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Chapter 32 – Special Considerations in Trauma 1

Chapter 32 – Special Considerations in Trauma

I. Objectives

Knowledge Objectives 1. Discuss mechanisms of injury associated with trauma in pregnancy.2. Discuss the unique anatomy, physiology, and pathophysiology

considerations of the pregnant trauma patient.3. Discuss the assessment findings associated with trauma in the

pregnant patient.4. Describe the emergency care of the pregnant trauma patient.5. Discuss mechanisms of injury associated with pediatric trauma.6. Discuss the unique anatomy, physiology, and pathophysiology

considerations of the pediatric trauma patient.7. Discuss the assessment findings associated with trauma in infants

and children.8. Describe the emergency care of the pediatric trauma patient.9. Discuss mechanisms of injury associated with trauma in older

adults.10. Discuss the unique anatomy, physiology, and pathophysiology

considerations of the older adult trauma patient.11. Discuss the assessment findings associated with trauma in older

adults.12. Describe the emergency care of the older adult trauma patient.13. Define cognitive impairment and discuss challenges in assessing

the cognitively impaired patient.Attitude Objectives 14. Value the importance of maintaining a trauma patient’s modesty

during assessment and management.Skill Objectives 15. Demonstrate assessment and appropriate emergency care of a

pregnant trauma patient.16. Demonstrate completing a prehospital care report for a pregnant

trauma patient.17. Demonstrate assessment and appropriate emergency care of a

pediatric trauma patient.18. Demonstrate completing a prehospital care report for a pediatric

trauma patient.19. Demonstrate assessment and appropriate emergency care of a older

adult trauma patient.20. Demonstrate completing a prehospital care report for an older adult

trauma patient.21. Demonstrate assessment and appropriate emergency care of a

cognitively impaired trauma patient.22. Demonstrate completing a prehospital care report for a cognitively

impaired trauma patient.

II. Preparation

Copyright 2010, McGraw-Hill

2 Emergency Medical Responder Instructor’s Lesson Plans

Corresponding textbook pages: 546-560Audiovisual equipment: Chapter 32 PowerPoint presentation

Computer Multimedia projector

EMS equipment: Gloves, blood pressure cuffs, stethoscopes, various dressings and bandages, blankets, airway equipment

Course administration materials: Attendance sign-in sheet

III. Personnel

Primary instructor qualifications: One EMR instructor knowledgeable in trauma in pregnancy, pediatric trauma, and trauma in older adults.

Assistant instructor qualifications: The instructor-to-student ratio should be 1:6 for psychomotor skill practice.

Individuals used as assistant instructors should be knowledgeable in trauma in trauma in pregnancy, pediatric trauma, and trauma in older adults.

IV. Key Terms Presented in This Lesson

Abruptio Placentae Condition that occurs when a normally implanted placenta separates prematurely from the wall of the uterus (endometrium) during the last trimester of pregnancy; also called placental abruption.

Cognition The mental functions including memory, learning, awareness, reasoning, judgment, and the ability to think, plan, form and comprehend speech, process information, and understand and solve problems.

Cognitive Impairment A change in a person’s mental functioning caused by an injury or disease process.

Ruptured Uterus The actual tearing of the uterus that can result from strong labor for a long period or abdominal trauma.

Shaken Baby Syndrome A term used to describe the group of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child; also called abusive head trauma.

V. Skills Presented in This Lesson There are no skills identified for this lesson.



VI. Lesson Outline

Slide # Instructor Notes1 A. Special Considerations in Trauma2 B. Objectives3 C. Trauma in Pregnancy4

Objective 11. Mechanism of injury

a. Trauma is the leading cause of death in pregnant patients and the leading cause of death in women of childbearing age.

b. Although pregnant patients can sustain all types of trauma, motor vehicle crashes are the most frequent cause of injury, followed by falls and intimate partner violence.

c. Direct or indirect trauma to a pregnant uterus can cause injury to the uterine muscle. This can cause the release of chemicals that cause uterine contractions, perhaps inducing premature labor.

d. The effects of trauma on the fetus depend on:1) The length of the pregnancy (the age of the fetus)2) The type and severity of the trauma3) The severity of blood flow and oxygen disruption to the uterus

5 e. Motor vehicle crashes are the most common cause of serious blunt trauma in pregnancy.

f. Gunshot wounds and stab wounds to the abdomen of a pregnant patient do not usually result in the mother’s death. However, the likelihood of fetal death is high.

6 g. One in four pregnant women experiences a fall during pregnancy, becoming more common after the 20th week of pregnancy. 1) A woman’s center of gravity shifts as the size of her abdomen

increases during pregnancy and her pelvic ligaments loosen. 2) As a result, a pregnant patient must readjust her body alignment

and balance, which increases her risk for falls and injury. 3) Some of these falls are a result of slippery floors, hurrying, or

carrying objects.7 h. For some women, pregnancy is a time when intimate partner

violence starts. Physical abuse can result in the following conditions:1) Blunt trauma to the abdomen2) Severe bleeding3) Uterine rupture4) Miscarriage5) Premature labor6) Premature rupture of the amniotic sac

8 i. A thermal burn of more than 20% of the mother’s body surface area increases the risk of fetal death. 1) In cases of electrical burns, the likelihood of fetal death is high,

even with a rather low electrical current. 2) This is most likely because the fetus is floating in amniotic fluid

and has a low resistance to the current.



Slide # Instructor Notes9

Objective 22. Anatomic changes occur during pregnancy that affects nearly every

organ system. a. In the respiratory system, the diaphragm becomes elevated and the

mother’s resting respiratory rate increases because of the enlarging uterus.

b. During pregnancy, the speed with which food and liquids move through the gastrointestinal tract decreases, increasing the risk of vomiting and aspiration after trauma.

c. The mother’s blood volume circulates through the uterus every 8 to 11 minutes at term. 1) As a result, the uterus can be a source of significant blood loss if

injured. 3. Before the 12th week of pregnancy, the uterus is protected by the bones

of the pelvis. a. After the 12th week of pregnancy, the uterus begins to rise out of the

pelvis and becomes susceptible to injury. b. By the 20th week, the uterus is at the level of the umbilicus and at

34 to 36 weeks it reaches the costal margin. c. Thus the risk of trauma to the mother and fetus increases as

pregnancy progresses. 4. As the uterus increases in size, the mother’s abdominal organs are

displaced superiorly. a. This displacement decreases the likelihood of injury to the mother’s

liver, spleen, and intestines but increases the likelihood of uterine and fetal injury.

10Objective 2

5. Early in the pregnancy, the mother’s body begins to produce more blood to carry oxygen and nutrients to the fetus, resulting in an increased plasma volume and an increased volume of red blood cells.

6. Her heart rate gradually increases by as much as 10 to 15 beats/min during pregnancy.

7. During the first 6 months of pregnancy, the mother’s systolic blood pressure may drop by 5-10 mm Hg. a. Her diastolic blood pressure may drop by 10-15 mm Hg. b. During the last 3 months of pregnancy, her blood pressure gradually

returns to near normal. 11

Objective 28. You will recall that an increase in heart rate is one of the earliest signs of

shock. a. The changes in vital signs that typically occur during pregnancy can

make it difficult to detect shock, particularly in late pregnancy. b. When shock occurs, the mother’s blood pressure is preserved by the

shunting of blood from nonvital organs, such as the uterus, to vital organs.

c. Constriction of the uterine arteries decreases perfusion to the uterus, potentially compromising the fetus to save the mother.

d. The fetus will often show signs of distress before any change in maternal vital signs.

e. In fact, the healthy pregnant patient can lose 30% to 35% of her blood volume with no change in vital signs. However, her condition will rapidly worsen when blood loss exceeds this amount.




Objective 29. The uterus grows from a pre-pregnancy size of 70 g to a term pregnancy

size of about 1000 g. a. When a woman in late pregnancy is placed on her back, the weight

of the fetus compresses major blood vessels, such as the inferior vena cava and the aorta.

b. This compression decreases the amount of blood returning to the mother’s heart and lowers her blood pressure (supine hypotensive syndrome). As a result, the amount of oxygen and nutrients delivered to the fetus is decreased.

c. A woman who is 20 weeks pregnant or more should be positioned on her left side. 1) Positioning the patient on her left side shifts the weight of her

uterus off the abdominal vessels. 2) If the patient is immobilized to a backboard, tilt the board

slightly to the left by placing a rolled towel, small pillow, blanket, or other padding under the right side of the board.

3) Doing so will shift the weight of the patient’s uterus and decrease the pressure on the abdominal blood vessels.

13Objective 2

10. Fetal death may occur because of death of the mother, separation of the placenta, maternal shock, uterine rupture, or a fetal head injury. a. Of these, maternal death is the number one cause of fetal death. b. The second most common cause of fetal death is abruptio placentae.

1) Abruptio placentae (also called placental abruption) occurs when a normally implanted placenta separates prematurely from the wall of the uterus (endometrium) during the last trimester of pregnancy.

2) If the placenta begins to peel away from the wall of the uterus, bleeding occurs from the blood vessels that transfer nutrients to the fetus from the mother. The larger the area that peels away, the greater the amount of bleeding.

3) The placenta may separate partially or completely. Partial separation may allow time for treatment of the mother and fetus.

14Objective 2

4) Separation of more than 50% of the placental surface often results in death of the fetus.

5) Classic signs of placental abruption include abdominal pain, vaginal bleeding, and preterm labor. However, vaginal bleeding may be absent in 30% of abruptions following trauma.

15Objective 2

c. A ruptured uterus is the actual tearing of the uterus. 1) Uterine rupture can occur when the patient has been in strong

labor for a long period, which is the most common cause. 2) It can also occur when the patient has sustained abdominal

trauma, such as a severe fall or a sudden stop in a motor vehicle collision.

3) Signs and symptoms of uterine rupture include abdominal pain, vaginal bleeding, and shock.




Objective 211. Women should use automobile restraints while pregnant, whether

driving or riding as a passenger. a. Correct seat belt use can significantly reduce both maternal and fetal

injury following motor vehicle crashes. 1) Studies have shown that unbelted pregnant women are twice as

likely to experience vaginal bleeding and two times more likely to give birth within 48 hours of a crash than properly belted pregnant women are.

2) Fetal death is three to four times more likely to occur when pregnant women are unbelted. Injuries can occur if restraints are improperly worn.

b. In a motor vehicle crash, uterine rupture can occur if a lap belt is worn too high over the pregnant uterus.

c. Wearing a lap belt without a shoulder strap can result in compression of the uterus with possible uterine rupture or abruptio placentae.

d. During pregnancy, correct positioning of the lap belt is underneath the pregnant abdomen across the hips and high on the thighs. 1) The shoulder strap should be positioned snugly between the

breasts and off to the side of the pregnant abdomen.17

Objective 212. Penetrating trauma in pregnancy is usually the result of gunshot or knife

wounds, of which gunshot wounds are more common. a. Abdominal stab wounds during pregnancy usually occur in the

upper abdomen above the umbilicus. b. Stab wounds to the lower abdomen are more likely to injure the

uterus. c. Although the maternal outcome of penetrating trauma in pregnancy

is usually favorable, the fetal death rate is high.18

Objective 213. Cardiac arrest in the pregnant trauma patient poses some unique

challenges. a. Because the pregnant patient’s diaphragm is elevated during

pregnancy, it may be necessary to ventilate using less volume. b. Chest compressions should be performed higher on the sternum,

slightly above the center of the sternum. c. If the patient is 20 weeks pregnant or more, it will be necessary to

perform chest compressions with the patient on a backboard tilted 15° to 30° to the left to offset the problems associated with supine hypotension.

19 D. Assessment of the Pregnant Trauma Patient




Objective 31. Conduct a scene size-up and ensure your safety. 2. Evaluate the mechanism of injury before approaching the patient. 3. Put on appropriate PPE. 4. As you begin your assessment, remember that you have two patients to

consider – the mother and fetus. 5. Carefully assess the patient’s airway while maintaining spinal

stabilization. 6. The pregnant trauma patient is at greater risk for vomiting and

subsequent aspiration. a. Suction as needed to keep the airway open and reassess the airway

often. 7. Never withhold oxygen from a pregnant trauma patient.

a. Give 100% oxygen, assisting ventilation as needed. 8. Assess the patient’s circulatory status and control hemorrhage with

direct pressure, if present. 9. Assess the patient’s level of consciousness using the AVPU scale. 10. Treat any life-threatening injuries before proceeding to the secondary

survey.21

Objective 311. A short on-scene time and rapid transport to an appropriate trauma

center are important when caring for the pregnant trauma patient. 12. Request an early response of EMS personnel to the scene. In situations

involving major trauma, an ALS intercept or air medical resources may be needed.

22Objective 3

13. Obtain the patient’s vital signs and gather the patient’s medical history. a. Remember that the mother’s vital signs may be with normal limits

despite significant internal bleeding. 14. In addition to the usual questions asked with obtaining a SAMPLE

history, additional key questions include the following:a. (If the mechanism of injury involved a motor vehicle crash) Were

you wearing a seatbelt? Lap belt and shoulder strap? b. Did you feel the baby move before the trauma? After the trauma?c. Did you experience any direct trauma to your abdomen?d. Are you experiencing any contractions?e. Are you experiencing any vaginal bleeding?

23Objective 3

f. Did your water break? If yes, what color was it?g. When was your last menstrual period?h. What is your due date?i. Have you received any prenatal care?j. Is this your first pregnancy? How many babies are expected?k. Do you have any medical problems (diabetes, high blood pressure)?

24 E. Emergency Care




Objective 41. Put on appropriate PPE. Keep on-scene time to a minimum.2. If spinal injury is suspected, immobilize the patient to a long backboard

and tilt the board to the left if the patient is 20 weeks pregnant or more.3. Establish and maintain an open airway. Have suction equipment within

arm’s reach.4. Administer 100% oxygen.

a. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min.

b. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.

c. Continue monitoring oxygenation using pulse oximetry. 5. Control external bleeding by applying direct pressure to the wound with

a sterile dressing. a. If blood soaks through the dressing, apply additional dressings and

reapply pressure. b. If signs of shock are present or if internal bleeding is suspected, treat

for shock. 6. Protect the patient’s modesty and provide emotional support. Keep the

patient warm.26

Objective 47. Generally, the pregnant trauma patient who has a heart rate of more than

110 beats/min, chest or abdominal pain, loss of consciousness, or is in her third-trimester of pregnancy should be transported to a trauma center. Follow your local protocols.

8. Reassess at least every 5 minutes. 9. Record all patient care information, including the patient’s medical

history and all emergency care given, on a PCR.27 F. Pediatric Trauma





a. Injuries are the leading cause of death in infants and children. Blunt trauma is the most common mechanism of serious injury in the pediatric patient.

b. The injury pattern seen in a child may be different from that seen in an adult. 1) For example, if an adult is about to be struck by an oncoming

vehicle, he will typically turn away from the vehicle. 2) This results in injuries to the side or back of the body. 3) In contrast, a child will usually face an oncoming vehicle,

resulting in injuries to the front of the body.c. In a motor vehicle crash, an unrestrained infant or child will often

have head and neck injuries. 1) Restrained passengers often have abdominal and lower spine

injuries. 2) Child safety seats are often improperly secured, resulting in

head and neck injuries. 3) Contributing factors to pediatric motor vehicle–related injuries

include failure to use (or improper use of) passenger restraints, inexperienced adolescent drivers, and alcohol abuse.

d. Deaths resulting from pedestrian injuries are common among children 5 to 9 years of age. 1) The child is unable to judge the speed of the traffic and typically

bolts out into the street. 2) Children are often injured while chasing a toy, friend, or pet into

the path of an oncoming vehicle. 3) A child struck by a car is likely to sustain injury to the head,

chest or abdomen, and an extremity (Waddell’s Triad). The vehicle first strikes the left side of the child.

4) The bumper contacts the left femur, and the fender strikes the left side of the child’s abdomen.

5) The child is thrown against the vehicle’s hood or windshield. The child is thrown to the ground, striking his head on the pavement as the vehicle comes to a stop.

6) The child is then often run over by the vehicle.




Objective 52. Bicycle-related injuries often involve head trauma, abdominal injuries

(from striking the handlebars) and trauma to the face and extremities. 3. Sports injuries often involve injuries to the head and neck.4. Drowning is a significant cause of death and disability in children

younger than 4 years of age. Alcohol appears to be a significant risk factor in adolescent drowning.

5. Most fire-related deaths occur in private residences, usually in homes without working smoke detectors. Smoke inhalation, scalds, and contact and electrical burns are especially likely to affect children younger than 4 years of age.

6. Injuries caused by a firearm include an entrance wound, exit wound, and an internal wound. a. Most guns used in unintentional shootings are found in the home

and often found loaded in readily accessible places. b. The presence of a gun in the home has been linked to an increased

likelihood of adolescent suicide.7. Falls are a common cause of injury in infants and children.

a. Infants and young children have large heads in comparison to their body size, making them more prone to falls.

b. Note the distance of the fall, the surface on which the child landed, and the body area(s) struck.

c. Any fall more than 10 feet or more than 2-3 times the child’s height should be considered serious.1) Concrete and asphalt are associated with more severe injuries

than other surfaces. 2) Children who land on hard ground or concrete sustain more

severe injury than those who hit grass, even when the heights of the falls are similar.

d. If the child fell from a height or was diving into shallow water, suspect injuries to the head and neck.

30Objective 6

G. Anatomic and Physiologic Considerations1. Children are prone to head injuries because their heads are large and

heavy when compared with their body size. a. The younger the child, the softer and thinner the skull is. b. The force of injury is more likely to be transferred to the underlying

brain instead of fracturing the skull. c. The blood vessels of the face and scalp bleed easily. d. Even a small wound can lead to major blood loss. e. When the head is struck, it jars the brain. The brain bounces back

and forth, causing multiple bruised and injured areas.



Slide # Instructor Notes31 2. Shaken baby syndrome (also called abusive head trauma) may cause

brain trauma. a. The National Center on Shaken Baby Syndrome defines shaken

baby syndrome as a term used to describe the group of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child.

b. Shaken baby syndrome occurs when an infant or child is shaken by the arms, legs, or shoulders with enough force to cause the baby’s brain to bounce against his skull.

c. Just 2 to 3 seconds of shaking can cause bruising, swelling, and bleeding in and around the brain. It can lead to severe brain damage or death.

d. Never shake or jiggle an infant or child.

→ Airway and breathing problems are common with head injuries. The most common cause of hypoxia in the unresponsive head injury patient is the tongue obstructing the airway. You must make sure that the child’s airway is open and that his breathing is adequate.

32Objective 6

3. Signs of blunt trauma to the chest and abdomen may be hard to see on the body surface. a. The younger the patient, the softer and more flexible his ribs are.

Therefore, rib fractures are less common in children than in adults. b. However, the force of the injury can be transferred to the internal

organs of the chest, resulting in major damage. c. The presence of a rib fracture in a child suggests that major force

caused the injury. d. Bruising of the lung (pulmonary contusion) is one of the most

frequently observed chest injuries in children. This injury is potentially life threatening.

33Objective 6

4. The abdomen is a more common site of injury in children than in adults. a. The abdomen is often a source of hidden injury. In fact, abdominal

trauma is the most common cause of unrecognized fatal injury in children.

b. The abdominal organs of an infant or child are prone to injury because the organs are large and the abdominal wall is thin.

c. As a result, the organs are closer to the surface of the abdomen and less protected.

d. In infants and young children, the liver and spleen extend below the lower ribs. Their location gives them less protection and makes them more susceptible to injury.

e. A swollen, tender abdomen is a cause for concern.




Objective 65. Pelvic fractures are uncommon in children.

a. However, when they do occur, they are often the result of the child’s being struck by a moving vehicle.

b. Because the pelvis contains major blood vessels, you must be alert for signs of internal bleeding and shock.

6. Extremity trauma is common in children. a. The younger the child, the more flexible his bones are. b. When a child has multiple injuries, fractures are often missed. c. Assessing non-displaced fractures in young children can be difficult

because they cannot verbalize well. d. If a child is not walking on an injured extremity or using an upper

extremity during normal activity, suspect a fracture until proven otherwise.

e. Fractures of both thighs can cause a major blood loss, resulting in shock.

f. Extremity injuries in children are managed in the same way as for adults.

35Objective 7

H. Patient Assessment 1. When arriving on the scene, complete a scene size-up before beginning

emergency medical care. 2. Evaluate the mechanism of injury before approaching the patient and put

on appropriate PPE. 3. Be sure to comfort, calm, and reassure the patient throughout your

assessment. Find out the child’s name and use it when providing care.4. Keep on-scene time to a minimum. 5. Request an early response of EMS personnel to the scene.

36Objective 7

6. As you approach the patient, form a general impression and assess the child’s appearance, work of breathing, and skin color.

7. Perform a primary survey to determine the presence of life-threatening injuries.

8. If the child is not alert or the mechanism of injury suggests that the child experienced trauma to the head or neck, stabilize the child’s spine. a. Assume that any patient who has an injury above the collarbones has

a spinal injury and immobilize accordingly. b. An unresponsive infant or child should always be immobilized,

especially when the cause is unknown. c. Remember that you may need to place padding under the torso of

infants and young children to maintain the cervical spine in a neutral position.

37Objective 7

9. Making sure the child’s airway is open and clear of secretions is the most important step in managing a trauma patient. a. Gurgling or stridor may indicate an upper airway obstruction. b. Vomiting is common in the pediatric trauma patient.

1) Make sure suction is within arm’s reach. 2) Suction the mouth as needed with a rigid suction catheter.

c. Because a young infant breathes primarily through his nose and not his mouth, be sure to keep the nasal passages clear.

d. If the patient is unresponsive, use the jaw thrust maneuver to open the airway.

e. Insert an oral airway to help keep the airway open.




Objective 710. Because inadequate breathing is common in the pediatric trauma patient,

carefully assess the rate and depth of the patient’s breathing. a. The respiratory rate of an infant and child is faster than that of an

adult. Rates that are too fast or slow can indicate respiratory failure. b. Look for signs of increased work of breathing, such as retractions

and accessory muscle use. c. If the child’s breathing is inadequate or there is no air movement,

assist breathing with bag-mask or mouth-to-mask ventilation. 1) Remember to ventilate with just enough force to produce gentle

chest rise to reduce the risk of gastric distention. d. Give supplemental oxygen to all pediatric trauma patients, even if

there is no apparent breathing difficulty. 39

Objective 711. Control obvious bleeding if present. 12. Check for signs of shock by assessing the child’s mental status, heart

rate, peripheral versus central pulses, and skin color. a. In an injured child, delayed capillary refill time (if the child is 6

years of age or younger), cool distal extremities, and decreases in peripheral versus central pulse quality are generally more reliable signs of shock than blood pressure.

b. This is because a healthy child can maintain a normal blood pressure until he has lost 25% to 30% of his total blood volume.

c. The extremities of a young child may appear mottled in response to cold. Remember to keep the child warm.

d. If signs and symptoms of shock are present with a closed head injury, look for signs of other injuries (such as internal bleeding) that may be the cause of the shock.

40Objective 7

13. Assess the child’s mental status using the AVPU scale. a. Repeat your mental status assessment each time you repeat the

patient’s vital signs. 14. Obtain the patient’s vital signs, recognizing that respiratory rates, pulse

rates, and blood pressures vary by age. a. A blood pressure in children younger than 3 years of age is

unreliable. b. Remember to assess a brachial pulse in infants. c. Regardless of age, a slow pulse rate in an infant or child indicates

hypoxia until proven otherwise. d. Normal vital signs in an injured child can be deceiving.

1) It is essential to obtain vital signs frequently and look closely for changes in the child’s respiratory rate, heart rate, and blood pressure that may indicate impending respiratory failure or shock.

41Objective 7

15. Obtain a SAMPLE history from the patient or family members. 16. Throughout your assessment and delivery of emergency care to the

patient, remember to talk to your patient. 17. Keep the family informed of what you are doing and where the patient

will be transported for further care.




Objective 8I. Emergency Care

1. Put on appropriate PPE. 2. Keep on-scene time to a minimum. Request an early response of ALS

personnel to the scene.3. If spinal injury is suspected, maintain manual in-line stabilization until

the patient is secured to a long backboard. a. Provide padding beneath an infant and young child from the

shoulders to the hips during immobilization to prevent flexion of the neck.

Establish and maintain an open airway.4. Give oxygen.

a. If the patient’s breathing is inadequate, assist his breathing with a bag-mask device connected to 100% oxygen.

b. Consider the cause of a slow heart rate in a pediatric patient a sign of hypoxia and assist ventilation as needed.

43Objective 8

5. Promptly seal an open chest wound with an airtight dressing. a. Tape the dressing on 3 sides. b. If signs and symptoms of a tension pneumothorax develop after an

airtight dressing has been applied, release the dressing. c. Reassess the patient’s airway, breathing, circulation, and mental

status. d. If the patient’s breathing returns to normal, replace the airtight

dressing and again secure it in place over the wound by taping it in place on 3 sides.

6. Control external bleeding by applying direct pressure to the wound with a sterile dressing. If blood soaks through the dressing, apply additional dressings and reapply pressure.

7. If signs of shock are present or if internal bleeding is suspected, treat for shock. Keep the patient warm.

8. Do not remove penetrating objects; rather, stabilize in place with bulky dressings.

9. Manage avulsed or amputated parts as other soft tissue injuries.10. Extremity injuries should be stabilized by immobilizing the joint above

and below the fracture site. a. In the critical patient, this should be done en route to a trauma center

as time permits. b. Remember to assess pulses, motor function, and sensation in the

affected extremity before and after immobilization. 11. Reassess at least every 5 minutes. 12. Record all patient care information, including the patient’s medical

history and all emergency care given, on a PCR.44 J. Trauma in Older Adults





a. Falls are the most common cause of injury in older adults. b. Most falls involving older adults occur at home and are low-level

falls (falls from a standing height). c. Injuries to the head, pelvis, and lower extremities are common. d. Fractures sustained during a fall usually involve the hip, femur, and

wrist. e. Factors that increase an older adult’s risk of falling include the

following:1) Older age2) Female gender3) Sedative use4) Impaired vision5) Syncope6) Arthritis7) Lower extremity weakness8) Balance difficulties9) History of stroke, previous fall10) Environmental hazards (rug, stairs, lighting, uneven ground)

46Objective 9

2. Motor vehicle crashes involving older adults often occur during the daytime, close to home, and at an intersection. a. Factors increasing the risk of MVCs in older adults include

decreased hearing and vision and slower reaction time. b. Injuries sustained by older adults in MVCs are similar to those of

younger patients except adults over 65 years of age have an increased incidence of sternal fractures from seatbelts.

3. Pedestrian versus vehicle incidents involving older adults are associated with a high death rate, usually from a severe head or major vascular injury. a. The older adult is frequently struck within a marked crosswalk or

walks directly into the path of an oncoming vehicle. b. Factors increasing the risk of pedestrian versus vehicle incidents

include poor eyesight and hearing, decreased mobility, and longer reaction times.

47Objective 9

4. Most burn injuries in the older adult occur at home. a. Although the frequency of burn injuries is lower in older adult than

in younger patients, the death rate from burn injuries in older adults is high.

b. Any older adult who has experienced a burn injury should be triaged to a burn center, if available in your area.

48Objective 9

5. Elder neglect should be suspected if the patient has signs of dehydration, malnutrition, untreated bedsores, or poor personal hygiene.

6. Consider the possibility of elder abuse if your assessment reveals any of the following:



Slide # Instructor Notesa. Bruises, black eyes, welts, lacerations, rope marks b. Bone fractures, skull fractures c. Open wounds, cuts, punctures, untreated injuries in various stages of

healingd. Older adult’s report of being hit, slapped, kicked, or mistreated e. Physical signs of being subjected to punishmentf. Signs of being restrainedg. Older adult’s sudden change in behavior h. Caregiver’s refusal to allow visitors to see an older adult alone

49Objective 10

K. Anatomic and Physiologic Changes1. Changes associated with aging in the pulmonary, cardiovascular,

neurologic, and musculoskeletal systems make older adults susceptible to trauma.

2. As the brain shrinks with age, there is a higher risk of cerebral bleeding following head trauma.

3. Loss of strength, sensory impairment, and medical illnesses increase the risk of falls.

4. Skeletal changes cause curvature of the upper spine that may require padding when stabilizing the spine.

5. Cardiovascular system changes associated with aging include thickening of the blood vessels, decreased vessel elasticity, and increased peripheral vascular resistance, which contribute to reduced blood flow to organs. a. There is often a marked increase in the systolic blood pressure and a

slight increase in the diastolic blood pressure because of increased peripheral vascular resistance.

b. In some situations, a “normal” blood pressure in an older adult who is usually hypertensive may actually represent hypotension.

50Objective 10

6. Older adults often take multiple medications including cardiac drugs, diuretics (“water pills”), sedatives, antidepressants, and medications that affect blood blotting. a. Tachycardia, an early indicator of shock, may not be evident in the

older adult taking cardiac medications such as beta-blockers and calcium channel blockers.

b. The patient who is taking a diuretic may have a decreased blood volume even before an injury occurs.

c. Sedatives and antidepressants can alter mental status, increasing the older adult’s risk of injury.

d. Many older adults who have a history of stroke, an irregular heart rhythm, or who have had a heart valve replaced are prescribed anticoagulants (such as aspirin, Coumadin, Plavix), which affect the blood’s ability to clot. 1) Anticoagulants can worsen bleeding, such as in situations

involving internal and external hemorrhage and intracranial bleeding.




Objective 11L. Patient Assessment

1. Conduct a scene size-up and ensure your safety. 2. Evaluate the mechanism of injury and put on appropriate PPE before

approaching the patient. 3. If you have been called to the patient’s residence, take a moment to scan

your surroundings. a. Is the home well kept or littered with trash?

1) An untidy home may be a symptom of decreased mobility, depression, or lack of interest in self-care.

2) Falls leading to trauma must be investigated as to the reason for the fall and the information relayed to healthcare professionals at the receiving facility.

b. Is the temperature in the room reasonable based on the time of year, or too hot or too cold? 1) A cold home in winter or very warm home in the summer may

be a symptom of a fixed income and rising electric bills.52

Objective 114. As you approach the patient and form a general impression, note the

patient’s appearance, work of breathing, and skin color. 5. Fractures of the spinal column are common in older adults.

a. If trauma is suspected, carefully assess the patient’s airway while maintaining spinal stabilization.

b. Keep in mind that the older adult may wear dentures that, if ill fitting, may cause an airway obstruction. If they do not fit well, remove them.

6. An older adult’s cough reflex may be diminished, so suction as needed to keep the airway open.

7. Assess the patient’s rate, depth, and rhythm of breathing. a. Give 100% oxygen, assisting ventilation as needed.

8. Assess the patient’s circulatory status and control hemorrhage with direct pressure, if present. a. When assessing the patient’s pulse, note its rate, rhythm, and

quality. b. Bear in mind that an older adult’s pulse may be irregular, and a

slower than expected heart rate may be caused by prescribed cardiac medications.

53Objective 11

9. Assess the patient’s level of consciousness using the AVPU scale. a. Assessing the mental status of an older adult trauma patient can be

challenging, particularly if the patient has a medical condition such as Alzheimer’s disease. 1) In situations like this, it will be difficult to determine if the

patient has an altered mental status that is “new” versus what is “normal” for the patient.

2) If a family member or caregiver is available, ask what is normal for the patient and compare their response with your assessment findings.




Objective 1110. Expose the patient as necessary, remembering to respect his modesty.

a. Because the older adult’s ability to regulate body heat production and heat loss is altered, it is important to minimize the areas of the body exposed, keeping him covered as much as possible to maintain warmth.

11. Treat any life-threatening injuries before proceeding to the secondary survey.

12. Generally, it is a good idea to do a head-to-toe examination of any older adult who has been injured, including repeated vital sign assessments. a. A thorough examination is important because even minor injuries in

an older adult can be significant. b. Carefully assess the patient using the DCAP-BTLS memory aid to

ensure injuries are not missed. 13. Remember to look for medical jewelry that can provide valuable

information regarding the patient’s history.55

Objective 12M. Emergency Care

1. Put on appropriate PPE. Keep on-scene time to a minimum.2. If spinal injury is suspected, maintain manual in-line stabilization until

the patient is secured to a long backboard. a. The musculoskeletal system is the most commonly injured organ

system in older adult trauma patients. b. Nontraditional immobilization techniques and extra padding may be

necessary to adapt to musculoskeletal changes, such as curvature of the upper spine.

3. Establish and maintain an open airway. a. Because respiratory difficulty can develop quickly, make sure that

airway adjuncts and suction equipment are readily available.4. Administer supplemental oxygen to all older adult trauma patients.

a. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min.

b. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.

c. Continue monitoring oxygenation using pulse oximetry. 5. Control external bleeding by applying direct pressure to the wound with

a sterile dressing. a. If blood soaks through the dressing, apply additional dressings and

reapply pressure. b. If signs of shock are present or if internal bleeding is suspected, treat

for shock.




Objective 126. Do not remove penetrating objects; rather, stabilize in place with bulky

dressings.7. Manage avulsed or amputated parts as other soft tissue injuries. Every

effort should be made to locate the amputated part.8. Do not touch protruding organs. Carefully remove clothing from around

the wound. Apply a large sterile dressing, moistened with sterile water or saline, over the organs and wound. Secure the dressing in place with a large bandage to retain moisture and prevent heat loss.

9. Protect the patient’s modesty and provide emotional support. Keep the patient warm.

10. Reassess at least every 5 minutes. 11. Record all patient care information, including the patient’s medical

history and all emergency care given, on a PCR.57 N. Trauma in the Cognitively Impaired Patient58

Objective 131. Cognition refers to mental functions including memory, learning,

awareness, reasoning, judgment, and the ability to think, plan, form and comprehend speech, process information, and understand and solve problems.

2. A cognitive impairment refers to a change in a person’s mental functioning caused by an injury or disease process.

3. A cognitive impairment affects a person’s ability to process, plan, reason, learn, understand, and remember information.

59Objective 13

4. Individuals who are cognitively impaired may have a condition such as Alzheimer’s disease, vascular dementia, Down’s syndrome, autistic disorders, traumatic brain injury, or history of a stroke.

60Objective 13

5. Although signs and symptoms vary, a patient with a cognitive impairment may be confused or easily agitated. a. Some patients bang their heads. b. Others injure themselves or are unafraid of danger, making them

more susceptible to trauma. 6. Some patients have difficulty communicating and interacting with other

people. a. The patient may seem withdrawn, may not make eye contact with

you, and may become agitated if they are touched. 7. The degree of cognitive impairment varies.

a. Many patients attend school, maintain a job, and are cared for at home.

b. Others may be bedridden or under nursing home care.61

Objective 138. The patient’s inability to communicate his complaints can pose

significant challenges to healthcare professionals. a. Depending on the degree of impairment, the patient may be an

unreliable historian regarding his past medical history or events of trauma.

b. The adult patient may not be legally able to consent to treatment.




Objective 139. Family members and caregivers often are important resources that

should be tapped when you are called to provide care to a cognitively impaired patient. a. They will know the patient’s medical history. b. They will also know if the patient’s vital signs, assessment findings,

or capabilities are different from normal. c. This information can help you assess the urgency of the patient’s

condition.10. Examples of questions to ask include the following:

a. Can you tell me why you called us today?b. What is the patient’s name?c. How does the patient normally communicate?d. How aware is he of the environment?e. What are his usual motor skills and level of activity?f. What is his usual sleep pattern and appetite?g. Does he have any problems with his sight?h. Does he have any problems with his hearing?

63Objective 13

11. Generally, it is helpful to have a caregiver present during the physical exam.

12. Ask for the patient’s name and use it when providing patient care. 13. Ask the patient’s family or caregiver to describe the patient’s normal

mental status. Then ask if the patient’s behavior today is different from usual and if so, how the behavior is different. a. The AVPU scale may not be accurate for these patients.

14. While enlisting the help of the family, attempt to take the patient’s vital signs when he is calm.

15. Patients with mild to moderate cognitive impairment can often communicate the presence of pain through verbal or nonverbal communication and rate the intensity of their pain. a. Careful observation of the patient’s posture and facial expressions

can be helpful when determining the presence or absence of pain. b. Family members or caregivers can also provide important

information about changes in the patient’s behavior that might indicate the presence of pain.

64 O. Questions?



VIII. Lesson Enhancements

The materials on the following pages are provided to enhance the information presented in this lesson.

Chapter Quiz. This quiz was created for you to copy and give to your students. These questions are also available in a computerized test bank on the McGraw-Hill OLC.

o Chapter Quiz Answers

Activities

o Activity 1. Word Challenge

o Activity 2. Instructor Scenarios. Patient scenarios are provided to reinforce the material presented in this lesson. Each scenario contains information about emergency calls involving real patients. Details such as the care given and patient outcome are not included so that you may modify the scenarios as you wish.



Chapter 32 Quiz – Special Considerations in Trauma

Name __________________________________ Date __________________

True/False Decide whether each statement is true or false. In the space provided, write T for true or F for false.____ 1. Adults over 65 years of age have an increased incidence of sternal fractures from seatbelts.

____ 2. When caring for a pregnant trauma patient, it is best to administer oxygen only when signs of respiratory distress (such as accessory muscle use) are present.

____ 3. When suctioning an infant or child, do not apply suction for more than 15 seconds at a time.

____ 4. Injury to the spleen or liver usually results in significant blood loss.

Multiple ChoiceIn the space provided, identify the letter of the choice that best completes each statement or answers each question.____ 5. Which of the following statements is TRUE regarding the pediatric patient?

a. Extremity trauma is common in children. b. Airway and breathing problems are common with head injuries.c. Injury patterns seen in children are identical to those seen in an adult.d. Penetrating trauma is the most common mechanism of serious injury in the

pediatric patient.____ 6. Which of the following is the most frequent cause of injury in the pregnant trauma patient?

a. Fallsb. Gunshot woundsc. Motor vehicle crashesd. Intimate partner violence

____ 7. Which of the following statements is true about abdominal trauma in the pediatric patient?a. Abdominal injuries are more common in adults than in children.b. Abdominal injuries often go unrecognized in an infant and child.c. The liver and spleen of an infant and young child are well protected by the rib

cage.d. The abdominal wall of the pediatric patient is thick, providing substantial

protection from injury.____ 8. Which of the following statements is true about falls in older adults?

a. Most falls involving older adults occur in grocery stores.b. Falls are the least common cause of injury in older adults.c. Most falls involving older adults are from a height of 10 feet or more.d. Fractures sustained during a fall usually involve the hip, femur, and wrist.

____ 9. Which of the following regarding circulation in infants is correct?a. Assessment of blood pressure is vital to monitoring the progress of these patients.b. When assessing peripheral pulses, the correct location is the carotid artery of the

neck.c. Capillary refill assessment provides valuable information about the patient's



circulatory status.d. An early sign of hypoxia in these patients is a heart rate of 200 beats/min or more.

____ 10. Which of the following is usually the first sign of a major head injury in children?a. Seizures.b. Vomiting.c. Unequal pupils.d. Altered mental status.



Chapter 32 Quiz Answers – Special Considerations in Trauma

TRUE/FALSE1. ANS: T

Injuries sustained by older adults in MVCs are similar to those of younger patients except adults over 65 years of age have an increased incidence of sternal fractures from seatbelts.OBJ: Discuss mechanisms of injury associated with trauma in older adults.

2. ANS: FNever withhold oxygen from a pregnant trauma patient. Give 100% oxygen, assisting ventilation as needed.OBJ: Describe the emergency care of the pregnant trauma patient.

3. ANS: FWhen suctioning an infant or child, do not apply suction for more than 10 seconds at a time. When suctioning, do not suction an adult for more than 15 seconds at a time.OBJ: Describe the emergency care of the pediatric trauma patient.

4. ANS: TThe solid organs of the abdominal cavity (such as the spleen, liver, and kidneys) are extremely vascular structures. Damage to these organs commonly result in significant blood loss.OBJ: Discuss the assessment findings associated with trauma in infants and children.

MULTIPLE CHOICE5. ANS: B

Airway and breathing problems are common with head injuries. The most common cause of hypoxia in the unresponsive head injury patient is the tongue obstructing the airway. Extremity trauma is common in children. Blunt trauma is the most common mechanism of serious injury in the pediatric patient.

The injury pattern seen in a child may be different from that seen in an adult. For example, if an adult is about to be struck by an oncoming vehicle, he will typically turn away from the vehicle. This results in injuries to the side or back of the body. In contrast, a child will usually face an oncoming vehicle, resulting in injuries to the front of the body. In a motor vehicle crash, an unrestrained infant or child will often have head and neck injuries. Restrained passengers often have abdominal and lower spine injuries. Child safety seats are often improperly secured, resulting in head and neck injuries. Contributing factors to pediatric motor vehicle related injuries include failure to use (or improper use of) passenger restraints, inexperienced adolescent drivers, and alcohol abuse.OBJ: Discuss mechanisms of injury associated with pediatric trauma.

6. ANS: CTrauma is the leading cause of death in pregnant patients and the leading cause of death in women of childbearing age. Although pregnant patients can sustain all types of trauma, motor vehicle crashes are the most frequent cause of injury, followed by falls and intimate partner violence.OBJ: Discuss mechanisms of injury associated with trauma in pregnancy.

7. ANS: B



The abdomen is a more common site of injury in children than in adults. The abdomen is often a source of hidden injury. In fact, abdominal trauma is the most common cause of unrecognized fatal injury in children. The abdominal organs of an infant or child are prone to injury because the organs are large and the abdominal wall is thin. As a result, the organs are closer to the surface of the abdomen and less protected. In infants and young children, the liver and spleen extend below the lower ribs. Their location gives them less protection and makes them more susceptible to injury. A swollen, tender abdomen is a cause for concern.OBJ: Discuss the unique anatomy, physiology, and pathophysiology considerations of the pediatric trauma patient.

8. ANS: DFalls are the most common cause of injury in older adults, followed by motor vehicle crashes, pedestrian versus vehicle incidents, and assaults. Most falls involving older adults occur at home and are low-level falls (falls from a standing height). Injuries to the head, pelvis, and lower extremities are common. Fractures sustained during a fall usually involve the hip, femur, and wrist.OBJ: Discuss mechanisms of injury associated with trauma in older adults.

9. ANS: CWhile capillary refill in adults is generally considered less than reliable, it is a valuable tool in assessing the perfusion status of children 6 years of age or younger. Normal capillary refill is less than 2 seconds. To assess capillary refill, blanch (pinch) the nail beds, then observe the amount of time necessary for the return of normal color to the nail bed. Blood pressure in children 3 years of age or younger is an unreliable indicator of perfusion status. The brachial artery is the correct area to assess peripheral pulses in infants. Consider the cause of a slow heart rate in a pediatric patient a sign of hypoxia and assist ventilation as needed.OBJ: Discuss the assessment findings associated with trauma in infants and children.

10. ANS: DWhile it is sometimes difficult to evaluate, a change in the child's mental status is the first sign of head trauma. One of the most effective techniques for evaluating a child's mental status is to ask a parent or guardian, "Does he or she appear to be acting normally to you?" Subtle changes that may elude health care providers are generally evident to the patient's family and friends. Seizures, vomiting, and unequal pupils may be indicative of a major head injury, but do not occur as early as does an altered mental status.OBJ: Discuss the assessment findings associated with trauma in infants and children.



Activity 1. Word Challenge – Special Considerations in Trauma

Name __________________________________ Date __________________

L N K Y J H R D R H R M C S T L U D A R E D L O

I F T M C F N L O W L E V E L F A L L A N E Q K

N M W N X N G X M X R Q N X H N H V I N M F E S

T H F L E D A M W B K G N Z Z Y T T X O N R T V

I A P E Y M R N R T G B T K M N N J R J U R T E

M T U A Q X R N G D W M U R X E L D J T O X R L

A H J T N T F I L E Q F P R M R N N P K T K A A

T E T N I M R D A Y R J N E N Y K U E R V T U C

E S J E D S T V W P H P D C S C R R L H R M M S

P A J C J J T L W B M R X Y K E E T Q A Z F A A

A E V A D Z L I M B A I B N N D J N U Z W V T M

R S C L F G C J C L S A E I H T H M T L M K I OT I J P K L J M U D B T R V J V A G R E J Y C C

N D M O Q T N C W N I E A C I C M G V K R X B W

E S Z I N H S G E J T S J B E T P Y M Q Z F R O

R R C T R A R K C U L M O N W P I T H K Q R A G

V E Q P V C A Z K Y H K T R N O C N L R L R I S

I M R U B H P Z M K N E L Y D P U H G X M B N A

O I L R S Q X D K J R W T J L E J N W O Z Y I L

L E X B L M R C K F M T N Q L X R N D C C D N G

E H T A G U N S H O T W O U N D S S R S M K J J

N Z Q Z T Y P D O W N S S Y N D R O M E X Z U B

C L G Z N O I S N E T O P Y H E N I P U S L R K

E A N O I S U T N O C Y R A N O M L U P R C Y P

www.WordSearchMaker.com

Word List

Abruptio placentaeAlzheimers diseaseAutistic disordersBurn centerCognitive impairmentDowns syndromeGlasgow Coma Scale

Gunshot woundsIntimate partner violenceLow level fallOlder adultsPregnancyPulmonary contusionShaken baby syndrome

Stab woundsStrokeSupine hypotensionTrauma centerTraumatic brain injuryUterine rupture



Activity 1. Word Challenge Solution – Special Considerations in Trauma

L N K Y J H R D R H R M C S T L U D A R E D L OI F T M C F N L O W L E V E L F A L L A N E Q K

N M W N X N G X M X R Q N X H N H V I N M F E ST H F L E D A M W B K G N Z Z Y T T X O N R T V

I A P E Y M R N R T G B T K M N N J R J U R T E

M T U A Q X R N G D W M U R X E L D J T O X R L

A H J T N T F I L E Q F P R M R N N P K T K A A

T E T N I M R D A Y R J N E N Y K U E R V T U C

E S J E D S T V W P H P D C S C R R L H R M M S

P A J C J J T L W B M R X Y K E E T Q A Z F A A

A E V A D Z L I M B A I B N N D J N U Z W V T M

R S C L F G C J C L S A E I H T H M T L M K I OT I J P K L J M U D B T R V J V A G R E J Y C C

N D M O Q T N C W N I E A C I C M G V K R X B W

E S Z I N H S G E J T S J B E T P Y M Q Z F R O

R R C T R A R K C U L M O N W P I T H K Q R A G

V E Q P V C A Z K Y H K T R N O C N L R L R I S

I M R U B H P Z M K N E L Y D P U H G X M B N A

O I L R S Q X D K J R W T J L E J N W O Z Y I L

L E X B L M R C K F M T N Q L X R N D C C D N GE H T A G U N S H O T W O U N D S S R S M K J J

N Z Q Z T Y P D O W N S S Y N D R O M E X Z U B

C L G Z N O I S N E T O P Y H E N I P U S L R K

E A N O I S U T N O C Y R A N O M L U P R C Y P



Activity 2. Instructor Scenarios – Special Considerations in Trauma

Scenario 32-1

You are called for a 16-year-old female who was in a motor vehicle collision. She was the restrained passenger of a vehicle whose air bags deployed, causing superficial burns to both forearms. She is alert and oriented to person, place, time, and event and is ambulatory upon your arrival. She states she is seven months pregnant. She denies abdominal pain and feels the baby moving. She denies other complaints.

Allergies NoneMeds Prenatal vitaminsPast Hx NoneLast intake DinnerEvents See above

Time Pulse BP Resp Pupils Skin0113 80 strong, regular 130/70 20 PERL Pink, warm, dry0119 80 strong, regular 128/72 16 PERL Pink, warm, dry

Scenario 32-2

You are called for a child who fell. Upon arrival, you find a 23-month-old male in his mother’s arms. She states he fell off a 12” tall bench and landed on his back on the floor. You note the patient is acting appropriately for his age. The physical exam is unremarkable.

Allergies NoneMeds NonePast Hx NoneLast intake DinnerEvents See above

Time Pulse BP Resp Pupils Skin1742 110 strong, regular Strong brachial pulse 32 PERL Pink, warm, dry1748 112 strong, regular Strong brachial pulse 36 PERL Pink, warm, dry


Documents

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