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?