international trauma life support for emergency care providers chapter seventh edition scene size-up...

International Trauma Life Supportfor Emergency Care Providers

CHAPTER

seventh edition

Scene Size-up

1

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Scene Size-up

© Jack Degley Photography

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Overview

• Steps of Scene Size-up• Two basic mechanisms of motion injury• Three collisions associated with MVCs• Common forms of MVCs• Potential injuries associated with restraint

systems

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Overview

• Assessment criteria and anticipated injuries from falls

• Two most common forms of penetrating injury

• Blast injury factors related to assessment

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Trauma Care

• Teamwork is important! • You must know:

– What you can handle and what you can't– What you should handle and what you

shouldn't– When to stay and when to leave– Fastest route there and fastest route away– What to do, what not to do, and when to wait

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Scene Size-up

• A critical part of trauma assessment • Anticipate what you will find at scene• Anticipate equipment and resource needs• Form a plan of approach• Be prepared to modify that plan• Failure to size-up can jeopardize lives

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Scene Size-up

• First step in ITLS Primary Survey

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Scene Size-up

1. Standard precautions

2. Scene safety

3. Initial triage (total number of patients)

4. Need for more help or equipment

5. Mechanism of injury

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Standard Precautions

• Exposure to blood or OPIM very likely at a trauma scene

• Appropriate PPE must be worn– Covered in more detail in Chapter 22

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Scene Safety

• Ambulance positioning– Safe place to park– Facing away from scene

• Windshield survey– Threats to you– Threats to/from patient– Threats to/from bystanders

Courtesy of Bonnie Meneely, EMT-P

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Initial Triage

• Total number of patients– Call for backup– Medical command– Initiate MCI protocols– Any more patients?

Courtesy of Bonnie Meneely, EMT-P

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Need for More

• Essential equipment– Carry to scene for time efficiency– Change gloves between patients

• Additional resources – Call early– Relay where to respond and any dangers

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Mechanism of Injury

• Energy follows physics laws.– Injuries present in predictable patterns

• High-energy at risk of severe injury.– Consider injured until proven otherwise

• Type of MOI– Generalized– Focused

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Basic Motion Mechanisms

• Blunt injuries– Rapid forward

deceleration– Rapid vertical

deceleration– Blunt instrument

energy transfer

• Penetrating injuries– Projectiles– Knives– Falls upon objects

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Motor-Vehicle Collisions

Each collision is three collisions:

Machine Collision1 Body

Collision2 Organ Collision3

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Other Collisions

• Secondary collisions– Objects are missiles – Additional impacts– Vehicle collides with

another object– Other vehicles collide

with original vehicle

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Clues to Injury

• Deformity of vehicle– What forces were involved in collision?

• Deformity of interior structures– What did patient hit?

• Deformity or injury patterns on patient– What anatomic areas were hit?

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Common Collisions

• Common types– Frontal-impact– Lateral-impact– Rear-impact– Rollover– Rotational

(© Jack Dagley Photography)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Frontal-Impact Collision

• Windshield injuries– Brain, soft-tissue injury,

cervical spine

• Steering wheel injuries– Traumatic tattooing of skin

• Dashboard injuries– Face, brain, cervical spine,

pelvis, hip, knee

(Courtesy of Maria Dryfhout, Shutterstock )

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Lateral-Impact Collision

• Similar to frontal-impactwith lateral energy – Not easily predicted– Consider organ damage

• Check impact side– Head, neck, upper arm,

shoulder, thorax, abdomen, pelvis, legs

(Photo courtesy of Anthony Cellitti, NREMT-P)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Rear-Impact Collision

• Posterior displacement– Rapid forward

deceleration also possible

• Headrest position– Hyperextension injuries

• Damage back and front– Deceleration injuries

(Courtesy of Bonnie Meneely, EMT-P)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Rollover Collision

• Multiple impacts– Multiple directions– Multiple injuries

• Axial-loading injuries– Spine injury

• Ejection– Chance of death

increases 25 times

Courtesy of Bonnie Meneely, EMT-P

(Courtesy of Bonnie Meneely, EMT-P)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Rotational Collision

• Head-on, lateral-impact combination– Converts forward motion

to spinning motion

• Windshield, dashboard, steering wheel, side– Same possible injuries

of both mechanisms

© Dedyukhin Dmitry / Shutterstock.com

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Occupant Restraint

• Lap belt– Clasp knife effect– Abdomen– Lumbar spine

• Three-point restraint– Cervical spine– Clavicular fracture

• Air bags– First impact only– Always “lift and look”– Lumbar spine

(Courtesy of Olivier Le Queinec, Shutterstock.com)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Tractor Accidents

• 50% of farm fatalities– Side overturns 85%

Likely to throw clear

– Rear overturns 15% Likely to entrap or crush

• Common injuries– Crush injuries– Thermal or chemical burns

Courtesy of Roy Alson, MD

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Small-Vehicle Crashes

• Small vehicles– Motorcycles– All-terrain vehicles– Personal watercraft– Snowmobiles

• Factors– Protective gear– Additional impacts

© Orientaly / Shutterstock.com

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Pedestrian Injuries

• Mechanism– Primary collision– Additional impacts

• Common injuries– Internal injuries and

fractures Adult: bilateral leg, knee Children: pelvis, torso Courtesy of Bonnie Meneely, EMT-P

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Falls

• Vertical deceleration– Distance of fall– Anatomy impact– Surface struck

© Pearson

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Penetrating Injuries

• Knife-wound severity– Anatomic area penetrated

Fourth intercostal space may be chest and abdomen

– Length of blade– Angle of penetration

• Stabilize impaled object– Minimize external

movement

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Penetrating Injuries

• Firearms– Type of weapon

Low-velocity High-velocity

– Caliber Missile size Bullet construction Tumbling/yaw

– Distance traveled

Courtesy of Roy Alson, MD

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Penetrating Wounds

• Entry wound– Smaller– May be darkened, burned

• Exit wound– One, none, or many– Larger– May be ragged (©Edward T. Dickinson, MD)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Wound Ballistics

• Factors– Missile velocity– Missile size– Missile deformity– Missile design– Tumbling and yaw

(Courtesy of Roy Alson, MD)

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Wound Ballistics

• Internal wound– Tissue contact damage– High-velocity transfer of energy

Shock waves Temporary cavity Pulsation of temporary cavity

• Damage proportional to tissue density– Highly dense tissue sustains more damage

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Blast Injuries

• Primary– Initial air blast

• Secondary– Material propelled

• Tertiary– Impact on object

• Quaternary– Dispersed hazardous material

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Caution

Do not approach until

Scene Size-up is complete!

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Summary

• Time is critical; teamwork is essential• Scene size-up can be lifesaving• Mechanism of injury:

– An aid to predict injury– Part of overall management of trauma patient

• Record scene and mechanism findings