Chapter 6 Trauma injury

Duration: -----
Objectives
 Identify the most common causes of death from traumatic injury.
 Provide a summary of scene size-up components.
 Explain how scene size-up improves provider safety and prevents patient injury.
 Explain the link between kinetic injury and injury severity.
 Recognize three types of crashes in motor vehicle accidents and link probable patient
injuries to vehicle, interior, and body structural deformities.
 Explain how vehicle safety mechanisms influence injury patterns.
 Identify characteristics that predict the degree and type of fall-related injuries.
 Explain how bullets induce tissue harm and the correlation between bullet properties and
injury severity.
 Relate the five injury processes in explosion injuries to scene size-up and patient
evaluation.
 Explain prehospital trauma care priorities and their relationship to preventable causes of
death.
 Discuss how preventative actions can reduce the incidence of trauma-related injuries and
fatalities.

6.1 Introduction

Traumatic injuries in the prehospital setting are a critical aspect of emergency medical services
(EMS). Traumatic injuries refer to physical injuries of sudden onset and severity which require
immediate medical attention. These can include blunt trauma (e.g., car accidents, falls) and
penetrating trauma (e.g., gunshot wounds, stabbings).

6.2 Most Common Causes of Traumatic Death

 Road Traffic Injuries

  Homicide

 Suicide

 Falls

 Traumatic Brain Injury (TBI)

 Drowning

 Burns

6.3 Scene Size-up

Scene size-up is a crucial first step in managing traumatic injuries in the prehospital setting.
Scene size-up begins at dispatch, when you anticipate what you will find at the scene. It involves
a quick, systematic assessment to ensure the safety of both the responders and the patient, and to
gather essential information for effective care.

6.3.1 Scene Size-Up steps in Traumatic Incidents

I. Standard precaution (personal protective equipment)

Personal protection equipment (PPE) is required in a trauma scene. Wear protective gloves,
as well as eye and face protection, in every situation.

It is advisable for the emergency care professional in charge of airway management to wear a
face shield, eye protection, and mask.

In extremely contaminated environments, impermeable gowns with masks or face shields

may also be required.

In a hazardous workplace, chemical suits and gas masks may be required.

Change gloves between patients to prevent body fluid contamination.

II. Scene safety

 Position response vehicle away from hazards, but close enough to retrieve equipment
efficiently and in a direction to leave scene easily.
 Consider using vehicle as barrier to hazards (such as oncoming traffic) to create a safe
place to work.
 Windshield survey:-Look out windshield for hazards before leaving your response
vehicle.
 Look for threats to you as you approach:
 Threats to or from patient
 Threats to or from bystanders
 In Crash and rescue scenes is there a risk from fire or harmful substances? Is there a risk
of electrocution? Are there any unstable surfaces or structures that could collapse, such as
ice, water, slopes, or buildings Areas that may have low oxygen levels?
 In Hazmat incidents, placards on vehicles indicate hazardous materials. These placards
vary by country. If you see these signs, do not approach without proper protective gear
and training.
 On farms, avoid entering silos without proper equipment and training. Be cautious of
livestock, machinery, and manure dumps or ponds.
 At crime scenes, danger may still be present. Be cautious of fleeing or hiding individuals,
and those who are armed or threatening. Do not approach without law enforcement
present to ensure safety and preserve evidence.
 Bystanders can pose a danger. Look for loud, angry voices, fights, weapons, signs of
alcohol or drug use, domestic violence, or dangerous animals. Request law enforcement
if there’s any sign of violence.
 Explosions can result from industrial accidents or terrorist activities. Always consider the
possibility of a secondary device aimed at harming responders when approaching an
explosion scene.
 Safety measures during mass shooting or active shooter events should be considered.
 Figure ….Warning placards indicating presence of hazardous material.
III. Mechanism of Injury

In prehospital care, Mechanism of Injury (MOI) is crucial for assessing trauma patients. It
helps determine the potential severity of injuries and guides the approach to patient care. Here’s a
breakdown of the two types you mentioned:

Types of MOI

Generalized MOI

 Definition: Refers to injuries that occur due to a broad or widespread impact.

 Examples: Motor vehicle collisions, falls from significant heights, explosions.

Focused MOI

 Definition: Refers to injuries that are localized to a specific area of the body.

 Examples: A direct blow to the head, a stab wound to the abdomen, a gunshot wound to
the leg.
  Traumatic injuries are predictable
 Trauma is directly related to the laws of physics
 High-energy = risk of severe injury

Two major types of traumatic injury due to motion

1. Blunt trauma

High-Energy Mechanism of Injury (MOI)

 Newton’s First Law: A body in motion stays in motion unless acted upon by an
external force. This principle helps explain how energy transfer during trauma can
cause injuries.
 Energy Exchange: Motion is created by force, and when this force is suddenly
stopped, energy is transferred to the body, potentially causing tissue damage.

Blunt Trauma Injury Events

1. Machine Collision: The vehicle or object impacts another object, causing a sudden
stop.
2. Body Collision: The person inside the vehicle or object continues moving until they
collide with the interior of the vehicle or another object.
3. Organ Collision: Internal organs continue moving until they collide with the inside of
the body, potentially causing internal injuries.
 Motor Vehicle Collisions

Clues to Injury
 Deformity of the vehicle
 What forces were involved in collision?
 Deformity of the interior structures
 What did the patient hit?
 Deformity or injury patterns on patient
 What anatomic areas were hit?
 Mechanisms of Motion Injury and Potential Injury Patterns
Mechanism of injury Potential injury patterns
Frontal impact  Traumatic brain injury
 Cervical spine fracture
 Facial injuries
 Myocardial contusion
 Pneumothorax/hemothorax
 Aortic disruption
 Spleen or liver laceration
 Posterior hip dislocation
Lateral impact (T-bone)  Contralateral neck sprain
 Cervical spine fracture
 Pneumothorax
 Lung contusion
 Laceration of spleen, liver, kidney pelvic
fracture
 Extremity injuries on the side of impact
Rear impact  Cervical spine injury

Pedestrian versus car  Head injury

 Abdominal visceral injuries
 Fracture of the lower extremities and pelvis
Tractor accidents  Crush injury
 Thermal burns
Small-vehicle crashes (motorcycle, all-  Traumatic brain injury
terrain vehicle, personal watercraft,  Facial fractures
snowmobile)  Pneumothorax/hemothorax
 Extremity and pelvic fractures
 Spinal fractures
 Degloving injuries
 Clothesline injuries with airway compromise
 Rectal and vaginal trauma

 Falls
 Falls are the second leading cause of unintentional injury deaths worldwide, particularly
in children and older adults. The mechanism of injury for falls is vertical deceleration.
The type and severity of injuries sustained depend on the following four factors

 Distance of fall,
 Anatomic area impacted,
 Surface struck
 Patient age

Typical injuries include:

 Head trauma
 Axial loading or hyperextension/hyper flexion injury to the spine
 Extremity fractures
 Hip and/or pelvic injuries
 Vertical deceleration forces to the organs

NOTE:-The greater the height, the greater the potential for injury.

2. Penetrating trauma
Penetrating trauma occurs when an object pierces the skin and enters the body, creating an open
wound. This type of injury can be caused by various objects, such as bullets, knives, or shrapnel
from explosions. The severity of penetrating trauma depends on several factors, including the
type of object, its velocity, and the body part affected

Common Causes:

 Gunshot wounds: High-velocity projectiles can cause extensive internal damage.

Trauma related to gunshot wound depends on:
 The part of the body damaged
 The bullet velocity
 The bullet caliber
 Stab wounds: Typically involve knives or other sharp objects.
Knife wound severity
 Anatomic area penetrated
 Length of the blade
  Angle of penetration
 Explosive devices: Shrapnel can cause multiple penetrating injuries
3. Blast Injuries
Blast injuries are complex and can result from direct or indirect exposure to an explosion.
They are categorized into four main types, each with distinct mechanisms and effects.

Types of Blast Injuries:

1. Primary Blast Injuries

 Caused by the blast overpressure (shock waves) affecting gas-filled organs like the
lungs, ears, and gastrointestinal tract. These injuries can include pulmonary
barotrauma, tympanic membrane rupture, and mild traumatic brain injury
(concussion) without physical head injury.
2. Secondary Blast Injuries:
 Result from flying debris and bomb fragments propelled by the explosion. These can
cause penetrating injuries, lacerations, and blunt trauma.
3. Tertiary Blast Injuries
 Occur when the blast wind throws the body against solid objects, leading to blunt
force trauma, fractures, and traumatic amputations.
4. Quaternary Blast Injuries
 Include all other explosion-related injuries such as burns, inhalation of toxic gases,
and crush injuries.
5. Quinary Blast Injuries
 Result from post-detonation environmental contaminants, including chemical,
biological, and radiological substances. These can cause chemical burns, radiation
sickness, and infections.
 6.

Figure ---- Explosions can cause injury with the initial blast, when the victim is struck by debris,
or by the victim being thrown against the ground or fixed objects by the blast.

IV. Initiation triage

The primary goal of prehospital trauma care is to minimize injury and reduce preventable deaths.
This involves treating life-threatening conditions on scene, preventing further harm, and quickly
transporting the patient to a facility equipped to handle their injuries. Timely and organized
evaluation and treatment are crucial for saving lives.

Trauma Triage Decisions

Organized trauma systems improve survival rates. Emergency care providers face the challenge
of deciding which patients trauma center need care versus community-level hospital care. Over
triage can overload trauma centers; while under triage can worsen patient outcomes. Guidelines
developed by the CDC and the American College of Surgeons help in the triage process.

Step 1

The first step is to measure the vital signs and level of consciousness. This is done by determine
the systolic blood pressure, the respiratory rate, and the Glasgow Coma Scale.

The injured patient is taken to the highest level trauma center available if the answer to any of
the following questions is yes:
 The Glasgow Coma Scale is less than or equal to 13.
 The systolic blood pressure is less than 90 mm Hg.
 The respiratory rate is less than 10 or greater than 29 breaths per minute. The respiratory rate
is less than 20 in infant less than 1 year).
 The patient needs ventilator support
 If the answers to all of the above questions are no, then the EMT/paramedic proceeds to
Step2.

Step 2

The second step is to assess the anatomy of the injury.

The injured patient is taken to the highest level trauma center available if the answer is yes to any
of the following:

 All penetrating injuries to the head, neck, torso, and extremities proximal to elbow or knee.
 Chest wall instability or deformity (e.g., flail chest).
 Two or more long bone fractures.
 Crushed, degloved, mangled or pulseless extremities.
 Amputation proximal to wrist or ankle.
 Pelvic fractures.
 Open or depressed skull fractures.
 Paralysis.

If none of the above is present, then the EMT/paramedic proceeds to Step 3.

Step 3

The third step is to assess the mechanism of injury and evidence of high-energy impact.

The injured patient is taken to a trauma center (the level of the trauma center depends on trauma
system) if any of the following apply:

Falls

 Adults greater than 20 feet (one story equals ten feet).

  Children (age < 15 years) greater than 10 feet or two or three times the height of the
child.
 High-risk auto crash
 Intrusion, (5) including roof: > 12 inches occupant site; > 18 inches any site.
 Ejection (partial or complete) from automobile.
 Death in same passenger compartment.
 Vehicle telemetry data consistent with high risk of energy.
 Auto versus pedestrian/bicyclist, thrown, run over, or with significant (> 20 mph) impact.
 Motorcycle crash > 20 mph.

If none of the above applies, then the EMT/paramedic proceeds to Step 4.

Step 4

The fourth step is to assess for special patient or system considerations.

If any of the following apply, then “Transport to a trauma center or hospital capable of timely
and thorough evaluation and initial management of potentially serious injuries.”

 Older adults (age greater than age 55 years)

 Risk of injury/death increases after age 55 years.
 SBP < 110 might represent shock after age 65 years.
 Low impact mechanisms (e.g. ground level falls) might result in severe injury.
 Children should be triaged preferentially to pediatric capable trauma center.
 Anticoagulation and bleeding disorders
 Patients with head injury are at high risk for rapid deterioration.
 Burns
 Without other trauma mechanisms: triage to burn center.
 With trauma mechanism: triage to trauma center.
 Pregnancy > 20 weeks
When in doubt, transport to a trauma center

Figure: -- Guidelines for the Field Triage of Injured Patients—U.S. CDC 2011. (Source: Centers
for Disease Control and Prevention)
Prevention and Public Education
Recent perspectives view trauma as a disease with identifiable causes, prevention strategies, and
treatments. While managing trauma post-injury is crucial, prevention is more effective in
reducing injuries and fatalities. For instance, seat-belt campaigns have significantly decreased
motor vehicle crash (MVC) deaths.
6.-- Abdominal trauma
Abdominal injuries are challenging to evaluate, especially in the field. Hemorrhage from
intra-abdominal injuries is a major cause of preventable traumatic death, requiring
immediate recognition, intervention, and documentation.
Penetrating injuries often need urgent surgery, while blunt injuries, though more subtle,
can be equally deadly.
Abdominal injuries, whether blunt or penetrating, can cause life-threatening hemorrhage
and infection.
Immediate vigilance for signs of shock is crucial. While infection presents later and
requires prevention of contamination, hemorrhage needs prompt attention.
The role of emergency care providers has evolved, showing that timely interventions by
paramedics can improve outcomes. Rapid assessment, early shock treatment, and prompt
transport to definitive care are essential in managing abdominal trauma.

Types of Abdominal Injuries

 Blunt
 Most common: mortality 10–30%
 Mechanism
 Direct compression of abdomen
 Deceleration forces
 Accompanying injuries
 Head, chest, extremity: 70% MVC victims
 Evidence of injury
 Often no or minimal external evidence
 Significant blood volume concealed in regions
 Seat-belt sign: 25% intra-abdominal
 Pain or tenderness
 Often no pain or overshadowed by other pain
 Figure – blunt abdominal injury

 Penetrating
 Gunshots: mortality 5–15%
 Stabbings: mortality 1–2%
 Mechanism
 Direct trauma to organ and vasculature Projectile and fragments
 Energy transmitted function of mass and velocity of bullet
Caution
 Vigorous fluid resuscitation may do more harm
 Projectile pathway not always obvious
 Abdominal injury is chest; chest is abdominal
 Gluteal area in 50% of significant injuries
 Concern
 Intra-abdominal bleed with hemorrhagic shock
 Sepsis and/or peritonitis

Figure – penetrating abdominal trauma

Abdominal Assessment
 Primary Survey
 Scene Safety and Initial Assessment:
 Ensure the scene is safe.
 Perform a general impression of the patient.
 Check responsiveness and level of consciousness.
 Airway:
 Ensure the airway is open and clear.
 Use airway adjuncts if necessary.
 Breathing:
 Assess breathing rate, depth, and effort.
 Look for signs of respiratory distress or failure.
 Circulation:
 Check for a pulse.
 Assess skin color, temperature, and condition.
 Control any major bleeding.
 Disability:
 Perform a quick neurological assessment (AVPU: Alert, Verbal, Pain,
Unresponsive).
 Exposure:
Expose the patient to identify any hidden injuries.

Prevent hypothermia by covering the patient after the assessment.

 Abdominal Assessment
 Inspection:
Look for :-
 Deformities: Abnormal shapes or structures in the abdomen, indicating possible fractures
or internal damage.
 Contusions: Bruises caused by blunt force trauma, leading to bleeding under the skin.
 Abrasions: Scrapes or scratches on the skin, often caused by friction against a rough
surface.
 Punctures: Small, deep wounds caused by sharp objects penetrating the skin and
underlying tissues.
 Evisceration: The protrusion of internal organs, especially the intestines, through a
wound in the abdominal wall.
 Distention: Swelling or enlargement of the abdomen, often due to internal bleeding, gas,
or fluid accumulation.
 Note any signs such as:
 Cullen’s Sign: Periumbilical bruising indicating retroperitoneal hemorrhage.

 Grey-Turner’s Sign: Flank hematoma indicating retroperitoneal injuries.

 Seat-Belt Sign: Bruising across the abdomen indicating possible intra-

abdominal injury.
  Auscultation:
 Listen for bowel sounds to assess for peristalsis or absence of sounds, which may
indicate injury.
 Palpation:
 Lightly palpate the abdomen to check for tenderness or rigidity.
 Deeply palpate all four quadrants to assess for tenderness, distention, or guarding.
 Note any referred pain, such as:
 Kehr’s Sign: Left posterior shoulder pain indicating splenic injury.

 Right Posterior Shoulder Pain: Possible liver injury.

Management of abdominal injury in pre hospital setting

 If you suspect abdominal injury, give IV FLUIDS
 Do not give food or drink
 IF bleeding occur manage bleeding
 If shock occur manage the shock (see shock page--)
 Urgent transfer to the receiving hospital
 Special Situations
 Evisceration
 Do not push viscera back into abdomen
 Gently cover with moistened gauze
 If extended transport time; apply non-adherent material
Figure ---Evisceration dressing
 Impaled object
 Do not remove can cause Uncontrollable hemorrhage
 Gently stabilize object
 Avoid movement

 Pelvic fracture
 Pelvic binder should be placed (see figure---)
 Stabilizes pelvis
 Decreases pelvic volume
Head trauma