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