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					Introduction to Trauma
Trauma
   Trauma is the leading cause of death in
    persons age 1 – 44.
   4th in relationship to all causes
   80% of teenage deaths are secondary to
    trauma.
   60% of childhood deaths are secondary to
    trauma.
   140,000 deaths annually. 11,000,000 are
    temporarily disabled every year, 450,000
    are permanently disabled.
   >40,000 deaths related to automobiles
Morbidity and Mortality
   Focus of EMS creation in 1960s
    – White Paper of 1966
   Survival largely (not entirely) dependent
    upon time to definitive care
    – “The Golden Hour”: Concept vs. Rule
   EMS role
    – Early recognition through assessment
    – Prevention of Secondary Injury
    – Rapid transport to appropriate facility
Trauma System Components
   Injury prevention      Interfacility
   Prehospital care        transportation
   Transportation         Trauma critical
   Trauma triage           care
    guidelines             Rehabilitation
   Emergency              Data collection/
    department care         trauma registry
                           Research
Trauma Systems
   Trauma centers
    – Levels
       • I, II, III and IV
    – Qualifications
       • Essential
       • Desired
    – Voluntary
      Designation
Trauma Transport Considerations
 Level of receiving facility needed
 Mode of transport
    – Ground transport
       • Appropriate facility reached within reasonable time
       • To a landing zone for air medical transport
    – Air medical transport
       • Indications
       • Contraindications
       • Procedure
Prevention
 Integral part
  of EMS
 Early
 Immediate
 Late
Mechanisms of Injury:
The Kinetics of Trauma
The Kinetics of Trauma
 Mass and Velocity.
  The amount of kinetic
  energy a moving body
  contains.
 Acceleration and
  Deceleration. The
  faster a change in
  speed, the greater the
  amount of force
  exerted.
Newton’s First Law of Motion
   A body at rest will
    remain at rest and
    a body in motion
    will remain in
    motion unless
    acted upon by
    some outside
    force
    Physics
 Energy cannot be
  created or
  destroyed, but can
  be changed in form.
 Energy may become
  a form of
  mechanical, thermal,
  electrical, or
  chemical energy.
Kinematics vs. Mechanism
Energy, Changing Forms
Kinetic Energy
   Energy in motion related to weight
    (mass) and speed (velocity).



     KE=M/2 x V2
Impacts
 Vehicle Collision-the vehicle
  suddenly stops.
 Body Collision-the patient comes to
  an abrupt stop against part(s) inside
  the vehicle.
 Organ Collision-the patient‟s internal
  organs come to an abrupt stop
  striking other body structures.
Vehicle Collisions
Vehicle Collisions
 The greater the speed of the
  collision, the greater the chance for
  life-threatening injury.
 Maintain a high index of suspicion
  for trauma:
    – With the death of another occupant in
      the passenger compartment.
    – Unresponsive patients
    – Patients with altered mental status
Deaths in MVC
Frontal Impact
 Frontal Impact Collision
 Driver continues to move forward at the
  same speed the vehicle is traveling.
 May proceed up and over the steering
  wheel, causing injuries to the head,
  neck, chest, and abdomen with possible
  ejection.
 May proceed down and under the
  steering wheel, causing injuries to the
  knees, femurs, hips, acetabulum, and
  spine.
Frontal Impact
Passenger Injuries
Up and Over
Down and Under
Rear-End Impact
Rear-End Impact
 Initial movement is backward,
  causing hyperextension of the neck.
 Followed by the forward movement
  of the head and torso causing
  hyperflexion of the neck, up-and-over
  or down-and-under injuries.
 Coup / Contrecoup head injuries
Coup / Contrecoup Injury
Hyperflexion / Hyperextension
Lateral (Side) Impact
Lateral Impact
   Results in injuries to the head
    and neck
   Chest and abdomen
   Spine
   Pelvis and femurs
Lateral Bending
Injuries to Side of Impact
Rotational or Rollover Impact
Rotational or Rollover Impact
 Many different points of impact.
 It is impossible to predict what
  injuries the patient will receive.
 Ejection from vehicles accounts for
  27% of the 125,000 trauma deaths
  that occur each year.
Motorcycle Accidents
Motorcycle Collisions
Motorcycle Collisions
 Head-on impacts are most often
  associated with the driver being thrown
  some distance from the motorcycle.
 Angular impact strikes an object at an
  angle causing injury to the lower
  extremities and lateral bending.
 Laying the bike down results in the driver
  sustaining abrasions to body from
  dragging the pavement or ground.
Bicycle Accidents
Bicycle Accidents
 Very similar injury patterns as
  motorcycle accidents
 Abdominal injuries (especially to the
  liver) from handlebars common.
 Young children often get fingers and
  toes in chains and spokes.
Vehicle vs. Pedestrian Accidents
Vehicle-Pedestrian Collisions
   The extent of injury depends on:
    – How fast the vehicle was traveling
    – Part of the patient‟s body that was
      struck
    – How far the patient was thrown, up-
      and-over or down-and-under (age
      dependent)
    – The surface the patient lands on
    – Body part that impacts first
Pedestrian Injuries
Vehicle-Pedestrian Collisions
   Common injuries in children
    – A combination of injuries to the femur,
      chest, abdomen, and head.
   Common injuries in adults
    – Fractures to the tibia and fibula
    – Injuries to the back, chest, abdomen, and
      head.
   Waddell‟s Triad: Femur/Pelvis,
    Abdomen/Chest, Head
Restraints
 Common cause of hidden injuries.
 Seat restraints should restrain the
  patient at one or two points low on
  the pelvis and the shoulder.
 Infants seats should face backward
  in the upright position with all infants
  and children restrained in the back
  seat.
Penetrating Injuries
   The amount of damage is
    determined by the amount
    of kinetic energy transferred
    to tissue and the area of the
    body it penetrates.
   Low-velocity penetrating
    injuries usually caused by a
    knife or impaling type
    injuries.
   Medium and high velocity
    injuries usually caused by
    firearms.
Low Velocity Penetrating Injuries
Medium and High Velocity
Penetrating Injuries
                        RECOIL TABLE
               Bullet          Charge   Muzzle     Gun      Recoil       Recoil     Recoil
Cartridge      Weight          Weight   Velocity   Weight   Impulse      Velocity   Energy
(HG =          (gr.)           (gr.)    (f.p.s.)   (lb.)    (lb.-sec.)   (f.p.s.)   (ft.-lb.)
handgun)

.22 Hornet     45              11.5     2690       7        .74          3.4        1.3


.223 Rem.      55              27       3240       7        1.27         5.8        3.7


.243 Win.      80              48       3350       8        2.04         8.2        8.4


.30-30 Win.    170             32       2200       7        2.23         10.2       11.4


.30-06         180             56       2700       8        3.15         12.7       20
.300 Wby. M    180             85       3245       9        4.10         14.7       30.1


.375 H&H M     300             76       2530       9        4.72         16.9       39.8


.45-70         405             30       1330       8        2.92         11.8       17.2
.458 Win. M    500             66       2040       9        5.70         20.4       58.1


.460 Wby. M    500             130      2700       10       8.3          26.7       110.8


.22 L.R. HG    40              1.1      800        .5       .16          10.3       0.8


.357 Mag. HG   158             16       1235       2.1      1.15         17.6       10.1



.44 Mag. HG    240             22.5     1180       3        1.66         17.8       14.7
Entrance and Exit Wounds
Path of Destruction
Cavitation
 Energy exchange produces particle
  motion
 Temporary cavity
    – Short lived
    – Produced by stretching
    – Dependent on the elasticity of the object
      involved
    – Produces particle compression at the limits of
      the cavity
   Permanent cavity
    – Visible when the energy exchange has been
      completed
    – Produced by compression and destruction
GSW


   The amount of damage depends on:
    – Trajectory, the path or movement of the
      projectile during travel.
    – Drag, factors that slow the projectile down.
    – Profile, impact point of the projectile.
    – Cavitation, pathway or cavity in the body
      tissues formed by the projectile.
    – Shotgun pellets increase the surface area
      impacted.
Blast Injuries and Explosions
Blast Injuries
Blast Injuries
   Primary Phase Injuries
    – Due to the pressure wave of the blast.
    – Primarily affects hollow organs.
   Secondary Phase Injuries
    – Due to flying debris from the blast.
   Tertiary Phase Injuries
    – Due to impact with immovable objects
      after being thrown away from the blast.
Falls
Falls
   Factors Contributing to Injury
    – Height of fall
    – Surface of the impact
    – Objects struck during the fall
    – Body part of first impact
      • Feet first
      • Head first
      • Parallel
Sports and Recreation
Sports Injuries
 Typically involve young, previously
  healthy individuals.
 Musculoskeletal injuries with injuries
  to joints being the most common.
 Mechanism of injury can lead to
  serious spinal cord and closed head
  injuries.
The Golden Hour


     (And   the Platinum Ten Minutes)
“The Golden Hour”
A severely injured
patient has the best
chance for survival
if surgical
intervention takes
place within one
hour from the time
of injury.
“Platinum 10 Minutes”
The maximum
amount of time out
of the „Golden
Hour‟ the EMS crew
should devote to
on-scene activities
for the severely
injured patient.
“High Index of Suspicion”
 Always maintain a high index of
 suspicion that the patient has severe
 injuries, if there is any indication that
 there is potential for those injuries to
 exist.
 Your suspicion is based on the
 mechanism of injury and the
 patient‟s chief complaint.
    Predicting Severe Injury
 Ejection from Vehicle
 Death of other occupant
 Falls > 10 feet
 Pedestrian (> 20 mph)
 High energy Transfer
   – Head on, T-bone
   – Significant Intrusion
 Motorcycle, ATV,
  Bicycle
 Prolonged
  Extrication/Transport
Predicting Severe Injury
   Co-Morbid Factors
    – Extremes of Age
    – Underlying Disease & Poor General
      Health
    – Pregnancy
    – Environmental Extremes
    – Protective Devices
    – TIME
Scene Size-Up (Special Tow)

 S-Senses. What do you see, smell, hear,
 taste, sense or feel?
 P-Protection. Do you need Law
 Enforcement or fire suppression?
 E-Extension. What can the situation lead
 to? What direction is the patient
 headed?
 C-Control. What is needed to control the
 scene? Patient? Crew? Other rescuers?
Special Tow continued
 I-In. Is there a way in? Consider
 doors, windows, stairs, corners, etc.
 A-Area. Consider the neighborhood,
 work area, lighting. Establish a „safe
 zone‟ if needed.
 L-Life Hazards. Carefully evaluate
 the scene for immediate threats to
 you, your crew, and your patient.
Special Tow continued
 T-Time. What time of day and how will it
 affect your response? What is your time
 on scene?
 O-Out. Have you got a way out? Is it
 available to your patient if necessary?
 W-Weather. Is the wind, temperature,
 humidity, or precipitation a factor? What
 effects will the weather have on the
 scene, the patient, your crew, other
 rescue personnel on scene?
Always remember the four human
components to every call:

         1. You
         2. Your partner
         3. Your patient
         4. The public you serve
Patient Management
   Primary Focus
                              – Organ Perfusion
    – Rapid Assessment
                                 • BP target >90
    – Airway Control
                                   mm Hg
       • Immediate and/or
                                 • Control internal
         Preventative
                                   & external
    – Ventilatory Ability          bleeding
       •  Inspired O2        – Prevent further
       • Adequate rate and      Spinal Injury
         TV                      • Immediate &
       • Correct mechanical        Continued
         obstacles            – Minimize
                                Secondary Injury
    Patient Management
   Therapies
    – Extrication              – Perfusion
    – SMR                         • Controllable
                                    Bleeding
    – Airway Control
                                  • IV Access
       • Suctioning               • Cautious fluids
       • Endotracheal             • PASG/MAST
         Intubation            – Minimize 2° injury
    – Ventilation              – RAPID TRANSPORT
       • Oxygen                  to Surgical Facility
       • BVM
       • Chest decompression
Summary
   Traumatic mechanisms constitute a
    significant portion of EMS responses
    – Most result in minor or no injury
    – Small percentage are severe or life-
      threatening injuries
 Paramedic‟s role lies in recognition
  and aggressive management of this
  small group
 Focus
    – preventing secondary injury
    – appropriate transport
Questions?

				
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