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Chapter1 scene size up
- 1. International Trauma Life Support for Emergency Care Providers CHAPTER eighth edition International Trauma Life Support for Emergency Care Providers, Eighth Edition John Campbell • Alabama Chapter, American College of Emergency Physicians Scene Size-up 1
- 2. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Scene Size-Up
- 3. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Objectives • Discuss the steps of Scene Size-up • List two basic mechanisms of motion injury • Identify three collisions associated with MVCs, and relate potential patient injuries to deformity of vehicle, interior structures, and body structures • Name the five common forms of MVCs
- 4. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Overview • Describe potential injuries associated with proper and improper use of seat restraints, headrests, and air bags in a head-on collision • Describe potential injuries from rear- end collisions • Describe the three assessment criteria for falls, and relate them to anticipated injuries
- 5. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Objectives • Identify the two most common forms of penetrating injury, and discuss associated mechanisms and extent of injuries • Relate five injury mechanisms involved in blast injuries and how they relate to scene size-up and patient assessment
- 6. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 7. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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 perform size-up can jeopardize lives
- 8. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Scene Size-up • First step in ITLS Primary Survey
- 9. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 10. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 11. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 12. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Initial Triage • Total number of patients – Call for backup – Medical command – Initiate MCI protocols – Any more patients? Courtesy of Bonnie Meneely, EMT-P
- 13. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 14. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 15. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Basic Motion Mechanisms • Blunt injuries – Rapid forward deceleration – Rapid vertical deceleration – Blunt instrument energy transfer • Penetrating injuries – Projectiles – Knives – Falls upon objects
- 16. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Motor-Vehicle Collisions Each collision is three collisions: Machine Collision1 Body Collision2 Organ Collision3
- 17. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Other Collisions • Secondary collisions – Objects are missiles – Additional impacts – Vehicle collides with another object – Other vehicles collide with original vehicle
- 18. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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?
- 19. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Common Collisions • Common types – Frontal-impact – Lateral-impact – Rear-impact – Rollover – Rotational (© Jack Dagley Photography)
- 20. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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 )
- 21. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Lateral-Impact Collision • Similar to frontal- impact with 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)
- 22. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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)
- 23. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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)
- 24. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 25. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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)
- 26. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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 – Possible chemical exposure: insecticides Courtesy of Roy Alson, MD
- 27. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Small-Vehicle Crashes • Small vehicles – Motorcycles – All-terrain vehicles – Personal watercraft – Snowmobiles • Factors – Protective gear – Additional impacts © Orientaly / Shutterstock.com
- 28. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 29. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Falls • Vertical deceleration – Distance of fall – Anatomy impact – Surface struck © Pearson
- 30. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 31. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Penetrating Injuries • Firearms – Type of weapon Low-velocity High-velocity – Caliber Missile size Bullet construction Tumbling/yaw – Distance traveled Courtesy of Roy Alson, MD
- 32. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Penetrating Wounds • Entry wound – Smaller – May be darkened, burned • Exit wound – One, none, or many – Larger – May be ragged • Do not label wounds as entrance or exit in your notes. (©Edward T. Dickinson, MD)
- 33. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Wound Ballistics • Factors – Missile velocity – Missile size – Missile deformity – Missile design – Tumbling and yaw (Courtesy of Roy Alson, MD)
- 34. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 35. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Blast Injuries • Primary – Initial air blast • Secondary – Material propelled • Tertiary – Impact on object • Quaternary – Dispersed hazardous material
- 36. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved
- 37. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Caution Do not approach until Scene Size-Up is complete!
- 38. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
Notas do Editor
- Key Lecture Points Explain the relationship of time to patient survival and how this affects our actions at the scene. Explain the steps of the Scene Size-up and the importance of each step. Explain the importance of being aware of mechanisms of injury. Briefly review the concept of transfer of energy. Stress the concept of the “three collisions.” Briefly review the highlights of specific situations. Large vehicle accidents Frontal deceleration—effect on driver and passengers Lateral impact Rear impact Rollover Effect of restraints—lap belts, cross-chest lap belts, and air bags Tractor accidents Small vehicle accidents Motorcycles All-terrain vehicles Personal watercraft Snowmobiles Pedestrian injuries Falls Penetrating injuries Knives Gunshot wounds Blast injuries
- NOTE: Overview of presentation – continued on next slide.
- NOTE: Overview of presentation – continued on next slide.
- NOTE: Overview of presentation.
- Often patient's life depends on how well you manage details, and not all details are at scene. You or a member of your team must: Know how to maintain your ambulance or rescue vehicle so that it is serviced and ready to respond when needed. Know quickest way to scene of an injury. Know how to size up a scene in order to recognize dangers and identify mechanisms of injury. Know which scenes are safe and, if not safe, what to do about them. Know when you can handle a situation and when to call for help. Know when to approach patient and when to leave with patient. Know your equipment and maintain it in working order. Know most appropriate hospital and fastest way to get there. Know where to put your hands, which questions to ask, what interventions to perform, when to perform them, and how to perform critical procedures quickly and correctly.
- A good scene size-up is essential to maximize patient care.
- NOTE: This is presented as an overview for a frame of reference for Scene Size-up. Assessment will be taught in detail in another section. Emphasize that first step in assessment is always Scene Size-up. Performing a good Scene Size-up will facilitate a good assessment; a poor Scene Size-up will complicate ensuing assessment and management.
- Scene Size-Up includes taking standard precautions to prevent exposure to blood and other potentially infective materials, evaluating scene for dangers, determining total number of patients, determining essential equipment needed for this particular scene, and identifying mechanisms of injuries. Scene Size-Up actually begins at dispatch, with anticipation of what will be found at scene. At that time, think about what equipment will be needed and whether other resources may be needed. Information from dispatch is useful in enabling you to begin to think about a plan, but this information is often exaggerated by caller or even completely wrong. Be prepared to change your plan depending on Scene Size-Up. Includes information about hazards, such as HAZMAT or other special resources.
- NOTE: Covered in more detail in Chapter 22. Trauma scenes are among most likely to subject rescuer to contamination by blood or other potentially infectious material (OPIM). Gloves, eye protection or face shields, impervious gowns as needed Remember to protect your patient from body fluids by changing gloves between patients.
- Position response vehicle away from hazards, but close enough to retrieve equipment efficiently and in a direction to leave scene easily. Consider using vehicle as barrier to hazards (like oncoming traffic). Windshield survey: Look out windshield for hazards before leaving your response vehicle. Look for hazards as you approach.
- IMAGE: Where are patients at this scene? Where should you look? Where else should you look? It is possible a patient could have been located off-screen to top-left of image.
- The following equipment is always needed for trauma patients: Personal protection equipment. Long backboard with effective strapping and head motion-restriction device. Appropriately sized rigid cervical extrication collar. Oxygen and airway equipment (suction equipment, BVM should be included). Trauma box (bandage material, blood pressure cuff, stethoscope).
- Missed or overlooked injuries may be catastrophic. 5–15% of patients involved in a high-energy event, despite normal vital signs and no apparent anatomic injury on initial assessment, will exhibit severe injuries on later examination. A strong correlation exists between injury severity and automobile velocity changes, as measured by amount of vehicle damage. Severity of vehicle damage has also been suggested as a nonphysiologic triage tool. Generalized mechanisms may require a rapid trauma survey whereas focused mechanisms may only require a focused exam.
- Motion (mechanical) injuries are by and large responsible for the majority of mortality from trauma in United States and the industrial world. Generally, blunt trauma is more common in rural settings, and penetrating trauma is more common in urban settings. Rapid forward deceleration is usually blunt, but may be penetrating. Most common example of rapid forward deceleration is motor vehicle collision (MVC).
- Note: Slide animation Consider all MVCs to occur as three separate events (Figure 1-2). Machine collision Body collision Organ collision To explain forces involved, consider Sir Isaac Newton's first law of motion: “A body in motion remains in motion in a straight line unless acted upon by an outside force.” Motion is created by force (energy exchange), and, therefore, force will stop motion. If this energy exchange occurs within body, damage of tissues is produced.
- ANIMATION: ON CLICK package flies in from left of screen and hits patient's head. Additional impacts may make it more difficult to predict injuries in these cases. Quickly but carefully look for clues inside vehicle.
- NOTE: Overview of next slides.
- In head-on collision, the body is brought to a sudden halt, and energy transfer is capable of producing multiple injuries. Windshield injuries: of utmost concern is the potential for serious airway and cervical-spine injury. Steering wheel deformity is a cause for alarm and must heighten your index of suspicion. You must also relay this information to receiving physician. Potential injury patterns Deformed steering wheel Cervical-spine fracture Dashboard knee imprints Flail chest Spider deformity of windscreen Myocardial contusion Pneumothorax Aortic disruption Spleen or liver laceration Posterior hip dislocation Knee dislocation
- Potential injury patterns include: Contralateral neck sprain. Cervical-spine fracture. Lateral flail chest. Pneumothorax. Aortic disruption. Diaphragmatic rupture. Laceration of spleen, liver, kidney. Pelvic fracture.
- Sudden forward increase in acceleration from rear-impact mechanisms produces posterior displacement of occupants and possible hyperextension of cervical spine if headrest is not properly adjusted. If seat back breaks and falls backward into rear seat, there is greater chance of lumbar-spine injury. Rapid forward deceleration may also occur if car suddenly strikes something in front or if driver applies brakes suddenly. Note deformity of auto anterior and posterior as well as interior deformity and headrest position. Potential injury patterns Cervical-spine injury
- The chance for axial-loading injuries of the spine is increased in this form of MVC.
- Rotational collision: One part of the vehicle stops and the rest of the vehicle remains in motion, converting forward motion to a spinning motion. The results are a combination of frontal-impact and lateral-impact mechanisms with the same possibilities of injuries from both mechanisms.
- Restrained occupants are more likely to survive a collision because they are protected from much of impact inside the vehicle and are unlikely to be ejected. If seatbelt is in place and victim is subjected to a frontal deceleration crash, his body tends to fold together like a clasp (or pocket) knife. Air bags aka passive restraints: Do not prevent “down and under” movement, so may still impact with legs and suffer leg, pelvis, or abdominal injuries. Small drivers who bring seat up close to steering wheel may sustain serious injuries as air bag inflates. Infants in car seats placed in the front seat may be seriously injured by air bag. Supplemental restraint systems are only effective if occupant is NOT out of position (OOP).
- Two basic types of tractors are two-wheel drive and four-wheel drive. In both, center of gravity is high, and thus tractors are easily turned over. The majority of fatal accidents are due to tractor turning over and crushing driver. Primary mechanism is crush injury, and severity depends on part of anatomy involved. Additional mechanisms are chemical burns from gasoline, diesel fuel, hydraulic fluid, or even battery acid. Thermal burns from hot engine parts or ignited fuel are also common. Possibility for chemical exposure from insecticides Liquid nitrogen systems are very cold and can produce frostbite.
- Operators of these machines are not encased within them and wear no restraining devices. They could be considered high-speed pedestrians. Only forms of protection Evasive maneuvering Helmet usage Protective clothing (such as leather clothes, helmet, boots) Use of vehicle to absorb kinetic energy (such as bike slide) NOTE: If any of these small vehicles are common in your area, include additional information from chapter.
- IMAGE: “Exploded” leg from being struck by an auto. Pedestrian almost always suffers severe internal injuries as well as fractures. This is true even if vehicle is traveling at low speed. Adult usually has bilateral lower-leg or knee fractures plus whatever secondary injuries occur when body strikes hood of car and then ground. Children are shorter, so bumper is more likely to hit them in pelvis or torso. They usually land on their heads in secondary impact.
- IMAGE: How high up was patient when he fell? Primary groups involved in vertical falls are adults and children under age of 5 years. Children Most commonly involve boys and occur mostly in summer months in urban high-rise, multiple-occupant dwellings. Head injuries are common. Adults: Generally occupational or due to influence of alcohol or drugs. “Lover's leap” fall Attempt to land on feet, impacts initially on feet and then falls backwards, landing on buttocks and outstretched hands Fractures of feet or legs Hip and/or pelvic injuries Axial loading to lumbar and cervical spine Vertical deceleration forces to organs Colles fracture of wrists The greater the height, the greater the potential for injury. Think about transference of energy from impact—what path did it follow? Surface density and irregularity also influence severity.
- IMAGE: Figure 1-16: Stab wounds at nipple level or below frequently penetrate abdomen. Upper abdominal stab wound may cause intrathoracic organ injury, and stab wounds below fourth intercostal space may have penetrated abdomen. Usually stabilize any impaled object in place. Ensure that stabilization minimizes movement of object that will cause further damage. Impaled objects in cheek of face and those blocking airway are exceptions to this rule.
- IMAGE: High-velocity leg wound. Notice entrance and exit wounds. Remember that you treat patient and wound, not description of weapon. Low-velocity Less than 2,000 feet per second, include essentially all handguns and some rifles. Injuries are much less destructive than those sustained from high-velocity weapons. High-velocity Wounds carry additional factor of hydrostatic pressure. Factors that contribute to tissue damage include: Missile size. The larger the bullet, the more resistance and larger permanent tract. Bullet construction Missile deformity. Hollow point and soft nose flatten out on impact, resulting in involvement of a larger surface. Semijacket. The jacket expands and adds to surface area. Tumbling. Tumbling of missile causes a wider path of destruction. Yaw. The missile can oscillate vertically and horizontally (wobble) about its axis, resulting in a larger surface area presenting to tissue.
- Penetrating wounds consist of 3 parts: entry wound, exit wound, and internal wound. REFRAIN FROM LABELING WOUNDS AS ENTRANCE AND EXIT in your record. None of us are experts on wound ballistics. Leave that for surgeon or pathologist. List wound location and number.
- IMAGE: Figure 1-17b. High velocity is greater than 2,000 feet (610 meters) per second; less than that is low velocity (e.g., handguns, some rifles). Missile deformity: Projectile flattens out on impact increasing its surface area and causing more damage. Missile design: Semi-jacketed, soft nose, etc., expand differently. Tumbling causes a wider path of destruction. Yaw is the missile wobbling, resulting in a larger area presenting to the tissue.
- IMAGE: Figure 1-17a: High-velocity vs. low-velocity injury. Penetrating wounds consist of 3 parts: entry wound, exit wound, and internal wound. Low-velocity projectiles inflict damage by tissue contact. High-velocity projectiles inflict damage by tissue contact and transfer of kinetic energy to surrounding tissues. Shock waves Temporary cavity, which is 30 to 40 times bullet's diameter and creates immense tissue pressures Pulsation of temporary cavity, which creates pressure changes in adjacent tissue Shotgun wounds, injury determined by kinetic energy at impact, which is influenced by: Powder charge. Size of pellets. Choke of muzzle. Distance to target.
- NOTE: Figure 1-19 depicts blast areas. Primary air-blast injuries are almost exclusive to air-containing organs. Secondary injuries may be penetrating or blunt. Tertiary injuries are much same as when a person is ejected from an automobile. Now that terrorists are using explosives to disperse chemical, biological, or radiological material, some classify injuries resulting from this as “quaternary injuries.”
- Stress need to do an accurate patient assessment. MOI is a tool but not an absolute. We do not know all forces body may have been exposed to.