hello and welcome to chapter 25 the trauma overview chapter of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will have an understanding of the basic concepts of energy and its effects on the human body the general injury patterns associated with different types of impacts falls and penetrating trauma and the basic application of laws of physics on the assessment of trauma patients you will begin to demonstrate critical thinking and making predictions of injuries and adjusting index of suspicion based on the analysis and of evidence gathered in the scene size up you will also understand some common injury patterns to major body systems okay so let's get started for people younger than 44 years old traumatic injuries are the leading cause of death in the united states trauma emergencies occur as a result of physical forces applied to the body whereas medical emergencies occur from an illness or condition not caused by an outside force so evaluation of the mechanism of injury for a trauma patient will provide you with an index of sufficient for different types of serious or life-threatening underlying injuries index of suspicion is your awareness and concern for potentially serious underlying and unseen emergencies so let's talk about energy and trauma so traumatic inner injury occurs when the body's tissues are exposed to energy levels beyond their tolerance mechanism of injury describes the forces or energy transmission acting on the body that causes the injury there are three concepts of energy and they're typically associated with injury you have potential energy kinetic energy and energy of work energy can be neither created nor destroyed it can only be converted or transformed so work is defined as force acting over distance forces that bend or compress tissue bodies beyond their inherent limits result in the work that causes the injury okay so kinetic energy is the energy of a moving object it reflects the relationship between the mass which is the weight of the object and the velocity which is the speed at which it's traveling okay potential energy is a product of the mass force of gravity and the weight mostly associated with the energy of falling objects okay so mechanism of injury profiles so there are different types of mechanism of injury it will produce many types of injuries okay so you have non-significant mechanisms of injury and that's when the injury is to an isolated body part a fall without a loss of consciousness then you have significant mechanism of injuries okay and these can be injury to more than one body system which we call multi multi multi-system trauma fall from heights motor vehicle or motorcycle crashes car versus pedestrian or bicycle or motorcycle a gunshot wound or a stabbing okay so let's talk about blunt and penetrating trauma so traumatic injuries can be divided into two separate categories blunt trauma and penetrating trauma so blunt trauma is the result of force to the body that causes injury without penetrating the soft tissues or internal organs and cavities penetrating trauma causes injuries by objects that primarily pierce or penetrate the surface of the body and cause damage to soft tissues internal organs and body cavities so either type may occur from a variety of mechanisms of injuries then you have blunt trauma so blunt trauma results from an object making contact with the body so motor vehicle crashes and falls are the most common mois be alert for skin discoloration and pain as they may only be the sign of blood trauma and maintain a high index of suspicion for hidden injuries okay when you have a motor vehicle crash so crash typically consists of three collisions okay so let's say there's a car against a tree then you have the tree or objects okay so by assessing the vehicle that has crashed you can often determine the mechanism of injury so the passenger against the interior car that is um one of the crashes okay and that kinetic energy produced by the passenger's mass and velocity is converted into the work of stopping his or her body and its common passenger injuries include lower extremity fractures ribs and head trauma then you have the passengers internal organs against the solid structures of the body okay so internal injuries may not be as obvious as external injuries but they are often the most life-threatening so significant mechanisms of injury are associated by or suggested by death of an occupant in the vehicle okay severe deformity of the vehicle or intrusion into the vehicle moderate intrusion from the lateral from a lateral accident or severe damage from the rear or crashes in which a rotation is involved okay or an ejection from the vehicle so let's talk about the different types of crashes next and we're going to talk about frontal crashes first okay so evaluate the supple um the restraint system determine whether the pasture was restrained by a full or properly applied three-point restraint and determine whether the airbag was deployed seat belts and airbags are effective in preventing a second collision inside the motor vehicle so seat belts may decrease the severity of the third collision airbags decrease the severity of deceleration injuries and decrease injuries to the chest face and head despite airbags suspect injuries to extremities which uh result from the second collision or internal organs that's result from the third children shorter than four foot nine should ride in the rear seat remember that if the airbag did not inflate during the accident it may deploy during the extrication and remember that supplemental restraint systems can also cause harm if they're applied if they're applied improperly so his hip dislocations may result of seat belts award too low internal injuries can occur if the belt is worn too high and lumbar spine fractures are also possible particularly in children and older adults so look for points of contact between the patient and the vehicle as you perform a simple quick evaluation from the interior of the vehicle okay so now let's talk about rear end crashes and these are known to cause whiplash type injuries particularly in the absence of a properly placed headrest as the body is propelled forward the head and neck are left behind acceleration type injury to the brain as possible and passengers in the back seat wearing only the lap belt may have a higher incident of injury to the thoracic and lumbar spine okay next let's talk about the lateral type crash and this is a common cause of death associated with motor vehicle accidents so a vehicle struck from the side is usually struck above the center of gravity it begins to rock away from the side of the impact as a result in the passenger sustaining a whip-like whiplash type in injury if there is substantial intrusion into the passenger compartment please suggest lateral chest and abdominal injuries on the side of the impact possible fractures in the lower extremities and pelvis or ribs for organ damage from the third collision and then rollover crashes so large trucks and sport utility vehicles are prone to rollover because they have a high center of gravity so injuries depend on whether the passenger was restrained the most common life-threatening event in a rollover is the ejection or partial injection of the pasture from the vehicle even when restrained pastures can sustain severe injuries and then let's talk about rotational crashes so rotational crashes such as spins are conceptually similar to rollovers the rotation of the vehicle acid spins produces opportunities for the vehicle to strike objects such as utility poles all right so now let's talk about the car versus the pedestrian injuries are often graphic and apparent there can also be serious unseen injuries like we talked about you should be um aware of the speed of the vehicle whether the vehicle was thrown or whether the patient was thrown through the air and at what distance and off and surface the patient landed on whether the patient was struck and pulled under the vehicle so evaluate the vehicle that was struck the patient for structural damage advanced life support should be summoned for any patient who have or are thought to have been sustained a significant mechanism of injury all right so now let's talk about car versus bicycle so we're going to evaluate the mechanism of injury in such the manner that the car versus the pedestrian crashes we want to evaluate the damage position of the position of the bicycle if the patient was wearing a helmet inspect it for damage presume that the patient has sustained an injury to the spinal cord and until proven otherwise at the hospital okay so spinal immobilization must be initiated and maintained during the encounter okay now we're at the car versus the motorcycle and you can get protection from the helmet and uh it does not protect against severe cervical injury however and then the leather or abrasion resistant clothing and they will protect against road abrasion but not against blood trauma from secondary impacts and also there's boots that will protect the feet so when assessing the scene of a motorcycle crash look for deformity to the motorcycle side of the most damage distance of the skid in the road deformity of secondary objects or other vehicles and the extent and location of deformity in the helmet there are four types of motorcycle impacts okay so first you have the head-on and that's when the motorcycle strikes another object and stops its forward motion while the driver continues forward okay and then you have the angular crash and that's when the motorcycle strikes an object or another vehicle at an angle so that the rider sustains direct crash injuries to the lower extremity between the object and the motorcycle then there's the ejection so the rider will travel at a high speed until something stops him okay so either it's a secondary object another vehicle or a road drag then you have a controlled crash okay this is a technique used to separate the rider from the body of the motorcycle and the object to be hit is referred to as laying the bike down okay so now that we've gotten through the cars let's move on to the falls okay the injury potential of a fall is related to the height from which the patient fell the greater the height of the fall the greater the potential energy a fall from more than 20 feet is considered significant and internal injuries pose the greatest threat to life patients who fall and land on their feet may have less severe internal injuries because their legs may have absorbed much of the energy of the fall however they may have serious injuries to the lower extremities and pelvis and spinal injuries take into account the height of the fall the type of the surface struck in the part of the body that hit first followed by the path of energy displacement okay next let's talk about penetrating trauma okay so penetrating trauma is the second leading cause of death in the united states after blunt trauma there's low energy penetrating trauma and that's caused by it could be accidentally by an impalement or intentionally by something such as a knife or ice pick or another weapon with low energy penetrations injuries are caused by the sharp edges of the object moving through the body and therefore close to the object's path so knives may have been deliberately moved around internally causing more damage than the external wind suggests in a medium and high velocity penetrating trauma the path of the projectile which is usually a bullet may not be easy to predict the bullet may flatten out tumble or even ricochet within the body before exiting the path of the projectile causes its trajectory and fragmentation will increase damage so cavitation results from a rapid change in the tissue and fluid pressure that occur with the passage of a projectile temporary cavitation injuries result from the stretching of the tissue that occurs with the pressure changes and permanent cavitation injuries results closer to the bullet path and remains after the projectile has passed through the tissue the relationship between the distance and the severity of the injury depends varies on the type of weapon involved okay so air resistance often refers to the drag slows the projectile decreasing the depth of the penetration and energy of the projectile and thus reducing damage to the tissues the area that is damaged by a medium and high velocity projectiles is typically many times larger than the dynamic diameter of the projectile itself this is one reason that exome exit wounds are often many times larger than the entrance wounds the energy available for the bullet to cause the damage is more a function of its speed than its mass an important factor for the seriousness of a gunshot wound is the type of tissue through which the projectile passes so this table on the slide shows the signs of a developing problems in trauma patients next let's talk about blast injuries so although most commonly associated with military conflict blast injuries are also seen in civilian practice and mines shipyards chemical plants and in associated with terrorist activities figure on this slide shows the four mechanisms of blast injuries so let's talk about those okay you have the um primary blast injuries and these are due to extreme entirely to the blast itself so the damage to the body is caused by the pressure wave generated by the explosion then you have the secondary blast injuries and that's the damage to the body from being struck by flying debris then you have tertiary blast injuries and the victim is hurled by the force of the explosion against a stationary object then you have the fourth type of blast injury and that's when the burns from hot gases are fired started by the blast it could be respiratory injury by inhaling the toxic gas or a crush injury from the collapse of the buildings perhaps suffocation poisoning or other medical emergencies or contamination of wounds from environmental chemical or toxic substances most patients who survive an explosion will have some combination of all four types of the injuries we just mentioned tissues at risk so organs that contain air such as the middle ear lung or the gi tract are most susceptible to pressure changes the ear is the most sensitive to blast injuries pulmonary blasts are defined as pulmonary trauma and that results from short-range exposure to a detonation of explosives a pneumothorax is a common injury and may require emergency decompression in the field one of the most concerning pulmonary blast is arterial air emboli so this happens when the um alveolar disruption of air embolism into the pulmonary vasculature okay and it can produce disturbances in vision or changes in behavior perhaps changes in the state of consciousness or a variety of neurological signs solid organs are relatively projected from shock wave injury but may be injured by a secondary missile or being hurled so neurologic injuries and head trauma are the most common causes of death from blast injuries extremity injuries including traumatic amputations are also common then you have when we talk about trauma you could have multi-system trauma so what this is is when trauma involves more than one body system so you have you could have a head and spine trauma chest and abdomen chest and multiple extremity or you so you must be alert um and call medical control and transport rapidly multi-system trauma patients have a high level of morbidity and mortality so the golden principles of pre-hospital trauma care your main priority is to ensure of course your safety that's number one then we're going to do the safety of our crew then the safety of the patient we want to determine the need for additional personal and equipment of course and evaluate the mechanisms of injury we need to identify and manage life threats then focus on patient care so hemorrhage control is the highest priority of course we want to access and manage the airway including the ventilatory support and high flow oxygen while maintaining appropriate spinal restriction and that's the second priority okay then ensure that other shock therapy is completed and protect the spine and proceed with the spinal immobilization if indicated transport the patient immediately to the appropriate facility in most patients with multi-system trauma definitive care requires surgical intervention so scene time should be limited to 10 minutes or less during transport obtain the sample history and complete the secondary assessment and you also want to consider advanced life support intercept and or maybe air medical transport okay so let's start the patient assessment portion of the lecture so when you are caring for a patient who has experienced a significant mechanism of injury and the patient is considered to be serious or critical condition you should rapidly perform the physical exam with the patient who is experiencing a significant moi focus on the chief complaint while assist assessing the patient as a whole so let's do injuries to the head let's talk about that disability and unseen injury to the brain may occur bleeding or swelling inside the skull is often life-threatening include frequent neurologic examinations in your assessment some patients they will not have obvious signs or symptoms until minutes or even hours after the injury has occurred next we're going to talk about injuries to the neck and throat so airway problems may result that could quickly become a serious life threat your assessment must include frequent physical exams including decap hls in the neck region also assess the jugular vein distension and tracheal deviation so swelling may prevent blood flow to the brain and cause injury to the nervous system and a training injury may result in an air embolism a crushing injury to the upper part of the neck may cause the cartilage of the upper airway and larynx to fracture next we're just moving down the body so injuries to the chest the chest contains the heart lungs and large vessels many life-threatening injuries may occur you could have broken ribs which may hinder bleeding bruising that may occur to the heart and cause an irregular heartbeat or large vessels of the heart may be torn inside the chest causing massive unseen bleeding also air may collect between the lung tissue and the chest wall and this is known as a pneumothorax or the collection of blood in the chest is also called a hemothorax a penetrating or perforation of the integrity of the chest is called an open chest wound okay so if this is left in treating shock may occur and it is imperative that you assess the chest region every five minutes assessment should include decap btls lung sounds and chest rise and fall now moving down into the abdomen so the abdomen contains vital organs that require very high amount of blood flow to perform the functions necessary for life solid organs may tear lacerate or fracture which can cause serious bleeding into the abdomen solid organs include the liver spleen pancreas and kidneys then when you have hollow organs they may rupture and leak their toxic digestive chemicals into the stomach area and its causes uh could cause a life-threatening infection hollow organs include the stomach large and small intestines and urinary bladder the rupture of blood vessel can also cause a serious unseen bleeding so management so our same time survival is critical when it comes to trauma patients and so on scene time for critically injured patients should be less than 10 minutes the following criteria will help you identify a critically injured patient so was there a dangerous mechanism of injury is there decreased level of consciousness are there any threats to the airway breathing or circulation patients who are very young or very old or have chronic illness should also be considered to have a high risk all right so decision so where are we going to take them trauma centers are classified by levels one through four with level one having the most resources level one facility provides every aspect of trauma care level two facility provides initial definitive care level three it provides assessment resuscitation emergency care then stabilization and then a level four that just provides advanced trauma life support all right so the association of air medical and and med evac foundation internationally identified the following criteria for appropriate use of emergency air medical services for trauma patients so here it is there is an extended period of time to access or extricate a re remote or trapped patient the distance to a trauma center is more than 20 to 25 miles the patient needs advanced care and there is no als level ground ambulance service available traffic conditions or hospital availability make it unlikely that the patient will get to trauma center by ground there are multiple traumatic patients who will overwhelm the hospitals nearby ems systems require bringing a patient to the nearest hospital rather than bypassing a facility to go directly to a trauma center this may add delay to receiving definitive surgical care or if there's a mass casualty event trauma centers are categorized as either adult trauma centers or pediatric trauma centers but not necessarily both so types of transports so modes of transports ultimately come in one of two categories and that's ground or air so ground ems units are staffed by emts and paramedics whereas air ems units or critical care transport units are staffed by critical care nurses and paramedics okay and so this is going to show you basically a flow of the transport decision process all right so when it comes to transport and destinations so there are special considerations remain calm complete and organized assessment correct life-threatening injuries do no harm and never hesitate to contact advanced life support backup or medical control for guidance okay so that concludes the lecture portion of chapter 25 the trauma overview chapter now we're just going to see what we've learned all right so when it comes to kinetic energy it's the calculation of and i think it's the weight and speed yeah so calculation is the weight and speed which is the mass and velocity so energy cannot be destroyed only converted okay a 20 year old man has a major open facial injuries after his vehicle struck a tree head-on oof which of the following findings within the car would most likely explain the injury pattern okay so a non-intact windshield looks like it might be the head that went through um i would think so the mechanism of injury the vehicle yep that's right the non-intact windshield okay which of the following would most likely result from the third collision in the tree three collision effect that occurs during a high speed frontal impact motor vehicle crash okay frontal i'm thinking it's the aortic rush rupture or compression injury and yep so the third collision the body's internal organs keep going forward right a young male experienced severe blood chest trauma when his passenger car struck another vehicle head-on during your inspection of the interior of his vehicle which would you most likely find okay so we have blunt chest trauma chest area would be the steering wheel deformity i would assume yep and then respraying driver collided with a bridge pillar upon inspection of the interior of the vehicle you note the lower dashboard is crushed during your initial assessment of the patient you would most likely encounter i'm thinking the pelvis yep trauma to the pelvis whiplash injuries are most common following blank impacts oh i think that this is rear-end rear-end impacts yes death from a rollover motor ethical crash is most often secondary to i think that that when you get ejected from the vehicle and then the the car yep that is the ejection okay severe abrasion injuries can occur when motorcycle riders are slowed after a collision by road drag road track is most often associated with which type of motorcycle impact all right so this is going to be severe abrasion injuries occur when they are ejection from the bike okay when assessing a stab wound it's important for an emt to remember hmm i think it's d more internal damage can be present than the external one suggests yep okay and finally a 40 year old male is standing near a building when it exploded he has multiple injuries including a depressed skull fracture severe brooms burns and an impelled object in his abdomen his head injury was most likely the cause of i think it is the third the third injury right yes so it is the tertiary okay thank you for joining me for the traumatic the trauma overview chapter chapter 25 um we hope you enjoyed the lecture and um go ahead and subscribe because we'll be coming out and doing the whole book all the lectures in the whole book okay have a great night