PCTH I - SMR & Soft Tissue Injuries

Question 1

Provide three reasons why full immobilization for any trauma was revised in the BLS to be applicable to only some patients.

Answer 1

1) paraplegics/quadraplegics likely sustained this injury from their index incident anyways
2) wasting precious time doing immobilization may end up increasing risk of death, especially in penetrating trauma patients
3) potentially adding injury to non-injury (i.e. creation of back pain, pressure sores)

Question 2

Which of the following is not a purpose as to why paramedics hold c-spine?

1) prevent further injury
2) support patient’s head
3) make attempts to maintain spine in anatomical alignment
4) minimize gross movement

Answer 2

1) prevent further injury (studies have shown that paraplegics/quads have likely sustained these injuries from the index incident itself, so us doing things isn’t going to really make it worse - it’s already damaged)

Question 3

What are the 9 conditions/mechanisms that a paramedic shall consider for any patient with a potential spinal/spinal-cord injury, as per SMR standards?

Answer 3

1) any trauma associated with complaints of neck/back pain
2) sport accidents (impaction, falls)
3) diving accidents and submersion injuries
4) explosions, other types of forcefull acceleration/deceleration injuries
5) falls (eg stairs)
6) pedestrians struck
7) electrocution
8) lightning strikes
9) penetrating tauma to head/neck/torso

Question 4

If a patient meets the criteria for any of the mechanisms of injury listed as per SMR standards, what is a paramedic’s next steps?

Answer 4

Determine if the patient exhibits ANY risk criteria

Question 5

What are the 9 risk criteria when determining if a patient requires SMR?

Answer 5

1) neck or back pain
2) spine tenderness
3) neurological signs and symptoms
4) altered LOC
5) suspected drug/EtOH intoxication
6) a distracting painful injury
7) anatomical deformity of the spine
8) high-energy mechanism of injury
9) age 65+ including falls from standing height

Question 6

As per SMR standard, if patient meets mechanism and risk criteria, how is the paramedic providing SMR?

Answer 6

1) cervical collar ONLY (no spinal boards)
2) attempt to minimize spinal movement
3) secure patient to stretcher with stretcher straps

Question 7

When assessing risk criteria, specifically neurological signs and symptoms, what is a paramedic looking for? (5 things)

Answer 7

1) weakness
2) lack of coordination
3) paralysis (any part of body)
4) paresthesia
5) priapism

Question 8

List 6 conditions that are considered high-energy mechanisms of injury.

Answer 8

1) fall from elevation greater than 3 ft/5 stairs
2) axial load to the head
3) high speed MVCs (100+ km/hr speed), rollover, ejection
4) hit by bus or large truck
5) motorized/ATV recreational vehicles collision
6) bicyclist struck or collision

Question 9

If patient has penetrating trauma to the head/neck/torso, what is the paramedic looking for to determine if patient will receive SMR (6)?

Answer 9

ANY of the following (just need at least one S/S):

1) spine tenderness
2) neurological S/S
3) altered LOC
4) evidence of drug/EtOH intoxication
5) distracting painful injury
6) anatomical deformity of the spine

Question 10

True or false: always document neurological status before and after SMR on the ACR.

Answer 10

True

Question 11

Spinal boards and adjustable break-away stretchers (i.e. scoop) should be considered primarily as what type of device?

Answer 11

extrication/patient lifting device (NOT FOR IMMOBILIZATION)

Question 12

Briefly describe guidelines for use of spinal boards (5 points).

Answer 12

1) spinal boards/scoops to be primarily for extrication/lifting patients
2) goal is to remove them from said devices as soon as it is safe to do so
3) log roll patient to stretcher during loading or aftering loading into ambulance (with sufficient people to do so safely)
4) devices can remain in place if safer/more comfortable (and considering transport times of less than 30 minutes)
5) always use scoop for suspected pelvic fractures (don’t know why BLS would include spinal boards that’s wild)

Question 13

Patients with SMR may be placed in ______ or ______ positions (based on patient comfort/clinical condition.

Answer 13

semi-sitting; supine

Question 14

Patient is intoxicated and uncooperative. It is appropriate for the paramedic to just apply c-spine manual immobilization until appropriate SMR has been applied.

Answer 14

True

Question 15

When is a patient allowed to self-extricate in an MVC? What is the proper steps for self-extrication?

Answer 15

if patient remains in a vehicle and ONLY has isolated neck/back pain, no neurological S/S or indications of major trauma

• patient uses stand, turn, and pivot to stretcher for self-extrication (and paramedic should coach patient to maintain neutral spinal alignment)

Question 16

You arrive on scene to a pool, and a lifeguard indicates to you that the staff have already placed the patient on a spinal board as per their protocol. What is the next appropriate steps for you as a paramedic, as per the BLS?

Answer 16

Still assess for SMR as per Standard, and SMR may be modified to meet this standard if required.

Question 17

What are the SMR standards for patient undergoing inter-facility transfers?

Answer 17

SMR may be modified as per Standard in consultation with sending physician (ex. this may involve removal of a spinal board, if appropriate)

Question 18

What are some considerations for SMR with agitated patients?

Answer 18

• there may be circumstances where applying SMR increases agitation of patient (leading to safety hazard to paramedic or patient)
• apply SMR to the best of your ability and secure patient to stretcher with stretcher straps
• document your ass off (the circumstances of the hazard, resulting inability to apply SMR)

Question 19

True or false. ABCs takes priority over SMR.

Answer 19

ALWAYS TRUE

Question 20

What is the protocol for neck/back injuries, as per Blunt/Penetrating Injury Standard (5 points)?

Answer 20

1) if patient has penetrating neck injury, assume vascular and airway lacerations/tears
2) auscultate lungs for decreased air entry and adventitious sounds
3) observe for: diaphragmatic breathing, neuro deficits, priapism, urinary/fecal incontinence or retention
4) do a secondary (minimum) to assess S/S (covered in another flashcard)
5) if patient has penetrating wound: assess for entry/exit wounds, apply pressure lateral to airway (not directly over it), and apply occlusive dressings to wounds not circumferential bandaging

Question 21

When performining a secondary survey on a neck/back injury patient, what specifically will a paramedic be assessing as per the Blunt/Penetrating Injury Standard (4)?

Answer 21

1) for airway and/or vascular penetration (eg. frothy/foamy hemoptysis - aka coughing up blood)
2) lungs (for decreased air entry and adventitious sounds)
3) head/neck for JVD and tracheal deviation
4) chest, for subQ emphysema

Question 22

Provide 5 examples of categories of open wounds?

Answer 22

1) avulsions
2) lacertaions
3) abrasions
4) penetrations/punctures
5) amputations

Question 23

Define abrasion

Answer 23

an area damaged by scraping or wearing away

Question 24

What are 3 common characteristics of abrasion injuries?

Answer 24

• injuries are no deeper than epidermis (only superficial damage to skin)
• minimal bleeding (usually oozing)
• typically no scarring

Question 25

Define laceration

Answer 25

a deep cut or tear in skin or flesh

Question 26

What are two characteristic features of lacerations?

Answer 26

• often irregular/jagged

- often contaminated with bacteria/debris from whatever caused the damage

Question 27

Define puncture/penetration

Answer 27

wound caused by penetration of the skin (often by small, pointed objects)

Question 28

True or false. If punctures or penetrations were left untreated, they can lead to infection

Answer 28

True

Question 29

Define avulsion

Answer 29

the act of pulling or tearing away

Question 30

Describe the following characteristics of avulsions:

• cause
• severity of bleeding
• severity of tissue damage

Answer 30

• cause: usually blunt force trauma
• severity of bleeding: moderate to severe due to force involved
• severity of tissue damage: deeper tissues, usually has skin flap attached

Question 31

Define amputation

Answer 31

an open injury caused by the cutting/tearing away of a limb, body part, or organ

Question 32

True or false: find the amputated part before you transport

Answer 32

FALSE - NEVER delay transport looking for amputated part

Question 33

True or false: bleeding can typically be controlled with direct pressure to the stump in amputation injuries

Answer 33

True

Question 34

What are two assessments that a paramedic would complete on a soft tissue injury?

Answer 34

• 5P’s

- bleeding assessment

Question 35

What are the 5 factors to consider when assessing bleeding of a soft tissue injury?

Answer 35

1) location and size
2) colour of blood (bright red vs dark)
3) controlled vs uncontrolled
4) clotting/medication hx
5) amount of blood loss (estimated)

Question 36

As per the Soft Tissue Injuries Standard, what are the 9 steps in which a paramedic shall follow? long answer ahead

Answer 36

1) consider underlying injuries to deep structures (nerves, vessels, bones)
2) control hemorrhaging
3) attempt removal of large surface contaminants but leave embedded object in place
4) irrigate injury surface with saline/sterile water if patient is stable
5) manually stabilize any impaled object (log cabin) if not done so already
6) cover any protruding organs/tissues with non-adherent materials (eg. moist, sterile dressing or plastic wrap)
7) dress and bandage open wounds prior to splinting
8) if dressing digits, dress them individually and leave tips of fingers/toes uncovered to allow observation of neurovascular status (5Ps) unless otherwise indicated in standards
9) re-ax and monitor distal neurovascular status (5Ps) after treatment (dressing, bandaging, splinting); loosen if needed to restore 5Ps (if you did it too tight)

Question 37

What are the standards for controlling hemorrhaging of a wound located on an extremity, as per the Soft Tissue Injuries Standard?

Answer 37

1) apply well-aimed, direct digital pressure at bleeding site
2) apply tourniquet (if 1st tourniquet fails, add another one)
3) if 2nd one fails too or if for any reason you can’t use a tourniquet, pack wound with hemostatic dressing (and if unavailable or contraindicated, then use standard gauze, maintain pressure, secure with pressure dressing)

Question 38

What are the standards for controlling hemorrhaging of a wound located on a junctional location, as per the Soft Tissue Injuries Standard?

Answer 38

1) apply well-aimed, direct digital pressure at bleeding site
2) pack wound with hemostatic dressing (if appropriate and available), or standard gauze (if hemostatic dressing contraindicated/unavailable) and maintain pressure and secure with pressure dressing

Question 39

What are junctional locations on the body?

Answer 39

transition areas between torso and extremities: head, neck, shoulders, armpits, pelvis, groin

Question 40

What are the standards for controlling hemorrhaging of a wound located in hollow spaces of skull, chest, or abdomen, as per the Soft Tissue Injuries Standard?

Answer 40

1) apply manual pressure with flat palm and hemostatic dressing (topical) where available and appropriate OR standard gauze if cannot use hemostatic dressing
2) do not pack dressing of any kind into hollow spaces of skull, chest, abdomen
3) DO NOT insert fingers into hollow space of skull, chest, abdomen

Question 41

What are the guidelines for applying well-aimed direct pressure on a wound to control hemorrhaging (5 steps)?

Answer 41

1) exposure wound cavity
2) visualize source of bleeding
3) clear away blood/debris to better visualize
4) be FIRM and AGGRESSIVE (lol) in applying pressure (may destroy some surrounding tissue)
5) apply pressure as accurately, directly, firmly and within as small a surface area as possible

Question 42

What are the guidelines for applying a tourniquet (6 steps/considerations)?

Answer 42

1) consider more vs. less effective locations to place a tourniquet (good on thighs/arms; not great on joints and twinned long bones)
2) once applied, do not remove in pre-hospital setting
3) document time of tourniquet application and communicate this to facility
4) for MCI, document time of tourniquet application on tourniquet AND patient
5) do not cover tourniquet once in place
6) if one tourniquet fails, apply another one. If that one fails, immediately use pressure and hemostatic dressings

Question 43

What are the guidelines for applying a hemostatic dressing on a wound to control hemorrhaging?

Answer 43

1) maintain pressure on bleeding site continuously while packing junctional or extremity wounds
2) ensure wound cavity is completely filled with densely packed dressing material
rmb: DO NOT remove dressings, once wound is packed, and do not apply subsequent dressings on top

Question 44

What is the function of hemostatic dressings?

Answer 44

they advance coagulation by rapidly absorbing fluid which results in an accumulation and concentration of cellular blood components and coagulation factors at wound site

Question 45

When would you remove an impaled object (2 circumstances)?

Answer 45

1) when it’s compromising airway

2) if it’s interfering with CPR in a cardiac arrest patient even after attempts to change hand position

Question 46

If patient has a partial amputation/avulsion, what is to be assessed prior to any treatment, as per Amputation/Avulsion standard?

Answer 46

1) consider potential life/limb function threats, such as : hemorrhagic shock, loss of limb, and loss of function
2) CSM at injury site, and assess pulse and CSM distal to injury

Question 47

If patient has an amputation/avulsion, what is the standards for treatment at injury site, as per Amputation/Avulsion standard (6 steps)?

Answer 47

1) control bleed (as per Soft Tissue Injury Standard)
2) irrigate - cleanse wound of gross surface contamination
3) if partial amp/avulsion, place remaining tissue/skin bridge in near-normal anatomical position as possible
4) if compete amp, cover stump with moist, sterile pressure dressing and then a dry dressing
5) immobilize affected extremity
6) elevate if able to

Question 48

If patient has an amputation/avulsion, what are the standards for treatment of amputated/avulsed part, as per Amputation/Avulsion standard?

Answer 48

1) if located prior to transport: preserve all amputated tissue, irrigate if contaminated, wrap exposure end with moist sterile dressing and place in container and then in cold water
2) if cannot locate, engage with allied agencies or bystanders to locate it and bring it to facility; DO NOT DELAY TRANSPORT

Question 49

Define dislocation

Answer 49

injury or disability caused when normal position of a joint or other part of body is disturbed

Question 50

most common places for dislocations are:

Answer 50

shoulders, fingers

Question 51

Define fracture

Answer 51

the cracking or breaking of a hard object or material

Question 52

Assessment of dislocations/fractures (extremity injuries) involves what?

Answer 52

• 5P’s
• bleeding assessment (location/size, colour, controlled vs. uncontrolled, clotting/med hx, blood loss)
• gathering hx

Question 53

If multiple fractures are present, what are the splinting priorities?

Answer 53

1) spine (neck, thoraco-lumbar, head)
2) pelvis
3) femur
4) lower legs
5) upper extremity

Question 54

List the 8 steps to follow regarding splinting extremity injuries, as per Extremity Injury Standard.

Answer 54

1) assess distal CSM before and after splinting (5 P’s)
2) splint joint injuries as found
3) if distal pulse is abense or fracture is severly angulated, apply gentle traction (splint as found if lots of resistance or severe pain when traction is applied)
4) if open/closed femur fractures, splint with traction splint unless limb is partially amputated (i.e. sager)
5) if extremity injury affects a joint, immobilize above and below injury site
6) if adequate circulation/sensation is absent after splinting and re-manipulation is possible, gently re-manipulate to restore neurovascular status
7) elevate if possible and practical
8) ice pack

Question 55

According to Extremity Injury Standard, what shall a paramedic do in the case of open fractures (2 steps)?

Answer 55

1) irrigate with saline or sterile water if gross contamination
2) cover ends with moist, sterile dressing and/or padding

Question 56

In situations involving a patient with an extremity injury, the paramedic shall: 3 steps

Answer 56

1) splint injured extremities
2) consider open fractures and tx for such
3) re-ax distal neurovascular status in the affected extremity every ~10 minutes if status was compromised on initial ax

Question 57

What can a paramedic while attending an extremity injury call do if splints are too big for children?

Answer 57

• can splint body parts together (arm to trunk, leg to leg) and pad in-between
• for fractured femur/tibia: stabilize by securing it to uninjured leg prior to transfer to a spinal board/scoop; and if log-rolling, roll to uninjured side if possible