment program and organized research to help direct new innovations in trauma care
Level 1 (I)
Level __ trauma center
Able to provide prompt assessment, resuscitation, and stabilization of injured patients and emergency operations
- 24-hour immediate coverage by emergency medicine physicians and prompt availability of general surgeons and anesthesiologists
- Program dedicated to continued improvement in trauma care through a comprehensive quality assessment program
- Has developed transfer agreements for patients requiring more comprehensive care at a Level I or Level Il trauma center
- Committed to continuing education of nursing and allied health personnel or the trauma team
- Must be involved with prevention and have an active outreach program for its referring communities
Level 3 (III)
Level ___ trauma center
Able to initiate definitive care for all injured patients
24-hour immediate coverage by general surgeons
2. Availability of orthopaedic surgery, neurosurgery,
anesthesiology, emergency medicine, radiology, and critical
care
3. Tertiary care needs such as cardiac surgery, hemodialysis, and microvascular surgery may be referred to a Level |
trauma center
4. Committed to trauma prevention and continuing education of
trauma team members
5. Provides continued improvement in trauma care through a comprehensive quality assessment program
Level 2 (II)
Level __ trauma center
Able to provide advanced trauma life support before transfer of patients to a higher level trauma center
- Includes basic emergency department facilities to implement
ATLS protocols and 24-hour laboratory coverage - Transfer to higher level trauma centers follows the guidelines outlined in formal transfer agreements
- Committed to continued improvement of these trauma care activities through a formal quality assessment program
- Involved in prevention, outreach, and education within its community
Level 4 (IV)
A ____facility is a regional resource center and generally serves large cities or heavily populated areas. Level _facilities must be capable of providing every aspect of trauma care from prevention through rehabilitation; therefore, the facility must have adequate personnel and resources. Because of the extensive requirements, most Level __ facilities are university-based teaching hospitals
Level I
A Level__ facility is typically located in less populated areas. Level___ centers are expected to provide initial definitive care, regardless of injury severity. These facilities can be academic institutions or a public/private community facility. Because of its location and resources, a Level ___trauma center may not be able to provide the same comprehensive care as a Level I trauma center.
Level II
Level___ facilities serve communities that do not have access to Level I or Il facilities. Level___ facilities provide assessment, resuscitation, emergency care, and stabilization. A Level___ facility must have transfer agreements with a Level I or Il trauma center and must have protocols in place to transfer patients whose needs exceed the resources of the facility.
Level III
Level___ facilities are typically found in remote outlying areas where no higher level of care is available. These facilities provide ATLS prior to transfer to a higher level trauma center. Such a facility may be a clinic urgent care facility, with or without a physician.
Level IV
___are categorized as either adult trauma centers or pediatric trauma centers, but not necessarily both.
Pediatric trauma centers are not nearly as common as adult trauma centers. When transporting a pediatric trauma patient, you must be certain to transport your patient to a pediatric trauma center if there is one in your area; do not make
Trauma centers
The____ is most commonly used for patients with head trauma because it is weighted to compensate for major head injury without multisystem injury or major physiologic changes.
The RTS is a physiologic scoring system that is also used to assess the severity of a trauma patient’s injuries. Objective data used to
calculate the RTS include the GCS score, systolic blood pressure (SBP), and respiratory rate (RR). In addition to assessing injury severity, the RTS has demonstrated reliability in predicting survival in patients with severe injuries. The highest RTS a patient can receive is 12; the lowest is 0. The RTS is calculated as shown in
Revised Trauma Score (RTS)
The___ calculates a number from 1 to 16, with 16 being the best possible score. It accounts for the Glasgow Coma Scale (GCS) score, respiratory rate, respiratory expansion, systolic blood pressure, and capillary refill. The GCS is an evaluation tool used to determine level of consciousness (TABLE 25-3). It evaluates and assigns point values (scores) for eye opening, verbal response, and motor response; these scores are then totaled and help to effectively predict patient outcomes. Note that the lower the score, the more severe the extent of brain injury.
trauma score
Signs of a pulmonary blast injury include
Coughing up blood
